Throwing wrenches at the gears

I just finished my first week back on the labor and delivery service and happened to be on call on Saturday. As we were discussing patients in the workroom my senior resident inquired if I had asked a patient whether or not she wanted her son circumcised. I replied that I had not asked and that I would not be asking that question of anyone in the future.  Well sparks flew!

At this particular hospital infant male circumcision has become so institutionalized that it is treated almost as casually as a fast food worker asking, “Do you want fries with that?” “So you had a boy, huh? You want a circ with that?” On one hand we are appalled at the female circumcision that so many of our Somali patients have undergone yet we barely bat an eye at the other. Why are we so horrified by the surgical modification of female genitalia by another culture when we are so flippant about surgically modifying the genitals of our own infant boys?

So what is female circumcision anyway? It is a procedure done in parts of Africa, Asia and the Middle East where as little as the clitoral hood to as much as the entire clitoris and labia are excised. What little tissue remains after this procedure grows together (often aided by leg binding) sometimes leaving  a hole so small that sexual intercourse is physically impossible. In the U.S. we code it as “female genital mutilation” but of course no such verbiage is used with infant male circumcision. Now granted, I completely understand that cutting off some penis skin is not nearly as morbid as cutting off a clitoris. But less bad is still bad! Both procedures are forcefully performed without the consent of the individual receiving it and both have permanent consequences.

Many physicians and new parents justify their decision to participate in infant male circumcision for social or religious reasons. Others speak to its public health merit in reducing the transmission of HPV (the virus that causes cervical cancer in women) and HIV (the virus that causes AIDS). Yet all of these excuses (and yes, they are excuses) fail to consider the rights of the people involved. Infant boys are clearly unable to provide informed consent. Period.

One of the four ethical principles to which we prescribe as physicians is “Autonomy” – the right of each patient to make informed medical decisions regarding his/her own care. Also within the Hippocratic oath we take is the principle “First, do no harm.” It is impossible to honor these guiding ideals while performing circumcision or any other elective cosmetic genital surgery on infants and children.

And why are OB/GYN providers doing circumcisions anyway? For a specialty that prides itself on treating women only it is quite surprising how many providers perform this little side gig on infant boys. What infant penises have to do with women’s health I’ll never understand.

So what happened with my refusal to participate? Well I met with the residency program director today who affirmed my right to refrain from participating in procedures I am morally opposed to. I will not be forced to ask patients if they want us to maim their sons. I will continue to wear my Genital Autonomy badge with honor and I will continue to throw wrenches at the gears of status quo.

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27 thoughts on “Throwing wrenches at the gears”

  1. Thank you!
    As a PA in family medicine, I challenged a lot of my colleagues on the issue and over a period of 4 years was able to convince all but the Jewish physicians that it was harmful and should end. We rarely have a boy circumcised these days. I hope it stays that way.
    Hold your ground!
    Brian

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  2. At last, a doctor who stands up for the rights of their (infant) patients. Congratulations!

    Several years ago, while manning an information table in Phoenix, AZ, re: the advantage to life of leaving men intact, a woman approached and confessed that her husband, a physician, was opposed to “circumcision”, but wouldn’t advertise the fact for fear of being ostracized. Perhaps there are more physicians like you, but we’ll never know if they won’t speak up.

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    1. Sounds like you’ve been fed some myths. It is not cosmetic. It’s about peosrnal choice(sometimes religous)and hygenic reasons. I can’t count how many women have told me about their son or their grandson getting circumcised at 6yrs old!Why because the foreskin trapes bacteria and if it’s not cleaned can cause a painful infection leading to circumcison. Why not do it when they’re born and save them from a possible infection in the future. I know an 18yr old who had to get it done and said it’s the most painful thing he could ever have gone through. So looking back I’d say it’s worth it,my son is and yes it does look better to us ladies.

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  3. I am a nurse who is opposed to circumcision. Thank you!! The only piece I would add/change on your post is the bit about an infant foreskin being “loose skin”. As I’m sure you know, an infant foreskin is adhered to the glans and must be forcibly and painfully torn off during circumcision… Since it often doesn’t naturally separate until puberty.

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  4. I am a complete stranger, yet I feel as proud of you as your own mother could be. Thank you for standing up for those who cannot speak for themselves.

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  5. Thank You!!

    As a grown man that was cut without consent I appreciate you standing up for those infants that cannot consent either. If only those circumcised knew what they were missing.

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  6. Orchids to you Dr. Pate! Your personal integrity is to be admired.

    On behalf of the many boys your efforts will save, thank you.

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  7. Thank you Dr. Pate! We desperately need more ethical doctors such as yourself. I hope you’ll be able to help parents see infant circumcision for what it is, an necessary procedure that has little, if any, value.

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  8. Thank you Dr. Pate! I always write in my birth plan that not only do we not want to circumcise – we don’t want to be ASKED about it, as I find even the offer to be extremely upsetting and unethical. Every time hospital staff solicits for circumcision, they give an implied medical endorsement. No wonder parents are confused about the purpose. Ask parents, they say, “Doctors Do it!” ask Doctors they say, “Parents demand it!” …and is it any wonder that parents are often billed for circumcisions that didn’t even happen? The whole BUSINESS is sick.

    Q: Why do OBGYN’s do the most circumcisions?
    A: Circumcise him quick… before someone else does!

    I once offered a female OBGYN a flyer with 10 great reasons to quit circumcising babies… she defiantly faced off with me and proudly proclaimed that she had circumcised over 5000 babies… and the ONLY ones she felt bad about were the Jews because she was taking the money away from the Mohel. I was dumbstruck by her horrifyingly cruel honesty.

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  9. Thank you Dr. Pate,

    As an RN in labor and delivery and a doula, I spend my time talking to patients about why they should leave their babies intact, as nature made them. I work with several physicians who feel the same way and I will continue to provide information and education so that more baby boys go home whole! It is refreshing to hear a physician talk about genital integrity and patient autonomy, let alone informed consent. Thank you and keep on talking. What is left in the dark will fester, what is open to the light and air will grow.

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  10. As a mother who had her first son mutilated 20 years ago, I have been horrified to learn the truth about what he really endured. My intuition told me not to, but I deferred to his father. I knew it was wrong, but I didn’t know how wrong.
    Watching just one video, relatively recently, has changed me from someone who didn’t believe in it to an intactivist, on fire to get the truth out there.
    I am touched, and motivated, by your position.
    I hope and pray to see this abominable custom die in my lifetime.

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    1. I agree with you. I find it ironic that it’s okay to ciiucmcrse boys, but not girls. Note: I am NOT for circumcision of boys or girls. I’m just saying it’s ironic one is allowed and practiced, but not the other, and many don’t see any inconsistency.

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  11. Good for you. Your views aren’t as uncommon amongst medical professionals btw. All these medical society quotes can be found at their own websites:

    Canadian Paediatric Society
    “Recommendation: Circumcision of newborns should not be routinely performed.”
    “Circumcision is a ‘non-therapeutic’ procedure, which means it is not medically necessary.”
    “After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions.”

    Royal Australasian College of Physicians
    “After extensive review of the literature the Royal Australasian College of Physicians reaffirms that there is no medical indication for routine neonatal circumcision.”
    (those last nine words are in bold on their website, and almost all the men responsible for this statement will be circumcised themselves, as the male circumcision rate in Australia in 1950 was about 90%. “Routine” circumcision is now *banned* in public hospitals in Australia in all states except one.)

    British Medical Association
    “to 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.”

    Drops in male circumcision:
    USA: from 90% to 57%
    Canada: from 47% to 32%
    UK: from 35% to about 5% (less than 1% among non-Muslims)
    Australia: 90% to 12.6% (“routine” circumcision has recently been *banned* in public hospitals in all states except one, so the rate will now be a lot lower)
    New Zealand: 95% to below 3% (mostly Samoans and Tongans)
    South America and Europe: never above 5%

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  12. As a man that was maimed by a Jewish doctor that cut half my glans off. I applaud you. I have lived a life of loneliness and shame. I am scarred so bad both physically and mentally that relationships and sex is impossible.

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  13. Good work. Circumcision is just plain wrong. Every human with half a brain should be able to figure that out.

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  14. Dr. Pate, now you know how Ignaz Semmelweis felt 150 years ago in Vienna, trying to get other doctors to wash their hands when examining women about to give, during, and after giving birth. I am glad to see other healthcare workers leaving constructive and encouraging comments at your site.

    I hope a credentialed healthcare worker will examine the link between neonatal circumcision and ADHD, a highly male-prevalent neurological disorder here in the U.S. I did a simple, undergraduate research project using HCUP data on male-prevalent neurological disorders and found a disturbing and significant correlation between the two (although I found only a slight positive correlation for ASD, and almost no correlation for alzheimer’s).

    Scholarly, credentialed research on the longrun, neurological impact of neonatal circumcision on boys and men is long overdue. ADHD is the primary target I would like to suggest. This is outside the field of my academic interest, otherwise I would do this type of extensive, longitudinal research myself.

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    1. What do you say in response to these madciel organizations statements against infant male circumcision? 2004 College of Physicians and Surgeons of British Columbia, Infant Male Circumcision: “Current understanding of the benefits, risks and potential harm of this procedure no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and madcielly unnecessary intervention.”2003 British Medical Association, The Law and Ethics of Male Circumcision: Guidance for Doctors: “The madciel benefits previously claimed have not been convincingly proven… The British Medical Association considers that the evidence concerning health benefits from non-therapeutic circumcision is insufficient for this alone to be a justification for doing it.”2002 Royal Australian College of Physicians, Policy Statement on Circumcision:“There is no madciel indication for routine male circumcision.”2002 American Academy of Family Physicians, Position Paper on Neonatal Circumcision: “Evidence from the literature is often conflicting or inconclusive… A physician performing a procedure for other than madciel reasons on a nonconsenting patient raises ethical concerns.”2000 American Medical Association (AMA), Report 10 of the Council on Scientific Affairs: “Virtually all current policy statements from specialty societies and madciel organizations do not recommend routine infant circumcision…The AMA supports the general principles of the 1999 Circumcision Policy Statement of the American Academy of Pediatrics.” 1999 American Academy of Pediatrics, Circumcision Policy Statement: “Existing scientific evidence … [is] not sufficient to recommend routine neonatal circumcision.”1996 Canadian Paediatric Society, Neonatal Circumcision Revisited: “Circumcision of newborns should not be routinely performed.”1996 Australian Medical Association, Circumcision Deterred: “The Australian College of Paediatrics should continue to discourage the practice of circumcision in newborns.”1996 British Medical Association, Circumcision of Male Infants: Guidance for Doctors: “To circumcise for therapeutic reasons where madciel research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate.”1996 Australasian Association of Paediatric Surgeons, Guidelines for Circumcision: “The 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 [foreskin], 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 risks which may arise. In particular, we are opposed to male children being subjected 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.”

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  15. Research is needed! How do we get circumcised men to talk about it though?!

    I would like to see a study on the majority of men in this country ages 30-60 that were circumcised. What the long-term effects are physically, emotionally, their attitudes toward circumcision, how much they know about it, why they chose circ for their sons, etc.

    Thank you, keep throwing wrenches!

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  16. Awesome! I’m about a week away from being a graduate nurse (hopefully a month away from being an R.N.) here in the cities, and I’d love the privelege to work with a doctor who actually stands up for pt rights and autonomy. When I did my OB Clinicals at a certain local hospital that is almost known for it’s OB interventions, I was pretty upset with how casual it was treated. I assisted with one, and that was more than I ever want to see. So glad I made the right choice for my boys!

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    1. Circumcision in the U.S is a Normal practice for New Infants(I Think Now You can opt out of this)In other Countries it is etiher a Religious Welcoming or done for Medical Reasons!The U.K. Does not advocate circumcision and is not deemed to be a priority-Or until it steps into the medical realms.Some exponents say it’s Mutilation(Like that Of Female Muslims Circumcision),but I will lean on the health and well-being side!

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  17. Thank you for speaking for those who cannot speak for themselves. When I was pregnant with my first child, I was asked by my midwife if we planned to circumcise (if it had been a boy). We had not discussed it yet, but my first instinct was to say no. With a minimal amount of reading my opinion was set against the procedure, though my husband took a bit more time to get to the point of feeling as strongly about it as I do. Needless to say, both our son and daughter still have all of the body parts that they were born with.

    It is my understanding that our family doctor also refuses to perform circumcisions. I love her for many reasons, and this is right up there. You have some good colleagues here in town, Doctor.

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  18. Dr. Pate, you are to be commended for sticking up for men’s rights. I find it so ironic that there are female physicians who will gladly take a knife to a boy’s penis and cut it up yet would be the first ones to scream bloody murder if anyone even suggested so much as a pin prick to a girl’s genitals. This country needs more honest, caring, ethical physicians like yourself to end this barbaric practice. We thank you!

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