Monthly Archives: July 2013

patrick_izimba

Safe Male Medical Circumcision in Uganda results in penile amputation

Circumcision, like every other surgery, carries some risks. The problem is when promoters argue for a surgery without medical indication and minimizing every risk in order to entice the patients to undergo the procedure.

As we know, the West is currently promoting VMMC (voluntary male medical circumcision, safe male medical circumcision) in some countries of Africa as part of the package for HIV prevention. A lot of emphasis has been set on reducing the costs of the procedure by looking for new methods (such as the PREPEX, the TaraKlamp, the Shang Ring) and trying to perform the procedure without the need for a surgeon, with minimally trained personnel.

Of course this is going to lead to complications, such as what happened to Patrick Izimba in Uganda, reported on July 16th of 2013. Patrick Izimba was enticed by one of the signs offering safe male medical circumcision, and what followed is every man’s nightmare. His penis suffered gangrene and was transferred to a specialist. Plastic surgery will be used to reconstruct his penis, but he won’t be able to have sex.

When you promote mass circumcision, these events are bound to happen. Yet, this the the message that circumcision promoters are sending to Africa:

Check out the explicit manifesto on their page: “Importance of establishing circumcision as a social norm is stressed“. It’s not about health, it’s not about preventing a disease, it’s about creating a social norm.

Let’s quickly visit the WHO’s manual for male circumcision with anesthesia, and on page 16 let’s check the listed risks:

Risks
As for any surgical procedure, there are risks associated with
circumcision. While the benefits of circumcision may be wide-ranging
and long-term, any problems generally occur during or soon after the
procedure. They include:

•pain;
•bleeding;
•haematoma (formation of a blood clot under the skin);
•infection at the site of the circumcision;
•increased sensitivity of the glans penis for the first few months
after the procedure;
•irritation of the glans;
•meatitis (inflammation of the opening of the urethra);
•injury to the penis; 
•adverse reaction to the anaesthetic used during the circumcision.

These complications are rare when circumcision is performed by well
trained, adequately equipped, experienced health care personnel, and
are usually easily and rapidly resolved. Data from controlled trials
show that fewer than 1 in 50 procedures result in complications.

Did I miss loss of the penis? Or is the loss of the penis darkly lumped into “injury to the penis”? When considering the reality of a man who just lost his sexual organ, does it make sense that these complications are rare and easily and rapidly resolved?

The news article about Patrick Izimba mentions anesthesia as possible cause of the gangrene. The WHO’s manual on male circumcision with anesthesia indicates:

“Lidocaine with epinephrine must not be used because there is a risk of constriction of the blood vessels to the whole penis, which can cause gangrene and loss of the penis”. 

Is this what happened? Was he told that gangrene and loss of the penis were possible risks of the procedure? If not, his consent was not informed consent.

Page 148 of the manual also states indicates:

Worsening wound infection with signs of gangrene. A rare risk
of genital surgery is infection with multiple bacteria, causing
progressive skin loss. In this situation, the blood supply is cut off,
and the skin becomes necrotic and turns completely black. This
condition is known as Fournier’s gangrene (synergistic gangrene
or necrotizing fasciitis) and is more common in men who have
diabetes. Any man with signs of spreading infection or black
gangrenous skin should be urgently transferred to a referral
centre. At the referral centre, it is usually necessary to give a
general anaesthetic and remove all the dead skin

And while we are in page 148 of the manual, let us wonder if men are advised about the possible late sexual complications, or are they reassured that their sexual function won’t be impacted? Page 148-149 describes late complications such as:

In the long term, the client may complain of:

• decreased sensitivity of the glans;

• oversensitivity of the glans;

• unsightly circumcision wounds, ragged scars or other cosmetic
concerns;

• persistent adhesions at the corona and inclusion cysts. These
problems can be avoided if the foreskin is fully retracted during the
operation and all adhesions carefully divided;

• discomfort during erection from the scrotal being skin pulled up the
shaft of the penis and a tight scrotal sac. This can result from
removal of too much skin during the circumcision. These problems
can be avoided by careful preoperative marking of the incision
lines.

• torsion (misalignment) of the skin of the penile shaft. This can be
avoided by taking care during the operation to align the midline
raphe with the frenulum.

Is this the new social norm? Males with unsensitive glans, unsightly scars and uncomfortable erections when the scrotum is pulled up by the penis because it doesn’t have enough skin to accommodate a normal erection? Is this the American gift to Africa? Are we transferring the American wound?

Appendix 6.2 of the WHO’s Manual shows a sample consent form for a minor. The consent form does not list the risks and complications of circumcision. It merely states that the parents were counseled on the existing risks. Without a written record, how are they to ensure that providers won’t be lying about the complications and exaggerating the benefits, when their expressed intention is to establish circumcision as a social norm?

Background

Gangrene and loss of penis is a frequent complication of traditional African circumcisions, due to the risk of infections and terrible conditions in which the procedure is usually carried. However, loss of the penis also occurs in sterile conditions. It happened in 2012 to a man in China, 2 weeks before his wedding.  In 2008 a man in Kentucky had his penis removed without consent during a circumcision because the doctor found a cancerous tumor; the man sued on grounds that he should have been waken up and given information prior to the amputation, and yet the court sided with the doctor as the consent form enables the doctor to perform any other procedure deemed necessary. And of course there is the well known case of David Reimer, who lost his penis while being circumcised as a baby, was raised as a girl until his teenage years, was reverted (breast reduction, penile reconstruction…), and committed suicide at 39 years.

Circumcision for HIV prevention remains nothing but speculation about a protective effect, with no proven causal reason. The African studies have been challenged by scientists and general public, but for some reason the UNAIDS and the WHO continue to promote circumcision as part of the HIV prevention package without stopping to think critically, sponsored by PEPFAR and the Bill & Melinda Gates Foundation.

The Doctors promote SkinMedica, manufactured with a process involving baby foreskin

I was aware that the TV show “The Doctors”, and particularly Lisa Masterson and Andrew Ordon, had shown a clear pro-circumcision bias, as shown on this video-critique.

Even when they had the chance to speak about personal choice and foreskin restoration, they were not able to discuss the benefits of foreskin restoration, the loss caused by circumcision, rather stating somewhat naively that “surgery on a man’s penis is fraught with complications” (apparently without realizing that this statement on its own is condemning of circumcision)

But what I didn’t know was that they had promoted SkinMedica, an anti-aging cream that is manufactured with a byproduct of culturing foreskin cells. In other words, a newborn’s foreskin is grown over and over and some proteins generated during this procedure are used to make this cream, which is quite expensive. This is only one of many industrial uses of newborn foreskins, and the problem with this is that having an industry that relies on non-therapeutic amputation of foreskins creates an financial incentive to perpetuate the practice of newborn circumcision regardless of any actual benefit or risk to the patient.

Danish Health Board decides that circumcision ban is not necessary

Danish Health Board decides that circumcision ban is not necessary. The current guidelines for male circumcision only require that boys aged 15 and over must consent to the procedure.

Genital mutilation is about power. Minors don’t have it.

The findings disappointed anti-circumcision group Intact, whose deputy chairman Leo Milgrom stated in a press release that it will mean that boys will continue to lose the right to decide over their own body.

“Even without all the weighty ethical considerations, and without all the many legal, sexual and psychological consequences, at the very least a scientific precautionary principle should apply: circumcision should be immediately stopped simply as a result of the scientific uncertainty described in the health agency’s own report,” Milgrom stated.

Intact argues that male ritual circumcision should be stopped because of unpredictable and unintended psychological consequences that the boys might suffer later in life. They argue that banning female circumcision yet allowing male circumcision, which they argue is equivalent, is discriminatory.