Tuesday, November 13, 2012

Circumcision and the AAP - when the risks outweigh the benefits

In the last week I posted a few of the worst case scenarios of medical circumcision:

The 4 year old boy in Texas who last year suffered bleeding, was cauterized, developed fistulas (holes) where urine would come out (with blood and pain). Begging to just have it cut off so he can be a girl. He will need more surgeries in the future. (This is the only non-fatal case I'm mentioning here but it's far from being a unique occurrence)

Brian M. Brandt, victim of a severely botched circumcision that left him mutilated. Committed suicide at 28 years, 2011.


Ryan White, born 1971, hemophiliac, bleeding uncontrollably after circumcision (which could have killed him). Injected with an experimental drug made from human blood, which ended up transmitting HIV to him. Died at 19 years.

Those cases are far from being alone, even if they are really bad.

David Reimer, raised as a girl after he lost his penis during circumcision at 4 months. His testicles were removed. Renamed and taught to be a girl but he never adjusted. In puberty he was told the truth, underwent breast reduction (he was in hormones), reconstruction of the penis. Got married. Never felt complete. Committed suicide in 2004 at 39 years.

Joshua Haskins, born with a severe heart condition. After heart surgeries, he was circumcised. He kept bleeding and died from cardiac arrest. 2010. He should have never been circumcised - the doctors should have know better than to circumcise a child with a severe heart condition. *

Jamaal Coleson, died at 2 years. He was supposed to have local anesthesia for his circumcision but was given general anesthesia. He awoke from the operation, but then felt bad and his condition deteriorated.

Ryleigh McWillis died at 1 month of age in Canada 2004. Bleeding from his circumcision wound.

More cases are documented here: http://www.cirp.org/library/death/

In light of this, I think it's interesting to compare what the AAP (American Academy of Pediatricians) and the KNMG (Royal Dutch Medical Association) say about the risks, including some "confidential" talking points from the AAP that were used as script for physicians when asked questions about the new Policy Statement in August 2012:

Statements from the AAP (taken from the Technical Report):

Financial costs of care, emotional tolls, or the need for future corrective surgery (with the attendant anesthetic risks, family stress, and expense) are unknown.

The majority of severe or even catastrophic injuries are so infrequent as to be reported as case reports (and were therefore excluded from this literature review).

Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it.

Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.

Statements from the KNMG (from their Viewpoint on Non Therapeutic Circumcision of Male Minors):

There is no convincing evidence that circumcision is useful or necessary in terms of prevention or hygiene. Partly in the light of the complications which can arise during or after circumcision, circumcision is not justifiable except on medical/therapeutic grounds.

Contrary to what is often thought, circumcision entails the risk of medical and psychological complications.

There are good reasons for a legal prohibition of non-therapeutic circumcision of male minors, as exists for female genital mutilation. However, the KNMG fears that a legal prohibition would result in the intervention being performed by non-medically qualified individuals in circumstances in which the quality of the intervention could not be sufficiently guaranteed.

Statements from AAP (taken from their "talking points" - the talking points require login, but for a leaked version...):

[T]he Royal Dutch Medical Association issued a statement in 2010 concluding that in light of the lack of convincing medical benefits, non-therapeutic circumcision of male minors conflicted with the child’s right to autonomy and physical integrity and that physicians should inform parents and caregivers seeking circumcision about the medical and psychological risks and the lack of convincing medical benefits. While this conclusion differs from the conclusions of the new AAP statement, it is important to recognize that the Dutch Medical Association statement does not include a comprehensive, systematic review of the scientific literature.

Circumcision is a procedure with few risks and considerable health benefits. Parents who make the decision in the best interests of their child’s health are within their child custody rights.

Male circumcision has been shown scientifically to provide benefits to the person being circumcised, and has a proven track record for safety.

And a HUGE LIE by the AAP in these Talking Points :

Isolated cases of morbidity and mortality after ritual circumcision have been reported in the U.S., and have been related to circumcisions that were not performed under sterile conditions. These cases and the practices that led to them have been limited to a specific group.

My note:

None of the cases highlighted above were religious circumcisions! All of them and many many more were medical procedures. The above statement from the AAP to the Physicians is misleading in suggesting that no morbidity or mortality has been recorded in medical settings in the United States. They don't say that, but they suggest it - basically using the Herpes related deaths caused by the Metzitzah b'Peh practice by Orthodox Jews in New York as a red herring, a distracting point to sweep all the other deaths and mutilations behind the rug. Wow they really underestimate the general public.

Conclusions

This entry highlights some of the cases that the AAP calls "case reports". Each "case report" meant one death or one person with severely damaged genitalia for life. If this "case report" was my child, how would I look him in the eye and tell him that it was for his own good? That his circumcision provided benefits and was safe? What would I write in the gravestone?

The AAP criticizes the KNMG's statement by saying that it doesn't include a comprehensive review of scientific literature. But the KNMG's statement is written from an ethical and human rights perspective. When you risk killing or damaging a person's life, how acceptable are those benefits?

Are those benefits so great that we can ignore (or exclude) those case reports? Are those cases really so rare? What is the tolerance level? How many yearly deaths are acceptable? How many yearly severe mutilations are acceptable?

I've read the AAP's technical report many times and I don't find the answer to my questions. All they say is that the costs of those cases is unknown and cases like these are excluded from the review.

Case reports = The children that the AAP failed to protect.










* Extra information on the cae of Joshua Haskins: The case of Joshua Haskins is one of special public sensitivity. His mother is a blogger, and she was documenting the birth, the procedures and everything online. When his health deteriorated and she documented it, many intactivists reacted angrily leaving rude comments. Unfortunately this is one bad side of intactivism: many activists are so emotional about it that they lack sensibility and compassion to treat other people, especially parents who had their children circumcised (after all, many activists happen to be males who are emotionally, physically or psychologically hurt by their circumcision or parents who regret circumcising their children - so emotions run high). Joshua and his parents deserved compassion in that sad moment - not guilt. The doctors are the ones to blame - they should have know better than to circumcise a baby with a severe heart defect.

This case was also recently misrepresented by Douglas Diekema bioethicist and member of the AAP Task Force that wrote the new Policy Statement, in an interview presenting the document. Diekema said: "for example, there's at least one of these cases that gets trotted out that involved a very sick baby that was likely to die anyway and his parents wanted him circumcised before his death. And to attribute that to a circumcision is silly." http://www.kqed.org/a/forum/R201208290900


Doug Diekema's lies:

"his parents wanted him circumcised before his death": No. Big lie. His parents believed he was going to live. Otherwise they wouldn't have been subjecting him to hearth surgeries. If they believed their child was going to die, they would have let him die peacefully. But they chose to fight the fight, to fight for his life. And stating differently only disrespects their pain.

"to attribute that to a circumcision is silly". The baby kept bleeding after circumcision. Without circumcision, he wouldn't have bleed through a non-existing wound on his penis. Without bleeding, his heart wouldn't have stopped at that time. Maybe he wouldn't have had a long life, or maybe yes, we don't know. But circumcision certainly didn't give him any health benefit. It caused profuse bleeding, and the bleeding caused his heart to stop. The doctors should have known that a baby with a heart defect is not a good candidate for circumcision. The doctors should have discouraged the procedure.

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