This is a direct appeal to Certified Nurse-Midwives.
Like you, I work in healthcare. I am a licensed physical therapist with over 25 years of experience in inpatient rehabilitation helping people recover functional mobility following strokes and other debilitating injuries and illnesses. Although we don't know one another, the fact that your background and training are in nursing tells me that you share the same concern for the well-being of others that motivates most of us who work in healthcare. It also means that we have a historical connection, since the first physical therapists were nurses. As a physical therapist, I'm proud to work in healthcare and I'm proud to work in a profession that has its roots in nursing because nursing epitomizes what healthcare is all about: alleviating pain, helping patients heal and helping people live safe, healthy and independent lives.
The fact that you are a midwife also tells me something about you. Midwifery epitomizes the values and philosophy of healthcare that I believe all providers ought to be guided by. These include appreciating and respecting that which is natural and normal in human anatomy and in biological processes, taking a holistic approach to healthcare, eschewing unnecessary and unnecessarily invasive medical interventions, and maintaining the utmost regard for the rights and dignity of patients. Thus, although you and I move in different orbits in the healthcare delivery system and provide entirely different kinds of services to our patients, I believe that we share the same humanistic values and that these values are central to who we are and what we do - so much so that this is why many of us view our role in healthcare not as a job but as a calling.
Besides being one of the most honorable of human endeavors, healthcare is also among the most rigorously
scrutinized and highly regulated. Even so, medical practice is not without its share
of
historical missteps. From
bloodletting to lobotomy, the history of medicine is replete with medical reversals: treatments and practices that once were considered state of the art but
that subsequently came to be recognized not only as medically
unnecessary but even harmful. If anything, the practices of obstetrics and gynecology (probably not coincidentally, given that they are branches of women's health, have even more than their fair share of now-discredited treatments. As one prominent ob-gyn, Jennifer Lang, MD reminds us (see her post of September 9, 2019),
A brief historical tour through some of the highlights of our particular profession would reveal such peer-reviewed published wisdom as applying manure, honey or astringent-soaked sponges to the prolapsed uterus, hanging women upside down by their ankles and bouncing them up and down, or "scaring" the uterus back up into a woman's body by attacking it with a red-hot branding iron.
Lang also notes
the widespread prescription of diethylstilbestrol (DES) to prevent miscarriage and preterm deliveries leading to thousands of DES daughters with cervical and vaginal cancers. Or how about the obstetricians of the past routinely treating preterm labor with IV ethanol (alcohol)? And let's not forget the decades of prevailing wisdom that all women in labor needed to be knocked unconscious with ether, have their pubic hair shaved and perineum surgically prepped before routine episiotomy and forceps-extraction of the baby. . . .
If some of these discarded treatments were well-meaning interventions that simply did not withstand the test of time, the history of medicine also includes practices that are far less honorable: "treatments" that have become impossible to reconcile with contemporary standards of medical ethics and human rights. The forced sterilizations of thousands of marginalized women (mostly poor women and women of color) is one example. The notorious "Tuskegee Study of Untreated Syphilis in the Negro Male" is another. Still another is medicine's disgraceful history of labeling homosexuality a "psychiatric disorder" and subjecting gay men and women to electroconvulsive therapy, even lobotomies in a misguided attempt to "cure" them of their gayness.
As long as medical practice has existed, medical malpractice and human-rights violations committed in medicine's name have existed alongside it. That is why - as the history of obsolete and rejected treatments amply demonstrates - practitioners at all levels and in all branches of healthcare must be willing to question medical dogma, look at the evidence with an open mind, test hypotheses objectively, recognize our own biases, and revise our practices accordingly. And in those cases in which an intervention fails to live up to medicine's own ethical standards - as it has so many times in the past - or is no longer compatible with evolving standards of human rights and personal autonomy, we who enjoy the privilege of calling ourselves healthcare providers have a special obligation to call medical practice to account and to demand better.
That is why I am reaching out to you today, as one healthcare professional to another. The history of discredited medical practices - discredited both ethically and by the failure of evidence to support them - is still not completely behind us. To this day, and about 3,000 times every day in fully accredited hospitals throughout the United States, children are subjected to a medically-unnecessary genital surgery that permanently alters their bodies and, in so doing, violates their right to bodily integrity and their right to bodily autonomy. I am referring to nontherapeutic, neonatal penile circumcision and these are the facts about this surgery:
- Penile
circumcision found its way into medical practice during the 19th
century as the epitome of quackery - promoted as a cure for everything
from "masturbatory insanity" to paralysis to epilepsy.
Since then, every time a claim for circumcision has been debunked, new
ones are put forward to take its place in an endless quest to discover "just what kinds of 'health benefits' might follow from cutting off parts of the penis."
- Every professional medical organization, both here in the United States and abroad, that has investigated neonatal circumcision has concluded that it is not medically necessary.
- As long ago as 1971, the American Academy of Pediatrics (AAP) concluded that "there are no valid medical indications for circumcision in the neonatal period."
- Medical reversals typically occur when "medical practices are implemented and then are later found to be either ineffective or harmful . . . through properly conducted randomized controlled trials (RCTs). . . . " To put it simply, RCTs are the gold standard in determining the safety and efficacy of medical interventions, yet there has never been an RCT in order to establish the safety and efficacy of neonatal penile circumcision.
- The AAP last issued a Policy Statement offering qualified support for nontherapeutic circumcision in 2012 (which one of its authors now concedes was tantamount to "a 'permission slip' for those who want to circumcise their children so society cannot say they are bad parents. . . ."). Both this Policy Statement and a contemporaneously published Technical Report on penile circumcision expired in 2017 - almost ten years ago - and have never been reaffirmed or renewed. This means that the 2012 Policy Statement on nontherapeutic circumcision is no longer considered an official recommendation of the AAP.
- Two of the authors of the AAP's expired policy statement on nontherapeutic circumcision have now reversed themselves. One of these, Douglas Diekema, MD, MPH, now states "I don't think you can honestly say in a recommendation that the benefits outweigh the risks." The other, Andrew Freedman, MD, has recently acknowledged that nontherapeutic circumcision is "not really a medical practice. It's only a 'medical practice' in the sense that medical professionals are performing it."
- Between 100 and 200 circumcisions would need to be performed (the Number-Needed-to-Treat, or NNT) to prevent a single UTI. To make that concrete, up to 200 infants would have to be subjected to this genital surgery in order to prevent the occurrence of a single UTI in one infant.
- From 4,000 to just over 7,000 circumcisions would need to be performed to prevent a single case of penile cancer.
- Nontherapeutic circumcision violates the important best-practices principle that providers should always opt for the least invasive treatment available and should only resort to more aggressive measures when conservative treatments have failed (a concept known as proportionality). That applies to prophylactic interventions, as well. Yet there is not a single claimed "health benefit" of penile circumcision that cannot be achieved through non-invasive, less harmful, less costly and less painful methods, such as
- the
use of antibiotics to treat UTIs, as is routinely done in the case of girls
- in adulthood, the use of condoms and other safe-sex practices to prevent the transmission of STIs.
- Nontherapeutic neonatal circumcision is always performed without the consent of the person subjected to it.
- Any
intact, adult male can undergo circumcision if he wants to and, although
very few men (unsurprisingly) make this choice, those who do are not harmed by waiting until they are adults and capable of
exercising informed consent. (The American College of Obstetricians & Gynecologists compares the risk of complications of adult circumcision unfavorably to neonatal circumcision yet, as the AAP itself acknowledges,
"the true incidence of complications after newborn circumcision is
unknown." It follows that one cannot possibly know that the risk
of complications increases later in childhood or in adulthood, as ACOG claims on its website.)
- Circumcision causes real-time and post-operative pain.
- As with any unnecessary surgery, unnecessary circumcision causes unnecessary pain.
- Neonatal pain can alter brain development and has been shown to "[alter] infant physiological and behavioral stress responses."
- Nontherapeutic neonatal circumcision has risks and potential complications including (but not limited to) infection, hemorrhage, meatal strictures, sexual dysfunction in adulthood, loss of the glans or even the entire penis and, in rare cases, death. None of these risks or complications is justified by a surgery that is performed largely for reasons of social conformity or because of the personal cosmetic preferences of the child's parents.
- Neonatal circumcision disrupts the bonding process between the mother and her baby.
- Penile circumcision removes a natural, essential, sensitive and functional body part.
- Nontherapeutic neonatal circumcision, because it is medically unnecessary, is harmful by definition. As attorney and legal scholar Peter Adler has argued, "courts have noted [that] unnecessary surgery is inherently harmful. For example, in 2006 . . . the California appeals court stated, '. . . unnecessary surgery is injurious and causes harm to a patient. Even if a surgery is executed flawlessly, if the surgery were unnecessary, the surgery in and of itself constitutes harm [citations omitted].'"
- The penile prepuce (or foreskin) is the primary sensory structure
of the penis. It is erogenous tissue that is densely innverated with
specialized light-touch receptors (such as those found on the hands and
face) and that has been shown to be much more sensitive than the glans or any other part of the penis. All of that erogenous sensation is
permanently destroyed by circumcision. As Sorrells et al. concluded in 2007, "Circumcision ablates the most sensitive parts of the penis."
- Circumcision is irreversible.
- The overwhelming majority of men who were not circumcised as infants value their foreskins and choose not to have them surgically removed.
- Close to 20 million (up to 15 percent of involuntarily circumcised) men in the United States object
to having been subjected to circumcision. While that number may not
seem large in a population of approximately 130 million circumcised
men, 19.5 million individuals constitutes a class that deserves and has a right to be acknowledged.
This number - the number of men (that we know about) who object to having been
circumcised - is greater than the individual populations of all but four
states, is more than twice the number of men who identify as gay, is more than the number of women of child-bearing age who have had an abortion, is roughly three times the number of intersex people in the United States, and is larger than the populations of every individual religious minority in the United States. Their views matter. When asked, these circumcision survivors are unequivocal: had they been allowed to make this choice for themselves, they would not have
chosen to have this part of their genitals removed. Among the reasons they cite are decreased penile sensation and resentment of having been deprived
of their fundamental right to bodily autonomy. Of course, it's too late for them, but how many infants subjected to circumcision today will similarly come to resent the surgical alteration to their genitals that was imposed upon them without their consent?
- Nontherapeutic circumcision is considered, under current regulatory statutes, to be a legitimate element of "an expanded scope of practice" for nurse-midwives.
My own perspective, which I hope you will come to share if you don't already, is that of a healthcare provider who believes that it is unethical to subject a healthy child - whether female, male or intersex - to any irreversible genital surgery that the child does not seek for itself and that is not medically necessary.
I am not speaking just as a healthcare professional, however. I am also reaching out to you today because I want to share my perspective as someone who was subjected to this surgery. I believe that it's critically important that healthcare professionals respect the basic right of patients to make their own informed decisions about their healthcare and about their bodies. That's especially true in the case of a surgery that is irreversible and, if possible, it's even more true when that surgery is universally regarded as medically unnecessary. When the patient is a neonate and lacks the capacity to exercise and articulate informed consent, medical ethics and respect for the fundamental right of bodily integrity require that the surgery - unless emergently indispensable to protecting the infant's health - be deferred until the individual is old enough to decide for himself whether to undergo it. As we know, most men, when their right to choose has not been precluded by the imposition of circumcision during infancy, choose not to get circumcised. That's the choice - about my own body - that was permanently denied to me.
Although I don't expect you to fully appreciate or comprehend - if it hasn't happened to you - what it's like to have the most erogenously sensitive part of your genitals surgically removed, I do trust that your capacity for empathy - that same human quality that prompted you to become a nurse-midwife the first place - will enable you to appreciate the perspective of the millions of men like me who object to what was done to our bodies without our consent. Ultimately, my hope is that you will come to share our view, as well, that the time has come for medical professionals to stop performing medically-unnecessary penile circumcisions on unconsenting minors.
If you do already, the good news is that we are not alone. Routine, nontherapeutic, neonatal circumcision is opposed by more and more human-rights advocates, psychologists, attorneys, bioethicists, physicians, nurse-midwives, public health professionals, anthropologists, psychologists, sexologists, sociologists, legal scholars and professional medical organizations around the world. A recent paper, published in the American Journal of Bioethics, entitled "Genital Modifications in Prepubescent Minors: When May Clinicians Ethically Proceed?" reflects the inexorable trend in bioethics toward greater respect for the bodily integrity, the physical boundaries, and the rights of children, including as these relate specifically to nontherapeutic penile ("male") circumcision:
With respect to children categorized as female at birth . . . there is a near-universal ethical consensus in the Global North. This consensus holds that clinicians may not perform any nonvoluntary genital cutting or surgery, from "cosmetic" labiaplasty to medicalized ritual "pricking" of the vulva, insofar as the procedure is not strictly necessary to protect the child's physical health. All other motivations, including possible psychosocial, cultural, subjective-aesthetic, or prophylactic benefits as judged by doctors or parents, are seen as categorically inappropriate grounds for a clinician to proceed with a nonvoluntary genital procedure in this population. . . . [T]he main ethical reasons capable of supporting this consensus turn not on empirically contestable benefit-risk calculations, but on a fundamental concern to respect the child's privacy, bodily integrity, developing sexual boundaries, and (future) genital autonomy. . . . [T]hese ethical reasons . . . do not only apply to . . . female children, but rather to all children regardless of sex characteristics, including those with intersex traits and endosex [i.e., non-intersex] males. . . . [A]s a matter of justice, inclusivity, and gender-equality in medical-ethical policy . . . clinicians should not be permitted to perform any nonvoluntary genital cutting or surgery in prepubescent minors irrespective of the latter's sex traits or gender assignment, unless urgently necessary to protect their physical health.
These ideas - that boys (and intersex children, too) are born with the same right to genital integrity that girls are and that healthcare professionals should not be violating that right - are not new. Thirteen years ago, in response to the AAP's 2012 Technical Report and Policy Statement on male circumcision, over three dozen physicians and other healthcare professionals from Europe and Canada collaborated on a point-by-point refutation of the AAP's assertions. The authors (Frisch, et al.) of this paper, "Cultural Bias in the AAP's 2012 Technical Report and Policy Statement on Male Circumcision" concluded that,
Cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious. The conclusions of the AAP Technical Report and Policy Statement are far from those reached by physicians in most other Western countries. . . . [O]nly [one] of the aforementioned arguments has some theoretical relevance in relation to infant male circumcision; namely, the questionable argument of UTI prevention in infant boys. The other claimed health benefits are also questionable, weak, and likely to have little public health relevance in a Western context, and they do not represent compelling reasons for surgery before boys are old enough to decide for themselves. Circumcision fails to meet the commonly accepted criteria for the justification of preventive medical procedures in children. . . .
The AAP report lacks a serious discussion of the central ethical dilemma with, on [one] side, parents' right to act in the best interest of the child on the basis of cultural, religious, and health-related beliefs and wishes and, on the other side, infant boys' basic right to physical integrity in the absence of compelling reasons for surgery. Physical integrity is [one] of the most fundamental and inalienable rights a child has. Physicians and their professional organizations have a professional duty to protect this right, irrespective of the gender of the child.
There is a growing consensus among physicians, including those in the United States, that physicians should discourage parents from circumcising their healthy infant boys because nontherapeutic circumcision of underage boys in Western societies has no compelling health benefits, causes postoperative pain, can have serious long-term consequences, constitutes a violation of the United Nations' Declaration of the Rights of the Child, and conflicts with the Hippocratic Oath: primum non nocere: First, do no harm.
As
these authors noted, the growing consensus among physicians who have
come to reject nontherapeutic circumcision on both evidentiary and
ethical grounds includes physicians here in the United States. At the
vanguard of this medical reform movement is Doctors Opposing Circumcision (DOC), an organization that was founded over
30 years ago by George Denniston, MD, MPH in order to help bring
about an end to the practice of subjecting unconsenting
children to this medically-unnecessary genital surgery. DOC is comprised of
like-minded physicians and others who share the principles, the ethics
and the core values that all of us, as healthcare providers, are
obligated to uphold. These ethical principles include:
- beneficence: the principle that the care and services we provide must benefit the patient
- nonmaleficence: the principle that we must not harm or injure our patients
- justice: the principle that all patients should be treated equally and fairly
- respect for autonomy: the principle that every patient, regardless of age, sex, religion, race, ethnicity or anything else, has a fundamental and absolute right of bodily self-ownership
Nontherapeutic neonatal penile circumcision violates every one of these ethical principles. It violates the principle of beneficence because it has "no compelling health benefits"; it violates the principle of nonmaleficence because any unnecessary surgery that removes a normal, healthy part of the body constitutes a harm, in and of itself; it violates the principle of justice because it treats boys (or children with penises) unequally solely on the basis of sex; and it violates the principle of autonomy because it permanently precludes the individual's right to make his own decisions about this part of his body.
Nontherapeutic circumcision also violates both the spirit and the letter of several of the specific provisions of the American College of Nurse-Midwives' Code of Ethics, the ACNM's Philosophy of Midwifery, and the International Confederation of Midwives' Philosophy and Model of Midwifery Care. For example, this last-named document states that "Midwives promote and protect the health and rights of women, girls, gender diverse people, adolescents, and newborns [my emphasis]." It also "promote[s] and advocate[s] for non-intervention in normal childbirth." And it enshrines as one of its "guiding principles" the "person- and human-rights centered approach inherent in [its] Philosophy and Model of Midwifery Care." Non-therapeutic circumcision is irreconcilable with and even antithetical to these precepts. Similarly, the practice of nontherapeutic circumcision violates the very first item in the ACNM Code of Ethics, namely, that midwives will "Respect basic human rights and the dignity of all persons." Perhaps nowhere is the conflict between the reality of nontherapeutic circumcision and the ideals of midwifery more glaring than in the ACNM's Philosophy of Midwifery which affirms in unqualified terms "the individual's absolute right to bodily autonomy."
Nontherapeutic neonatal penile circumcision is well on its way to joining lobotomies, forced sterilizations, routine hysterectomies and other harmful and unethical practices on the scrap heap of medical reversals. This is why Doctors Opposing Circumcision has chosen to stand on the right of history and is working to end what has been, since its introduction, a cure in search of a disease - a deeply entrenched cultural practice masquerading as medical care.
I hope you will take a few minutes to listen to Dr. Denniston explain, in his own words, why DOC exists and why this cause is so important. I also encourage you to read this short column by Adrienne Carmack, MD, a board-certified urologist and one of the board members of Doctors Opposing Circumcision. For a concise yet compelling discussion of this issue, particularly as it relates to midwives (and doulas), see "Doulas, Midwives, and the Fight Against Routine Circumcision: Guardians of Birth, Protectors of Choice." Another excellent resource specifically for midwives on this topic can be found here. And for a comprehensive, evidence-based review of nontherapeutic penile circumcision, see Evidence and Ethics on: Circumcision by Rebecca Dekker, PhD, RN and Anna Bertone, MPH.
I also encourage you to visit the website of Doctors Opposing Circumcision. Here you can find useful information and resources, including information on conscientious objection if you are currently involved in performing nontherapeutic circumcisions but would like to begin seeking a path that can lead you toward a more ethical practice of neonatal care. Once you have come to the unavoidable conclusion, as many of us in healthcare already have, that to perform medically-unnecessary genital surgeries on unconsenting minors is incompatible with the ethical duties of healthcare providers, you will find it difficult, if not impossible, to do so. The DOC website has guidance for medical professionals that can help.
Finally, I would like to personally extend to you an invitation to join us at DOC. Membership is both free and anonymous, and nurse-midwives are especially welcome.
