Posted by: Anon | 2011-06-11

Much ado about circumcision: A pediatric urologist’ s view

Since you ladies are really airing your views and true feelings on circumcision, here is more food for thought and why you are right on with preference for your guy being circumcised.

Frequently writing on faith issues from my vantage as a co-founder of a Hindu advocacy group, my faith and family, interests and occupation overlap. But in the circumcision debate, I check my religion at the door and take a seat inside. The doctor, a pediatric urologist, is in.
Nearly every day, I perform a circumcision. During my discussions with the family prior to the procedure, I discuss the position statement put forth by two organizations that have published evidence based policy statements on circumcision: the American Academy of Pediatrics and the American Urological Association. Both statements state clearly the facts: neonatal circumcision reduces the risk of urinary tract infection in the first year of life, eliminates the risk of penile cancer, and significantly reduces the risk of syphilis and HIV transmission. I tell the families in the same breath that these statements also caution that the urinary tract infection risk in uncircumcised boys is as low as 1%, and that access to good hygiene also prevents penile cancer. Of epidemiological interest, despite the fact that regions in China and Scandinavia do not practice circumcision for newborns, the incidence of penile cancer is exceedingly high in the former and very low in the latter, presumably due to excellent cradle to grave medical care in Scandinanvian countries. And while circumcision’ s reduction of HIV risk by 60 percent has led the World Health Organization to embrace the procedure as a critical step, it can never substitute for safe sex practices.
I echo the ambivalence of the profession to which I belong when families ask about the procedure. I present the facts. And nearly 80 percent of the time in the United States, the parents will choose circumcision for their child. I will receive as much for doing the procedure as I would for seeing any patient in the office for fifteen minutes. It is not an income source. But I offer the service because families truly, deeply, and sometimes, desperately, want the procedure for their son. And if they decide to go forward, I will place an antibiotic cream on the penile skin and then inject an additional milliliter of lidocaine to provide enough anesthesia that most children barely whimper, though some will cry.
The data is mixed, there is no wrong or right answer. Families deal with the nebulous every day and make a decision that is right for their children. But to me, the inanity over the circumcision debate lies also in its ignorance of medical realities. If a child has had recurrent urinary tract infections or a lower urinary tract anomaly, circumcision can protect the child from the risk of renal damage by nearly 10 to 15 fold. If a child has a hypospadias, an anomaly where the urethral opening opens along the shaft of the penis rather than at the tip, then I will use the foreskin to reconstruct the urethra, and a circumcision results. And while my clinic is full of children, also, with partially done circumcisions, adhesions that have formed, and urethral openings that have narrowed after circumcision requiring additional surgery and health care dollars, my clinic is just as full of children with foreskin that is painfully infected, scarred with lichen sclerosis, ballooning, torn and tight that may necessitate a circumcision..
A circumcision in childhood is a rapid outpatient procedure  a circumcision after adulthood can be traumatic, painful, and substantially more expensive. A procedure costing $250 in the newborn period would cost $5000 in adulthood due to the need for anesthesia and perioperative care. Any type of blanket ban on a circumcision until the age of consent so ignores the real medical necessities of circumcision in some cases, that the concept is beyond contemplation  it is medically irresponsible and dangerous.
Circumcision rates will drop naturally if the medical data disproves putative benefits. There is no circumcision industry or lobby that influences or supports the medical profession, buying the procedure’ s perpetuity. The procedure lives because there are some benefits and Americans have rendered the procedure a cultural norm. I am well aware that our colleagues in Canada, England, and France, to name a few, snicker at the American propensity to cut foreskin and believe that circumcisions are overdone in this country. Many pediatricians and pediatric urologists here in the States will even agree.
But the concept of banning the procedure does not enjoy credibility even overseas where they are not commonly done, simply because circumcision has been performed for five thousand years and is intertwined with faith, preference, and cultural realities. The current publicity given to the stunt in San Francisco frightens me not for its medical ignorance, but for its overt and retrograde anti-Semitism. The animated depictions of the Jewish ritual bris& mdash the innuendo eliciting comparisons to genital mutilation& mdash are overwrought and shocking.
There is room for a healthy debate on the medical necessity for circumcision and whether it should be performed as routine. Any answer lies in a robust review of properly performed population studies that control for confounding factors. Indeed, it was just such trials that confirmed the spectacular benefit of a circumcision for reducing the transmission of HIV. But never could we support a comprehensive ban for a procedure that has established benefits for certain children. And because we must empower parents to make choices for their children& mdash they are difficult decisions with long term implications& mdash but decisions parents make everyday.
The industry dedicated to cirumcision’ s end, seems more a misdirected passion, based on a medically dubious altruism at best, and anti-Semitism at its worst. And these voices will, undoubtedly, alienate reasoned, thoughtful voices that could begin an enlightened dialogue.

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Our expert says:
Expert ImageSexologist

Interesting debate.

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Our users say:
Posted by: asdasdasd | 2011-08-22

God put the forskin on for a reason.
youre dick is a internal organ really...
do the math...

Reply to asdasdasd
Posted by: Anon | 2011-06-14

WJA, you yourself are circumcised and you bring up a law that in the US is completely unconstitutional. The San Francisco proposed ban would never stand up in court even if the nut cases in San Francisco pass it. I can dispute every one of your statistics. Clearly you pull your information from an intactivist website. As for the drop in circumcision as reported in the US, this specifically refers to RIC done in the hospital as reported by the institution. BIG news for you, most parents are opting to have it done on an out patient basis at the doctor''s practice or an outpatient facility that is not required to report these surgeries, nor is that information factored into the CDC report (by their own policy). Also, as the circumcision rate declines in the US due to the immigrant population, you are seeing America''s position in the world leadership deteriorate as well. So know where the reduction is coming from and what effect it is having. Statement was made by a medical expert at a closed medical meeting on AIDS is the US a few years ago.

As for using condoms, sure you can preach that, but reality is that you cant predict the sexual behavior of any child nor do all children carry condoms at all times. Condoms have a much higher failure rate with uncircumcised men anyway. I believe you were 18 with raging hormones at some point as well. Did you use condoms every time??

Just to update you, the CDC will be publishing a reversal on their existing statement of neutrality on circumcision that will be changed to recommended. That will be followed by AAP revising their statement to support as well. This expected change has been published.

Since you are so hell bent on saving foreskins, why don''t you do something about all the cultural circumcisions being performed in the Eastern Cape???? Clearly all this legal blabber you have stated here is not adhered to by the leadership of SA or they chose to look the other way. They cant nor do they want to do anything about it. Over 40 boys have died this last circumcision season. How many more will die this winter?? Can you tell me out of the over 1.2 million US circumcisions performed last year how many boys have died as a direct complication from their circumcisions??

Your facts are very questionable to say the least. Your accusation of MGM is completely unfounded and most medical doctors would dispute that as would most courts of law. So how about you get your facts straight from a reputable source and not some intactivist websites that have never acknowledged any medical and scientific information. That is the one common aspect of all intactivists, right down to Marilyn Milos of INTACT, when I spoke with her many years ago I challenged her on the medical facts and she said she did not believe in medical facts because they prevented her from her calling to save foreskins. That coming from a nurse who had never slept with an uncircumcised man and all three her own sons were circumcised as well.

She lost her nursing license in the state of California many years ago because she refused to do her job. The pro''s of circumcision outweigh the cons by a huge margin. Its been the case since biblical times and has been proven over and over again. That can''t be disputed nor can medical and scientific facts.

Consider yourself lucky to be circumcised when you were. Dont forget you have NO EXPERIENCE ever living with a foreskin yourself. ONLY what you have read about from radicals like yourself on intactivist websites.

Reply to Anon
Posted by: WJA | 2011-06-14

Anon, firstly one needs to place this article in context. This is a response to the currently proposed Circumcision ban (specifically Routine Infant Circumcision (RIC) performed in the absence of a valid medical justification) that has been cleared to appear in the November 2011 ballot in San Francisco (USA). If the measure passes, circumcision would be prohibited among males under the age of 18. The practice would become a misdemeanor offense punishable by a fine of up to $1,000 or up to one year in jail. There would be no religious exemptions.

The American Academy of Pediatrics official policy statement is “ Existing scientific evidence demonstrates POTENTIAL medical benefits of newborn male circumcision  however, these data are NOT SUFFICIENT to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is NOT ESSENTIAL to the child''s current well-being, parents should determine what is in the best interest of the child.

From a statistical perspective on the POTENTIAL benefits the following are not made clear to parents:
- Reduces the risk of urinary tract infection in the first year of life –  The reduction is less than 1%, or, 1:175
- Eliminates the risk of penile cancer –  The risk of contracting penile cancer is less than 1:10,000 and that access to good hygiene also prevents penile cancer
- Significantly reduces the risk of syphilis and HIV transmission –  whereas condoms are 98% effective at reducing the same risk
- Nearly 80 percent of the time in the United States, the parents will choose circumcision for their child –  In fact the CDC reports “ ..a precipitous drop in circumcision, to just 32.5 percent in 2009 from 56 percent in 2006.”  Clearly indicating that the American public are rejecting this as a cultural norm and are starting to realize the procedure for what it is –  Male Genital Mutilation.

From a South African perspective the South African Medical Association (2005) issued it’ s own statement “ ..from a medical point of view, there was no medical justification for routine circumcision in neonates and children.” 

Amendments to the South African Children’ s Rights Act make it harder for boys to be circumcised for frivolous reasons. To wit:
- Every child has the right not to be subjected to social, cultural and religious practices which are detrimental to his or her well-being.
- Genital mutilation or the circumcision of female children is prohibited.
- Circumcision of male children under the age of 16 is prohibited, except when (a) circumcision is performed for religious purposes in accordance with the practices of the religion concerned and in the manner prescribed  or (b) circumcision is performed for medical reasons on the recommendation of a medical practitioner.
- Circumcision of male children older than 16 may only be performed (a) if the child has given consent to the circumcision in the prescribed manner  (b) after proper counselling of the child  and (c) in the manner prescribed.
- Taking into consideration the child‘ s age, maturity and stage of development, every male child has the right to refuse circumcision.

The changes require informed consent of both parents, and the boy if he is old enough, and the signature of the circumciser, to be kept on record until the boy is 21 –  old enough to sue if he is not satisfied with the outcome. The Child Care Act was recently repealed and all sections of the Children’ s Act, as amended, have come into operation with the proclamation having been signed by the Deputy President.

So, not only is RIC not recomended,deemed medically unethical, it is also illegal to perform a RIC on a male child in South Africa.

Reply to WJA
Posted by: Sexologist | 2011-06-12

Interesting debate.

Reply to Sexologist

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