Wednesday, October 24, 2012

Open letter to pediatricians who circumcise

Dear Doctor, In recent days during the AAP conference in New Orleans, some doctors took offense at Jonathon Conte, member of the Bay Area Intactivists, walking around with a sign but this that read "Sex Criminals for Hire, Inquire Within".

This is the same message that Van Lewis, an intactivist icon carried in Tallahassee, Florida in 1970.

I think that maybe some doctors are appalled to see this message and unaware of the strong emotions that these "intactivists" assign to a simple procedure that is performed 1.2 million times every year in this country. I understand that everyone is in a different place in their personal journey, so let me please share with you some information and perhaps we can learn something along the way.

The AAP as you know just came with a new Policy Statement on Circumcision indicating that "the benefits outweigh the risks" and that "Parents ultimately should decide whether circumcision is in the best interests of their male child".

A pediatrician who took offense at the sign, when asked what she says to expectant parents that request circumcision for their sons, answered "I explain the medical risks & benefits & tell them it is a personal decision".

It seems as a reasonable posture, but it is not. There are omissions which the pediatrician may not be even aware of. Let's see:

* The foreskin has functions. Its removal causes damage (beyond the risks, the damage is something that always occurs as it is part of the nature of the procedure). A pediatrician who knows about the sexual functions of the foreskin could educate the parents about it; most parents wouldn't circumcise if they knew that this procedure is going to have negative lifelong effects on their son's sexuality. A pediatrician could also educate on how easy it is to care for the intact penis. However, the AAP's Policy Statement and Technical Report on Circumcision makes no attempt to explain the anatomy or functions of the foreskin.

* There are alternative ways of reaching most of the benefits without an amputation. But many American health workers often just state that they will get infections and need to get it done later and that its cleaner - which shows lack of understanding of the issue. In fact caring for an uncircumcised penis is so much easier. No need to retract. No open wounds inside the diapers. No pain during urination.

* For contrast, the Royal Dutch Medical Association states that "There is no convincing evidence that circumcision is useful or necessary in terms of prevention or hygiene", that "Contrary to what is often thought, circumcision entails the risk of medical and psychological complications", that "Non-therapeutic circumcision of male minors is contrary to the rule that minors may only be exposed to medical treatments if illness or abnormalities are present" and that "Non-therapeutic circumcision of male minors conflicts with the child’s right to autonomy and physical integrity." Their conclusion is that doctors should discourage parents, indicating that "There are good reasons for a legal prohibition of non-therapeutic circumcision of male minors". 1

* As a doctor, when parents ask you to circumcise their baby for no reason, you are not just required to go along and do whatever they want; you can take the opportunity to educate them.

* Per the AAP's committee on bioethics 1995, "The pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent." 2 It only follows that if you understand why circumcision causes damage, you have a responsibility to discourage parents from seeking a circumcision for their child and you have every right to refuse to provide the treatment.

But many American doctors don't know what is the damage that circumcision causes. Circumcision is so embedded in the American culture that we see it as the norm, not as the exception. We see it as an immunization (which it is not) and not as an amputation.

According to the online Encyclopedia of Surgery, "Amputation is the surgical removal of a limb or body part. It is performed to remove diseased tissue or relieve pain." 3 Circumcision is an amputation but it doesn't remove diseased tissue nor relieves pain. Circumcision of infants removes healthy erogenous tissue. Circumcision, in addition to skin, removes:

* Muscle tissue (dartos fascia)

* A high concentration of Meissner corpuscles (responsible for sensitivity to light touch)

* The ridged band, a specific erogenous zone. 4.

* Apocrine glands. These glands produce pheromones, nature’s invisible yet compelling signals to potential sexual partners.

Photo by deviantArt user ~tottus, used with kind permission - illustrates the ridged band

Sorrells et al, 2007, shows that "The transitional region from the external to the internal prepuce [the ridged band] is the most sensitive region of the uncircumcised penis and more sensitive than the most sensitive region of the circumcised penis." and concludes that "Circumcision ablates the most sensitive parts of the penis." 5.

This doesn't mean that a circumcised man cannot feel pleasure or that he cannot make a woman pregnant. However, it means that there is an effect on his sexuality, which is hard to quantify. Dr. Douglas Diekema, member of the Task Force on Circumcision of the AAP, even said: "Circumcised men may experience sex differently than uncircumcised men -- intuitively that makes sense -- but it's simply not the case that we have an epidemic of uncircumcised men that don't get pleasure or can't function sexually." 6 (It's likely that he meant "epidemic of circumcised men", but this is the way it was published)  It is clear and even intuitive that circumcision, the alteration of the male genital organ, causes changes in the sexual experience of the adult man. However Taylor goes further to state "that the real importance of the ridged band to sexual intercourse lies in an ability to trigger a reflex contraction of muscles responsible for ejaculation." 7.

Circumcision also removes the protection of the glans. The AAP states in their technical report on circumcision that "Circumcision reduces the bacteria that accumulate under the prepuce which can cause UTIs and, in the adult male, can be a reservoir for bacteria that cause STIs." 8. However, the removal of the foreskin causes keratinization of the glans over the years: "When the foreskin is removed, the surface of the glans becomes thickened (keratinized). ... Some reports by men circumcised later in life indicate a significant decrease in perceived sensation to touch over the glans after the procedure, compared with the level of sensation to touch perceived before the procedure." 9. In the case of men circumcised as babies, they never get to experience that level of sensation to touch prior to the procedure, and by the time they become sexually active their glans has already become dried and hard, which is why they don't report a decrease of sensation: because they never had the opportunity to experience the same high level of sensation!

Comparison of the glans in an intact penis (above) and a circumcised penis (below) Photo:
Circumcision also removes the gliding function of the skin. The foreskin is the only moving part of the penis. During any sexual activity, the foreskin and glans work in unison; their mutual interaction creates a complete sexual response. In heterosexual intercourse, the non-abrasive gliding of the penis in and out of itself within the vagina facilitates smooth and pleasurable intercourse for both partners. Without this gliding action, the corona of the circumcised penis can function as a one-way valve, dragging vaginal lubricants out into the drying air and making artificial lubricants essential for non-painful intercourse 10.

Photo by deviantArt user ~oTupeiraX, used with kind permission to illustrate the gliding function

Is is then clear that circumcision permanently alters the sexual experience of the male and can have a negative effect on his female partners by drying and chaffing the internal walls of the vagina during intercourse due to the lack of gliding action.

So this routinary procedure performed on approximately 1.2 million babies every year has a permanent effect in the sexuality of those babies as they mature.

If you look back at the history of circumcision in the United States, you will see that it was started by individuals such as John Harvey Kellogg in the XIX Century as a way to "cure masturbation". In 1888, Kellogg wrote: "A remedy which is almost always successful in small boys is circumcision, especially when there is any degree of phimosis. The operation should be performed by a surgeon without administering an anesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment, as it may well be in some cases. The soreness which continues for several weeks interrupts the practice, and if it had not previously become too firmly fixed, it may be forgotten and not resumed" 11.

In fact, Moses Maimonides, a Jew Philosopher (1135-1204) wrote: "with regard to circumcision, one of the reasons for it is, in my opinion, the wish to bring about a decrease in sexual intercourse and a weakening of the organ in question, so that this activity be diminished and the organ be in as quiet a state as possible." and "The bodily pain caused to that member is the real purpose of circumcision. None of the activities necessary for the preservation of the individual is harmed thereby, nor is procreation rendered impossible, but violent concupiscence and lust that goes beyond what is needed are diminished. The fact that circumcision weakens the faculty of sexual excitement and sometimes perhaps diminishes the pleasure is indubitable." 12

As you can see dear doctor, circumcising a baby has been and still is an act of violence that reduces the pleasure of the sexual organ and of intercourse for both males and females. It was only in the 60s that American doctors started stating that circumcision had no effect on sexuality: the American and British doctors who had been advocating circumcision prior to that time (including the previously quoted J.H. Kellogg) were all aware that circumcision had effects on sexuality. Perhaps the reason the doctors in the 60s did not know about the sexual effects of circumcision was because they were circumcised at birth themselves!

In the United States, circumcision is seen as a decision to be made by the parents. In most of the world this is not the case. In most of the world, the parents won't be asked if they want to circumcise, and won't request a circumcision for their baby. It's not a decision to make. Circumcision is used when needed for strong medical reasons or based on an adult patient's request for his own body.

TLC Tugger - one of several
devices for the purpose of foreskin
Thousands of adult men are trying to restore their foreskins through non-surgical process of foreskin restoration, as can be evidenced in foreskin restoration forums such as . This is a tedious and slow process of tissue expansion that takes years, and its final result is cosmetically a foreskin without critical structures such as the Meissner's corpuscles or the ridged band, which cannot be recreated (nor the frenulum in those cases where it was removed).

Further inspection of these forums shows that many of these men still feel anger towards the doctors that circumcised them and towards their parents for consenting to the operation. Many of these men have suffered physical and psychological effects, such as lower sexual sensitivity and pleasure in the mid-age period, and a sense of loss and betrayal over having being subjected to a medically unnecessary amputation.

Many of these men feel that their bodies were violated when they were most vulnerable. Furthermore, the violation is permanent since they still carry the scar and still miss the body part that was removed. I recently read words by one of these men stating how he was realizing that his penis had been fondled by strangers when he was a baby in order to remove the foreskin, and how just thinking about that made him feel even more sexually violated.

Intactivists protesting across the AAP Convention in New Orleans 2012, photo by James Loewen

This, doctor, is the nature of the procedure that is so often performed in our country, and these are the emotions that the "patients" or "victims" develop overtime. Many of these man have grown and sought the doctors that circumcised them to confront them and ask questions that have no good answers at all.

You may feel that the signed consent form exonerates you from any responsibility in the decision to circumcise; that the child, if unhappy, should go to his parents, not to you. But while legally you may be somewhat protected by the consent form, in the eyes of the adult man you were still the person who raised a scalpel to his penis, just like you were the person who could have saved him from circumcision by just speaking to his parents.

Poster by Intact America, presented during the protest at the AAP Convention 2012

Truth is, many parents are confused and struggling with this decision but they are afraid to ask questions, and when they ask the vague answers just make them think that they are bad parents if they don't circumcise; that they are being irrational and anti-science, when it's quite the opposite. A compassionate doctor or nurse who helps parents through their struggle can release them from much social pressure and give them the freedom to take their child intact home.

And even the courts have shown that a parental consent can be deemed invalid, as they did when William Stowell sued the doctor who circumcised him and the hospital where it took place.

So when you see Jonathon Conte protesting with his "Sex Criminals for Hire, Inquire Within", please know that this message, offensive as it seems at first sight, comes from a place of introspection and vulnerability and is shared by many circumcised men. This message has existed for more than 40 years, and yet the American medical community refuses to acknowledge it. Many of us, intactivists, are the children that doctors like you circumcised decades ago, and we are here to tell you that it was not okay, that you should not have done it, that you should have educated our parents, that you should have educated yourselves to the functions and value of the foreskin, that you should have refused to hurt our sexual organs in lack of a medical reason to do it.

If carrying signs that read "Sex Criminals for Hire" is what's needed to get doctors to listen, we will carry them. Anything to get you to understand that you are doing to non-consenting babies what would be considered sexual battery and aggravated assault if you were to do it to a non-consenting adult. Because just like we don't like what was done to us, we don't want another generation to have to be in the same situation in 20, 30 or 40 years. We want to protect those children so they don't have to suffer what we suffered, and they don't have to restore what was their right to have, like we are restoring ours right now.

(Please watch videos after the footnotes)

1 Royal Dutch Medical Association. Viewpoint on Non-therapeutic circumcision of male minors. KNMG 2010: p.16

2 American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995;95(2):3 14-7.

3. Encyclopedia of Surgery: Amputation - procedure, test, blood, removal, pain, complications, adults, time, infection, operation, medication, children, rate, Definition, Purpose, Demographics, Description

4. Winkelmann RK. The erogenous zones: their nerve supply and significance. Mayo Clin Proc 1959;34(2):39-47.

5. Sorrells et al. 2007. "Fine-touch pressure thresholds in the adult penis."

6. Broward Palm Beach New Times, American Academy of Pediatrics to Come Out More Strongly in Favor of Circumcision, Suggests Dr. Doug Diekema, Member of Task Force, by Deirdra Funcheon, 02/14/2012

7. Taylor, John R. (July 2007). "Fine-touch pressure thresholds in the adult penis (letter)". BJU International 100 (1): 218. doi:10.1111/j.1464-410X.2007.07026_4.x. PMID 17552969.

8. Task force on Circumcision. Male Circumcision - Technical Report. Pediatrics, 2012. Volume 130, Number 3. pg. 763

9. Parenthood in America: An Encyclopedia, Volume 1. pag. 126.

10. O'Hara, K. and O'Hara, J., "The effect of male circumcision on the sexual enjoyment of the female partner," British Journal of Urology, 83, Supplement 1, (1999): 79-84.

11. Kellogg, J.H. (1888). "Treatment for Self-Abuse and Its Effects". Plain Facts for Old and Young. Ayer Publishing. pp. 294–296. ISBN 0-405-05808-X, 9780405058080.

12. Maimonides, Moses. The Guide of the Perplexed. Translated by Shlomo Pines. Chicago: The University of Chicago Press, 1963.


  1. Thank you! Your videos are awesome, thank you for everything that you do for the cause of genital integrity :)