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, 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 - 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. Yet 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 gone so far as to explicitly reverse themselves, one of them (Douglas Diekema, MD, MPH) stating "I don't think you can honestly say in a recommendation that the benefits outweigh the risks," and the other (Andrew Freedman, MD) stating "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 (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.
- 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.
- Nontherapeutic neonatal circumcision is irreversible.
- Most men who were not circumcised as infants value their foreskins and do not want to have them surgically removed.
- Statistically significantly numbers of men who were subjected to non-therapeutic neonatal
circumcision report, when asked, 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 are decreased penile sensation 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. . . ."
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.
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