An Appeal to Obstetrician-Gynecologists

 

This is a direct appeal to obstetrician-gynecologists.  

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 you and I move in different orbits in the healthcare delivery system and provide entirely different kinds of services to our patients, what we have in common is a desire to help people live safe, healthy, and independent lives.  Without knowing you personally, the fact that you are a physician tells me that you are motivated by the same concern for the well-being of others that motivates most of us who 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 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, because 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 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 guidelines (as has also happened many times in the past) or is no longer compatible with those guidelines - not because the ethics themselves have changed but simply because of our society's growing recognition that these ethical guidelines must be applied consistently and universally, to all patient populations - we who enjoy the privilege of calling ourselves healthcare providers have an obligation to call medicine to account and to bring what we do or don't do in our practices into line with contemporary standards of universal human rights and personal autonomy.

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."
  
• 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.  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."  If that is true, then one cannot possibly know that the risk of complications increases later in childhood or in adulthood, as ACOG claims on its website.)
  
• As with any surgery, 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 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.
• Penile circumcision removes a natural, essential, sensitive and functional body part.
• Nontherapeutic neonatal circumcision, because it is medically unnecessary, is harmful by definition.  As 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 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.
• As many as 15 million men in the United States object to having been subjected to circumcision.  While that number may not seem large out of a population of approximately 80 million circumcised men, this is a class that deserves and has a right to be acknowledged.  The number of men (that we know about) who object to having been circumcised 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.  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. 
  
• Most nontherapeutic circumcisions in the United States are performed by obstetricians.

Perhaps you have never really considered nontherapeutic circumcision critically - the way you might routine episiotomy or hysterectomy.  The fact is, this genital surgery has been performed for so long and so routinely that it is now treated almost as a sacrosanct ritual of childbirth with little or no thought - including by many healthcare providers, themselves - as to the reality of what this surgery entails, why we are doing it, and why we shouldn't.  That needs to change.  My hope is that, when you consider the facts about nontherapeutic circumcision, you will come to view it differently from the way you may have been accustomed to viewing it up until now - just as we now view other discredited medical practices differently from the way they were viewed by previous generations. 

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; if possible, it's even more true when that surgery is universally regarded as medically unnecessary.  And when the patient, such as a neonate, lacks the capacity to exercise and articulate informed consent, unless that surgery is emergently indispensable to protecting that infant's health, medical ethics and respect for the fundamental right of bodily integrity require that that surgery be deferred until that 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 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 permanently removed, I do trust that your capacity for empathy - that same human quality that prompted you to become an ob-gyn in 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 this inexorable trend in bioethics toward greater respect for the bodily integrity, the physical boundaries, and the rights of children, including as these relate 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) are born with the same right to genital integrity that girls are and that healthcare professionals should not be violating that right - is 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 cohort 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 human being, 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,"  (which is simply another way of saying that it is unethical for a medical practitioner to provide a treatment in the absence of a medical problem, such as a disease or harmful congenital deformity).  Nontherapeutic circumcision 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 and unfairly 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 many of the specific provisions of the American College of Obstetricians and Gynecologists' Code of Professional Ethics - perhaps none more so than the principle of autonomy, which is enshrined in the Code as "fundamental." 

For all of these reasons, Doctors Opposing Circumcision 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.  (Additionally, 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 forward 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 if you have any questions or would like to discuss this further, please do not hesitate to contact me directly (my email address is balashinsky@yahoo.com) or Dr. Denniston through the DOC website.

Thank you,

David Balashinsky, P.T.

 

 

About me: I am originally from New York City and now live near the Finger Lakes region of New York. I have been a physical therapist for over 25 years and began my career at NYU Medical Center in New York.  I now do inpatient rehabilitation in a major central NY hospital system.  I currently serve on the board of directors of the Genital Autonomy Legal Defense & Education Fund, (GALDEF), the board of directors and advisors for Doctors Opposing Circumcision and I also serve on the leadership team for Bruchim, an organization that fosters welcoming spaces for Jews opting out of circumcision.
 

An Appeal To Nurses

This is a direct appeal to nurses.  

Like you, I work in healthcare.  I am a licensed physical therapist with over 25 years of experience helping people recover functional mobility following strokes and other debilitating injuries and illnesses.  Although we don't know one another, the fact that you are a nurse 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, I'm proud of my profession, and I'm especially proud to work in a profession that has its roots in nursing because nursing epitomizes what healthcare is all about: helping people heal and alleviating their pain.

Healthcare is not just one of the most honorable human endeavors.  Because of its life-and-death consequences, it is also one of the most rigorously scrutinized and highly regulated.  Even so, it is not without its share of historical missteps.  From bloodletting to lobotomy to the use of IV ethanol as a tocolytic agent to the widespread prescription of Thalidomide to routine episiotomies and unnecessary hysterectomies, the history of medicine is replete with treatments and practices that once were considered state of the art but that subsequently came to be recognized as not only medically unnecessary but, in many cases, even harmful.

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 demonstrates - the scientific method is so essential.  Practitioners at all levels 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 medical practice fails to live up to its 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, even now, not completely behind us.  To this day, and about 3,000 times every day, children are subjected to a harmful and medically-unnecessary genital surgery in fully accredited hospitals throughout the United States under the guise of medical care.  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, as each claim for circumcision has been debunked, a new one has arisen to take its place.
  
• 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."
  
• The AAP last issued a statement endorsing qualified support for nontherapeutic circumcision (even as it conceded that it is not medically necessary) in 2012.  This policy statement expired in 2017 - almost ten years ago - and has never been reaffirmed or renewed.  By definition, this means that the 2012 AAP policy statement on nontherapeutic circumcision is no longer considered an official recommendation.
• 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 "it's 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.
• There is not a single claimed "health benefit" of penile circumcision that cannot be achieved through less 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 females
  
• 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 in any way by having waited until they are adults and capable of exercising informed consent.
  
• As with any surgery, 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 complications including (but not limited to) infection, hemorrhage, meatal strictures, sexual dysfunction in adulthood, loss of the entire penis and, in rare cases, death.
• Penile circumcision removes a natural, essential, sensitive and functional body part.
• The penile prepuce (or foreskin) is the primary sensory organ 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 has been shown to be much more sensitive than the glans of the penis.  All of that sensory function is permanently lost to circumcision.
• Circumcision is irreversible.
  
• Most men who were not circumcised as infants value their foreskins and do not want to have them surgically removed.
• Between 10 and 15 million men in the United States (a number greater than the populations of all but four states in the U.S.) who were subjected to non-therapeutic neonatal circumcision report that, 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, besides loss of the foreskin itself, are scarring at the circumcision site, loss of shaft skin mobility, painful erections, and resentment of having been deprived of their fundamental right to bodily autonomy.
  
• There is an emerging consensus within the medical profession 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, . . . constitutes a violation of the United Nations Declaration of the Rights of the Child, and conflicts with the Hippocratic Oath. . . ."

Perhaps you haven't really thought much about nontherapeutic circumcision before.  The fact is, this genital surgery is performed so routinely that even many healthcare providers seldom think about the reality of what this genital surgery is and what it entails.  That needs to change.  My hope is that, when you consider the facts about nontherapeutic circumcision, you will come to view it differently from the way you may have been accustomed to viewing it up until now - just as we now view other discredited medical practices differently from the way they were viewed by previous generations. 

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.  At the same time, my perspective is that of someone who was subjected to this surgery.  Although I don't expect you to fully understand, if it hasn't happened to you, what it's like to have had the most sensitive part of your genitals removed without your consent, I do trust that your capacity for empathy - that same human quality that prompted you to become a nurse in 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 human-rights advocates, psychologists, attorneys, ethicists, physicians, nurse-midwives, public health professionals, anthropologists, psychologists, sexologists, sociologists, legal scholars and professional medical organizations around the world.  Here, in the United States, one of the organizations that is leading the way is Doctors Opposing Circumcision.  Doctors Opposing Circumcision is 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 human being, 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, health 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 and unfairly solely on the basis of sex; and it violates the principle of autonomy because it permanently forecloses the individual's right to make his own decisions about this part of his body.

It also violates both the spirit and the letter of most of the specific provisions of the American Nurses Association Code of Ethics for Nurses, especially Provision 3: "The nurse promotes, advocates for, and protects the rights, health, and safety of the patient."

Aside from these guiding ethical principles, nontherapeutic penile circumcision violates several other specific principles regarding medical practice.  One of these is that providers may not provide a treatment in the absence of a medical problem (such as a disease or harmful congenital deformity).  Another is that, when there is a disease or other pathological condition, providers should always opt for the least invasive  treatment available and should only resort to more aggressive measures when conservative treatments have failed.  Still another is that providers must obtain consent from the patient before rendering care unless the patient is incapable of providing consent and the treatment is required urgently to save life or limb. Nontherapeutic infant circumcision violates every one of these principles, as well.  Above all, nontherapeutic neonatal circumcision violates the cardinal principle of medical ethics: Primum non nocere; "First, do no harm."

For all of these reasons, Doctors Opposing Circumcision 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.

After listening to Dr. Denniston, I strongly recommend that you listen to the firsthand accounts of a group of nurses - medical professionals like yourselves - who decided that they could no longer in good conscience participate in the harmful practice of non-therapeutic neonatal penile circumcision.  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 comprehensive, evidence-based review of nontherapeutic penile circumcision, see Evidence and Ethics on: Circumcision by Rebecca Dekker, PhD, RN and Anna Bertone, MPH.  And for a more thorough discussion of the ethics of genital modifications in unconsenting children, see "Genital Modifications in Prepubescent Minors: When May Clinicians Ethically Proceed?" 

Finally, I urge 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 obstetrics and neonatal care.  Once you have come to the unavoidable conclusion, as many of us in healthcare already have, that to participate in medically-unnecessary and non-consensual genital surgeries 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.

And if you have any other questions or would like to discuss this further, please do not hesitate to contact me directly at my email address: balashinsky@yahoo.com.

Thank you,

David Balashinsky, P.T.

 

 

About me: I am originally from New York City and now live near the Finger Lakes region of New York. I have been a physical therapist for over 25 years and began my career at NYU Medical Center in New York.  I now do inpatient rehabilitation in a major central NY hospital system.  I currently serve on the board of directors of the Genital Autonomy Legal Defense & Education Fund, (GALDEF), the board of directors and advisors for Doctors Opposing Circumcision and I also serve on the leadership team for Bruchim, an organization that fosters welcoming spaces for Jews opting out of circumcision.
 

 

Dear Jessica Grose - If You're Switzerland, I'm Ukraine (an Open Letter to Jessica Grose)

Dear Ms. Grose,

In your recent essay for the Times, ("Kennedy's Comments on Circumcision Are Only Going to Confuse and Shame Parents," Oct. 15, 2025), you wrote, "Let me say upfront that on the issue of circumcision, I am Switzerland."  Let me say up front that if you're Switzerland, I'm Ukraine.  I say this not to trivialize the monumental suffering and horrendous loss of life among the Ukrainian people nor to equate the harm that was done to my body with the harms that have been done to thousands of Ukrainians but simply to illustrate, in a way that is consistent with your own metaphor, a few important points about your approach to the topic of forced circumcision.  After all, even though there are no credible reports that it has been used in Putin's war against Ukraine, forced circumcision is, in fact, considered a war crime and a crime against humanity and is a tactic with a long history of use in conflicts around the world, including as recently as 2007 in Kenya.  (What does it say about a practice that in one context is viewed as a parent's "choice" but that, in another, is considered a war crime?)

But, to your metaphor - first, as you are no doubt aware, Ukraine's president, Volodymyr Zelenskyy, has repeatedly been excluded by Trump from his discussions with Putin, who is incontrovertibly the aggressor in Russia's war of conquest against its much smaller neighbor.  I think we can agree that it defies reason and the basic principles of conflict resolution - to say nothing of justice - for bilateral talks to include an aggressor nation (Russia) and a third party (the United States) but not the invaded nation itself (Ukraine).  Yet, this is exactly how you approach the topic of forced circumcision in your essay.  Your concern is exclusively for how parents may be made to feel ("confused" and "ashamed") by HHS Secretary Kennedy's assertions concerning a conjectured (and unproved) link between acetaminophen and autism in the context of post-circumcision pain-reduction.  Completely absent is any concern for the infants themselves or for the boys, men, and transwomen that such infants inevitably become and how we might feel about having been circumcised against our will.  If only you had the same concern for our bodies and our right to bodily autonomy that you have for parents' feelings.  Excluding our voices (failing even to acknowledge that they exist) from any consideration of the topic of forced circumcision is like excluding Ukraine from negotiations to end the war.

Second, you profess neutrality on forced circumcision yet, immediately after doing so, you make a categorical statement in support of it (". . . there are real health benefits to the procedure. . . .").   And while there have been numerous peer-reviewed, scientific and academic papers and professional medical position statements raising serious ethical, medical, and epidemiological objections to forced circumcision, you fail to acknowledge any of these in your essay.  An impartial treatment of the topic (even one in which the topic of forced circumcision is almost tangential since Kennedy's comments were primarily about acetaminophen) would have included, at the very least, an acknowledgement that there is (and has been for a long time) a robust body of criticism of forced circumcision (to say nothing of providing links to some of these sources) by legal scholars, medical researchers, ethicists and physicians themselves.  Instead, the only published academic works to which your article links are those supporting forced circumcision.  That's not Switzerland. 

At the same time, following the example set by Mark Joseph Stern - whom you quote at length and to whose essay criticizing intactivism your essay links - you lump all forced-circumcision opponents together under the label of "intactivists" whom you characterize as "entrenched and aggressive internet partisans" and whom Stern, as you paraphrase him, has accused of making "untrue and exaggerated claims."  Let us assume, if only for the sake of argument, that everything you (and Mr. Stern) say in disparagement of the most hardcore intactivists is true: pointing to internet trolling and portraying intactivist keyboard warriors as the sole representatives of the movement to end non-therapeutic, forced penile circumcision (which, you should know, is but one part of a broader genital autonomy movement that includes efforts to eradicate female genital cutting and medically unnecessary intersex surgeries) is merely a way of discrediting that movement.  This rhetorical technique is first cousin to a straw-man argument.  Focusing solely on extremist spokespeople for a cause makes it easy to delegitimize the cause altogether and saves one the trouble of having to engage with its more temperate emissaries on the actual merits of their position.  Thus does your essay depict forced-circumcision opponents to your readers (many of whom are likely unfamiliar with the mainstream medical and ethical objections to this practice) as being invariably hyperbolic, "anti-establishment," unscientific, and unreasonable in contrast to forced-circumcision advocates whom you represent as "reasonable."  This oppositional and highly unbalanced framing strongly suggests a bias against the former and in favor of the latter.  That's not Switzerland, either.  If anything (and to stretch the Switzerland/Ukraine analogy a bit), it's Belarus.

You wondered whether "it's useful . . . to get into the wacky statements Kennedy makes" (and by the way, I happen to agree that they are not only "wacky" but dangerous) but ultimately concluded that "it's necessary because his public statements have so much power and reach." You might not have quite the platform that Kennedy has but much the same can be said of you, which is why I'm writing this open letter.  After all, 50 to 100 million people visit the New York Times each week.  That's an awful lot of potential readers of an article that greatly mischaracterizes and even misrepresents the truth about forced circumcision, about those who support it and about those who oppose it.  So allow me to attempt to undo some of the damage by correcting, both in a general way and specifically, some of the misinformation in your essay.

First, since your approach to this topic at least to some extent mirrors that of Mark Joseph Stern (though without the contumely), I think you should be aware of a point-by-point rebuttal to Stern that was written by Brian D. Earp not long after Stern's piece came out in Slate.  Dr. Earp is a widely respected bioethicist who has written extensively on this topic.  He currently serves as an Associate Professor of Biomedical Ethics at the National University of Singapore and is also a Research Associate of the Uehiro Oxford Institute of the University of Oxford.  Not coincidentally, Dr. Earp was a finalist for the John Maddox Prize (in 2020).  This is known, informally,  as the "Standing Up for Science" Prize and is awarded jointly by Sense About Science and Nature. The Maddox Prize recognizes "researchers who stand up and speak out for science and evidence-based policy [my emphasis], advancing public discussion around difficult topics, despite challenges or hostility, and successfully making a change in public discourse or policy."  Earp, to put it simply, is the antithesis of the stereotype of intactivists that you presented to your readers.  He cannot be dismissed as an "entrenched and aggressive internet partisan" nor does he make "untrue and exaggerated claims."  On the contrary, one need not resort to such polemical excesses in order to refute, as I believe Earp has successfully done, Stern's opinion piece in Slate.  Rather than reinvent the wheel, therefore, I will simply encourage you - nay, I implore you - to read Earp's "An Open Letter to the Author of 'How Circumcision Broke the Internet.'"  Everything Earp says there applies to your recent essay, as well.

Second, your readers deserve to know a thing or two about the authors you cite in support of forced circumcision and whose opinions and conclusions you treat as dispositive.  The first of these is Aaron A. Tobian, MD, PhD, to whose paper, "The Medical Benefits of Male Circumcision" your article links with the statement "there are real health benefits to the procedure."  According to Retraction Watch, which reports retractions in scientific journals and which is a project of The Center for Scientific Integrity (itself the recipient of a MacArthur Foundation grant in 2014), Tobian was the "sole reviewer" of a 2016 article in support of medical circumcision by Brian Morris (with whom Tobian is a "frequent collaborator") co-authored by John N. Krieger and Jeffrey D. Klausner in the World Journal of Clinical Pediatrics.  As RW reported, because of the inherent conflict of interest (Tobian's having reviewed the article notwithstanding his prior collaboration and ongoing association with Morris), the article should have been retracted.  The publisher of WJCP, however, refused to pull the article and, as a result, its editor resigned in protest.  When RW contacted Tobian, "he declined to comment, saying 'I am conflicted.'"  RW notes in its reporting on this episode that there were two comments on Morris's article, one by "circumcision critic John Dalton and the other a response by Morris."  RW then includes part of Dalton's comment, which provides context for anyone who wants to evaluate the merits of any pro-circumcision article written by Dr. Tobian:

Morris, Krieger, Klausner and reviewer Tobian are members of an authorship cartel who seek to promote circumcision by co-authoring papers and reviewing each other's work.  They also seek to repress papers with opposing views by writing damning reviews.

Your readers should have been informed, therefore, that the authority whom you cite in support of forced circumcision is every bit as much a partisan as the intactivists you criticize for their partisanship.  Incidentally, do the tactics of Tobian et al. described here - "seek[ing] to repress papers with opposing views by writing damning reviews" - differ substantially from the online tactics of intactivists that you (and others linked through your article) decry?  

As for Brian Morris, since his name has come up, although you did not cite him directly nor link to any of his published "studies," Stern does in his screed against intactivists that you cite in your essay.  Responding to Stern, Earp likewise provides some context about Brian Morris:

. . . Professor Morris runs a pro-circumcision advocacy website, has founded a highly active circumcision lobby group (some of whose board members derive a substantial income from performing circumcisions), and has recently been profiled in the International Journal of Epidemiology as being engaged in systematically distorting the academic literature on circumcision [hyperlinks in original]. . . .

The point of all this is that, while calling yourself Switzerland, you very clearly apply a double standard to the antipodes in the forced-circumcision controversy.  Those who oppose it you dismiss as "[v]ery loud anticircumcision partisans [who] have been flooding the comments of articles and social media posts about the procedure for over a decade."  Those who support it, on the other hand, you cite uncritically as measured, disinterested authorities - the "adults in the room," if you will.  The result, if not the intent (or is it?), of this disparate treatment is to present opposition to forced circumcision as inherently irrational and support of it as valid by default.  Again, that's not Switzerland.

Consistent with this approach, the other ostensibly neutral but arguably pro-forced-circumcision authority that you cite is the American Academy of Pediatrics.  Quoting the AAP's defunct 2012 Circumcision Policy Statement (a document that expired years ago and that should be regarded as having only as much relevance as is consistent with that status) you write that it "seems reasonable" to claim that "'parents ultimately should decide whether circumcision is in the best interests of their male child'" and that "'they will need to weigh medical information in the context of their own religious, ethical and cultural beliefs and practices [my emphasis].'"  Only in a nation where male genital cutting is a deeply entrenched social custom - one in which male genital cutting has been normalized and medicalized - could an otherwise thoughtful journalist write in the New York Times that it "seems reasonable" to claim that "religious, ethical and cultural beliefs and practices" are valid criteria on the basis of which a parent may decide to subject a child to a medically unnecessary genital surgery.  Or, to put that more bluntly (and at the risk of appearing to be one of those internet partisans), that it "seems reasonable" for the AAP to cite "religious, ethical and cultural beliefs and practices" in support of a parental right to visit upon a child precisely the same act that in another context is considered a war crime.  That's also not Switzerland.  

If the AAP's 2012 position on forced circumcision "seems reasonable" to you, the reason it does - to give you the benefit of the doubt - may simply be that you are writing from the perspective of someone who is a product - as we all are - of a male-genital-cutting culture.  To me, however, someone who was subjected to this genital surgery without my consent and who has had to live with the consequences of it, the AAP's 2012 Policy Statement is anything but reasonable.  On the contrary, I don't see how it is any different from arguing that it is the prerogative of parents to decide that female genital cutting (but let's call it "labiaplasty" or, better still, "female circumcision") is in "the best interests" of their female child after weighing the "medical information in the context of their own religious, ethical and cultural beliefs and practices."  This "medical information," after all, could include the opinions of medical professionals who actually claim that female circumcision has health benefits ("It has been proven scientifically that women are healthier if they are circumcised," according to one Egyptian gynecologist as reported by Amy Wright Glen in 2015), or it could simply include the (implied) medical imprimatur for female circumcision that one may reasonably infer from the fact that more than 25 percent of female genital cutting procedures worldwide are now performed by healthcare providers.  What about parents who decide to withhold medical treatment from their children after weighing the "medical information in the context of their own religious, ethical and cultural beliefs and practices"?   What about parents who choose "conversion therapy" for their gay or gender-non-conforming child after weighing the "medical information in the context of their own religious, ethical and cultural beliefs and practices"?  How is any of this different from anti-vaxxers (to get back to Kennedy) who withhold life-saving vaccines from their children because vaccines violate "their own religious, ethical and cultural beliefs and practices"?

The problem with this approach, as should be obvious from all of these examples, is that, in attempting to justify "access to [forced circumcison] for families who choose it" the AAP was inviting parents to compare apples to oranges or, more specifically, to weigh matters from two distinct and mutually exclusive "non-overlapping magisteria," as Steven Jay Gould put it.  Gould reconciled the seeming incompatibility and not-infrequent conflicts between religion and science by ceding to each only that which is properly in the domain of each:

The net of science covers the empirical universe: what it is made of (fact) and why does it work this way (theory).  The net of religion extends over questions of moral meaning and value.  These magesteria do not overlap, nor do they encompass all inquiry. . . .  [W]e get the age of rocks, and religion retains the rock of ages. . . .

What, then, would it actually mean to come to a decision about forced circumcision by "weigh[ing] medical information in the context of . . . religious, ethical and cultural beliefs and practices"?  The classic image that comes to mind of the figurative use of "weigh" in this sense is that of Lady Justice holding a double-pan balance scale - like this one:

 

                                                                           GALDEF

- in which facts or evidence supporting one point of view are placed in one pan and facts or evidence supporting an opposing point of view are placed in the other.  While Gould was speaking specifically about religious beliefs, I  think it's fair to say - broadly speaking - that "cultural beliefs and practices," as well as religious beliefs, are not facts and they are not evidence.  The AAP does not specify the amounts of each (that is, how much weight to give them) that should go into the pans or even which pan they should go into.  Were the authors of the AAP 2012 Policy Statement saying that scientific evidence should go in one pan and religion in the other?  Or did they mean that conflicting scientific evidence should go into opposite pans but that the religious and cultural context in which the weighing of evidence occurs should be permitted to alter the gravitational field (to skew the results, that is) so that the scale agrees with a religiously- and culturally-desired outcome?  However the items from these non-overlapping magisteria are distributed, what the AAP asserted in its 2012 statement was nothing less than the radical (and pre-Enlightenment) idea that, in the case of forced circumcision - but only in the case of forced circumcision - whether or not to subject an infant - and only if that infant has a penis - to genital-modification surgery is not a decision that need be made strictly on the basis of medical evidence and in strict conformity with standard, well-established medical ethics (as opposed to personal and culture-specific ethics) and informed by contemporary universal principles of bodily autonomy and individual rights but, rather, is one in which the parents' personal religious, ethical and cultural beliefs and practices may be given as much or even more weight.  That's not science, it's not medicine, and it certainly isn't "reasonable." 

Don't take my word for it.  Almost as soon as it came out, the AAP's 2012 Policy Statement was widely criticized - not just by "entrenched and aggressive internet partisans" but by, among others, physicians from numerous technologically advanced nations with widely respected healthcare systems.  Their response, which, to its credit, the AAP published in its journal Pediatrics, not only criticized the AAP's policy statement on scientific, medical, and ethical grounds but, significantly, concluded that "Cultural bias [in the AAP Policy Statement] reflecting the normality of nontherapeutic male circumcision in the United States seems obvious."  Because it would appear that you are not familiar with this rebuttal to the AAP Policy Statement that you defend as "reasonable" in your article,  an extended quotation is warranted here:

The conclusions of the AAP Technical Report and Policy Statement are far from those reached by physicians in most other Western countries. As mentioned, only [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.  [A condition that, as the authors note elsewhere, can easily be treated with antibiotics and, in any case, is so rare that approximately 100 circumcisions would need to be performed in order to prevent a single case of UTI.] The other claimed 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 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.

Several years after this critique of the AAP's 2012 Policy Statement was published, one of the lead authors of the Policy Statement itself, Andrew L. Freedman, MD, FAAP, published another commentary in Pediatrics in which he as much as conceded the cultural bias for which the AAP had been criticized.  In "The Circumcision Debate: Beyond Benefits and Risks," Dr. Freedman wrote,

To understand the [AAP's 2012] recommendations, one has to acknowledge that when parents decide on circumcision, the health issues are only one small piece of the puzzle.  In much of the world, newborn circumcision is not primarily a medical decision.  Most circumcisions are done due to religious and cultural tradition.  In the West, although parents may use the conflicting medical literature to buttress their own beliefs and desires, for the most part parents choose what they want for a variety of nonmedical reasons.  There can be no doubt that religion, culture, aesthetic preference, familial identity, and personal experience all factor into their decision.  Few parents when really questioned are doing it solely to lower the risk of urinary tract infections or ulcerative sexually transmitted infections.  Given the role of the phallus in our culture, it is not illegitimate to consider these realms of a person's life in making this nontherapeutic, only partially medical decision.

. . . 

In circumcision, what we have is a messy, immeasurable choice that we leave to parents to process and decide for themselves rather than dictate to them. . . .

[W]e have to accept that there likely will never be a knockout punch that will end the debate.  It is inconceivable that there will ever be a study whose results are so overwhelming as to mandate or abolish circumcision for everyone, overriding all deeply held religious and cultural beliefs.

You were right to point out that the AAP "stops short of a universal recommendation" of forced circumcision but the way that you did so (again, not Switzerland) blurs the distinction between medical practice and social custom.  Yes, "the issue is complex," as you say, but it's not medically complex.  The reason the AAP stopped short of making a universal recommendation is because one simply cannot be justified by the medical evidence.  Yet despite this, the AAP still wanted to preserve "access to [forced circumcision] for families who choose it."  "Protecting this option," Freedman wrote in 2016, "was not an idle concern at a time when there are serious efforts in both the United States and Europe to ban the procedure outright."

If there were any doubt as to the lack of a medical justification for forced circumcision sufficient to override (or usurp, more properly) the right to physical integrity and the right to bodily autonomy of people who have been (and continue to be) subjected to it, perhaps it will now be dispelled once and for all by the even more candid admissions by Dr. Freedman and another one of the authors of the AAP's 2012 Policy Statement, Douglas S. Diekema, MD, MPH, in a recently published article in the Journal of Medical Ethics by Max Buckler.  For this paper ("As controversies mount, circumcision policies need a rethink"), Buckler interviewed Freedman and Diekema and both now explicitly acknowledge that, on balance, forced circumcision cannot be justified on medical grounds.  "When you look at all the data," Diekema explains, "I don't think you can honestly say in a recommendation that the benefits outweigh the risks."  Of the 2012 Policy Statement, Diekema now says

"My feeling was that there was not sufficient data to suggest that this is a procedure that should be outlawed, particularly given that there were multiple religious communities for whom this was an important practice.  But I also didn't think paediatricians should be recommending it.". . .  "The only situation in which I would give a recommendation is to the parent who is on the fence.  To them I would say they are probably better off not doing the procedure."

For his part, Freedman likewise acknowledges unambiguously that forced circumcision 

"is a non-therapeutic procedure.  If it can be called a preventative medicine, it is at the very weakest level. . . .  [Y]ou cannot recommend circumcision based on the medical benefit alone." . . .  "[T]he best analogy is that the AAP guidelines are a 'permission slip' for those who want to circumcise their children so that society cannot say they are bad parents or outlaw the practice." . . .  [But] . . . "it's not really a medical practice.  It's only a 'medical procedure' in the sense that medical professionals are performing it."

By that definition, of course, female genital cutting is also a "medical procedure" because medical professionals are performing it.

One can only hope that this will prove to be the final nail in the coffin of medicalized male genital cutting in our society.  It's not, however, the final thing I wanted to mention in relation to your article.  There remains one more non-Switzerland-like passage that I need to address because it epitomizes the rhetorical technique that I have been criticizing here.  Namely, the repetition of the bluntest and most sensational claims of intactivists in order to represent objections to forced circumcision (and by the principle of guilt by association, all objections to forced circumcision) as outlandish and hyperbolic.  Not surprisingly, it is one of your quotations of Mark Joseph Stern, so credit (or blame) goes to him.

"Check any internet message board, and you'll find the same ideas peddled as unimpeachable fact: Circumcision is amputation, a brutally cruel and despicable form of abuse.  It damages penises and violates human rights.  And it irrevocably, undeniably ruins male sexuality for life. . . ."

These ideas do seem shocking on their face.  I can imagine that they would seem especially so to someone who, like Stern - and you, and me, and your readers - was raised in a male-genital-cutting culture.   But the "problem with these arguments" is not, as Stern goes on to say in his Slate essay, "that they're either entirely made up or thoroughly disproven."  The problem, rather, is that they're mostly true. 

My medical dictionary (Mosby's Medical, Nursing, & Allied Health Dictionary) defines "amputation" as "the surgical removal of a part of the body or a limb or part of a limb."  The prepuce, or "foreskin" is a part of the body and an integral part of the penis.  Ergo, removing it surgically is, by definition, an amputation.  While there are those who prefer to categorize circumcision as an "ablation," Mosbys' first definition of "ablation" is simply that it is a synonym for "amputation."  In its second sense, "ablation" is differentiated from "amputation" by defining the former as "an excision of any part of the body or a removal of a growth or harmful substance."  Given that the male prepuce has been devalued in our culture and is often regarded as mere "excess skin," I can see how "ablation" might be the preferred term to describe its removal among those who share the view that the prepuce is an extraneous "growth."  Similarly, because the penile prepuce has been pathologized for over 150 years (Peter Charles Remondino, for example, referred to the prepuce as a "malign influence" and another popular nineteenth-century source called it a "mark of Satan"), I can see how "ablation" of the foreskin fits with the view of the penile prepuce as a "harmful substance."  But no matter how you slice it (to be tastelessly apposite) circumcision is, medically-speaking, an amputation.

As for whether or not forced circumcision "damages penises," given what study after study after study after study have all demonstrated about the sensory and functional properties of the penile prepuce and how critical it is to the overall natural functions of the penis, it goes without saying that removing it "damages" the penis.  That would be true of any body part: removing an ear would damage one's hearing; removing a finger damages the hand; removing a fingernail damages a finger.  Only in the case of the penile prepuce is an exception so often made to this rule of bodily integrity such that removing it is not held to be damaging but, rather, is treated as benign at worst and downright beneficial, at best.  But, again, this is a cultural view of the penile prepuce as a worthless or even a "malign" appendage.  (If it's worthless, how can the penis be damaged by removing it?)  It is not the view of the penile prepuce, however, that is supported by science, including the sciences of anatomy, physiology, and medicine. 

Forced circumcision "violates human rights."  Yes, it does.  Most emphatically it does.  Several important human-rights instruments, including the Universal Declaration of Human Rights, include language under which forced, nontherapeutic penile circumcision cannot be viewed as anything other than a human rights violation.  As Frisch et al. have pointed out, forced circumcision "constitutes a violation of the United Nations' Declaration of the Rights of the Child."  Cutting off part of an infant's or child's normal, healthy genitals - whatever their sex or gender may be - before they can consent or effectively object is a human rights violation.  That should be obvious to anyone who values bodily integrity and subscribes to the belief that every human being has an innate and inviolable right to bodily self-ownership.

As for the claim that forced circumcision "ruins male sexuality for life," that's a subjective determination, which means that if it cannot be proved that it does, neither can it be proved that it doesn't.  Stern cites the examples of men who exercised a (presumably) informed choice to undergo circumcision who didn't regret doing so but ignores other similarly situated men who did come to regret it, citing, among other things, diminished sexual sensation and function.  Speaking for myself only, I was in my 50s before it even dawned on me that PIV intercourse is supposed to be physically pleasurable for the male partner.  Having compared my experience with other men who were subjected to circumcision and contrasted it with others who were not, there is no doubt in my mind at all that what I experience or don't experience in the way of sensation is due entirely to the fact that I was subjected to circumcision.  On the principle of Occam's Razor, the fact that the primary sensory part of my penis was removed shortly after birth is the explanation for this that is most likely to be the right one.  Can I prove what I feel or don't feel?  Of course not.  But the fact remains that, because I was subjected to circumcision at birth, I have no way of knowing what intercourse might feel like otherwise.  More to the point, I will never know what sex is supposed to feel like because what was done to me cannot be undone.  Was my sexuality "ruined"?  Not completely.  But it was definitely harmed and that harm has been present throughout my life and will last for the remainder of my life.

As for the claim that forced circumcision is a "a brutally cruel and despicable form of abuse," as I have mentioned already, forced circumcision is considered a war crime and a crime against humanity.  Calling it "a brutally cruel and despicable form of abuse," therefore, does not seem so far-fetched or out of bounds.  If a comparable act of genital cutting were committed against any adult of any sex (that is, female, intersex or male), it would be treated under the law as a criminal assault.  If one is disposed to regard the forced circumcision of an infant or child as fundamentally different from the forced circumcision of an adult, it may be illuminating to watch a video (at 10:20 in this presentation) of this "procedure." 

Having said this, I do not share the view that forced circumcision, as routinely practiced, is intended as "a brutally cruel and despicable form of abuse," nor is that the view of most mainstream opponents of forced circumcision.  I have no doubt that, for the most part, parents who subject their children to circumcision believe that this particular form of genital cutting is not something they do to their children so much as something they do for them.  But that doesn't make it right or any less harmful.  Nor does it make it any less of a human rights violation.  After all, this is exactly the view of parents who subject their children to female genital cutting in those societies where this practice is still prevalent.  They don't view female genital cutting as "mutilation."  They view it as culturally significant, socially important and, in some cases, religiously mandated.  They also love their daughters every bit as much as we love our sons.  So, while there are certainly some intactivists who go out of their way to ascribe evil intent to those who impose genital cutting on their children, most opponents of genital cutting of all types, including forced circumcision, do not and, instead, prefer to live by the motto, "When we know better, we do better." 

It's not hard to understand why Stern was so triggered by the claims of intactivists.  As with any deeply entrenched cultural practice, forced circumcision is not just "normal" but normative, which is to say that the state of being circumcised is accepted as an unquestionable good and the practice of circumcising is regarded as sacrosanct.  Moreover, because it has been so thoroughly normalized in our culture, the state of being circumcised is treated as the default and the state of being intact is regarded as a deviation from the norm (hence, "uncircumcised," rather than "intact").  To someone who is of and a part of our own male-genital-cutting culture, any criticisms of forced circumcision are bound to seem like exaggerations and the critics themselves are bound to seem like extremists.   Forced circumcision is probably even more a special case among cultural practices because of the nature of the practice itself, including its involving an act of ritualized cutting and an act of cutting that which is regarded universally as intimate sexual anatomy.  Having it questioned, therefore, to say nothing of hearing it attacked in the "unfiltered" language that intactivists are wont to use, could easily lead to cognitive dissonance, the mental discomfort that results when new information conflicts with one's deeply held, preexisting beliefs.  That could explain the over-the-top scorn for intactivists that Stern displayed in his Slate essay.  This phenomenon, as it plays out in the case of society's coming to terms with forced circumcision, has been distilled into a few simple lines (which have been attributed to Marilyn Milos but also to Gabor Maté) : "No parent wants to believe that he has harmed his son, no man wants to believe that he was harmed, and no physician wants to believe that he has harmed a patient."

I hope you will revisit and revise your views on forced circumcision - both in your heart and in your column - and become less like Switzerland (to take you at your word) and more like Iceland (ranked number one in human rights).  (Not surprisingly, Iceland has come closer than almost any nation on Earth to banning the forced circumcision of anyone under 18 when not absolutely medically necessary.)  In time, if you view all the medical evidence in its totality, I believe you will come to agree with the medical professionals who have stated that forced "[c]ircumcision fails to meet the commonly accepted criteria for the justification of preventive medical procedures in children," that it "is a non-therapeutic procedure" and that parents "are probably better off not doing" it.  What's more, I hope you will weigh any medical evidence that you may find in support of forced circumcision not "in the context of . . .  religious, ethical and cultural beliefs and practices" that tilt the scales in favor of male genital cutting but, rather, in the context of contemporary standards of universal human rights which, by default, would result in an overwhelming preponderance of weight in favor of bodily integrity and personal bodily autonomy.  If you do this, I believe that you will conclude, as so many establishment medical professionals, legal scholars,  bioetchicists, and, yes, intactivists, have concluded, that physical integrity, self-defined boundaries, and autonomy deserve to be defended.  You know, like Ukraine. 

David Balashinsky

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About me:  I'm originally from New York City and now live near the Finger Lakes region of New York. I'm a licensed physical therapist and I write about bodily autonomy and human rights, gender, culture, and politics. I currently serve on the board of directors for the Genital Autonomy Legal Defense & Education Fund, (GALDEF), the board of directors and advisors for Doctors Opposing Circumcision and the leadership team for Bruchim.