Povenmire: Parental consent for circumcision (2/6)

Povenmire: Parental consent for circumcision (2/6)

Journal of Gender, Social Policy & the Law, Volume 7, Number 1, pages 90-97, 1998-1999.

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II. Historical and Medical Perspectives of Routine Infant Circumcision In the United States

Circumcision, as practiced in the United States, involves the surgical removal of the penile prepuce, or foreskin.15 The United States is the only western country to practice routine infant circumcision for non-religious reasons.16 For Jewish infants, the procedure is typically performed in a non-hospital setting by a specially trained lay person, or mohel (a religious leader who performs Jewish circumcisions),17 on the eighth day following birth, without anesthetic, except for the ritualized use of wine.18 For non-Jewish infants, the procedure is typically performed in a hospital within days of birth, also without the use of anesthetic.19 Approximately eighty percent of the males living in the United States in 1970 were circumcised.20 Given a total male population in the United States of approximately 130 million, it appears that approximately 104 million males have been affected by the practice in this country alone.21 The rate of infant circumcisions reported for the years 1991 through 1993 was approximately sixty percent, showing a decline in the acceptance of this technique.22 For Jews, circumcision is an ancient, highly ceremonial practice, signifying a covenant with God.23 The practice is widely believed among Jews to be a prerequisite for acceptance into the Jewish religion; so is therefore almost universal amongst Jewish men.24 Muslims also practice routine circumcision, although Islamic scholars are divided on whether the practice is mandated by the Muslim religion.25 The vast majority of circumcisions in the United States, however, are upon non-Jewish and non-Muslim men.26

For non-Jewish men, the practice of circumcision traces its origins to a complex set of causes beginning with the antimasturbation hysteria prevalent during the latter half of the nineteenth century.27 The practice of infant circumcision was popularized as part of the institutionalization of medical childbirth that began during the early years of this century.28 Although the antimasturbation rationale persisted until recently, other justifications for circumcision were also popularized.29 Such justifications for circumcision include: supposed hygienic benefits,30 resistance to venereal disease,31 resistance to cancer,32 suitability for armed service,33 and alleged improvement of sexual performance.34 Many people also believe that a circumcised penis is a cosmetic improvement35 and that a child will feel conspicuous with an uncircumcised penis.36 As the prevalence of circumcision declines, however, popular conceptions of what a penis looks like will undoubtedly change.37 It is entirely possible that the next generation will accept the natural whole penis as normal.38 Even though each of the supposed justifications for circumcision have now been seriously challenged or discredited,39 a belief in the benefits of circumcision remains prevalent.40

Studies conducted at U.S. Army hospitals beginning in1985, show an increased incidence of urinary tract infection in uncircumcised males an are cited as evidence of the benefits of circumcision.41 These studies, however have been severely criticized for analytical and methodological flaws.42 In particular the studies were retrospective, and based on potentially unreliable medical records.43 They also failed to account for the presence of urinary birth defects,44 hospital hygiene practices,45 and survey bias.46 Indeed, recent studies indicate a correlation between circumcision and urinary tract infection.47 The authoritative weight of recent studies favors routine penile hygiene, rather than circumcision, to prevent urinary tract infections in infants.48

Circumcision of adult males is a more involved procedure than routine infant circumcision, and this difference is sometimes offered as justification for the circumcision of infants.49 Such reasoning fallaciously presupposes the decision to amputate the foreskin in adulthood.50 Circumcision of adult men is rarely necessary for medical reasons.51

Routine infant circumcision was once practiced in Canada,52 England,53 and Australia,54 but now is uncommon in those countries. The British Medical Association,55 the Canadian Paediatric Society,56 and the Australasian Association of Paediatric Surgeons57 have all unequivocably disapproved of circumcision as a routine practice, citing a lack of proven medical benefits and the invasiveness of the procedure.58 Although the Australian College of Paediatrics59 and the American College of Obstetricians and Gynecologists60 have adopted more ambivalent positions, they are nonetheless unsupportive of circumcision.

The American Pediatric Society (``APS'') is alone among the medical societies of the developed western world, in providing tepid support of routine circumcision as a medical practice.61 The current APS position, adopted in 1989 in response to preliminary study results, states ``[n]ewborn circumcision has potential benefits and advantages as well as disadvantages and risks.''62 The weight of circumcision research done since 1989, however, has shown that APS reliance upon preliminary date was misplaced. [CIRP Note: The American Academy of Pediatrics (AAP) is herein referred to as the American Pediatric Society (APS).]

APS is currently reviewing its position on circumcision, and a statement is anticipated in the latter part of 1998.64 Undoubtedly, there are powerful political and economic pressures impinging upon APS in its decision making process.65 Despite these pressures, it is now time for APS to cast away the unnecessary ambiguity which its 1989 position has engendered, by adopting the medically conservative position that circumcision is unwarranted. Even if one recognized that the evidence against circumcision is incomplete, APS should err, if at all, on the side of patients' rights.66 [CIRP Note: The AAP subsequently published a statement in March 1999.]

Many people believe that circumcision has little or no adverse consequences. This popular misconception has been disproved by a number of recent studies confirming the presence of serious adverse effects from circumcision.67 The procedure is now known to be traumatic68 and painful,69 may interfere with proper bonding and nursing with the mother,70 and results in long-term heightened pain response.71 Circumcision reduces the sensitivity of the penis by amputating approximately eighty percent of he penile skin covering when erect, including highly specialized structures evolutionarily adapted to further the various functions of the penis.72 The amputation of the foreskin uncovers the tip of the penis, or glans, which then becomes dry tough, and relatively insensitive.73 The beneficial functions of the foreskin in providing a natural lubricant, protecting the glans, and facilitating vaginal penetration are also lost.74 Lastly, the operation has a surgical complication rate of one in five-hundred, ranging from constriction of the penis, to death from infection.75

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  1. ROSEMARY ROMBERG, CIRCUMCISION: THE PAINFUL DILEMMA, 162, 168 (1985) (explaining the Gomco and Plastibell techniques of circumcision).
  2. See Epstein, supra note 8, at Z14 (commenting on the factors parents consider when deciding whether to circumcise); see also EDWARD WALLERSTEIN, CIRCUMCISION: AN AMERICAN HEALTH FALLACY 1, 6-14 (1980) (stating that other countries conduct circumcision only or a step by step description of several different circumcision techniques, including illustrations see Ras religious rituals or puberty rites); infra notes 27-36 and accompanying text.
  3. See Epstein, supra note 8, at Z14 (discussing the circumcision procedure).
  4. See ROMBERG, supra note 15, at 41-47 (describing the Jewish circumcision ceremony from the night before until the time of circumcision). Jewish circumcision practices have varied over the course of history. Circumcision was initially practiced on adolescents. Id. at 36. Some aspects of the rite, such as the ritualized sucking of blood from the penile wound have been modified or abandoned. Id. at 45.
  5. See Katherine Kelly, M. Bruce Edmonsen & John M. Pascoe, Pediatric Residency Training in the Normal Newborn Nursery: A National Survey, 151 ARCHIVES OF PEDIATRICS AND ADOLESCENT MED. 511, 513 (1997) (stating that in a national survey of pediatric care practices, anesthesia was used in approximately ten percent of circumcisions).
  6. See WALLERSTEIN, supra note 16, at 217 (indicating that the rate of circumcision rose from approximately 5% in the year 1870 to approximately 85% in 1979). Some studies indicate that rates have been over 90% Id.
  7. The 1996 estimated population of the United States was 264,867,900. 1997 Market Statistics, available in 1997 WL POPDEMO.
  8. The rates of circumcision in the United States for 1991, 1992, and 1993 are 61.6%, 60.7% and 59.5% respectively. National Center for Health Statistics, Department of Health and Human Services, United States Official Circumcision Statistics (visited Oct. 3, 1998) <http://www.cirp.org/library/statistics/USA/> [hereinafter ``National Center for Heath Statistics'']. A slightly different method of computing the rate in 1994 resulted in a reported rate of 62.7%. Id. The higher rate in 1994, as compared with the general downward trend is not significant due to the different method of computation. Id.
  9. Id.
  10. See Tom Steadman, Circumcision, A Divisive Medical Practice, GREENSBORO NEWS & RECORD, June 10, 1997 at D1 (reporting that ``[a]mong Jewish families, where the rite of berit milah... is considered a religious and cultural event, the rate is closer to 100%'').
  11. See Peter Kandela, Court Ruling Means that Egypt Embraces Female Circumcision Again, 349 LANCET, Jul. 5 1997, at 41 (discussing the continuing debate as to the legal and religious implications of female circumcision).
  12. See Steadman, supra note 24, at D1 (stating that the rate of circumcision among the Gentile population has increased considerably).
  13. See Phil Nguyen, Foreskin Envy: Circumcising our Sons, VIETNOW MAG., Jul. 31, 1997, at 50 (stating that in the 1870s circumcisions were introduced to cure masturbation, which was believed to cause many diseases); see also WALLERSTEIN, supra note 16, at 2 (stating that circumcision was introduced a century ago to cure various physical and emotional ailments); ROMBERG, supra note 15 at 1 (stating that ``[s]ome historians have speculated that circumcision has been practiced for more than 5000 years among the native tribes of the West Coast of Africa''); Paul M. Fleiss, The Case Against Circumcision, MOTHERING, Dec. 22, 1997, at 2 (stating that anti-masturbation hysteria in America occurred during the Victorian era to punish boys for masturbating).
  14. See Fleiss, supra note 27, at 2 (claiming that this movement coincided with the discouragement of breastfeeding).
  15. See generally WALLERSTEIN, supra note 16, at 13 (stating that male circumcision was said to prevent masturbation); ROMBERG, supra note 15, at 6 (claiming that circumcision was used to weaken the sexual organ to reduce masturbation); Hanny Lightfoot-Klein, Prisoners of Ritual: An Odyssey into Female Genital Circumcision in Africa, (Oct. 3, 1998) <http://nocirc.org/articles/similar.html> (summarizing parallel beliefs surrounding both types of circumcision).
  16. See Charles J. Schleupner, Urinary Tract Infections Separating the Genders and the Ages, 101 POSTGRADUATE MED 231 (1997) (stating that the rate of urinary tract infections is higher in uncircumcised infant boys); T.E. Wiswell & J.D. Roscelli, Corroborative Evidence for the Decreased Incidence of Urinary Tract Infections in Circumcised Male Infants, 78 PEDIATRICS 96 (1986) (stating that in their study, the number of urinary tract infections increased as the number of male circumcisions decreased).
  17. See ROMBERG, supra note 15, at 4 (stating that one of the reasons for circumcision is hygiene). See generally WALLERSTEIN, supra note 16 at 2 (discussing the reasons why Americans practice circumcision). The belief in circumcision probably had its origins in demographic studies that showed which that sexually transmitted diseases less common among circumcised Jews during the mid-to-late 1800s. Id. at 80. These studies did not consider religious and cultural practices which insulated Jews from contagion. Id. Current observations indicate that circumcision has the opposite effect. See Fleiss, supra note 27 at 19 (stating that ``the U.S. has both the highest rates of sexually active circumcised males in the western world and the highest rate of sexually transmitted diseases... ''). Medical studies have found either no correlation between circumcision and transmission rates or a slight increase in transmission among circumcised men. See generally Basil Donovan, Ingrid Basset & Neil J. Bodsworth, Male Circumcision and Common Sexually Transmitted Diseases in a Developed Nation Setting, 70 GENITOURINARY MED. 317, 319 (1994); G.L. Smith, Robert Greenup &Earnest T. Takafoji, Circumcision as a Risk Factor for Urethritis in Racial Groups, 77 AM. J. PUB. HEALTH 452, 454 (1987); L.S. Cook, L.A. Kootsky, &K.K. Holmes, Clinical Presentation of Genital Warts Among Circumcised and Uncircumcised Heterosexual Men Attending an Urban STD Clinic, 69 GENITOURINARY MED. 262, 264 (1993) (concluding) circumcised men were more likely to have genital warts); Ingrid Bassett, Basil Donovan, Neil J. Bodsworth, Peter R. Field, David W. T. Ho, Stig Seansson, &Anthony L. Cunningham, Herpes Simplex Virus Type 2 Infection of Heterosexual Men Attending a Sexual Health Centre, 160 MED J. AUSTL. 697, 700 (1994) (claiming that the study ``found no evidence that intact foreskin is a risk factor for HSV-2 [herpes simplex virus type 2] infection''); Edward O. Laumann, Christophen M. Nasi, &Ezraw W. Zuckerman, Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice, 277 J. AM. MED ASS'N 1052, 1057 (1997) (claiming that circumcised men were ``slightly more likely to have had both a bacterial and a viral STD [sexually transmitted disease] in their lifetime'').
  18. The American Cancer Society has determined that ``perpetuating the belief that circumcision prevents cancer is in appropriate.'' Letter from Hugh Shingleton, M.D., National Vice President of the American Cancer Society, &Clark W. Health, M.D. Vice President of the American Cancer Society, to William Oh, M.D., &Peter Rappo, M.D. American Academy of Pediatrics (Feb. 16, 1996) (on file with author).
  19. See Steadman, supra note 24, at D1 (stating that during World War I, the U.S. Army performed circumcisions due to infections caused by lack of hygiene); Sharon Bass, Circumcision Persists Despite Doctor's disapproval, MAINE TIMES, Jan. 2, 1997, at 10 (claiming that many American soldiers in World War II failed physicals due to health conditionings relating to lack of circumcision); ROMBERG, supra note 15, at 179 (discussing the popular misconception of a circumcision requirement for military service).
  20. See Laumann, Nasi &Zuckerman, supra note 31, at 1054 (stating that circumcised males engage in oral sex, anal sex, and masturbation at greater rates than uncircumcised males). This study found a statistically significant correlation between circumcision and a reduced likelihood of impotence in older men, but also found that circumcised men engage in more elaborated sexual practices. Id. at 1054. Such practices include masturbation, possibly as a result of reduced penile sensitivity. Id. The behavior may better enable them to adapt as they age. Id. at 1056. This finding is particularly ironic in view of the Victorian-era justification of circumcision as an anti-masturbation measure. But see, Letter: In Praise of Foreskin, THE GUARDIAN, Sept. 26, 1997, at 018, available in 1997 WL 2403678, at *D1 (describing one man's negative sexual experience after circumcision).
  21. See Bass, supra note 33, at 10 (noting that circumcision in the United States is usually performed as a cosmetic procedure).
  22. Bass, supra note 33, at 10.
  23. See National Center for Health Statistics, supra note 22, at <http://www.cirp.org/library/statistics/USA/> indicating a decrease in circumcision rates).
  24. See Fleiss, supra note 27 (suggesting that the reasons given today for circumcision will be considered irrational in the next generation).
  25. See supra notes 34-38 and infra notes 39-50 and accompanying text; see also Kathleen Parker, Retire Primitive Practice of Circumcision, GREENSBORO NEWS AND RECORD, Mar. 31, 1997, at D1 (commenting that ``[t]oday, in the absence of medical justification, we continue to perform the [circumcision procedure for cultural and religious reasons and, well, `just because.'... Its time to take a closer look at why we just do and ask whether we really want to continue.''); Bass, supra note 33, at 10 (stating that ``[t]he alleged health benefits have been found questionable''); Epstein, supra note 8, at 240 (contrasting that ``[n]ow doctors are debating the whether the benefits, such as reducing the likelihood of urinary tract infections, outweigh the risks, such as the possibility of inflicting pain or the rare chance of an infection near the incision.... There is little medical consensus.''); Nguyen, supra note 27, at 50 (writing for the Vietnamese community in the United States and challenging various justifications for the practice of circumcision.).
  26. See Edgar J. Schoen, Letter to the Editor, 278 J. AM. MED, ASS'N 201,201 (1997) (stating that a previous article unfairly concluded that there was equal risk of Sexually Transmitted Diseases in circumcised and uncircumcised men). The tenacious defense of circumcision by many people in the face of mounting medical evidence suggests that the desire to preserve the practice runs far deeper than concerns for hygiene. Id.
  27. See American Academy of Pediatrics, Report of the Task Force on Circumcision (RE9148), 84 PEDIATRICS 388, 389 (1989) (reporting on studies from 1985 that showed uncircumcised males had a greater chance of getting urinary infections).
  28. See The Australian College of Paediatrics, Position Statement: Routine Circumcision of Normal Male Infants and Boys, May 1996, [hereinafter Australian College of Paediatrics] <http://www.cirp.org/library/statements/acp1996/> (visited Oct. 3, 1998) asserting that ``[s]tudies claiming these benefits [of reduced urinary tract infection, cancer, and sexually transmitted disease] do have methodological problems that could influence findings and these problems will be difficult to overcome''). In a review of those urinary tract infection studies which claimed a benefit from circumcision, a study by Dr. Martin S. Altshul ``found not a single confirmed case of UTI [urinary tract infection] in a normal male infant. All of the confirmed cases occurred in infants who had clear-cut urinary birth defects.'' Circumcision Information Centre, Circumcision Update: Circumcision Does Not Lower the Incidence of Urinary Tract Infection, (visited Oct. 3, 1998), <http://www.cirp.org/pages/riley/uti/> [hereinafter Circumcision Information Center].
  29. See Fetus and Newborn Committee, Canadian Paediatric Society, Neonatal Circumcision Revisited, 154 CAN. MED. ASS'N 769 (1996), [hereinafter Fetus and Newborn Committee] (visited Oct. 3, 1998) <http://www.cps.ca/english/statements/FN/fn98-01.htm> (recommending that circumcisions on newborns should not be routinely performed). The author commented that, ``[t]hese studies are retrospective, and therefore some caution must be exercised in their interpretation.'' Id. at 771.
  30. See Circumcision Information Centre, supra note 42 at <http://www.cirp.org/library/disease/UTI/> (quoting Martin S. Altshul on the connection between urinary tract infections and birth defects).
  31. Circumcision Information Centre, supra note 42, at <http://www.cirp.org/library/disease/UTI/>
  32. See Fetus and Newborn Committee, supra note 43 (referring to articles on circumcision and urinary tract infections). The report stated that ``[a] potential bias in these studies is that patients were admitted to hospitals because of their infections; since infections not requiring hospital treatment were excluded, the true incidence may have been under-reported.'' Id. at 771.
  33. See H.A. Cohen, M.M. Drucker &S. Vainer, Post Circumcision Urinary Tract Infection, 31 CLINICAL PEDIATRICS 322 (1992) (reporting on a study of the occurrence of urinary tract infections within the first year of life after circumcision); see also D. Amato &J. Garduno-Espinoza, Circumcision of the Newborn Male and the Risk Of Urinary Tract Infection During the First Year: A Meta-analysis, 49 BOL. MED. INFANT MEX. 652 (1992) (analyzing literature on the effect of circumcision and the incidence of urinary tract infection and examining their methodological limitations).
  34. See Fetus and Newborn Committee, supra note 43 (stating that in one study the hygienic procedures used by uncircumcised patients showed that they were less likely to have inflammation or adhesions).
  35. See Steadman, supra note 24, at D1 (noting the increase in infant circumcision following the Army's implementation of adult circumcision in World War I).
  36. See ROMBERG, supra note 15, at 193 (stating that the same American man elected circumcision for ``personal reasons'').
  37. See generally ROMBERG, supra note 15, at 193 (suggesting that cultural reasons have motivated American doctors to recommend circumcision). See also WALLERSTEIN, supra note 16, at 127-34 (stating that some males choose to be circumcised for cosmetic effect, religious conversion to the Jewish or Moslem faiths, and at the insistence of spouses based on fears of cancer.).
  38. See Rick Ansorge, An Agonizing Choice, CHI. TRIB., Mar. 7, 1997, at 7 (stating that ``[i]n Canada, the rate [of circumcisions performed] fell from forty-four percent in 1975 to four percent in 1995. In England and Europe, the rate is below one percent.'').
  39. See Epstein, supra note 8, at Z14 (stating that ``[I]n Britain, circumcision rates were about the same as in the United States until 1948, when the newly created National Health Service stopped paying for it and rates dropped to about five percent, what they are today.'').
  40. See The Australian College of Pediatrics, supra note 42, at ¶ 3 (addressing the fact that ``[d]uring the last 50-100 years, neonatal circumcision became widespread in English-speaking countries... . In Australia, the circumcision rate has fallen very considerably in recent years, and it is estimated that currently only ten percent of the male infants are routinely circumcised.'').
  41. See British Medical Association, Circumcision of Male Infants: Guidance for Doctors, Sept. 1996 (visited Sept. 30, 1998) <http://www.cirp.org/library/statements/bma/> [hereinafter British Medical Association] (arguing that to ``[t]o circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate... . It is rarely necessary to circumcise an infant for medical reasons.'').
  42. See Fetus and Newborn Committee, supra note 42, at 769 (stating that after, carefully reviewing all of the recent studies on circumcision, the Society recommended that ``[c]ircumcision of newborns should not be routinely performed''
  43. See J. Fred Leditschke, President of the Australasian Association of Paediatric Surgeons, Guidelines for Circumcision, (visited Apr. 1996) <http://www.cirp.org/library/statements/aaps/> The Guidelines state that:
    [T]he Australasian Association of Paediatric Surgeons does not support the routine circumcision of male neonates, infants, or children in Australia. It is considered to be inappropriate and unnecessary as a routine to remove the prepuce, based on the current evidence available... . We do not support the removal of a normal part of the body, unless there are definite indications to justify the complications and myths which may arise. In particular, we are opposed to male children being subject to a procedure, which had they been old enough to consider the advantages and disadvantages, may well have opted to reject the operation and retain their prepuce. Id.
  44. British Medical Association, supra note 55, at ¶ ¶ 9-10.
  45. See The Australian College of Pediatrics, supra note 42 at¶4 (stating that [a]t the present time it would be wrong to claim that there are definite health benefits for circumcision or to deny that they exist... . The possibility that routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven benefit.''
  46. See THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS, PLANNING FOR PREGNANCY, BIRTH AND BEYOND 41, 47 &211 (2d ed. 1990) (discussing the controversy about the need for circumcision and that there ``are no laws or hospital rules that require circumcision'').
  47. See AMERICAN ACADEMY OF PEDIATRICS, COMMITTEE ON FETUS AND NEWBORN, STANDARDS AND RECOMMENDATIONS FOR HOSPITAL CARE OF NEWBORN INFANTS 110 (5th ed. 1971 [hereinafter American Academy of Pediatrics]. Until somewhat recently the American Pediatric Society was not supportive of circumcision as a medical practice. Id. In 1971, the APS frankly admitted that ``[t]here are no valid medical indications for circumcision in the neonatal period.'' Id. The APS reiterated its position in 1975, 1977, and 1983. See National Organization of Circumcision Information and Resource Center Homepage, (visited Sept 30, 1998) <http://www.cirp.org/library/statements/aap/> reviewing the APS's positions regarding circumcision). In 1989, however, the APS altered its position, in response topreliminary data suggesting possible benefits of circumcision in reducing urinary tract infections, sexually transmitted disease, and cancer of the penis and cervix. AMERICAN ACADEMY OF PEDIATRICS, supra note 61, at 388.
  48. See AMERICAN ACADEMY OF PEDIATRICS, supra note 61, at 390. The APS gratuitously added that the ``the benefits and risks should be explained to the parents and informed consent obtained.'' Id. This comment argues that informed consent cannot be obtained from the parents under the 1989 APS position, absent unusual medical circumstances, because there is insufficient showing that the procedure is medically necessary and in the child's best interest. The legal community need not take direction from the medical community in determining the legal prerequisites of informed consent.
  49. Laumann, supra note 31, at 1057.
  50. Laumann, supra note 31, at 1057.
  51. Circumcision is not an insignificant source of income for hospital and pediatricians. The cost of circumcision is approximately $100-150. Sharon Bass, supra note 33, at 10. It is estimated that an enthusiastic pediatrician may earn $10,000 a year from the procedure. ROMBERG, supra note 15, at 111. The foreskin has also found use as a source of tissue in the manufacture of synthetic skin. Paul Recer, New Methods May Aid Those With Chronic Wounds, SEATTLE TIMES, Oct. 21, 1997, at A13. Five billion dollars a year is spent treating wounds for which synthetic skin has potential application. Id. Jewish and Islamic groups may also seek to sway the APS in order to safeguard the legality of circumcision as a religious practice. Id.
  52. See American Medical Association, AMA Principles of Medical Ethics, (visited September 8, 1998) <http://www.cirp.org/library/statements/ama/>. The article states that ``[a] physician shall respect the rights of patients, of colleagues, and of other health professionals, and shall safeguard patient confidences in the confines of the law.'' Id. at ¶ 5. The AMA principles do not mention the rights of parents. Id.
  53. See infra note 68-71 and accompanying text.
  54. See Robert N. Emde, Robert J. Harmon, David Metcalf, Kenneth L. Loening, & Samuel Wagonfeld, Stress and Neonatal Sleep, 33 PSYCHOSOMATIC MED. 491, 491-97 (1971) (showing that circumcision was initially followed by prolonged non-rapid eye movement (non-REM) sleep).
  55. See Paul Drake &Linda French, Analgesia During Circumcision, 45 J. FAM. PRAC. 100, 100 (Aug. 1997); Janice Lander, Barbara Brady-Fryer, James B. Metcalfe, Shemin Nazarali, & Sarah Muttitt, Comparison of Ring Block, Dorsal Penile Nerve Block, and Topical Anesthesia for Neonatal Circumcision: A Randomized Controlled Trial, 278 J. AM. MED. ASS'N 100, 103 (1997) (recommending use of analgesia during neonatal circumcision to decrease pain, and stating ``you could look at people with senile dementia and say they won't remember the pain either so we can operate on them without anesthesia''). Approximately 64% to 96% of newborns circumcised in North America do not receive anesthetics. Id. ``Without exception, newborns in this study who did not receive an anesthetic suffered great distress during and following the circumcision, and they were exposed to unnecessary risk (from choking or apnea). Therefore, we have concluded that circumcision should be performed with anesthetic.'' Id.; see also Larry Tye, Anesthesia Urged in Infant Circumcision, BOSTON GLOBE, December 25, 1997 at A3 (responding to those who suggest that the infant will not remember the pain).
  56. See Richard E. Marshall, Fran L. Porter, Ann G. Rogers, JoAnn Moore, Barbara Anderson &Stuart B. Boxerman, Circumcision: II Effects Upon Mother Infant Interaction, 7 EARLY HUM. DEV. 367, 367-74 (1982) (studying 59 mother-infant pairs during the first few days of infants' life to compare behavioral differences between circumcised and uncircumcised infants). The author states, ``[O]ur data suggest that circumcision has brief and transitory effects on mother-child interaction observed during hospital feeding sessions.'' Id. at 367.
  57. See Anna Taddio, Effect of Neonatal Circumcision on Pain Response During Subsequent Routine Vaccination, 349 LANCET 591, 599 (Mar. 1, 1997) (illustrating that neonatal circumcision in male infants is associated with increased pain response in vaccination four to six months after surgery); Maryann Napoli, Newborns and Pain: A Post Circumcision Study, HEALTHFACTS 6, 6 (Apr. 1997) (citing to the Anna Taddio's article in the Lancet which discusses whether there are lasting effects from the pain experienced during circumcision).
  58. Fleiss, supra note 27, available in 1997 WL9436554, at ¶ 9.
  59. Fleiss, supra note 27, at ¶ 33.
  60. Fleiss, supra note 27, at ¶ 23.
  61. See W.F. Gee & J.S. Ansell, Neonatal Circumcision; a Ten Year Overview: With Comparison of the Gomco Clamp and the Plastibell Device, 58 PEDIATRICS 824, 824-27 (1976) (stating that records of 5,882 live male births were reviewed to ascertain the incidence and nature of complications following neonatal circumcision, with the most frequent complications being hemorrhage, infection, and trauma).

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