Infant Circumcision: The debate over parents' rights,By GUSSIE FAUNTLEROY/For The New Mexican July 30, 2001
human rights and the right to choose
For almost two decades, Santa Fe and its nurses and doctors have been at the forefront of the growing international controversy over routine infant- male circumcision. As early as the mid-1980s, some nurses at St. Vincent Hospital began educating themselves and each other on the issue, refusing to assist with newborn circumcisions and offering parents information on the potential risks.
At a time when most American health-care practitioners and parents accepted the procedure without question, these nurses contacted Marilyn Milos, a registered nurse in California who founded the National Organization for Circumcision Information Resource Centers in 1986. Among the organizations's central tenets is the belief that newborn male circumcision not only provides no medical benefits, but is a violation of the child's human rights.
It is a belief that today is gaining attention in the international human rights arena, thanks in part to physicians such as Santa Fe's Dr. Christopher Fletcher, who see newborn-male circumcision as an unnecessary surgery done to a non-consenting patient who could experience harmful effects from it for the rest of his life.
Fletcher and others say they believe the practice continues in the United States primarily for the financial benefit of the medical industry.
In response to this kind of criticism, circumcision advocates are beginning to fight back with pro-circumcision organizations and Web sites. These include physicians interested in maintaining the status quo, Jewish proponents who say they believe ritual infant circumcision is a mandate of God and Jews who see anti-circumcision as a form of anti-Semitism.
Some physicians, including a couple of vocal Santa Fe doctors, frame the debate in terms of parents' rights, saying parents should have the right to decide if their sons will be circumcised, without "undue interference" or "harassment" by nurses who oppose the procedure. The question of nurses' participation in circumcision came to a head at St. Vincent Hospital in 1992, when a group of 24 nurses - about half the maternity-ward nurses, including all the ward's Jewish nurses - decided that on human-rights grounds they no longer could participate in newborn circumcisions.
It was the first time in the United States that a group of nurses had refused to assist with the surgery.
The nurses, who said they believed parents were not being properly informed about circumcision, also asked the hospital administration to provide a consent form that would explain the dangers of the surgery, including the possibility of "bleeding, infection, mutilation and even death."
Three years later, St. Vincent and the local chapter of the National Union of Hospital and Health Care Employees reached a mediated agreement, called a memo of understanding. The agreement did not result in a separate consent form for circumcision, which hospital officials argued would be too complicated to implement. The hospital instead continues to use a generic consent form for all types of surgery.
What the agreement did, however, was provide nurses with the legal, contractual right, as conscientious objectors, to refuse to participate in newborn circumcisions. At the same time, the memo stated the hospital will attempt to secure a nurse to assist with the surgery, for parents who decide to have it done.
In 1995, led by Mary Conant, Betty Katz Sperlich, Patricia Worth and Mary Rose Booker, the objecting St. Vincent nurses formed an organization called Nurses for the Rights of the Child. Affiliated with NOCIRC, it is a separate support and educational organization for nurses and health-care providers.
Since that time, the percentage of St. Vincent nurses declaring themselves conscientious objectors has remained steady despite normal staff turnover, and recently it climbed somewhat to about 55 percent of the maternity and women's-services nursing staff, according to records kept by Nurses for the Rights of the Child.
Also since the mid-'90s, the number of physicians doing routine newborn circumcisions at St. Vincent Hospital has declined dramatically, according to hospital records. And the hospital's rate of newborn circumcision - currently about 4 percent - has dropped to among the lowest in the United States.
At the same time, many newborn circumcisions take place in doctors' offices, where records are harder to track. When these are included, the total circumcision rate in Santa Fe is estimated to be between 10 and 20 percent of all newborn males.
Northern New Mexico's relatively low rate can be attributed in part to education by St. Vincent's nurses and also to the fact that newborn circumcision is not part of traditional Hispanic or Native American cultures, local nurses and physicians say.
Fletcher was trained to do circumcisions, and in his early practice as a family physician in Santa Fe, he did them.
In 1981, however, his employers at La Clinica de la Gente decided the clinic would discontinue routine newborn circumcisions, and they told Fletcher he no longer could do them.
Fletcher says initially he was indignant, as a physician, at being told what to do. However, when he began reading material given to him by La Clinica staff, he realized how little he actually knew about the issue.
He became convinced it was not a medical but a human-rights issue, and he stopped performing the surgery in 1981. For a while, he referred parents to other doctors who would circumcise, but as he learned more, he stopped even making referrals and gradually became a vocal opponent.
Since 1983, Fletcher has had a private family practice in Santa Fe and has continued to gather and disseminate information on circumcision. In 1998, he spearheaded a national survey that queried physicians around the United States on their personal beliefs, feelings and practices regarding circumcision, which continues to be the single most common surgical procedure in American medicine today.
Describing it as the first major survey of its kind, Fletcher presented the results at England's Oxford University in August 1998, at the fifth annual international symposium on sexual mutilation. The gathering was titled "Male and Female Circumcision: Medical, Legal and Ethical Considerations in Pediatric Practice," and papers presented at it were published in a book of the same title.
Among the most significant findings in Fletcher's survey: More than half (53 percent) of American doctors who perform circumcisions on newborn males say they believe the procedure is more harmful than beneficial. Of these doctors, 37 percent also say they personally oppose the operation but continue to perform it.
Combined with other responses, Fletcher says he sees these physicians' apparent ambivalence as confirming his belief that many doctors continue doing - and in some cases soliciting - the surgery largely because it is something they think parents expect. If the father was circumcised, he and the child's mother often believe their son will want to "look like daddy," physicians say.
Circumcision opponents, on the other hand, say they believe it actually might be the parents who want their child to look like daddy and who are uncomfortable with the idea of an uncircumcised son looking different. Parents rarely are given the information or skills to cope with these feelings, Worth said.
Fletcher says he believes the survey also indicates many American physicians themselves are under-informed on available current medical research and do not provide adequate information on the risks. The research, he says, points to no proven medical benefits of circumcision.
Worldwide, the United States is one of the few countries where routine newborn circumcision is widespread, with roughly half of all American baby boys (about a million babies) undergoing the procedure each year. And of the countries where circumcision is practiced, American doctors are virtually alone in justifying it on a medical, rather than religious, basis.
Over the past 150 years, various American medical journals have claimed the surgery as a cure for such diverse complaints as masturbation, idiocy, moral laxity, excessive sexual passions, criminal behavior, facial tics, indigestion, swollen feet, tuberculosis, diabetes, deafness, heart disease and kidney failure. Claims made by American physicians today focus primarily on prevention of penile cancer, urinary-tract infection and HIV/AIDS.
Israel maintains a high rate of circumcision on the grounds that it is required by God for all Jewish males, and in some parts of the world, Sunni Muslims also circumcise for religious reasons.
Including all cultures and religions, about 15 percent of the world's males are circumcised.
Those who oppose circumcision as a human-rights issue say they are fighting for the right of the newborn male not to have a healthy part of his body surgically removed without his consent.
On the other side of the debate locally, Dr. Richard Lieberman is among Santa Fe's self-described "advocates for free choice." Lieberman is an emergency specialist at St. Vincent who worked a number of years ago as a family physician doing obstetrics and family planning for the Indian Health Service.
In that position, he performed numerous circumcisions on male Indian babies.
While newborn circumcision is not part of his current job, Lieberman strongly defends what he believes is the right of parents to choose the procedure for their sons without undue interference by nurses or others who oppose it. He sees it as an inviolable religious right for Jews and Muslims.
At the same time, Lieberman acknowledges the procedure done on 2-day- old babies in hospitals does not conform to the letter of Jewish law, which calls for a mohel, or ritual religious circumciser to perform the rite on 8-day- old male babies in the family's home while saying the appropriate prayers.
Currently, only a handful of Santa Fe physicians perform newborn circumcisions at St. Vincent, with urologist Dr. Steve Lucero doing almost all of them, according to hospital records. Because of "animosity (by nurses) in the newborn nursery," Lucero also performs the surgery in his office, he said, adding that "sometimes parents are mislead and told it can't be done at St. Vincent, but there's no policy at the hospital that says it can't be done." Lucero said he began doing more circumcisions a number of years ago, after a number of mothers came to him complaining that nurses were calling circumcision child abuse and saying there was no medical reason for it.
Lieberman also is offended by language used by some nurses and other circumcision opponents - words such as mutilation, child abuse and "forced amputation of a healthy part of the genitals" - which he feels amounts to harassment of parents. Fletcher defends the use of such terms as technically and ethically accurate, especially in light of potential risks and complications, which he believes often are played down or covered up by doctors.
Fewer than half of all physicians provide adequate anesthesia or pain relief for newborn circumcisions, Fletcher said. A 1997 survey of pediatric residents around the United States (reported in the Archives of Pediatrics and Adolescent Medicine) states that only about 10 percent of residents and faculty members at teaching hospitals used anesthesia for circumcisions.
A pain-relief cream, EMLA, is used by some doctors, but is not FDA approved for use on infants under 3 months old and is not effective, Fletcher said, adding that it is physically impossible to apply an adequate quantity of the cream to a tiny newborn's penis.
Lieberman, on the other hand, quotes from studies and claims made by vocal pro-circumcision advocate Dr. Thomas Wiswell, who recommends use of the cream.
One of the most common problems associated with circumcision is curvature of the penis, which is present in about 70 percent of circumcised men and virtually non-existent among intact men, according to large-scale studies by Drs. Robert Van Howe and Christopher Cold.
In addition, between 5 and 15 percent of circumcisions in the United States are "botched" to the extent that they require reconstructive surgery, Fletcher said. Significant hemorrhaging occurs in 15 percent of American and British circumcisions, with 2 percent of these serious enough to be fatal or lead to transfusions. Infection - including systemic and septic infection - is not uncommon, according to a report by Fletcher to the Perinatal Committee at St. Vincent Hospital.
Among the most serious risks of the surgery is amputation of the penis, which has been reported twice in New Mexico in the past few years, the Perinatal Committee report states. (In both cases, the baby boy was "converted" to a girl.) And death, most often as a result of hemorrhage or septic infection, is reported at a rate of about 230 per year in the United States. However, circumcision opponents believe the death rate is actually higher. In many cases, opponents say, deaths are attributed to other causes, or a false cause of death is listed.
On the flip side of the issue, in the little-discussed arena of the sexual benefits of remaining intact, separate recent surveys indicate sexual pleasure is greater for both intact men and their partners. A main factor is the existence of special sensitive nerve tissue on the end of the foreskin. This sensitivity can be understood by gently stroking your lips and then your chin, Worth said. The level of sensitivity in the foreskin is similar to that of the lips, while sensitivity of the rest of the penis is comparable to that of the chin.
In addition, there is reduced vaginal friction as the penis glides in the foreskin, and the foreskin prevents drying and desensitization of the penis head.
Other studies also point out that the penis of an intact man is longer (by an average of a half-inch) and bigger around than one that is circumcised.
The issue of sexual function is one of the most important pieces of information parents should be given, said Katz Sperlich, St. Vincent nurse, adding that when they receive this information, many parents decide not to have their sons circumcised.
Lucero and Lieberman base their support of circumcision, at least in part, on what they view as medical evidence of potential health benefits, although Lucero said he tells parents the "risks of surgery pretty much balance out" with the risk of urinary-tract infection or penile cancer faced by uncircumcised males. At the same time, both Lieberman and Lucero cite the risk of urinary-tract infection and penile cancer as primary medical reasons for neonatal circumcision.
"Penile cancer is astronomically greater in uncircumcised boys and men, according to everyone's review of the literature. To deny this is to do people a disservice," Lieberman said.
Fletcher counters that penile cancer is very rare, occurring at a rate of fewer than 1 out of every 100,000 men worldwide. With more than 90 percent of Scandinavian men intact, the rate of penile cancer in that part of the world has dropped steadily in recent years and is lower than in the United States, Fletcher said.
Lieberman said he also believes there is growing medical evidence, especially in Africa, that circumcision "appears to be protective" against viruses that may be precursors to HIV/AIDS. But Fletcher sees things differently, saying, "The AIDS connection has been disproven. Ethiopia, with the one of highest rates of circumcision in Africa, also has the highest rate of AIDS."
How do national medical associations weigh in on the issue? The American Medical Association, the American Academy of Family Physicians, the American Cancer Society and the American College of Obstetrics and Gynecology have all issued statements recommending against routine newborn male circumcision, as have the Canadian Pediatric Society and the Australian Association of Pediatric Surgeons.
The American Academy of Pediatrics came out against circumcision in the 1970s, and it later reversed that position.
The Academy's most-recent statement, issued in 1999, concludes that "Existing scientific evidence demonstrates potential medical benefits of newborn circumcision; however, these data are not sufficient to recommend routine neonatal circumcision." So why does the procedure continue to be so widespread in this country?
According to Lieberman, Lucero and other local physicians who perform circumcision or support the right of parents to have it done, the main factors are cultural and parental expectations, religious mandates and beliefs and the potential for medical benefits.
According to opponents, one of the driving forces is money.
Circumcision opponents estimate the cost to insurers and parents in the United States at about $2 billion a year, including a host of related "hidden" hospital and doctor charges resulting from the procedure and complications. For physicians with busy metropolitan practices, 150 to 200 circumcisions a year can bring in as much as $60,000 through this one procedure alone.
Yet Fletcher notes that despite anonymity, more than half the doctors in his survey would not say how much they charge for the surgery. (Many said they couldn't remember.) Of those who responded, the average charge was $121 and ranged as high as $300.
The cost is covered by most insurance programs and by Medicaid in most states, with the highest Medicaid program paying almost $300. In New Mexico, Medicaid reimbursement pays almost $160.
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