MEDICAL FRAUD and the criminal assault of boys
"Straight Talk "
NEWBORN CIRCUMCISION - AN ENIGMA OF HEALTH
Dr George L Williams
Paediatrician / Perinatologist
Circumcision has puzzled me since my childhood. I was born in a country town, Worcester, in South Africa in 1947. Our family midwife at my homebirth slapped me to life as I was blue with breathing difficulties. My mother recounted that I needed to be spared circumcision as I had enough difficulty adjusting to my birth. My three brothers were circumcised in the newborn period. I would guess that circumcision was a prevalent practice in our community. We had no Jewish or Islamic affiliation and I am told my father was circumcised. During my childhood as I gazed with wonder at my brothers' exposed penises, I felt different and defective. This 'strangeness of the intact penis' was also noted by Romberg, mother of three circumcised sons, childbirth educator and author of the pioneering book "Circumcision: The Painful Dilemma".
As a medical intern I learned the surgical skills of circumcision in 1970. The procedure filled me with great concern and fortunately I did not have to perform further operations. I noted serious complications during my paediatric residency in South Africa and Australia.
In 1978 to 1980 whilst doing my postgraduate fellowship in Perinatal Medicine at The McMaster University (Canada), I learnt the epidemiological discernment of clinical trials.
In the ensuing years I explored the scientific validity of newborn circumcision. I will highlight this exploration of more than a decade. Circumcision is practiced at varying rates throughout the world, the United States of America still being the most prevalent circumciser in the order of 50-75%, Canada 25%, Australia 10% and New Zealand 2%. 75% of the world's population does not circumcise its males. This variation in practice is not accounted for by the religious ritual of Jews and Muslims. Despite the Medical Colleges of Paediatrics and Obstetrics discouraging the routine practice on medical grounds, the operation continues to be done for its alleged benefits. The benefits claimed are cleanliness, reduced urinary infections, improved sexual performance, pleasing aesthetic appearance, mature sexual identity and less genital cancer in adulthood.
These benefits have not been proven by cohort analytic study or randomized controlled trials - the best tests for scientific validity. The long-term effects of infant circumcision have not been evaluated. I have come to the conclusion that newborn circumcision does harm and offers no medical or surgical benefit. Circumcision is a surgical procedure with its inherent risks. These may include medical complications associated with infection, bleeding, disfigurement and stress-related sequelae.
The newborn infant has an immature haemostatic system with deficiency in certain clotting factors, decreased platelet aggregation, decreased clot retraction and reduced platelet 3 availability. In 1966 Patel reported risks of mild to moderate haemorrhage of 35% and severe haemorrhage of 1%. In 1978 Denton reported a haemorrhage risk of 2%.
The newborn is at risk for infection because of immature humoral and cell medicated immunity. The concentrations of most complement components are decreased relative to adult levels by 20 to 40%. The C8 C9 (complements) and reduced alternate pathway components lead to defective generation of chemotactic factors and incomplete opsonization.
There is absence of type-specific antibody and no placental transfer of IgA, IgM, IgD and IgE antibodies. The IgA absence in secretions enhances bacterial invasion of mucosal surfaces. The neutrophils by their chemotactic ability have difficulty localisation infection and show a diminished inflammatory response. The monocytic chemotaxis is decreased compromising the inflammatory response.
In 1966 Patel reported an early onset infection rate of 7% and septicaemia of 1%. In 1992 Cohen described ritual Jewish circumcision as a factor in causing urinary tract infection. In 1986 Amir found a higher incidence of urinary infections confirmed by bladder aspiration up to ten days after Jewish circumcision. In 1978 Sussman reported two cases of Fournier's Syndrome, which is a malignant gangrenous infection of the penis, scrotum and perineum. One infant ended up with a redundant scrotal sac and total necrosis of one testis. In 1980 Woodside reported extensive necrotizing fasciitis in a six day old infant circumcised on day 3 with the Plastibell technique. Staphylococcal scalded skin syndrome was noted in 1978 by Annunziato in three infants whose circumcisions became infected. Kaplan reported tuberculosis, diphtheria and tetanus in Current Problems in Paediatrics of 1977. Haematogenous osteomyelitis and lung abscesses were also reported in 1977 as complications.
Gastric rupture following circumcision was described in 1992 by Connelly. The well full term infant on day 2, commenced crying whilst restrained on a board in the supine position. He underwent an unanaesthetized Glomco procedure and cried vehemently for 90 minutes. Abdominal distention was noted prior to the circumcision. The gastric rupture was confirmed hours later by radiography. He underwent repair of an anterior mid-portion gastric rupture with placement of a gastrostomy. He was discharged on day 25 in good health receiving feeds via the oral and gastrostomy route.
A horrific story of mutilation was described in 1975 by Money. A young couple took their normal, identical twin boys to a physician to be circumcised when the boys were seen months old. The physician in the operating theatre used an electric cauterizing needle to remove the foreskin of one twin. When the baby's foreskin didn't give on the first try, or on the second, the doctor increased the current. On the third attempt, the severe heat from the electricity literally cooked the baby's penis.
Unable to heal, the penis dried up and in a few days sloughed off completely, like a stub of an umbilical cord. At the age of twenty-one months the 'little girl' was brought back to The John Hopkins Hospital for surgical feminization and removal of testes. Her mother reported that dolls and a doll carriage headed her Christmas list when she was five and that, quite unlike her brother, the girl was neat and dainty, experimented happily with styles for her long hair, and often tried to help in the kitchen. Finger pressure applied above the urethral opening ensured a downward urine stream. Vaginoplasty and hormone replacements were planned at puberty but the girl was not ready to accept hospitalization. The final outcome of this tragic case will be of interest.
The Cassell Pocket English Dictionary issued 1991 defines mutilate as "to cut off a limb or an essential part of; to maim; to mangle; to disfigure; to injure by excision.". Circumcision of the male newborn can be aptly described as penile mutilation. Boyd stated that the term is not only scientifically accurate but also honours the feelings of those who feel they are victims of circumcision.
The newborn does have the anatomical and functional components required for the perception of painful stimuli. In 1990 Milos as a student nurse has given this description of a circumcision - "He was struggling against his restraints - tugging, whimpering, and then crying helplessly.
The silence was broken by a piercing scream … the shriek intensified … the baby started shaking his head back and forth … began to gasp and choke, breathless from the shrill, continuous screams … the baby was limp, exhausted, spent."
The stress and pain responses have been characterized by several studies. The autonomic responses include an increase in heart rate, blood pressure, rapid and shallow respiration, fall in oxygenation, pallor or flushing, palmar sweating and dilated pupils. The behavioural responses may include diffuse body movement and purposeful withdrawal, rigidity or flaccidity and clenching of fists. There may also be changes in facial expression such as grimacing, furrowing of the brow and quivering of the chin, state disturbances such as altered sleep patterns, fussiness or irritability and vocalization such as crying, whimpering or groaning.
There is considerable anatomical maturity of nociceptive pathways by the gestational age of thirty weeks. The cutaneous sensory receptors appear at skin and mucosal surfaces by the 20th week of foetal life. The density of these nociceptive receptors in the skin is the same as in an adult.
Complete myelination of the nociceptive pathways occurs in the second and third trimesters of the foetus. The transmission of pain sensation is carried by two nerve pathways. A-delta fibers - these are thin, myelinated, rapid firing and associated with sharp pain ("first pain"). C-polymodal fibers - unmyelinated, slow conducting and associated with aching or burning ("second pain"). The fibers synapse in the dorsal horn of the spinal cord, ascends in the dorsal column and spinothalamic tract.
There are several relays and connections in the thalamus, limbic system and cerebral cortex. The posterior sensory area of parietal lobes in the postcentral gyrus stores memories of past sensory experiences. Neurochemical mechanisms subserve the nociceptive pathways and are operative before birth. Adrenaline, noradrenaline, dopamine and acetylcholine are proven neurotransmitters. The tachykinin system contains the putative neurotransmitters which are substance P, neurokinin
A and neuromedin K and others. Substance P is present in high concentrations in the newborn. The endorphins bind the opiate receptor sites in the brain and spinal cord and block the release of excitatory neurotransmitters. Beta-endorphins are released during the stress of hypoxaemia in a full term infant. After neonatal surgery there is an increase in the serum concentrations of catecholamines, growth hormone, glucagon, cortisol aldosterone, other steroids and reduced insulin release with resultant hyperglycaemia, pyruvic and lactic acidosis and catabolism.
I observe with dismay that analgesia and/or anaesthesia are hardly ever used in the maternity hospitals that I visit. I guess this unkind practice is prevalent throughout Australia. A variety of safe local and regional anaesthetic techniques are available. In 1968 Illingworth wrote that "circumcision without anaesthesia is a cruel practice." Marshall, Richards and Dixon clearly demonstrated altered behavioural states following circumcision. Dixon found that local anaesthesia abolished this altered state. In 1976 Talbert showed a dramatic rise in serum cortisol 20 to 40 minutes after circumcision. In 1981 Gunnar found a similar elevation in plasma cortisol in newborns undergoing circumcision without anaesthesia.
In 1971 Emde reported prolonged periods of non-rapid-eye-movement sleep. Irritability, wakefulness and later arousal levels were noted in 1974 by Anders and in 1975 by Blackbill. Circumcision probably affected the USA behavioural studies of Brackbill when compared to the observations in 1976 by Richards in England where babies were not circumcised.
In 1981 Verny and in 1976 Grof claim that every experience of the human organism is imprinted on the memory system in cortical cells and will be evidenced in many overt and covert ways in the life span of the individual.
Epidemiological evidence in 1987 and 1985 by Jacobson and Salk suggests that traumatic events at birth may increase risk of suicide, drug addiction and alcoholism in later life.
Meatal ulceration is common following circumcision and was noted in the 1966 Patel study at a frequency of 31%. Meatal stenosis was reported in the same study at 8%. In 1956 Berry found a meatal stenosis of 60% in circumcised adults and an unexplained high rate of 25% in intact males.
In 1971 Campbell reported rare but serious sequelae like urethral fistula, amputation and gangrene of the penis, avulsion of the scrotum and removal of needed skin for hypospadias repair. In 1977 Kaplan described chordee, which is tight banding of the frenulum resulting in a curved penis.
He also cited urinary retention, preputial retention cysts and lymphoedema as specific complications of circumcision. In 1985 Briggs in her revealed book "Circumcision" described inhalational pneumonia from vomiting following circumcision. She also cited the problem of inappropriate patient selection. In 1992 Ritter in his compelling book "Say No to Circumcision" states that premature ejaculation continues to be a problem for circumcised men. He also refers to a study showing a higher incidence of non-specific urethritis in circumcised men.
In 1949 Gairdner reported 16 deaths from circumcision and phimosis per year between 1942 and 1947 in England and Wales. Most of these were infants that were circumcised under the age of one year. In 1950 Hand reported 41 deaths of Jewish infants contracting tuberculosis from mohels. In 1966 Patel reported no deaths over a ten year period from 1952 to 1961 at the Kingston General Hospital in Ontario. In 1953 Speert reported one death in New York between 1939 and 1951. The same author estimated 2 deaths per million procedures in 1953. In 1977 in Australia, Scurlock described four desperately ill newborns with bacterial meningitis from infected circumcision sites. Two recovered, one survived with cerebral palsy and one died.
In 1978 Gellis stated that there were more deaths each year from circumcision than from cancer of the penis. Streitfeld predicted in 1981 in the USA, about 5 boys would die per year as a result of infection or bleeding. In 1989 Snyder presented such an infant death in Iowa from bleeding to the California Medical Association. Illingworth claimed in 1968 that most practicing paediatricians have either heard of or seen a circumcision death. Burger in 1974 in the USA stated a mortality rate of 1 in 500,000. In 1985 Briggs stated that "one thing can be generalized about circumcision deaths: they are almost always traceable to infection in one way or another". All present mortality data is open to question. Patients have not been monitored as a single study group and may die some time later from secondary complications. In 1980 Wallerstein, the pioneer preservationist, estimated that in the US there could be up to 225 deaths per year attributable to newborn circumcision, if late-occurring effects are counted.
I will now discuss the need for, and the value of retaining the foreskin. The foreskin contains sensitive nerve endings for erotogenic function. Adult men who have been circumcised as infants claim that they have reduced sensitivity of their glans penis. This is not surprising as the glans is exposed to dryness, superficial trauma and rubbing. The penis is designed to be a covered and protected organ in the resting state.
Modern foreskin restoration aims to redress the loss of sensation and protection. The intact penis, without manipulation and retraction, can be easily cleaned with soap and water. The foreskin covers and protects the glans from urinary and faecal contact at a time when the child is wearing nappies. Balanitis and phimosis are infrequent and may be caused by forcible manipulation. Herzog in a retrospective survey, found the frequency of medical visits for foreskin problems to be 10% for intact boys and 5% for the circumcised group. Most of these problems were minor. In USA the need for circumcision in older infants in 1971 was calculated at 15%. Boyce calculated the adjusted risk of uncircumcised males under 15 years to be 6.8/1000/year. In the same analysis the actual rate for expected circumcisions was 10%. In Scandinavia, where the foreskin problems are managed medically, the circumcision rate for men and older children is 0.002%. In Finland, a noncircumcising country, the operative rate in the postneonatal period is very low at 0.006%. The difference between 15% and 0.006% cannot be justified by medical criteria. Gordon felt that in Britain only 1 to 2% of boys need circumcision for medical reasons. Rickwood questioned the overdiagnosis of phimosis and the unnecessary high circumcision rate of 5.6% in the Liverpool and Mersey region. Recurrent balanoposthitis and balanitis xerotica obliterans, both uncommon, are the only indications for circumcision.
Urinary infections were shown by Wiswell to be more prevalent in intact male infants. He quoted a rate of urinary infection of 0.11% in the circumcised and 1.12% in the intact group. Of notable interest, the rate for females (0.57%) was twice for males (0.31%). These date remain in question as the studies were not prospective, unblinded, random allocation was absent and confounding variables were not controlled. The specific variables of concern of the Wiswell studies are rooming-in practices, breast feeding, length of hospital stay, bacterial colonization, prematurity, socio-economic status, penile hygiene/foreskin care and urinary tract abnormality. The variable end point determination and uncontrolled bias noted by Thompson further invalidates the results. Altshul noted, after examining the Kaiser Hospital records, a urinary infection rate of males in the first year of 0.12%. Winberg from Sweden showed a lower urinary infection rate. He stated that the increased urinary tract infections seen in intact young children may be due to "hospital strains" of uropathogenic P fimbriated Escherichia coli acquired in the unnatural environment of modern obstetric units rather than being related to the foreskin. Gellis poignantly stated that you have to perform 98 circumcisions to prevent two urinary tract infections. Denniston gives this perspective, "the largest number of infections that could be prevented by foreskin amputation, according to the author Dr Thomas Wiswell, is 20,000 per year in the USA.
So we do 1,500,000 (estimated annual male birth rate) foreskin amputations to prevent infections, now treatable with antibiotics, in less than 2% of the infants?"
In order to demonstrate a protective effect of circumcision against AIDS and sexually-transmitted diseases, a comparative-controlled trial of uncircumcised and intact men needs to be performed. The confounding variables to be controlled are sexual practices, host immunity, quality of genital hygiene, drug abuse and colonization status.
Cancer of the cervix in women, cancer of the prostate and of the penis in men have been attributed to the intact state. These studies have little scientific validity in the absence of a comparative intact group, confounding variables are unchecked, bias is not eliminated and no long term follow-up is reported. I echo the statement of Grossman that no significant correlation between genital cancer and circumcision status has ever been shown. Smegma is secreted by all mammals, both male and female and its carcinogenic potential has been discredited. Swafford stated that "the threat of penile cancer hangs over the discussion of circumcision like some mystical demon. It deserves to be exorcised, not circumcised."
The subject of circumcision in our society is plagued by bias and ignorance. I do not believe adequate education is given in the antenatal period/infancy about the care and value of the foreskin. Spontaneous natural foreskin retraction occurs throughout childhood and the data of Gairdner is still relevant today. He reported spontaneous retractility rates of 4% at birth, 50% at one year, 80% at 2 years and 90% at 4 years. The rate for intact boys aged 5 to 13 years was 94%. Oster reported 9,545 observations of Danish school boys, aged 6 to 17 years in 1957 to 1965.
In this elegant longitudinal study, he demonstrated synechial cleavage rates, resulting in natural full retractility of 37% (6-7yrs), 60% (12-13yrs), 80% (14-15yrs) to 97% (16-17yrs). The notion that 'congenital phimosis' is a birth defect is contradictory to the evidence of a natural developmental course.
There appears to be a misguided notion that the foreskin is a dangerous, troublesome and useless appendage. A wide variety of inappropriate parental and medical responses were sampled by Brown, Maisels, Lovell as reasons for circumcision. Some medical practitioners still believe in circumcision and recommend the procedure to parents. In 1982 two thirds of sampled USA obstetricians, paediatricians and family practitioners showed evidence of ignorance and misinformation about circumcision and foreskin care. From 1981 to 1982, at The Royal Hospital for Women (Crown Street in Sydney), I was given permission to counsel parents who requested circumcision. I was able to reduce the hospital circumcision rate by 25%. Parents often have the view that they want their sons to look like their father or brothers. They don't want them to be socially disadvantaged in having a foreskin. They need to be given truthful information that will allow them to make a considered choice. Several excellent leaflets and texts are available on the value of having an intact penis. Unfortunately this information is not widely available to the public. The United Nations Convention on the Rights of the Child recently ratified by Australia, guarantees the right of the children of ethnic, religious or linguistic minorities to enjoy their own culture. However, the Convention also calls upon all parties to 'take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children'. Circumcision is prejudicial to the health of children so its practice is to be condemned.
Newborn circumcision raises serious ethical and legal questions. Do parents have the right to choose medically unnecessary and harmful cosmetic surgery for their children? I do not believe so. Female circumcision is culturally abhorrent but male circumcision is acceptable in USA, Canada and Australia. Is circumcision battery, child sexual assault or false imprisonment? asked Boyd. Demetrakopoulos states that circumcision "is an invasion of the rights of new and unprotected citizens whom we reward after their elaborate entry into our world with hostility and pain." Erickson collected this quote … "fear, pain, crippling, disfigurement and humiliation are the classic ways to break the human spirit. Circumcision includes them all."
The First International Symposium on Circumcision of 1989 adopted these declarations which I endorse. They are:
"We recognize the inherent right of all human beings to an intact body. Without religious or racial prejudice we affirm this basic right.
We recognize the foreskin, clitoris and labia are normal, functional body parts.
Parents and/or guardians do not have the right to consent to surgical removal or modification of their children's normal genitalia.
Physicians and other health-care providers have a responsibility to refuse to remove or mutilate normal body parts.
The only persons who may consent to medically unnecessary procedures upon themselves are individuals who have reached the age of consent (adulthood), and then only after having been fully informed about the risks and benefits of the procedure.
We categorically state that circumcision has unrecognized victims.
In view of the serious physical and psychological consequences that we have witnessed in victims of circumcision, we hereby oppose the performance of a single additional unnecessary foreskin, clitoral or labial amputation procedure.
We oppose any further studies which involve the performance of the circumcision procedure upon unconsenting minors. We support any further studies which involve identification of the effects of circumcision.
Physicians and other health-care providers have a responsibility to teach hygiene and the care of normal body parts and to explain their normal anatomical and physiological development and function throughout life.
We place the medical community on notice that it is being held accountable for misconstruing the scientific database available on human circumcision in the world today.
Physicians who practice routine circumcisions are violating the first maxim of medical practice, "Primum Non Nocere," " First Do No Harm," and anyone practicing genital mutilation is violating Article V of the United Nations Universal Declaration of Human Rights: "No-one shall be subjected to torture or to cruel, inhuman or degrading treatment."
Somerville from the McGill Centre of Medicine, Ethics and Law in Canada questions the legality of male circumcision on present medical evidence. She stated that any wounding, and clearly circumcision involves this, is 'prima facie' illegal unless it can be justified. In the male infant informed consent of an adult is not a possibility, circumcision is non-therapeutic and involves irreversible consequences or harm. She concludes that both female and male circumcision be prohibited on legal grounds.
In USA, Australia, Britain and France, female genital mutilation is expressively prohibited by law. In Sweden, male circumcision on healthy children is not allowed and enshrined in legislation. The Law Reform Association (Australia) opined that "for a parent's consent on a child's behalf to the procedure to be lawful, it would have to be shown that it is therapeutic. A parent may validly authorize a non-therapeutic operation only if it is not actively against the child's interest."
While circumcision is likely to continue in our society, Boyd urges us to clear-headed thinking and analysis. A poignant quote from Ritter "the operation of routine, neonatal circumcision involves a paradox of absurdities completely at variance with sound medical-surgical-legal practice." We harm the honour and integrity of our profession if we continue with this neolithic practice.
This paper was first presented at the Second International Homebirth Conference, 4-7 October 1992, University of Sydney, Australia.
References are available on request.
Dr George L Williams
Paediatrician / Perinatologist
PO Box 248
Menai Central NSW 2234
Australia
Updated 30th January 2004.