Friday, April 29, 2016

ILLINOIS: American Academy of Pediatrics backs down, a bit, sort of.

Pediatrics
May 2016

The Circumcision Debate: Beyond Benefits and Risks

by Andrew L. Freedman and M.D. Faap

In 2007, following a flurry of reports describing a benefit of circumcision in the fight against HIV, the American Academy of Pediatrics reconvened the task force on circumcision to update its policy statement of 1999.[1] Rather than simply incorporating this new information, the committee chose to start from scratch and rereview the medical literature. The task force’s work culminated in a policy statement published in 2012, the centerpiece of which was the statement that “the health benefits of newborn male circumcision outweigh the risks.”[2] This formulation of the debate, “benefits versus risks” rather than “medical necessity,” [or "benefits and harms", or "functions of the foreskin" or "ethics"]  resulted in wide-ranging ramifications.

To many, especially in the lay press, this was interpreted as moving the needle from a neutral stance, as the 1999 guidelines were viewed, to being pro circumcision. It was vigorously criticized by anticircumcision activists, as well as many, primarily European, physicians and medical societies. Difficulties with this approach included the lack of a universally accepted metric to accurately measure or balance the risks and benefits.  [In fact, the AAP made no effort to balance them at all] In particular, there was insufficient information about the actual incidence and burden of nonacute [or acute] complications [or death].[3] In this issue, Sneppen and Thorup[4] use meticulous epidemiologic technique to assess the likelihood of needing a circumcision in a society in which the cultural norm is to preserve the prepuce. [And they find that likelihood to be less than one in 200] Work such as this, along with the subsequent avalanche of reports evaluating the risks and benefits [What "avalanche" apart from a flurry of advocacy articles by wild-eyed Brian Morris?], has helped to inform and animate the dialogue among physicians with a stake in the circumcision debate. But has this really helped to inform the public? Or are we just arguing among ourselves?

What is often lost in the reporting on the American Academy of Pediatrics guidelines was the second half of the benefits/risk sentence, “the procedure’s benefits justify access to this procedure for families who choose it, ” and later “health benefits are not great enough to recommend routine circumcision.” [This line was missing from most summaries.] What was the task force really saying?

To understand the recommendations, one has to acknowledge that when parents decide on circumcision, the health issues are only one small piece of the puzzle. In much of the world, newborn circumcision is not primarily a medical decision. [In most of the world it is not a decision at all.] Most circumcisions are done due to religious and cultural tradition. In the West, although parents may use the conflicting medical literature to buttress their own beliefs and desires, for the most part parents choose what they want for a wide variety of nonmedical reasons.

There can be no doubt that religion, culture, aesthetic preference, familial identity, and personal experience all factor into their decision. Few parents when really questioned are doing it solely to lower the risk of urinary tract infections or ulcerative sexually transmitted infections. Given the role of the phallus in our culture, it is not illegitimate to consider these realms of a person’s life in making this nontherapeutic, only partially medical decision. [The owner of a phallus, unlike a mere penis, is an adult man. He is the only one with any right to make this nontherapeutic, only partially medical decision.] The task force was sensitive to the fact that as physicians, although we claim authority in the medical realm, we have no standing to judge on these other elements.

The ethical standard used was “the best interest of the child,” and in this setting the well-informed parent was felt to be the best proxy to pass this judgment. [But there is no need for a judgement, and hence no need for a proxy.] Protecting this option was not an idle concern [Who said this option has to be protected, or that paediatricians have any role in protecting it?] at a time when there are serious efforts in both the United States and Europe to ban the procedure outright. [No, only to agre-restrict it until the owner is of an age to decide for himself whether  he wants less penis. ]

...

In circumcision, what we have is a messy immeasurable choice that we leave to parents to process and decide for themselves rather than dictate to them. [False dichotomy. The real choice is between leaving the baby alone and anyone being allowed to cut healthy parts off her or him or them.]  This may seem odd in a society in which circumcision is rarely sought, but makes perfect sense in the multicultural world in which many of us live. [The elephant in the room here is the ethics of performing unnecessary, nontherapeutic, only partially medical reductive genital surgery on a non-consenting person.]

To the medical community, your efforts to improve our ability to accurately educate parents are needed. [Physician, educate thyself. Learn about the complex structure and many functions of the foreskin before you claim any right to educate others about it.] But we have to accept that there likely will never be a knockout punch that will end the debate.

...

To the anticircumcision activists, I would suggest that rather than directing an angry focus on the negative and the courts, your efforts would be better spent to educate and promote the prepuce positively [which is why we call ourselves "intactivists"] , to win in the court of public opinion, and to change the culture, so as to make having a foreskin be the “popular thing to do.” {He still doesn't get it. Having a foreskin is not something you do, because it is "popular". A foreskin is something you have as of right because you were born with it, unless someone steals it from you.]

I know it sounds naïve, but my challenge to all of us is to imagine a day we can peacefully live in a world in which not all penises have to look the same. ['Why can't we just get along?' They don't have to look the same, but how they look should be up to their owners, nobody else. And it's not all about looks.]


REFERENCES

 1. American Academy of Pediatrics. Circumcision Policy Statement. Task Force on Circumcision. Pediatrics. 1999;103(3);686-693. Reaffirmation published on 116(3);796

 2. American Academy of Pediatrics Task Force on Circumcision. Circumcision policy statement. Pediatrics. 2012;130(3):585–586

 3. Blank S, Brady M, Buerk E, et al; American Academy of Pediatrics Task Force on Circumcision. Male circumcision. Pediatrics. 2012;130(3).
Available at: www. pediatrics. org/ cgi/content/ full/ 130/ 3/ e756

4. Sneppen I, Thorup J. Foreskin morbidity in uncircumcised males. Pediatrics. 2016;137(5):e20154340
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POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential confl icts of interest to disclose. [Except being paid to cut babies' genitals, and cutting his own son on his parents' kitchen table, contrary to all surgical protocols.]
 

To cite: Freedman AL and FAAP M. The Circumcision Debate: Beyond Benefi ts and Risks. Pediatrics. 2016;137(5):e20160594

LONDON: Secular Doctors hail Exeter ruling

National Secular Society (UK)
April 22, 2016

Secular medics welcome religious circumcision ruling

A High Court judge has ruled against a devout Muslim who wanted his children circumcised, finding that the boys should be able to make the choice themselves in a judgement welcomed by the Secular Medical Forum.

Dr Antony Lempert of the SMF described the ruling as a small but "welcome" step "towards safeguarding children from forced genital cutting."

Religious requirements "should not be allowed to override a person's most fundamental right to grow up with an intact body and to make their own choices about permanent bodily modifications," he said.

"It is a procedure that permanently removes healthy, erogenous and functional tissue from the most intimate part of a person's body without that person's consent and for no medical reason.

"That it should take a parental disagreement in court for a child to be protected from forced genital cutting remains a serious concern from a child safeguarding perspective."

The judge said that the boys' mother was "resolutely opposed" to having the children circumcised and ruled that "There is no guarantee that these boys will wish to continue to observe the Muslim faith with the devotion demonstrated by their father, although that may very well be their choice."

She added: "They are still very young and there is no way of anticipating at this stage how the different influences in their respective parental homes will shape and guide their development over the coming years."

James Chegwidden, who acted as junior counsel for the mother in the case, said that while he could not comment on the specifics of the case, the ruling was "an encouraging step towards the legal protection every child deserves."

He said that the decision was "a reminder that, together with the freedom to practise a religion or philosophy for oneself, comes the necessary obligation not to impose that religion or philosophy on others."

But he warned that the case revealed "just how limited our current legal protection of our children is."

"Bodily autonomy is a right of every child – it cannot be reduced or ignored simply because both its parents happen to be religious. For a right so fundamental as bodily autonomy for a child to depend totally on the whim of an adult is simply unacceptable.

"The court has still yet to classify infant circumcision as 'significant harm', despite the significant evidence that male genital cutting is at least as invasive as some forms of FGM."

The father, an Algerian-born Muslim who has lived in England for fifteen years, is now separated from the boys' mother, whom he had met ten years ago and subsequently lived with. He entered the UK using false travel documents but was subsequently given a British passport.

The couple separated after the mother, from Devon, and the two boys had to flee their home when he violently attacked her in 2012. He was described as "an increasingly controlling and violent individual who sought to impose restrictions on how she lived her life." He had previously "threatened many times that he will abduct the children to Algeria" and was "violent, threatening and controlling towards the mother."

Mrs Justice Roberts said ..."There are risks, albeit small, associated with the surgery, regardless of the expertise with which the operation is performed.

"There must be clear benefits which outweigh these risks which point towards circumcision at this point in time being in their best interests before I can sanction it as an appropriate course at this stage of their young lives."

The judge's warning about the risks of circumcision came as a medical tribunal heard the case of Dr Muhammad Chaudhary, a doctor accused of bungling a circumcision on a two month old baby, who then allegedly tried to bribe the child's family into dropping a claim against him.

He reportedly told the Muslim family that "Litigation in Muslim culture is not usually a route to adopt especially in ritual matters" in an attempt to stop action being taken against him.

Dr Chaudhary failed to repair the damage he had caused during four further surgeries. After he failed to fix the damage he had caused in the initial operation, he advised the family to "treat him [their son] like the Quran and be gentle."

The child was finally referred to a specialist surgeon, the Mirror reported, and had to endure three additional operations in a hospital.

Doctor Lempert said these cases occurred with "nauseating regularity."

There are practically no restrictions on who can perform forced genital cutting on young (male) children in the UK. The procedure is almost wholly unregulated in the UK. The reality is that we simply don't know the extent of harm caused to young children by ritual circumcision. We do know that many such children turn up in A&E and some need treatment in paediatric Intensive Care Units as a direct result of non-therapeutic circumcision.

"Dr Chaudhary is being investigated because he is a doctor who is alleged to have behaved dishonestly. Ironically, should Dr Chaudhary be removed from the medical register, he would no longer be required to satisfy even the limited requirements of the GMC in this matter and would be free to continue cutting young boys' genitals."

Earlier story

EXETER, UK: Court rules against cutting boys, (4, 6) till they are old enough to choose

BBC News
April 18, 2016

Muslim father loses circumcision court battle over sons

A Muslim father has failed to persuade a judge to rule his sons should be circumcised.

The man argued that circumcision would be in accordance with his religious beliefs.

But the boys' mother, who is separated from their father, disagreed.

At a Family Court hearing in Exeter, Mrs Justice Roberts said the boys, who are six and four, should first reach an age where they can make the decision for themselves.

'Individual choices'
The man had argued that it would be "in the children's best interests to allow them to be circumcised" in accordance with his "Muslim practice and religious beliefs".

His former partner "opposes that course until such time as the children have reached an age where they are competent to give consent to such a procedure," the judge added.

"There is no guarantee that these boys will wish to continue to observe the Muslim faith with the devotion demonstrated by their father, although that may very well be their choice.

"They are still very young and there is no way of anticipating at this stage how the different influences in their respective parental homes will shape and guide their development over the coming years."

Mrs Justice Roberts said she was deferring that decision "to the point where each of the boys themselves will make their individual choices once they have the maturity and insight to appreciate the consequences and longer-term effects of the decisions which they reach."

ONTARIO: Foreskin more sensitive to touch - study: headlines wrong

Cutting destroys foreskin sensitivity

by Hugh Young
The foreskin is more sensitive to touch than other sites on the penis, a study at Queens University, Ontario, has found.

It further implicitly found that the foreskin is infinitely more sensitive than its absence.
But that is not what the headlines would have you believe. Quite the reverse.

Psychology student Jennifer Bossio, her tutor Caroline Pukall and urologist Stephen S. Steele studied the sensitivity of the penises of 62 men, 32 intact and 30 cut. The men, aged 18 to 37, were excluded if they had sexual dysfunction. (Thus it was impossible to establish whether cutting has any effect on sexual dysfunction.)

The men were asked about their sexual functioning in five areas: erectile function, intercourse satisfaction, orgasmic function, sexual desire, and overall satisfaction. Genital cutting is likely to impact on ability to withhold orgasm until ready, pleasurable sensations during intercourse and before orgasm, and the quality of those sensations . The cut men of course could only rate their own satisfaction, not compare it with anyone else's.


The researchers measured touch sensitivity, touch pain threshhold, warmth detection and heat pain threshhold on four sites, two on the shaft, one on the glans and one on the outside of the foreskin, if any. (They also made the same measurements at a point on the forearm as a control.)

It is not clear why heat pain was studied. Few couples use painful heat as part of their lovemaking. (The notion that pain is an integral part of sex may be an artifact of male genital cutting.)

They established that the outside of the foreskin is no less sensitive to  the pain of pricking, to warmth, or to heat pain than the other sites of the penis (or to the site on the forearm). Thus its removal can only negatively impact on sexual sensation, just as the removal of the rest would. But they express this finding as a lack of  greater sensitivity, thereby stacking the deck.


They confirmed the finding of Sorrells et al. that "the foreskin was the most sensitive to tactile sensation stimuli." They comment that "given the high prevalence of fine-touch pressure receptors (Meissner corpuscles) in the preputial mucosa, this finding was not unexpected" and thereafter ignore it.


None of the many reports of this study picked up on this strange omission. Instead, under headings like:

- they promoted a finding quite the reverse of what the study actually established.

These misleading headlines and more have been collected by Circwatch.

The study has been thoroughly rebutted in the Huffington Post by Brian D. Earp

MEXICO: Male cutting officially discouraged

Pediatria Jovel
April 7, 2016

Mexico discourages infant male genital cutting

México desalienta la mutilación genital masculina infantil

Today April 7, 2016,  Mexico adopted the official standard for the care of women during pregnancy, childbirth and around it, and the newborn person.
El día de hoy 7 de abril de 2016, se aprobó en México la norma oficial para la atención de la mujer durante el embarazo, parto y puerperio y de la persona recién nacida.
This law fixed, in a nutshell, the minimum criteria for care during pregnancy, childbirth and puerperium of the woman and her baby; which will be of obligatory observance a day after its publication (from April 8, 2016) in all Mexico for all the public and private facilities that provide care to pregnant women and their babies before and after birth.
Esta ley fija, en pocas palabras, los criterios mínimos para la atención durante el embarazo, parto y puerperio de la mujer y su bebé; la cual será de observancia obligatoria un día después de su publicación (a partir del 8 de abril de 2016) en todo México para todos los establecimientos públicos y privados que brindan atención a mujeres embarazadas y sus bebés antes y después del nacimiento.
5.7.13 "avoid circumcision as a routine practice, since there is no scientific evidence proving a direct benefit to the newborn person".
5.7.13 "Evitar como práctica rutinaria la circuncisión, toda vez que no existe evidencia científica que compruebe un beneficio directo a la persona recién nacida"

SOUTH AFRICA: Youth kills himself after removal of his penis

Dispatch Live (South Africa)
March 25, 2016

Stricken teen ends his life after penile amputation due to circumcision complication

by Lulamile Feni
Instead of celebrating his grandson’s passage to manhood, a grieving archbishop now has to bury him.

Next Monday, Zion Methodist Church’s Archbishop Sipho Dlanaye will lay 16-year-old Minentle to rest at Ntsonyini village in Ngqeleni.

Minentle was found hanging by a rope at his grandfather’s house in Mchoncho village in Ngqeleni last Wednesday after a 10-month battle with a circumcision complication that saw him having a penile amputation.

The teenager had lived with his grandparents because his parents work in Johannesburg.

Dlanaye, who is also a police lieutenant, and his wife Noluthando Dlanaye spent months trying to counsel the stricken teen.

At an initiation school in May last year Minentle was ill-treated, assaulted with sticks and burnt on his buttocks.

He was treated in hospitals in Mthatha and Libode for complications following the circumcision.

“He could not take it any more. It was too heavy for him to deal with it and he could not see a future as a man after he had a penile amputation following the illegal circumcision that went horribly wrong,” said Dlanaye.

...Noluthando told the Daily Dispatch her grandson had shown no sign of suicidal tendencies during their weekly visits to him in hospital.

It was only last Monday that they realised he was looking drained and feeling frustrated.

“He denied that there was something worrying him. But two days later Minentle committed suicide,” said the grandmother.

She said she spoke to him on the phone an hour before he took his life and “he sounded happy”.
...

SYDNEY: Two jailed for 15 months for cutting girls, despite "no significant injury"

ABC News
March 18, 2015

Pair given jail time over genital mutilation of young sisters

by Jayne Margetts and staff
A mother and former midwife convicted over the genital mutilation of young girls have been sentenced to a maximum 15 months' imprisonment in a case believed to be the nation's first successful prosecution over female genital mutilation.

Former midwife Kubra Magennis, 72, and the mother of the victims, who cannot be named, were convicted in November of mutilating two sisters in separate procedures during religious ceremonies at homes in Wollongong and Sydney's north-west between 2009 and 2012.

The girls were about seven at the time.

A third offender, senior community leader Shabbir Mohammedbhai Vaziri, was found guilty of acting as an accessory after the fact by directing community members to lie to police about the practice.

He was also sentenced to 15 months' imprisonment.

The procedure, known as "khatna", involves nicking or cutting a girl's clitoris in the presence of several female elders and is considered a rite of passage by some members of the Dawoodi Bohra Muslim community.

Supreme Court Judge Justice Peter Johnson said these kinds of cases were "difficult to prosecute" because of their "unusual and novel circumstances".

He said the mother of the two girls requested that the former nurse and midwife carry out the procedure.

"I am satisfied KM affected injury to the clitoris of each child instructed by A2" and "used a metal instrument for the purpose of cutting," Justice Johnson said.

The court heard the girl's mother had been subjected to the same procedure as a child in Kenya.
The judge said A2 was a qualified pharmacist and an, "intelligent and well-educated woman".

One of the girls, known only as C1, told police "it hurt" when the procedure was carried out.

Justice Johnson said she was "told by her mother not to discuss it with anyone ... this is a big secret. Never tell anyone".

The judge found no significant physical injury had been inflicted on either child but there were "likely to be some adverse psychological effects".

During a sentencing hearing in the New South Wales Supreme Court, crown prosecutor Nanette Williams said the girls were "effectively voiceless" in the face of their mother and Magennis.

She said none of the offenders had shown any remorse and they had only given "qualified, ambiguous and self-serving" apologies.

All three offenders will be assessed for their suitability for home detention.