Journal of Nurse-Midwifery, Volume 37, Issue 2 (Suppl.): Page 875-965, March/April 1992.
By Marilyn Fayre Milos, RN, and Donna Macris, CNM, MSN
American parents and health care professionals are faced with medical/ethical dilemmas regarding whether or not to respect the natural integrity of the male newborn's body. In the English- speaking countries,, where circumcision of infants was initially adopted to prevent masturbation, medical "reasons" were postulated to justify a practice most of the world has never considered. This resulted in a spectrum of medical recommendations for surgical removal of normal genital tissue in all male newborns to prevent diseases (foreskin inflammation, urinary tract infections, and sexually transmitted diseases) that could be effectively treated medically without the risks of surgery. Only by denying the existence of excruciating pain, perinatal encoding of the brain with violence, interruption of maternal-infant bonding, betrayal of infant trust, the risks and effects of permanently altering normal genitalia, the right of human beings to sexually intact and functional bodies, and the right to individual religious freedoms can human beings continue this practice.
These, then, are the human genitals. Considering their great delicacy, complexity and sensitivity, one might imagine that an intelligent species like man would leave them alone. Sadly, this has never been the case. For thousands of years, in many different cultures, the genitals have fallen victim to an amazing variety of mutilations and restrictions. For organs that are capable of giving us an immense amount of pleasure, they have been given an inordinate amount of pain.-- Desmond Morris1
While some researchers believe that circumcision was practiced as early as 6,000 years ago on the west coast of Africa, the earliest record of circumcision, an Egyptian bas relief, dates back to 2800BC2 . Theories suggest that circumcision was practiced for religious reasons, as a punitive measure, as a puberty or premarital rite, as an absolution against the feared toxic influences of vaginal (hymenal) blood, and as a mark of slavery. Written documentation of circumcision first appears in the Bible. Both Jews and Moslems circumcise in accordance with Abraham's covenant with God (Genesis 17:10), which historians date to 1713 BC3 . Moslems also perform female circumcision (genital mutilation that often includes clitoridectomy), a practice probably of African origin4 .
Circumcision evolved from a religious ritual or puberty rite into routine surgery for "health" reasons in the English-speaking countries during the nineteenth century when the etiology of most diseases was unknown: "Within the miasma of myth and ignorance, a theory emerged that masturbation caused many and varied ills. It seemed logical to some physicians to perform genital surgery on both sexes to stop masturbation"5 . In 1891, P. C. Remondino, MD, advocated circumcision to prevent or cure alcoholism, epilepsy, asthma, hernia, gout, rheumatism, curvature of the spine and headaches6 . His book was last printed in 1974, the same year that one physician, writing in Medical Aspects of Human Sexuality, called the book "pertinent and carefully thought out"7 .
As scientific advancements found legitimate pathologic etiologies for diseases previously believed to be prevented or cured by circumcision, new excuses were adopted to substantiate this elective genital surgery. Since the turn of the century, one excuse after another has been used to perpetuate a practice most of the world has never considered.
Hygiene and prevention of venereal diseases became popular excuses for circumcision during World War I8,9 . The erroneous fear during the 1930s of foreskins causing penile cancer10,11 and during the 1950s of foreskins causing cervical cancer12-14 helped champion the practice of prophylactic circumcision. The most recent justifications for routine neonatal circumcision of boys include protecting infants from urinary tract infections (UTIs) during the first year of life15,16 and decreasing the risk of AIDS in the sexually active male17 . While the American medical community was presenting one pathology after another to support amputation of the foreskin, its European counterpart began to research the normal structure and function of the external male genitalia.
Medical enlightenment began in 1949 with publication in the British Medical Journal of Dr. Douglas Gairdner's classic article, "The Fate of the Foreskin"18 . Gairdner declared that the foreskin is normal, healthy tissue, and its adherence to the glans (head of the penis) by a common epithelium (synechia) serves the important function of protecting the glans penis from urine and feces in infancy and early childhood. Subsequently, the British National Health Service discontinued payment for the surgery and the practice ceased.
Following this study, Dr. Jacob Oster, a Danish medical officer who conducted a longitudinal study with nearly 10,000 observations, reported that the continuous, shared epithelium of the foreskin and glans penis separates spontaneously during childhood. He stressed that this natural process, should never be interfered with, and is usually complete by the age of 1819 . In his published study, he quoted Sir James Spence:
"The anatomists have not studied the form and the evolution of the preputial orifice...they do not understand that Nature does not intend it to be stretched or retracted...What looks like a pinpoint opening at 7 months becomes a wide channel of communication at 17."
Not until the national circumcision rate had reached 85% to 90% (26 years and millions of circumcised babies later) did the American medical community finally issue an official statement regarding circumcision. In 1975, the American Academy of Pediatrics' (AAP) Ad Hoc Task Force Committee on Circumcision declared "There is no absolute medical indication for routine circumcision of the newborn"20 . By the end of the 1970s, the American College of Obstetricians and Gynecologists had concurred21 .
A 1984 AAP pamphlet, "Care of the Uncircumcised Penis," shed new light on the subject. The section on the function of the foreskin read:
"The glans at birth is delicate and easily irritated by urine and feces. The foreskin shields the glans; with circumcision, this protection is lost. In such cases, the glans and especially the urinary opening (meatus) may become irritated or infected, causing ulcers, meatitis (inflammation of the meatus), and meatal stenosis (a narrowing of the urinary opening). Such problems virtually never occur in uncircumcised penises. The foreskin protects the glans throughout life.22
This pamphlet was, in fact, damning of a medical community that, after having made an oath to "do no harm," was admittedly causing problems in boys with normal penises. But, rather than respond to the apparent need to cease performing a surgery that was responsible for identifiable iatrogenic disorders, in 1986 the AAP revised its publication, excluding this litigiously provocative paragraph. Information important for helping parents make informed choices had been deleted.
Informed consent and self-determination for childbearing- childrearing health care were an essential component of the cataclysmic changes brought about by the Women's Movement. American women who had struggled to achieve these rights for themselves were now beginning to consider rights for their babies as well. The need to defend the baby's right to a peaceful beginning was brought to light by Dr. Frederick Leboyer in his landmark work, Birth Without Violence23 . This French obstetrician acknowledged the importance of a nonviolent birth coupled with a gentle newborn experience because he recognized the long-term impact that these early experiences have on emotional and psychological development. Many healthcare providers, including certified nurse-midwives (CNMs), responded to this need by performing gentle births.
The obvious contradiction of a gentle birth versus a painful newborn circumcision placed health care providers in a precarious position. With informed consent an issue, words that were once used euphemistically to describe circumcision now left parents feeling betrayed24,25 . Parents who watched their newborns being circumcised were horrified and considered themselves deceived by the dishonest portrayal of a surgery they had been led to believe was minor, necessary, and minimally painful26 . Health care providers themselves were often uninformed and unaware of the findings or proclamations of their own professional organizations. Those who questioned the ethics of circumcision and wanted to provide adequate information for an informed choice were often intimidated by employers who endorsed the practice.
In response to consumer demand for accurate information, the National Organization of Circumcision Information Resource Centers (NOCIRC) was founded in 1985. This organization serves as a clearinghouse for information on all aspects of male and female circumcision. In 1989, NOCIRC sponsored the First International Symposium on Circumcision (ISC), which was held in Anaheim, California. International experts from the diverse fields of cultural anthropology, theology, psychology, medicine, midwifery, law, and ethics gathered to discuss male and female genital mutilations and their human rights implications.
The Declaration of the First ISC was unanimously adopted by the general assembly on March 3, 1989. The first tenets of this declaration read:
We recognize the inherent right of all human beings to an intact body. Without religious or racial prejudice, we affirm this basic human right.
We recognize the foreskin, clitoris and labia arenormal, functional body parts.
Parents and/or guardians do not have the right to consent to the surgical removal or modification of theirchildren's normal genitalia.
Physicians and other health-care providers have a responsibility to refuse to remove or mutilate normal bodyparts.
The only persons who may consent to medically unnecessary procedures upon themselves are the individuals who have reached the age of consent (adulthood), and then only after being fully informed about the risks andbenefits of the procedure.
We categorically state that circumcision hasunrecognized victims.
The last tenet states:
Physicians who practice routine circumcision 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 Declaration of Human Rights: "NO ONE SHALL BE SUBJECTED TO TORTURE OR TO CRUEL, INHUMAN, OR DEGRADING TREATMENT..."27
Representatives from nine nations attended the Second ISC in San Francisco in the Spring of 1991. Dr. Benjamin Spock, one of America's best-known pediatricians, was honored with and accepted the first Human Rights Award of the ISC for reversing his position on this issue: "My own preference, if I had the good fortune to have another son, would be to leave his little penis alone"28 . The practice of genital mutilation of females in Africa was addressed by Dr. Asha Mohamud, an African pediatrician. Today, 100 million females, including young girls and infants, suffer the effects of this debilitating surgery. And now, with increased African immigration, American health care providers are faced with clinically caring for infibulated women29 and requests to infibulate theirdaughters.
The ISC is an international forum, networking with Women's International Network News (WIN News) and the Inter-African Committee to abolish the myths of genital mutilation of both males and females in defense of body ownership rights of all the world's children. The greatest tool of the ISC and related international groups is truth because of the many myths which still prevail.
Circumcision has a strong irrational bias that seeks validation, and many parents and health care providers continue to believe the old myths or to conjure up new ones. After reviewing current studies, which admittedly were "retrospective," "may have methodologic flaws," and often contain "conflicting evidence," the AAP broadened its 1975 policy. Their new 1989 position statement, ironically released just three days after the adoption of the Declaration of the First ISC, states "Newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks"30 . And, it went on to say, "...parents should be fully informed of the possible benefits and potential risks..." But, the AAP failed to mention that the health benefits of maintaining the normal, intact male genitalia far outweigh any "potential" benefits or the known risks of neonatal circumcision. Left with this meager AAP guideline, health care providers must take it upon themselves to become educated in order toprovide legally correct and accurate information.
To teach the parameters of normal genitalia adequately and effectively, health care professionals must first recognize and overcome personal bias regarding intact genitalia and the myths of circumcision. Dr. James DeMeo's broad cultural perspective gives insight:
Simply put, all forms of male genital mutilation to include infant circumcision, are ancient blood rituals associated with primitive religion and absolution of the male...The ritual has absolutely nothing whatsoever to do with medicine, health, or science in practically all cases. The fact that so many circumcised American men, and mothers, nurses, and obstetricians are ready to defend the practice in the face of contrary epidemiological evidence is a certain give-away to hidden, unconscious motives and disturbed emotional feelings about the penis and sexual matters in general. This is not a small point, as before such painful and traumatic mutilations can be perceived as "good" and be championed by both high caste priests and average people alike, certain other antisexual and antichild social factors must already be present and thriving.2
Addressing the myths used to "defend the practice in the face of contrary epidemiological evidence" may not convince those with "unconscious motives and disturbed emotional feelings about the penis and sexual matters in general," but it will serve to educate those who are brave enough to face personal bias and seek to have the myths demystified. These, then, are the most prevalent myths of the day.
MYTH: A circumcised penis is cleaner.
FACT: Personal hygiene is a major justification for circumcision, yet the experience of 85% of the world's men who are intact indicates that the intact penis is easily cared for. Cleansing the intact penis is similar to cleansing intact labia and is simply a matter of common sense. During infancy, when the foreskin and glans are attached to one another, external washing with only warm water is all that is required. Once the foreskin and glans separate, retraction of the foreskin and washing with warm water are all that are necessary.
After the age of reason, one hopes that a boy who has already learned to tie his shoes can be cajoled into washing behind his ears and directed to clean his penis. It is painless, takes only a few seconds, and when it takes any longer is probably associated with a smile.--Leonard J. Marino, MD31
The AAP itself refuted this myth by saying, "...good personal hygiene would offer all the advantages of routine circumcision without the attendant surgical risk"32 .
MYTH: Circumcision is minor surgery.
FACT: "Minor surgery is one that is performed on someone else," says Stanford University Medical School Professor, Dr. Eugene Robin. Circumcision, like all surgery, has inherent risks, which include hemorrhage, infection, mutilation, and death. And, although neonatal circumcision is the most commonly performed routine surgical procedure in America today, we have no accurate statistics on the resultant complications or deaths. In 1985, two Atlanta boys lost their penises and, adding insult to injury, doctors subjected one boy to a sex reassignment. He will live the remainder of his life as a female33 . That same year, two other boys were victims of staphylococcal infections, the port of entry was the circumcision wound. One boy died seven days after his birth from "scalded skin syndrome," the other is a blind, spastic quadriplegic34 . Circumcision is not a minor procedure and there are many unrecognized victims. Dr. Robin recommends, "If it ain't broke, don't fix it!"35 .
MYTH: Circumcision prevents penile cancer.
FACT: Penile cancer, which has been documented in both circumcised and intact men, is a rare disease of elderly men and one of the least common malignancies. It represents 0.5% of all cancers in men and occurs at "...a rate of less than one case per 100,000 per year in the United States"36 . Dr. James Snyder, past President of the Virginia Urological Society, notes that the low incidence of penile cancer in the United States is not due to circumcision because "...the population of American men born before 1940, now in the group at risk for this cancer, is a group of predominantly UNCIRCUMCISED men"36 . Research indicates that good hygiene prevents penile cancer and, according to Dr. Sydney Gellis, "It is an incontestable fact...there are more deaths from circumcision each year than from cancer of the penis"37 .
MYTH: Women with circumcised partners have a lower incidence of cervical cancer.
FACT: Inaccurate studies of the 1950s are to blame for the erroneous idea that cervical cancer occurs in women because their sexual partners are intact12-14 . According to Wallerstein, "Jewish women have a relatively low rate of cervical cancer, but Moslem women, whose husbands are circumcised in infancy, have a much higher rate. Parsis of India, who do not circumcise, have a lower cervical cancer rate than their Moslem neighbors, who do circumcise"13 . According to the most recent AAP report, "...evidence linking uncircumcised men to cervical carcinoma is inconclusive. The strongest predisposing factors in cervical cancer are a history of intercourse at an early age and multiple sexual partners"38 .
MYTH: Circumcision will decrease the risk of sexually transmitted diseases, including AIDS.
FACT: There is an epidemic of sexually transmitted diseases, including AIDS, in the United States, where the majority of sexually active men are circumcised. It is not the foreskin that causes these diseases, and circumcision will not prevent them. "It is relatively more important to alter exposure to infectious agents than male susceptibility to them," wrote D. W. Cameron, MD, FRCP (personal correspondence to NOCIRC, January 7, 1991). Cameron's AIDS research17 was erroneously and alarmingly reported by newspapers across the country with headlines that read, "Circumcision decreases risk of AIDS." Obviously, it is contact with specific organisms that causes specific diseases, and it is education about safe sex, not amputation of healthy body parts of newborns, that is sane preventative medicine for sexually transmitted diseases.
MYTH: Circumcision prevents urinary tract infection.
FACT: The AAP reported that studies reflecting an increase in UTIs among intact boys are "retrospective," may have "methodologic flaws," and "may have been influenced by selection bias"38 . The more recent research of statistician and pediatrician, Dr. Martin Altschul, refutes the earlier UTI studies39 . New York pediatrician, Dr. Leonard J. Marino, agrees with Altschul:
Since one fourth of my male infant patients are not circumcised, and if the frequency of UTI in the uncircumcised is as high as it is said to be, I should be seeing many UTIs in male infants. If I'm missing the diagnosis, they somehow are getting better without treatment. My experience reinforces the practice of discouraging routine circumcision, a cause of more morbidity than benefit40 .
MYTH: Circumcision prevents phimosis.
FACT: Phimosis (when the opening of the foreskin is so small that the foreskin cannot be retracted over the head of the penis) is normal in infancy18,19 and is not an appropriate diagnosis before the age of 1819 . Furthermore, some men live their entire lives without being able to retract their foreskin, and "...it appears to conclude that the (preputial) space is kept moist and also clean in those with preputial stenosis by the secretions of the prostate, supplemented by the seminal secretion and the mucin content of the secretion of the urethral glands"41 . The normal accumulation of sloughed epithelial cells (smegma) are lysed by these secretions. ("Smegma is probably the most maligned body substance. It is a normal, natural body product no more harmful than ear wax. It is definitely not a carcinogen...Adult smegma serves as a protective, lubricating function for the glans, just as adult smegma in women protects the clitoris"41 . Some men with phimosis, who prefer to have a retractile foreskin, employ nonsurgical measures, i.e., gentle stretching, to achieve the desired goal as described below:
My parents let my foreskin loosen at its own slow rate. I was about 12 before my urethral meatus was visible and 16 before I saw the corona of my glans. Even with this slow loosening of the foreskin, I never experienced irritation or inflammation. Before becoming sexually active, I spent a few minutes each day over a period of several months gradually stretching the foreskin by hand until it would easily retract.--(Personal correspondence to NOCIRC, March 28, 1991).
When scar tissue has formed at the preputial opening secondary to premature retraction or ammoniacal burns, there are surgical techniques (Y-V-plasties and Z-plasty)43,44 , which can be employed to make the foreskin retractable without amputating it. And if phimosis has been caused by a rare pathologic condition such as balanitis serotica obliterans, only the afflicted area need be removed.
Using the surgical treatment of circumcision to prevent phimosis is a little like preventing headaches by decapitation. It works but it is hardly a prudent form of treatment.--Eugene Robin, MD35 .
MYTH: Intact boys will be teased in the locker room.
FACT: Although this may have been an issue for a few boys when the circumcision rate in America was at its peak, the incidence of circumcision in the United States is steadily decreasing. The National Center for Health Statistics reports the national circumcision rate at less than 60%. In the western states, where 60% of the boys are now intact, the locker room scene has reversed. Circumcised boys have already begun to ask "Why am I different?" and "Why did you let them cut off part of my penis?" One man asked a friend if he felt "different" when he was the only intact guy in the shower, and he said, "Yes--gloriously different" (personal correspondence to John A. Erickson, Director, Gulf Coast Circumcision Information Center).
MYTH: A boy should look like his dad.
FACT: Ironically, this argument was never used when medical circumcision was initiated just a hundred years ago. Nor has it been used by Western feminists working to stop female circumcision in Africa. A simple explanation is all that is needed for children to understand that there are individual differences, and to help them feel good about themselves. A response something like this usually suffices: "People thought circumcision was important for health reasons when your dad (or brother) was born, but now we know better. Your body is perfect just the way it is. You did not need to be circumcised." In reality, children tend to feel bad when they learn that part of their father's or brother's body was cut off. More to the point, a father may be worried about being different from his son. One man wrote:
What was so difficult in leaving my son intact was not that my son would feel different in a locker room, but that I would feel different from him. I would then have to accept that I'm an amputee from the wars of a past generation45 .
MYTH: An intact penis looks funny.
FACT: To whom does an intact penis look funny? Certainly not to the baby, nor to most of an intact world. While circumcised African women consider intact female genitalia unacceptable, American health care professionals would find this inappropriate, if not repugnant, justification for performing female circumcision. Considering the potential physical and psychological harm of neonatal circumcision, as well as the infant's right to his own body, we must take responsibility for educating ourselves and overcoming our cultural bias with regard to the appearance of the intact penis. A review of classical art at a local library will illustrate what is normal.
MYTH: Circumcision prevents foreskin infections.
FACT: Yes, it does, in both males and females, and removing all the teeth would prevent cavities. Where does this argument end? Infections are caused by invading organisms and can be treated effectively with antibiotics. Fear of infection is no reason to routinely amputate a tonsil, anappendix, or a foreskin.
MYTH: Circumcision won't hurt if anesthesia is used.
FACT: To administer a penile dorsal nerve block for circumcision, injections must be made at the base of the penis. When the effect wears off, if the block was effective at all, the baby will feel pain at the site of the wound. The pain will intensify every time he urinates, defecates, has his diaper changed, or is held too tightly during the 10 days to two weeks it takes for the wound to heal. And, he will suffer the physical and psychological consequences of circumcision for the rest of his life. Most importantly, if we were amputating labia, would the use of lidocaine be the issue?
MYTH: Circumcision doesn't hurt, my son slept through it.
FACT: Cutting off any part of a body hurts! Some babies respond to the trauma by going into a semicomatose state. They only appear to be sleeping. The physiologic and behavioral changes associated with the pain of circumcision have been well documented by Anand and Hickey46 .
MYTH: It's better to circumcise babies because they won't remember the experience.
FACT: Quite the contrary. Overwhelming evidence indicates that experiences during the preverbal period affect the human being throughout life.
An infant does retain significant memory traces of traumatic events. When a child is subjected to intolerable, overwhelming pain, it conceptualizes mother as both participatory and responsible regardless of mother's intent. When in fact mother is truly complicit, as in giving permission for unanesthetized surgery, i.e., circumcision, the perception of the infant of her culpability and willingness to have him harmed is indelibly emplaced. The consequences for impaired bonding are significant.--Rima Laibow, MD47 .
Clearly, circumcision of an infant does interfere with maternal- infant bonding, is perceived by the baby as betrayal by the mother, prohibits successful completion of the first developmental task of establishing trust, encodes the brain with the experience of violence inflicted on a part of the body that should be experiencing pleasure48 , and occurs during the preverbal period when memory is locked into the emotions. Leboyer expresses his concern about the life-long consequences of circumcision:
Once we remember that all that takes place during the first days of life on the emotional level, shapes the pattern of all future reactions, we cannot but wonder why such a torture has been inflicted on the child. How could a being who has been aggressed in this way, while totally helpless, develop into a relaxed, loving, trusting person?--Frederick Leboyer, MD49 .
Retrieval of this subconscious information requires commitment and dedication to a therapeutic process destined to uncover early traumatic experience. In personal reports, men who have done this work describe their circumcision as both terrifying and excruciatingly painful.
MYTH: Better to do it now because it would hurt more later.
FACT: This first erroneously assumes that a postnewborn circumcision willbe necessary. Wallerstein reports:
The question of an uncircumcised child requiring later circumcision is used as a scare tactic--only in the United States. The question is not foreskin problems, but the attitude of the American medical profession in pushing what most physicians throughout the world consider unnecessary surgery. Worldwide, foreskin problems are treated medically,rarely surgically.50
Even if a circumcision were required later in life, the male would be able to understand the health problem, give an informed consent, and have the benefits of anesthesia and pain medication.
Researchers Anand and Hickey report that "...neonates were found to be more sensitive to pain than older infants"46 .
MYTH: Circumcision improves sexual staying power.
FACT: Following circumcision, changes occur to the sensitive mucous membrane of the glans penis that one researcher describes as the formation of a cornified layer. He explains this is "an additional outer covering of compressed, dead cells," with a depth of "about half the thickness of Saran Wrap"51 . Due to this scarification process, circumcision does render the penis less sensitive. However, premature ejaculation continues to be the most common sexual complaint of American men, most of whom are circumcised, so that this rationale seems, at best,dubious.
MYTH: It didn't hurt me, my penis is fine.
FACT: When normal, healthy, sexually functioning tissue is removed, it interferes with normal sexual functioning. Although circumcised men have no way of personally knowing what they are missing, men circumcised as adults can articulately describe the difference. In a letter to NOCIRC, a 37 year old laments:
My newly naked, sensitive glans penis was protected from irritation with bandages. Slowly the area lost its sensitivity and as it did I realized I had lost something rather vital. Stimuli that had previously aroused ecstasy had relatively little effect. There was a short period of depression, but acceptance of the situation developed, as it had to. The acute sensitivity never returned...circumcision destroys a very joyful aspect of the human experience for both males and females.
Another man wrote:
I was deprived of my foreskin when I was 26. I had had ample experience and was happy with the pleasure I could experience as an intact male. After my circumcision, that pleasure was utterly gone. Let me put it this way: On a scale of 10, the intact penis experiences pleasure that is at least 11 or 12; the circumcised penis is lucky to get to 3. If American men who were circumcised at birth could know the deprivation of pleasure that they would experience, they would storm the hospitals and not permit their sons to undergo this unnecessary loss.
MYTH: Christians should be circumcised like Jesus.
FACT: Circumcision became a controversy in the early Church because the first Christians were Jews. These Christians debated whether or not the Christian gentiles needed to be circumcised in order to be saved. Peter proclaimed that Christians were saved only through the grace of Jesus Christ52 . Paul later reaffirmed the concept: "For in Jesus Christ neither circumcision availeth anything nor uncircumcision; but faith which worketh by love"53 .
MYTH: Jews don't question circumcision.
FACT: A reexamination of circumcision (brit milah) is occurring within the Jewish community itself54,55 .
Like it or not, the American medical community has begun an intense reevaluation that eventually will reduce the frequency of nonreligious circumcision. The Jewish community cannot remain aloof from this development. For Orthodox Jews, who accept brit milah solely as a religious (not a health) practice, the medical discussion is irrelevant. But for all other Jews, who take some comfort in the health attributes, a profound soul-searching may be anticipated. The answer will not be found in the epithet "anti-Semite"56 .
Jewish writings of the last decade illustrate this process: "A Mother Questions Brit Milah"57 , "Letter to Our Son's Grandparents: Why We Decided Against Circumcision"58 , "A Baby-Naming Ceremony, Rochester Society for Humanistic Judaism"59 , and "Jesse's Circumcision"60 . Health care providers who are aware of resources will be able to provide information to Jewish parents who are grappling with this difficult issue. The Alternative Brit Support Group is onesuch resource.
MYTH: Parents have the right to decide whether or not to circumcise their son(s).
FACT: The consumer of a neonatal circumcision is the infant who is circumcised, not the parent(s) who requested and/or paid for the circumcision. Body ownership rights are now being introduced as an issue in circumcision lawsuits that claim that every human being has an inherent, inalienable right to his own intact body61,62 . These cases assert that the only person who can consent to a circumcision is a person making this personal decision for himself. And, with American men now expressing anger over what they believe was a violent violation of their bodies, we can no longer ignore the voices of the victims:
I think I could have accepted a deformity that was an accident of nature, but I can't accept that someone did that to me.
I have never been able to accept the fact that when I was a baby someone cut part of my penis off. The sheer monstrousness of it haunts every waking moment of my life. Sometimes I think I'm beginning to adjust to it, but then I see an unmutilated man in a shower or magazine and I become overwhelmed by uncontrollable feelings and disbelief that I was made the victim for life of something so sick.
My feelings about the doctor who circumcised me are too violent to describe.
I was just a baby...I couldn't stop them63 .
MYTH: All circumcised men are happy that they were circumcised.
FACT: Support groups such as RECAP (RECover a Penis) [now called NORM] and an information network, UNCIRC (Uncircumcising Information and Resources Center), are rapidly uniting men who perceive themselves as victims of a sexual assault inflicted upon them during their earliest days of life and against which they were unable to defend themselves. How does circumcision affect their lives? One man explained:
I have even gone so far as to use condoms, cut and placed in a tedious, time-consuming task on myself to simulate a foreskin; so strong the desire to know what all of my original parts would feel like. (Personal correspondence to NOCIRC, April 3, 1987)
There are thousands of American men who are in the process of foreskin restoration, a practice dating back to the first century, AD64 . Techniques for restoration, presented at the Second ISC, are as individual and varied as the men who employ them65 . Some men are manufacturing devices that gently stretch the foreskin remnant to recover the glans penis. Others are willing to subject their penises to surgical reconstruction in order to repair their shattered body images and/or dysfunctional sex organs. Often, when a man recovers the glans penis, not only is his self-esteem restored, so is lost sexual sensitivity and/or function. The newly protected glans regains its smooth, glistening appearance, normal coloration, and heightened sensitivity. Often, as sensation returns, men become acutely aware of what was taken from them. Perhaps health care professionals will hear in the articulate voices of the victims what they have failed to hear in the screams of babies. It's what any man with a knife held at his penis would say: "I don't want you to cut any ofit off!"
Knowing that men who have realized their loss would prefer to have their normal bodies intact, and in light of the fact that conclusive evidence for circumcision as an effective health measure has never been established, health care professionals are ethically and morally obligated to put their scalpels down27 .
To overcome the American double standard of the acceptance of circumcision for men but not for women, consider this: If it could be unequivocally proven that women had a decreased incidence of UTIs, sexually transmitted diseases, AIDS, vulvitis, vulvar cancer, and/or increased sexual staying power as a result of performing neonatal labiectomy, would the American medical and nurse-midwifery communities approve routine, unanesthetized neonatal labial amputation as a prophylactic measure? Of course not! If we wouldn't do this to our newborn females, we must take a hard look at why we condone and perform "prophylactic" foreskin amputations upon our newborn males. Women have struggled to achieve rights to body ownership for themselves. It is imperative that mutual respect for these inalienable human rights be extended, not only to the women in Africa with whom we can identify, but also to men, male children, and male newborns.
Consider further: The foreskin is normal, healthy, functioning tissue. Circumcision has inherent risks, including hemorrhage, infection, mutilation, and death. Circumcision is painful, even when an anesthetic is used. Circumcision causes both physical and psychological scars. Most importantly, every human being has an inherent, inalienable right to his own body.
Lawsuits have been filed to challenge circumcision as a violation of the basic right of every person to his or her own body. Circumcision violates many constitutional rights of infants and children, including the right to religious freedom, which is denied when an infant or child's body is marked. Health care professionals do, in fact, have a legal basis for claiming conscientious objector status with regard to participation in newborn male circumcision66 .
While this human rights issue is being addressed within the American legal system, it becomes urgent for the American College of Nurse-Midwives (ACNM) to consider the legal and the ethical implications of performing newborn circumcision. The ACNM is faced with ethical dilemmas unique to midwifery 1) that of genitally intact women, CNMs, performing permanent surgical alteration o the intact sex organs of nonconsenting newborn boys, and 2) that of CNMs, who as a group philosophically claim to be "guardians of the normal," not protecting normal male genitalia while protecting the integrity ofnormal female genitalia.
These ethical dilemmas warrant an ACNM review of its advocacy role on behalf of newborns. Regarding the ACNM advocacy role, the Journal of Nurse-Midwifery's Associate Editor, Jeanne Raisler, CNM, MPH, wrote "...from time to time, national policy issues arise that challenge our deepest sense of what is important and necessary for maternal-child health. We need a mechanism to discuss and debate these topics"67 . In the case of circumcision, a task force committee would provide that mechanism. And, until ACNM policy is established, a moratorium on the performance of routine newborn circumcision would protect CNMs as well as newborns.
As the ACNM ponders its advocacy role, CNMs will find guidance in the words of human rights activists, Fran P. Hosken:
Human rights are indivisible, they apply to every society and culture, and every continent. We cannot differentiate between black and white, rich and poor, or between male and female, if the concept of human rights is to mean anything at all68 .
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