An Appeal to Nurses

This is an appeal to nurses everywhere but, especially, here in the United States.  

Like you, I work in healthcare.  I am a licensed physical therapist with over 20 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 get better.

Unfortunately, although healthcare is among the most honorable and rigorously scrutinized of human endeavors, it is not without its share of historical missteps.  Sometimes, these have been well-meaning interventions that simply did not withstand the test of time.  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 have come to be recognized as not only medically unnecessary but, in many cases, even harmful.

Regrettably, the history of medicine also includes episodes that are even less honorable: practices that are 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, "aversion therapy," even lobotomies in a misguided attempt to "cure" them of their gayness.

Unfortunately, for as long as medical practice has existed, medical malpractice and human-rights violations committed in medicine's name seem to have existed alongside it.  That is why those of us who are medical professionals have a special obligation to speak out when medical practice fails, as it has so many times in the past, to live up to its own ethical standards, beginning with the cardinal principle, primum non nocere: "first, do no harm."

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 (more than one million times every year), 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 non-therapeutic neonatal penile circumcision and these are the facts about this surgery:

• Every professional medical organization, both here in the United States and abroad, that has looked at this surgery has concluded that it is medically unnecessary.
• Despite being medically unnecessary, non-therapeutic penile circumcision remains one of the most commonly performed surgeries in the United States.
• The medical profession acknowledges that neonatal penile circumcision is unnecessary yet permits this lucrative genital surgery to continue and profits from it anyway.
• 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 a medically unnecessary 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 (who develop UTIs ten times as often as males do)
  
• the use of condoms and other safe-sex practices to prevent the transmission of STIs.
• Non-therapeutic 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 actually make this choice (which is not surprising), those who do are not harmed in any way by having waited until they are adults and capable of exercising informed consent.
  
• When performed on infants, circumcision is excruciatingly painful yet often is performed without any anesthetic and always performed without adequate anesthetic.
• Penile circumcision removes a natural, essential, sensitive and functional body part.
• The penile prepuce (or foreskin) is the primary sensory organ of the penis with a greater concentration of specialized light-touch receptors than is found in the glans or in any other part of the penis or, for that matter, in any other part of the body except the fingertips and lips.  All of that sensory function is permanently lost to circumcision.
• Non-therapeutic neonatal circumcision is irreversible.
  
• The overwhelming majority of men who remain intact value their foreskins and do not want to have them surgically removed.
• Consistent with this, many men 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.  Beyond objecting to the irreparably diminished capacity for erotic experience that necessarily results from this surgery, they resent having been deprived of their fundamental right to bodily autonomy: the right to make their own decisions about their bodies, including which healthy parts they get to keep and which healthy parts get cut off.
  

 

Perhaps you haven't really thought much about non-therapeutic 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 non-therapeutic 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 also 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 a medically-unnecessary and irreversible genital surgery.  At the same time, my perspective - which I hope you do not share - is that of someone who was subjected to this surgery.  Although I don't expect you to comprehend what it's like to have had part of your genitals cut off without your consent if it hasn't happened to you, 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 respect 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 outrage, as well.

If you do already, the good news is that we are not alone.  Non-therapeutic neonatal circumcision has been condemned by many of the world's leading human-rights advocates, psychologists, attorneys, bio-ethicists, physicians and professional medical organizations.  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 more than 25 years ago by George Denniston, MD, MPH in order to help bring about an end to the unconscionable practice of subjecting unconsenting children to 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

Non-therapeutic neonatal penile circumcision violates every one of these ethical principles.  

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 [my emphasis]."

For all of these reasons, Doctors Opposing Circumcision is working to end what, for too long, has been 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 hope you will 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.  In 1995, these conscientious objectors went on to found the organization, Nurses for the Rights of the Child.  As explained on its website, 

Nurses for the Rights of the Child is a non-profit organization dedicated to protecting the rights of infants and children to bodily integrity.  As health professionals, we specifically seek to protect non-consenting infants and children from surgical alteration of their healthy genitals. 

I encourage you to visit the NRC website in order to learn what your fellow nurses are doing to protect children from medically-unnecessary genital surgery.

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 non-therapeutic penile circumcision, see Evidence and Ethics on: Circumcision by Rebecca Dekker, PhD, RN and Anna Bertone, MPH.

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.  Nurses for the Rights of the Child also provides information on conscientious objection in a brochure that can be downloaded from its website.  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.  Both the DOC and NRC websites have 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 twenty 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.