Saturday, November 21, 2015

TORONTO: Cutting unwanted, baby dies, doctor cautioned

National Post (Canada)
October 25, 2015

Ontario newborn bleeds to death after family doctor persuades parents to get him circumcised

by Tom Blackwell
TORONTO — An Ontario doctor has been cautioned after a 22-day-old baby bled to death from a circumcision gone horribly wrong, underscoring the heated debate over a simple yet contentious procedure.

Another physician involved in the case was urged by a medical governing body to be “mindful” of the operation’s dangers.

But Ryan Heydari’s parents say the regulators who handled their complaints have shed little light on what led to Ryan’s death – or how to prevent similar tragedies in future.

Ryan Heydari - dead from genital cutting
Ryan Heydari

They say they did not even want the newborn circumcised — a view in line with longstanding recommendations from the Canadian Pediatric Society — but were persuaded to do so by a family physician.

In fact, the case only became public because the couple appealed the original Ontario College of Physician and Surgeons rulings, which were rendered in secret.

An appeal tribunal upheld this month a decision by the College to caution the doctor who saw Ryan in the emergency department hours after his circumcision, his diaper stained red with blood.

The Health Professions Appeal and Review Board also confirmed the college’s separate advice to the pediatrician who conducted the procedure to be aware of its potential hazards, and document his efforts to get informed consent.

The pediatric society said in a recent report that death from bleeding caused by circumcision is “extremely rare,” though it’s not completely unheard of. A five-week-old B.C. baby bled to death after being circumcised in 2003.

Ahmadi gave birth on Jan. 3, 2013 to a boy who loved attention, cried relatively little and seemed to actually smile. “He gave us the most amazing moments of our life,” says Ryan’s mother.

She and husband John Heydari, who immigrated from Iran about 12 years ago, opposed having him circumcised, convinced that “mother nature created us the way she intended us to be.”

But their family physician persuaded them it was a good idea for medical reasons, despite contrary advice from pediatric specialists.

Once carried out on most Canadian boys and still common as a religious rite for Jews and Muslims, circumcision has generally fallen in popularity, rates hovering around 32 per cent.

The pediatric society has long held that its risks – including pain to a small baby, bleeding and the chance of disfigurement of the penis – outweigh its benefits.

The group revisited the issue with a report just last month that addressed growing evidence circumcision helps prevent sexually transmitted disease, acting almost like a vaccine in countries with high rates of HIV. ["Almost like a vaccine"? Only one person says that.

Circumcised boys [who survive] are also less likely to suffer urinary-tract infections and to develop rare penile cancer later in life, the society says.

But its report still recommended against routine circumcision of every newborn male, saying that it may make sense in certain cases. For those who have the procedure, “close follow-up in the early post-circumcision time period is critical,” the society warns.

One urologist says he has encountered a few cases where circumcised babies had to undergo transfusions because of dangerous bleeding, and sees less-serious complications routinely.

Dr. Jorge DeMaria of Hamilton’s McMaster University believes regulators should require doctors to prove they have undergone proper training before doing circumcisions. He also questions circumcising newborns for preventive-health reasons, in a country with low levels of HIV and wide availability of condoms.

Ahmadi says she and her husband knew almost immediately after their son’s procedure that something was seriously wrong.

The previously unfussy baby “was crying so much, so hard, and he wouldn’t stop,” she recalled in written answers to questions. “He was bleeding, and it only got worse over just hours … It was so obvious from the blood his tiny body had lost that he was in danger.”

The pediatrician who did the circumcision told the College he conducts many of them, that Ryan’s was uneventful and there was no bleeding when he checked the dressing before the family left.

The parents called about bleeding later that day, though, and he advised them to take Ryan to Toronto’s North York General Hospital, which they did.

“We … waited for care that could have saved his life, but that level of care never came,” says Ahmadi.

A sparse outline in the board’s decision says Ryan was eventually transferred to Sick Kids hospital, but died there seven days later. Pathologists said he succumbed to “hypovolemic shock” caused by bleeding from the circumcision, which emptied his body of 35 to 40 per cent of its blood.

The doctor at North York General — whose name has been withheld according to College policy — was cautioned for failing to recognize the seriousness of the boy’s condition or treating “compensated shock” – the first stage of the condition.

But the process left the family little further ahead in fathoming how Ryan could have died, said Brian Moher, their lawyer.

“My clients felt that there was a big gap in what the College had done with the investigations, essentially missing the point around the infant’s death.”

The devastated parents, meanwhile, have not had other children.

“The loss of Ryan, our only child, has made us realize that we can’t possess anything, even our hopes and dreams,” Ahmadi says. “We hope that this never happens to any other baby.”

SYDNEY: Father lied to police about daughter's cutting

The Guardian
October 15, 2015

Father in FGM trial tells court he lied to police about what he knew of ceremony

Father and mother were interviewed by police and then placed in a room with a listening device, the New South Wales supreme court hears

The mother of two girls who allegedly underwent female genital mutilation told her husband “just a little bit” when her husband asked if the ceremony involved cutting their clitorises, a court has heard.

The first trial of FGM in Australia is being heard in the New South Wales supreme court with the mother of the two alleged victims charged along with an older woman known as KM, who is accused of carrying out the FGM, and Shabbir Mohammedbhai Vaziri, a leader in the Dawoodi Bohra Shia Muslim community.

When the parents were initially interviewed by police in 2012 a listening device was placed in the waiting room and after he had talked to police, their father, known in court as A1 met his wife in the room.

“It took a long time, they asked many things, they ask me do you have any idea what they do in circumcision, I tell them I don’t know anything, if they ask you say you do not know … in us do they cut skin?” he asked her.

The mother responded: “No they just do little bit, just little.”

The father admitted in court he had not told police the truth when he said he did not know what khatna, the ceremony the girls took part in, involved.

“She explained to me it involved placing forceps in genitalia, and saying Qur’anic verses,” he told the court of what his wife told him khatna involved.

In previous evidence the father had said it involved “some sort of metal on on the private parts” and when asked by crown prosecutor Nanette Williams why he had changed evidence from “in” genitalia, to “on”, A1 said “I’m not sure where the forceps are placed, but it’s on the private parts somewhere”.

A1 also admitted he had not told the truth to the police when he said in 2012 he did not know what khatna involved.

“I knew what khatna was, I knew what my girls went through, I didn’t tell the truth to the police,” he said.

Asked by Williams if khatna involved an injury to genitalia, he responded: “not in my girls.”
The alleged FGM was allegedly carried out on the girls, known as C1 and C2, when they were each seven years old, between 2010 and 2012.

A conversation between A1 and C1 was recorded in 2012 in which C1 talked about being cut.
“You have no cut, we do not do cut, no we do not cut, we cannot cut, nothing was cut of yours, we cannot do the cut here,” her father responded.

When C1 said she had seen scissors during her khatna, her father said it was forceps that she saw, not scissors.

“Forceps used for cleaning purposes, for a check up,” he said.

The court has previously heard about the “Africa story”, a lie the mother and others had agreed to tell that part of the khatna that took place in Australia was a “check up” and if the girls had been cut it was in Africa.

The trial continues.

BRUSSELS: No, Europe's cutting concern undiminished

The Jewish Daily Forward
October 9, 2015

Europe Council Reiterates Opposition to Circumcision

he Council of Europe refuted reports in Israeli media that it had canceled a resolution from 2013 that called nonmedical circumcision of boys a harmful violation of children’s rights.

The clarification Thursday on the position of the Council, a body for pan-European dialog that has no executive powers and is not part of the European Union, came following statements by Israeli politicians, Jewish activists and media suggesting the Council had reversed its position on the practice.

According to those statements, the change came in the passing on Sept. 30 by the Council’s Parliamentary Assembly of Resolution 2076 on “Freedom of religion and living together in a democratic society.”

Milah UK, a leading Jewish advocacy group supporting the practice, on Tuesday said in a statement that Resolution 2076 “cancels a previous motion that had cast into doubt the legality of religious circumcision.” Milah is the Hebrew-language name for the ritual circumcision of eight-day-old males. Muslims also circumcise their children.

The previous resolution referenced by Milah UK is Resolution 1952, which the assembly passed in 2013 and which lists milah along with female genital mutilation and calls both practices a harmful “violation of the physical integrity of children.”

But Nathalie Bargellini, a spokesperson for the Council’s Parliamentary Assembly, on Thursday told JTA that Resolution 2076 “does not cancel nor replace Resolution 1952.” She noted the more recent resolution references the older one.

Bargellini also said that Resolution 2076 “calls for strict conditions governing the exercise of this practice.” According to the new resolution, “circumcision should not be allowed ‘unless practiced by a person with the requisite training and skill, in appropriate medical and health conditions,’” Bargellini said.

Resolution 1952 carried no such recommendation for outlawing certain types of circumcision — a divisive issue in Europe for its relevance to immigration by Muslims and to children’s rights.

Though it is nonbinding, the 2013 resolution was controversial and was seen as significant because it was the first time that a prominent pan-European institution weighed in on the circumcision debate.

Earlier story

JERUSALEM: Jews, Muslims unite to undo Europe's cutting caution

The Jerusalem Post
October 1, 2015

Council of Europe cancels anti-circumcision measure after joint Jewish-Muslim effort

Jewish and Muslim MKs united over past two years to advocate for reversal of Parliamentary Assembly of the Council of Europe resolution calling to ban ritual circumcision of children.
by Lahav Harkov

Two years of efforts by the Knesset to combat a resolution by the Parliamentary Assembly of the Council of Europe recommending that countries ban [no, age-restrict] ritual circumcision bore fruit Thursday, when it was reversed via a resolution on religious freedoms. Passed with 73 in favor and six opposed, the resolution recommends that PACE member states “seek reasonable accommodations with a view to guaranteeing equality that is effective, and not merely formal, in the right to freedom of religion.”

It gives general guidelines to promote coexistence and fight hate speech, allowing religious communities to practice their faith, manage welfare institutions and express their opinions.
The resolution refers specifically to Islamophobia, but not to anti-Semitism.

The council recommended that states require circumcisions to be performed by people trained to do so, in appropriate medical and health conditions, and that parents be informed of any medical risk to their child.

The resolution also addresses ritual slaughter, stating that PACE is not convinced it should be banned, and recommends following the French or German model of protecting animals from unnecessary suffering while respecting religious freedom.

MK Esawi Frej (Meretz), who represented the Knesset at the vote, called the decision a victory for common sense.

“The argument about whether to circumcise is legitimate, but opponents of the ancient ritual should fight through education and public relations and not try to force their opinions through legislation,” Frej said. [While those who cut children force their opinions with a knife.]

In October 2013, PACE’s Social Affairs, Health and Sustainable Development Committee approved a resolution by German rapporteur Marlene Rupperecht stating that ritual circumcision, in addition to piercings, tattoos, plastic surgery, medical intervention in cases of possibly transgender children and female genital mutilation, violates children’s right to protect their physical integrity. [The words "protect their" are not in the resolution. Obviously small children can not protect their own integrity.]

It also recommended that laws be passed “to ensure that certain operations and practices will not be carried out before a child is old enough to be consulted.” Jews perform ritual circumcision on boys when they are eight days old, and Muslims do so at the age of 13.
PACE resolutions are non-binding, but are taken seriously by member states.

Since the resolution passed, the Knesset, under Speaker Yuli Edelstein’s leadership and the guidance of Knesset Diplomatic Advisor Oded Ben-Hur, has sent delegations of MKs, Jewish and Muslim, to PACE and to countries from Azerbaijan in the East to Paris in the West, to enlist their European colleagues from other countries in the battle against the decision and other initiatives to ban ritual circumcision. MKs advocated for ritual circumcision to be dealt with as a matter of religious freedom, as opposed to children’s rights, moving it to PACE’s Culture, Science Education and Media Committee, which discusses religious issues, among others.

NEW YORK: Metzitzah: City not telling doctors about herpes cases

The Jewish Daily Forward
September 25, 2015

New Controversial Circumcision Rite Rules: Don't Ask, Don't Tell

by Paul Berger
New York City has not only stopped requiring mohels to obtain written consent before performing a controversial circumcision rite — the city has also stopped alerting doctors and the public when it suspects that a mohel has infected a baby with herpes following the ritual, known as metzitzah b’peh or MBP.

Between January 2013 and December 2014 — when the city enforced its short-lived attempt to regulate MBP through a consent form — each time health officials identified a neonatal herpes infection linked to the practice, they reminded doctors of the care and sampling procedures to follow if infants displayed symptoms.

The alerts also brought media and public attention to the ongoing health issues related to the practice.
During that period, there were six cases in which city health officials believed that the ritual — in which the mohel uses his mouth to suction blood from the circumcision wound — infected a baby with herpes.

Since 2000 MBP has been blamed for 18 cases of neonatal herpes in New York City. Two of those babies died, and two others suffered brain damage.

But at the beginning of 2015, under pressure from the ultra-Orthodox community, the administration of New York City’s mayor, Bill de Blasio, announced the city’s intention to revoke the consent form regulation.

At a meeting of the city’s board of health September 9, when the consent form regulation was officially revoked, health commissioner Dr. Mary Bassett revealed that there had been a case of neonatal herpes infection linked to MBP this past April.

... the department’s press secretary, Christopher Miller, ...<1--gave no explanation. He later--> told the Forward in an email that the department did not issue a health alert for the April case because “we believed that awareness at the provider level was sufficiently high given all the press in recent months.”

...<1--But media attention surrounding MBP, which is practiced exclusively by a subset of ultra-Orthodox mohels, has been no greater this year than in previous years.

According to a search of news articles and transcripts on LexisNexis during 2013 and 2014, when the health department issued five health alerts — one for each month in which it became aware of a case or multiple cases — there were some 200 media stories about MBP and neonatal herpes.

>What has changed this year is the city’s approach toward MBP. During his 2013 election campaign, de Blasio pledged to replace a city regulation of MBP enacted in 2012 under former mayor Michael Bloomberg.

The regulation, which enraged the ultra-Orthodox community, required mohels to get written consent from parents before performing MBP.

The consent form, drafted by the city’s health department, warned parents that MBP poses a risk of infecting their child with herpes, which could result in brain damage or death.

Many leading ultra-Orthodox rabbis and mohels do not believe that MBP causes herpes infection in infants.

The virus, which commonly causes cold sores, is prevalent in more than two-thirds of adults in New York City.

Mohels say that by using the correct infection control practices, such as gargling with mouthwash, they can prevent the spread of the disease.

They believe that many neonatal herpes cases the city attributes to mohels were caused by a family member or a caregiver touching the circumcision wound with a finger or hand.

Yerachmiel Simins, a lawyer who represents the ultra-Orthodox community ...said that the ultra-Orthodox community has still not come to an agreement with the health department over the terms of the DNA protocol. He said that the ultra-Orthodox community has been keen to conduct DNA testing on mohels for years, but the city has “steadfastly and consistently” refused.

...Jonathan Zenilman, chief of the infectious diseases division at Johns Hopkins University, said that by allowing the ultra-Orthodox community to continue performing MBP as it did before the consent form regulation was brought into force, the city’s health department was being cowardly by acting in a “pusillanimous” fashion.

Earlier story

FLORIDA: Secret agreement reached over visits to cut-dispute boy

Sun-Sentinel (Palm Beach, Florida)
September 16, 2015

Parents in circumcision fight appear to settle visitation dispute after judge, attorneys meet privately

by Marc J. Freeman
Heather Hironimus may soon be allowed supervised visits with the son she hid for months this year during her highly publicized battle against his circumcision. But the terms negotiated by attorneys Wednesday were not publicly disclosed after a judge abruptly halted a court hearing and convened private talks.

Palm Beach County Circuit Judge Jessica Ticktin printed copies of the agreement from her computer and distributed them to the attorneys through a courthouse deputy, more than two hours after she began meeting in her chambers with attorneys for the West Boynton mother and Dennis Nebus, father of the nearly 5-year-old boy.

The dialogue continued sometimes with and without the judge, who did not return to the bench to adjourn court after Hironimus and Nebus signed the pact. Hironimus has been seeking a reunion with her child for the first time since mid-May. The Boca Raton father has had temporary full custody.

Judge Ticktin did not return a call to the Sun Sentinel from a message left with her assistant, and the attorneys hurried past a reporter without commenting on what happened in place of an advertised, three-hour public court hearing. The official online court docket for the case did not show the agreement had been posted Wednesday night.

It was the latest twist in a battle that generated international headlines after Hironimus violated family court orders and fled with the boy to a Broward domestic violence shelter for about three months, until she was arrested and jailed for nine days.

She became the champion of circumcision opposition groups, after she decided to fight the procedure she agreed to in a 2012 parenting plan.

Wednesday's hearing began as expected, with Hironimus watching her attorney, Brian M. Moskowitz, arguing for her to visit with her son at a neutral site, a Delray Beach family center, with an off-duty cop watching at her expense.

"A mom has the absolute right to see her child as long as she abides by the law," the attorney said. He promised she will behave, because a violation could void a deal resolving her separate criminal case concerning an interference with custody charge and land her back in Palm Beach County Jail.

Hironimus, who signed a consent to the circumcision in May, "has no idea if her son has been circumcised," Moskowitz said of the procedure.

May L. Cain, attorney for Nebus, only said her client has been stymied each time he has tried to schedule the medical procedure, because of threats and intimidation from "crazy groups." [The only threats have been of legal action. It's not a medical procedure. The boy has no symptoms and no diagnosis.]
"Some of them call themselves intactivists," she told the judge.

Still, Nebus is agreeable to Hironimus being a part of her son's life if security precautions — including at least one deputy in the room along with a "parenting coordinator" — are put in place, Cain said.

"We're still afraid these groups are going to abduct this child," she said. "My client's main concern is to keep the parties' son safe."

His ground rules: The mother doesn't say a word about circumcision to the boy; she gets one, one-hour visit per week; and no photography will be allowed during the visits.

"We feel those photos will end up online somehow," Cain said, noting that in the past the child's maternal grandmother was responsible for leaking the "most private details of the child's life" on the Internet.

Nebus' hesitation is a result of the protracted circumcision battle and a lack of trust when it comes to Hironimus considering how she first tried to get state courts to block the surgery and then fled with the boy.

"The mother told the child the father was dead," Cain told the judge. "This is not," the attorney explained, "your normal run-of-the-mill case."

Both attorneys had announced they were calling several witnesses, including Hironimus and Nebus.
Judge Ticktin then said, "Counsel, why don't we take five minutes?" and called Cain and Moskowitz back to her chambers.

That left Nebus, 48, and Hironimus, 31, sitting in awkward silence, alone at opposing tables, for more than 45 minutes until their attorneys emerged without the judge.

The back-and-forth negotiations in the judge's chambers continued without explanation. Hironimus' criminal defense attorney, Richard Tendler, also joined some of the talks.

Hironimus appeared to be pleased upon signing the agreement, totally different from the scene that played out at the same table on May 23, when she cried and shook while signing a circumcision consent form.

On July 16, her criminal case was resolved as well, with a pretrial intervention agreement. Hironimus was not required to plead guilty, but she admitted "responsibility for interfering with a lawful custody order."

She's required to undergo a mental health evaluation and finish all recommended treatment; submit to random drug testing; and check in with a probation officer once a month. [Shouldn't Nebus, who has repeatedly and at length tried to force unnecessary surgery on the boy, be undergoing a mental health evaluation?]
The State Attorney's Office will drop the felony count in one year if Hironimus successfully meets the requirements, including the completion of a four-hour parenting course. If she fails, she could once again face prosecution and a maximum punishment of five years in prison for a conviction.


VICTORIA B.C.: Human Rights group criticises CPS policy

Children's Health and Human Rights Partnership (CHHRP)
September 9, 2015

Canadian Children's Rights Group Questions New Circumcision Policy

VICTORIA, BRITISH COLUMBIA-- A just released policy on infant male circumcision by the Canadian Paediatric Society (CPS) was judged today by the Children's Health & Human Rights Partnership (CHHRP) to be a step in the right direction, but was "nevertheless 'predictably inadequate' with respect to several specific issues."

CHHRP Medical Director Dr. Christopher Guest, MD, FRCPC, said the new policy is consistent with international paediatric associations that affirm infant boys should not have their healthy foreskins routinely removed.

Citing the position of the CPS that recognizes the unique sensory functions of the male foreskin, Dr. Guest asserted that, "A growing number of medical associations now recognize that an intact penis with a foreskin contributes to sexual pleasure for the male and his partner." According to Guest, in 2010 the Royal Dutch Medical Association concluded, "the foreskin is a complex erotogenic structure that plays an important role in the mechanical function of the penis during sexual acts."

"Circumcision alters the structure of the penis, which inevitably alters function. Long term harm to men from infant circumcision has never been studied" Guest said. Despite this, Guest says men are reporting long-term adverse consequences at the Canadian-based online Global Survey of Circumcision Harm. Although the CPS failed to include it, Guest says scientific evidence has emerged that supports these men's claims. In 2011, Dr. Morton Frisch published findings in the International Journal of Epidemiology showing that in Denmark, where circumcision is rare, 'circumcision was associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in their female partners, notably orgasm difficulties, dyspareunia [difficult or painful sexual intercourse] and a sense of incomplete needs fulfilment.'

Guest faulted the CPS for inclusion of  "convenient untruths, "most notably a discussion of HIV being lower in circumcised men. He says such claims are based on methodologically weak African trials, which contradict global HIV trends, for example the United States, which has a high circumcision rate, yet a significantly higher rate of HIV infection than Sweden and Japan where circumcision is rare. "Even if the African trials were scientifically valid, they cannot be used to justify infant circumcision because infants are not sexually active persons," he said. "Soap and water and safer sex practices, including condoms, can prevent disease."

According to Guest, the CPS failed to include crucial information from a 2012 report by the International NGO Council on Violence Against Children, which CHHRP sent to the CPS in 2014. The report stated that "non-consensual, non-therapeutic circumcision of boys, whatever the circumstances, constitutes a gross violation of their rights, including the right to physical integrity, to freedom of thought and religion and to protection from physical and mental violence."

"Medical associations in the Netherlands, Finland, Sweden, Norway, Denmark, Germany, and others confirm that there is no justification for circumcising infants in the absence of medical urgency," Guest stated. "The CPS is out of step with those medical associations, who also urge an end to the practice due to ethical and human rights concerns."

Although the CPS concluded that routine infant circumcision is not recommended, and that the benefits of the surgery do not outweigh the risks (contrary to a 2012 claim by the American Academy of Pediatrics), Guest contends that the position statement is still insufficient due to its ambiguity in leaving the decision up to parents. "Parents are not physicians. They do not have the medical knowledge to decide if surgery is medically indicated for their child," Guest asserted. He went on to say that, "Leaving a decision about medically unnecessary surgery up to parents is an ethical failure on the CPS' part. Where else in medicine do physicians place this burden on parents, in order to obviate their own professional responsibility?"

"Preservation of bodily integrity is a basic and universal human right that the CPS must articulate clearly in future statements," Guest said. "We Canadians, as well as our institutions and government, have an obligation to protect that right for all citizens, regardless of gender or age."

The Children's Health & Human Rights Partnership was established in 2012 as a partnership of professionals in the fields of medicine, ethics, and law to further public education regarding non-therapeutic genital surgery on Canadian children.

Earlier story