Monthly Archives: August 2016

AAP 1984 – or how circumcision causes amnesia

As told by Steven Svoboda of Attorneys for the Rights of the Child, on October of 2013 there was a debate at the Medical University of South Carolina in Charleston, South Carolina, during which, Dr. Michael Brady MD, one of the 8 members of the American Academy of Pediatrics’ task force on circumcision responsible for the Policy Statement and Technical Report of 2012, declared: “I don’t think anybody knows the functions of the foreskin,” and then reiterated, “Nobody knows the functions of the foreskin.”

That is strange, because just 29 years earlier the American Academy of Pediatrics had a pamphlet discussing the “Care of the uncircumcised penis”, which included a brief discussion of some of the functions of the foreskin, and a drawing clearly showing the anatomy of the intact penis.

The first edition of this 1984 pamphlet had the word “uncircumcised” spelled incorrectly: “uncircumcized”. There was a second batch printed with this misspelling corrected, but then, when a new batch was printed in 1990, the paragraph about functions of the foreskin and the anatomical drawing suddenly went missing.

Ronald Goldman, Ph.D., of the Circumcision Resource Center, started inquiring about this curious omission on January of 1996. He contacted the AAP eight times about this change. After having been passed by four  AAP officials, he finally obtained this response in September of 1996:

The reviewers felt it was not necessary to reinstate the paragraph because the revision of the brochure included a complete reorganization of the information contained in previous editions.”

According to Dr. Goldman, a comparison of new and previous editions did not show “complete reorganization of the information” and there was no reason why the removed information would have stopped being relevant to parents.

In fact, the AAP still has a page on the “Care for an uncircumcised penis” on their website. It is not a bad page, although there are some things that could be a lot better, and the functions of the foreskin are still missing.

Perhaps if they had listened to Dr. Goldman in 1996, Dr. Brady would have been able to describe some functions of the foreskin when asked about them, during the 2013 debate.

So… what was that controversial paragraph?

The Function of the Foreskin: The glans at birth is delicate and easily irritated by urine and feces. The foreskin shields the glans; with circumcision this protection is lost. In such cases, the glans and especially the urinary opening (meatus) may become irritated or infected, causing ulcers, meatitis (inflammation of the meatus), and meatal stenosis (a narrowing of the urinary opening). Such problems virtually never occur in uncircumcised penises. The foreskin protects the glans throughout life.

This is the anatomical drawing, prepared by Edward Wallerstein (author of the 1980 book “Circumcision: An American Health Fallacy“), which was included in the pamphlet:

wallerstein

It is important to note that no anatomical drawings are included in the 2012 AAP Policy Statement and Technical Report on circumcision. The word “Frenulum” (or “frenum”) does not even appear in either document.

This is a scan of the 1984 pamphlet, as shared by Dr. Goldman (click to enlarge).

AAP1

AAP2

Given these obvious omissions, it seems hypocritical from the AAP to claim, as they do, that “It is important that clinicians routinely inform parents of the health benefits and risks of male newborn circumcision in an unbiased and accurate manner.

Our conclusion is that perhaps circumcision causes amnesia. Selective amnesia. That, or they have a vested interest in maintaining high rates of circumcision for financial gain, but that would be dishonest, wouldn’t it?

Dr. Goldman’s discussion of the pamphlet: http://circumcision.org/pamphlet.htm

CIRP page mentioning this pamphlet: http://www.cirp.org/library/normal/aap/

CIRCUMSTITIONS discussion of this pamphlet: http://www.circumstitions.com/AAP-care.html

Attorneys for the Rights of the Child telling of the 2013 debate: http://www.arclaw.org/our-work/presentations/charleston-debate-marks-turning-point-movement-recognize-circumcision-human-r

AAP Current page: Care for an uncircumcised penis. https://www.healthychildren.org/English/ages-stages/baby/bathing-skin-care/Pages/Care-for-an-Uncircumcised-Penis.aspx

 

 

Doug Diekema and Brian Morris join forces – who made the biggest mistake?

One of our not-so-favorite pedoethicists, Dr. Doug Diekema, in cahoots with our favorite punching bag, Brian J. Morris Ph.D, emeritus (or retired) professor of the University of Sydney, just published a new paper called “critical evaluation of Adler’s challenge to the CDC’s male circumcision recommendation”. Other co-authors are Beth Rivin, Anna Mastroianni, John Krieger and Jeffrey Klausner.

The paper obviously intends to be a response to Peter Adler’s  “The draft CDC circumcision recommendations: Medical, ethical, legal, and procedural concerns”, Int. Children’s Rights 24 (2016), 239–264. It seems that many publications consider Brian Morris the go-to person to review circumcision papers, which also gives him the chance to write lengthy diatribes as response to any paper that oppose the circumcision of children. That way, in the future, Morris can claim that “experts (himself and anyone willing to lend his or her name as co-author) challenged this paper”, always ignoring any response to his response. Man, he can get really tiring.

This is typical Brian Morris’ modus operandi, but recently Mr. Morris has taken to have one of the coauthors appear as the first listed author. Nevertheless, the corresponding author is Mr. Morris.

Once you read the paper, it is nothing but a rehash of Morris’ usual arguments. But before we go into it any deeper, let’s consider the meaning of having Diekema as a co-author:

  • Diekema is one of the 8 members of the AAP Task Force on circumcision that authored the AAP Policy statement on circumcision of 2012.
  • The Policy Statement and accompanying Technical Report did not make reference to any publication by Mr. Morris
  • The members of the AAP Task Force characterized the policy statement as neutral. Diekema himself said to the New York Times We’re not pushing everybody to circumcise their babies, this is not really pro-circumcision. It falls in the middle. It’s pro-choice, for lack of a better word.”
  • Recently (April 2016), a fellow member of the AAP Task Force, apparently a more rational Dr. Andrew Freedman (in spite of circumcising his own baby on his parents’ kitchen table for religious reasons), wrote: “we 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

But, when we read this new “critical evaluation”, we find a position that is far more extreme than what the AAP has ever presented. It’s difficult to understand how Diekema decided to lend his name to this paper. Let’s see how some of the typical Brian Morris’ arguments develop in this paper:

  • Adler’s criticisms depend on speculative claims and obfuscation of the scientific data

    [Morris seems to think that anyone who opposes circumcision is obfuscating data, and that the decision to circumcise depends only on data, and not on the rights, desires and interest of the patient]

  • Adler’s central argument that circumcision in infancy should be delayed to allow a boy to make up his own mind as an adult fails to appreciate that circumcision later in life is a more complex  operation, entails higher risk, is more likely to involve general anaesthesia and presents financial, psychological and organisational barriers

    [To this argument we counter that since 2007 there are some circumcision devices invented with the purpose of making adult circumcision more simple, less expensive and painful, such as the FDA approved PrePex, so it’s up to the medical community to pick up on the new technology and offer those devices – which will likely reduce the cost of adult circumcision to the same levels of neonatal circumcision. It’s likely that the medical community is reluctant to do so because of the reduced profit though. But it’s unscientific to deny that such technology exists and is available at a fraction of the current costs. Besides, a circumcision CHOSEN by one person is less likely to induce psychological harms than one FORCED upon a person when they are too young to remove themselves from the situation]

  • Benefits of male circumcision include

    [Morris’ typical lethany… ]

  • Circumcision does not impair sexual function or pleasure.

    [To claim this, one would have to define sexual function, and would have to find an accurate way of measuring pleasure. Second, science can’t claim it “does not”. At most it can say “it does not appear to”. Third, far too numerous people know that it in facts alters sexual function and causes sexual difficulties which vary with different people. Brian Morris intended to erase this with a meta-analysis a few years back, but the argument is far from over. Morris himself has said that “The foreskin is an absolute requirement for a mutual masturbation practice amongst homosexual men known as "docking", in which the penis is placed under the foreskin of the male partner” – so if the foreskin an “absolute requirement” for this, then sexual function and pleasure are impacted, at least for this population. Docking is also possible between a male and some females, as long as the male has not been circumcised, so it is not something exclusive of the homosexual population, and even if it was, it would still be within their rights to make an autonomous decision.

  • Since the benefits vastly outweigh the risks, each intervention is in the best interests of the child.

    [This statement is particularly troublesome considering Diekema’s involvement on this article; the AAP specifically said: the benefits outweigh the risks (not “vastly”), “but the benefits are not great enough to recommend universal newborn circumcision” and “The true incidence of complications after newborn circumcision is unknown”. Fellow task forcer Andrew Freedman described circumcision as having "some modest benefits and some modest risks". So how Diekema could lend his name to the previous statement is really problematic.

  • From that point on, Morris states: “Below, we summarise the scientific and legal evidence that contradicts each of Adler’s arguments”

    [At this point however, I will quote Andrew Freedman, referenced above: “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”]

  • At the end of 3.4.1. Morris claims: “As noted above, the CDC found that benefits of IMF (infant male circumcision) exceed risks by ‘100:1’

    [No, the CDC did not find that. The CDC quoted one paper by Brian Morris where he claims this number, so this is just a circular reference to himself. BTW, this number really has no meaning, it's just an emotional argument disguised as a number.]

Brian Morris is selective as always in what he presents as evidence. For example he claims that “Early circumcision also greatly reduces the risk of penile cancer (Daling et al., 2005; Larke et al., 2011) and prostate cancer (Wright et al., 2012).” On prostate cancer, Wright himself explained to Reuters: “I would not go out and advocate for widespread circumcision to prevent prostate cancer. We see an association, but it doesn’t prove causality.”  That, however, doesn’t matter to Mr. Morris.

Most of the discussion though is really irrelevant. Everyone can find a reference to support their opinion, thus leading to the belief that such opinion is “scientific”. And then ignore any other reference which opposes that opinion, as “unscientific”. But the real argument is not one of science or not. It’s one of body ownership.

Trying to contradict this argument, Morris brings up a YouGov survey: “A recent survey found 29 per cent of uncircumcised men wished they had been circumcised, compared with only 10 per cent of circumcised men who wished that they had not been (YouGov, 2015)” It doesn’t matter to Morris that this is a non-scientific, non-peer reviewed, online survey. As long as it fits his views, he will claim it. However, it is important to notice that such comparison is not symmetric, since any uncircumcised man who wishes he had been circumcised could still opt for adult circumcision, particularly demanding the medical community makes available those devices such as the PrePex which would make adult circumcision more simple and less expensive, without the requirement of general anesthesia; however, any percent of men circumcised during childhood who wishes they had not been circumcised, are largely at loss, since the medical community has nothing to offer in the sense of foreskin regeneration, which once again becomes an argument to support delaying any decision until the person can offer informed consent.

It is important to recognize that scientists, even bioethicists (such as the Benatars, Arora and Jacobs, or Diekema himself) are not immune to religious and cultural bias. The Benatars and Jacobs are of Jewish faith and they make the fact that they consider infant circumcision vital to their Jewish identity (which not all Jewish people agree) clear; Jacobs along with Arora, just like Diekema, have gone as far to defend some forms of female genital cutting of minors as parental rights, something that Morris fails to mention.

On the topic of female genital cutting of minors, Diekema defended the ritual nick explaining that “[It] would remove no tissue, would not touch any significant organ but, rather [it] would be a small nick of the clitoral hood which is the equivalent of the male foreskin – nothing that would scar, nothing that would do damage” – again, a fact missed by Morris in his decision to call Diekema to join hands in this paper.

Diekema himself wrote: “The real art of bioethics is convincing other people why something is right or something is wrong and why something shouldn’t be done or should be done. Many people aren’t going to pay attention to you if that argument is crafted purely in religious language. One of the things that I’ve had to do is craft arguments in the language of the world, which I have not found to be particularly difficult. The reality is that medical ethics has its roots largely in theological ethics, so the basic principles that many people who are not religious subscribe to actually have very strong roots in the Bible and in religious belief.” For the open minded reader I ask, are those the arguments of a scientist or a theologian?

Finally, let’s just remember a few of Diekema’s faults (see IntactWiki for references):

  • Clearing the “Ashley treatment” – where a severely disabled girl was subjected to removal of her breast buds, hysterectomy, appendectomy and growth attenuation, a treatment later declared illegal without the order of a court. Dr. Daniel F. Gunther, a doctor involved in this case, committed suicide shortly after for unclear reasons
  • Defending the AAP’s policy statement on “Ritual genital cutting of female minors” and the ritual nick.
  • Defending parents who allowed a teenage son to die without medical treatment because he believed in faith healing.
  • Misrepresenting the death of baby Joshua Haskins in a radio interview (during the presentation of the 2012 policy statement). In this interview Diekema claimed that this case “involved a very sick baby that was likely to die anyway and his parents wanted him circumcised before his death” – when in fact the parents had been fighting along with the baby for his life, and they were told that their baby was now strong enough to tolerate the circumcision – but then allowed to bleed for several hours from the circumcision site, leading to the baby’s cardiac arrest and death.
  • Diekema and fellow task force Michael Brady were shamefully defeated in a debate, by Attorneys for the Rights of the Child member Steven Svoboda and his staff, a debate in which Brady declared:  “I don’t think anybody knows the functions of the foreskin. Nobody knows the functions of the foreskin.” One of Svoboda’s staff members was able to point to his experience as intact male, and how his foreskin is part of his sexual life on a regular basis.

After the release of the 2012 statement, Intaction offered Diekema the “Mengele award”, one that Diekema didn’t make a speech for.

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Intaction member Anthony Losquadro offers Doug Diekema the “Mengele award”
Photo by James Loewen.

 

So, after all this, I don’t know who made a more questionable mistake here, Brian Morris by enlisting the questionable Doug Diekema as a coauthor, or Doug Diekema, by lending his name to extreme pro-circumcision arguments that are not even compatible with those of the Policy Statement that he and his fellow AAP Task Force members presented. What do you think?