Category Archives: Litigation

Reflecting on Nebus vs. Hironimus

Phony phimosis – medical fraud

Physicians examining C.R.N.H. should be warned that they are being observed by thousands of activists, several intactivist organizations, the national and international media and the international community, and any fraudulent referral over “phimosis” will no doubt lead to reports of misconduct and ethics complaints.

In 2013, Dr. Saleem Islam published a study called: “Allocation of Healthcare Dollars: Analysis of Nonneonatal Circumcisions in Florida“, indicating that the cost of circumcisions in the state of Florida had “skyrocketed” since Medicaid stopped covering neonatal circumcisions.

Islam explained: “Parents often explained that they were unable to pay for the procedure after the child was born. We hypothesized that neonatal circumcisions were deferred among families in lower socioeconomic classes because public funding was not available. Circumcisions would then be done when the child was older, a costlier procedure requiring general anesthesia in an outpatient surgical facility.”

After the age of 1, circumcision is a more complex procedure and up to 20 times more expensive, now requiring general anesthesia. The risks also grow by 20 times, according to the CDC’s Charbel El Bcheraou.

Islam wrote: “Our data show the cost of nonneonatal circumcisions in Florida has more than doubled over the 5 years studied, the apparent result of defunding nonneonatal circumcisions. Our experience suggests that parents continue to want the procedure done in early childhood because of the availability of public financing. If public funding were available for the procedure in the neonatal period, they would have had the procedure done then.

But here’s where things go wrong. Neonatal circumcision was defunded because it was an elective, non-essential procedure. In order to obtain a referral and funding for a non-neonatal circumcision, the physician needs to provide a diagnosis – and this diagnosis is usually phimosis or congenital non-retractable foreskin. But the diagnosis of phimosis at that age is usually wrong because the foreskin at that age is not supposed to be retractable.

There is debate over what really constitutes phimosis. Some experts suggest that real phimosis is characterized by lesions caused by BXO – balanitis xerotica obliterans, not just the inability to retract the foreskin.

Øster showed that at age 10, less than 50% of the boys become capable of retracting their foreskins, but between 16 to 17 years close approximately 95% can retract. Thus, diagnosing non-retractable foreskin of a child as “phimotic” and referring to circumcision interrupts the normal development cycle of the foreskin and results in loss of normal healthy genital tissue.

The World Health Organization has made this travesty simpler  by codifying a normal condition as a disease: ICD-10-CM code N47-0 corresponds to “Adherent prepuce of newborn” – and it is a diagnosis that applies to males only. Other related diagnosis continue the N47 series, including phimosis, paraphimosis, deficient prepuce, etc.

Physicians consciously commit fraud when they refer a child for circumcision over a diagnosis of “phimosis”. By playing into the “wants” of the parents, the “tradition”, the cultural or religious arguments, or parental preferences, physicians ignore their duty to their patient and become cultural or religious brokers, referring a non-consenting patient to genital surgery without any real medical indication. This clearly shows that circumcision of children in the United States is nothing but a medical ritual, a harmful traditional practice affecting the health of the boy child – to paraphrase an expression used by the World Health Organization.

As we denounced two years ago, some medical institutions even today, check intact (uncircumcised) boys for retraction during their well checkups, and “offer the option of circumcision” – in what may be perceived by the parents as a recommendation.

Nebus vs Hironimus

This information is particularly relevant to the case of Nebus vs Hironimus, which we have covered in detail this last year. In 2014, Nebus argued that his son, C.R.N.H., suffered phimosis and it was causing him to urinate on his legs. A medical expert testified that C.R.N.H. did not have phimosis and had no medical need for circumcision – a testimony that was cherrypicked by Judge Gillen to suggest that the “benefits” of circumcision were enough to justify enforcing the parental agreement, ignoring the increased risks and fears and the child’s opinion.

Now that Hironimus has been forced to sign a “consent” form (under the threat of indefinite incarceration) and Nebus has been granted wide power to schedule the procedure, in or out of state, and without warning Hironimus in advance or afterwards, the next step is clear: Nebus will seek a referral for circumcision arguing “phimosis” – so that Medicaid or any applicable health plan will pay for the procedure.

Physicians examining C.R.N.H. should be warned that they are being observed by thousands of activists, several intactivist organizations, the national and international media and the international community, and any fraudulent referral over “phimosis” will no doubt lead to reports of misconduct and ethics complaints.

Florida circumcision case – update

Breaking news. Or, heart-breaking news.

After Monday’s first audience in front of a Federal Court, Attorney Thomas Hunker, attorney for Heather Hironimus, filed a Withdrawal of Motion and Notice of Voluntary Dismissal of the federal case.

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Another boy’s right to physical integrity and genital autonomy has gone down the drain. Father is now free to collect his trophy.

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cut these veins
Remember: the medical witness clearly said that the child does not have phimosis and the surgery is unnecessary. The mother expressed her fear of the risks, particularly the risk of death because of the anesthesia. Judge Jeffrey Dana Gillen did not see merit enough in that risk, or the risk of psychological harm, to protect a vulnerable child from an unnecessary genital amputation, performed only to appease the father.

United States of America, the country where men do not own their genitals. Land of the wounded, home of the mutilators.

Arrested for refusing to hand out her child to circumcision

Heather Hironimus, the mother who has been resisting for over one year the order to hand out her child to circumcision, was arrested yesterday at the Domestic Violence shelter where she had been hiding for 81 days. Her son has been handed to the father, Dennis Nebus, who has been fighting to have him circumcised in spite of the doctor’s assessment that there is no medical need for this child to be circumcised.

A Federal case was recently filed by Heather’s attorney against the father of the child, Dennis Nebus, the judge, Jeffrey Dana Gillen, and Palm Beach County Sheriff Ric Bradshaw., arguing that Chase’s constitutional rights have been ignored and are being violated.

Update: Federal Judge Kenneth Marra has scheduled a hearing on all the motions for Monday, May 18th, at 1 pm

Let’s remember that Chase is the vulnerable party in this issue, and the one person who has not been heard at all in the legal proceedings so far.

Heather and Chase still need our help. Please donate to the legal fund at http://www.chasesguardians.org

A candle light vigil is planned for tonight. Details: https://www.facebook.com/events/1579051002367331/

A protest is planned for Monday: https://www.facebook.com/events/1604629103155556/

More information about these disheartening developments:

http://joseph4gi.blogspot.com/2015/05/florida-circumcision-saga-mother.html

http://www.sun-sentinel.com/local/palm-beach/fl-heather-hironimus-booked-bso-20150514-story.html

http://www.cbs12.com/news/top-stories/stories/mom-circumcision-fight-found-jailed-25805.shtml?wap=0

Our first post about this case, May 12th of last year: http://circwatch.org/judge-keep-your-hands-off-my-penis/

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Dennis Nebus - the father of the child, says circumcision is "the normal thing to do".

Dennis Nebus – the father of the child, says circumcision is “the normal thing to do”.

Judge Jeffrey Dana Guillen has played doctor through the legal proceedings, touting the benefits of the procedure, dismissing the risks, dismissing Heather's fears and Chase's wishes, and ignoring the expert testimony that the circumcision is not medically necessary and the doctor himself wouldn't circumcise a son at that age.

Judge Jeffrey Dana Gillen has played doctor through the legal proceedings, touting the benefits of circumcision, dismissing the risks, stating that it can be done with local anesthesia (all real doctors will disagree) dismissing Heather’s fears and Chase’s wishes, and ignoring the expert testimony that indicated that the circumcision is not medically necessary in this case and the doctor himself wouldn’t circumcise a son at that age.

The new lawyer for Dennis Nebus, in his response to the federal lawsuit, called Heather a fugitive and a mentally unstable person. He argues that Chase is "looser" to the state court case, and simultaneously argues that the state court found that the circumcision is in the child's best interest (something that is not written in the ruling of the state court ruling). Both statements cannot be true at the same time. He also argues that the best interest of the child cannot be violated by the circumcision since all parties and the judge had his best interest in mind through the proceeding. There is little doubt that this lawyer has a cultural, if not religious, bias for circumcision.

The new lawyer for Dennis Nebus, Ira Marcus, in his response to the federal lawsuit, called Heather a fugitive and a mentally unstable person. He argues that Chase is “loser” to the state court case, and simultaneously argues that the state court found that the circumcision is in the child’s best interest (something that is not written in the ruling of the state court ruling). Both statements cannot be true at the same time. He also argues that the best interest of the child cannot be violated by the circumcision since all parties and the judge had his best interest in mind through the proceeding. There is little doubt that this lawyer has a cultural, if not religious, bias for circumcision.

 

Dr. Charles E. Flack – the expert witness in the case of Chase

Important: the fundraiser page moved to http://www.savingchase.org

The hearings for the case of Nibus vs. Hironimus took place between March of 2014 to May of 2014. During these hearings, Pediatric Urologist Charles Flack “testified by telephone upon agreement of the parties’ lawyers even though no notary was present with him to verify the Court’s administration of the oath“.

Dr Charles E. Flack

Dr Charles E. Flack
Office Location
10301 Hagen Ranch Rd
Suite C130
Boynton Beach, FL 33437
Contact
Phone: (561) 736-7313
Fax: (561) 736-2309

According to inside sources, Dr. Flack could be the pediatric urologist of choice by the father to perform the circumcision. If that is the case, it must be noted that there would be a conflict of interests as Dr. Flack would stand to profit from a ruling in favor of the father (and from performing an unnecessary surgery on a minor).

According to the order of May 9th, “while Dr. Flack did opine that the procedure was not medically necessary, significantly, he advised the Court and the parties that penile cancer occurs only in uncircumcised males and uncircumcised males have a higher risk of HIV infection than circumcised males. He further testified that the procedure last only 17 minutes and patients experience little post-operative discomfort and few recovery problems. Finally, he testified that performing the procedure on boys up to 10 years of age is medically acceptable, the concern being that with older boys who have reached puberty, an erection could cause tears in the sutures.

Court order from May 2014

Court order from May 2014

Well, let’s see if Dr. Flack’s assertions are supported by current standards of medicine (whether we agree with them or not).

Penile Cancer

Dr Flack: “penile cancer occurs only in uncircumcised male

AAP: “A history of phimosis alone confers a significantly elevated risk of invasive cancer (OR: 11.4). In fact, in men with an intact prepuce and no phimosis, there is a decreased risk of invasive penile cancer (OR: 0.5). When excluding phimosis, the risk disappears [...] The clinical value of the modest risk reduction from circumcision for a rare cancer is difficult to measure against the potential for complications from the procedure.” (AAP Technical Report on Circumcision from August 27th of 2012)

So, penile cancer is a rare disease and it occurs mostly on old men. It is usually associated with HPV and with phimosis during adulthood. HPV infection can occur in any sexually active individual. Adult phimosis can often be treated without circumcision. Penile cancer DOES, in fact, occur on circumcised men.

It would make more sense from a social health point of view to remove the breast buds of girls to reduce the risk of breast cancer, than removing the foreskin as a way to prevent penile cancer.

HIV

Dr Flack: “uncircumcised males have a higher risk of HIV infection

AAP: “40% to 60% for male circumcision in reducing the risk of HIV acquisition among heterosexual males in areas with high HIV prevalence due to heterosexual transmission (ie, Africa). [...] more than 619 000 people in the United States have died of AIDS since the epidemic began.38 In the United States, HIV/AIDS predominantly affects men who have sex with men (MSM), who account for almost two-thirds (61%) of all new infections. Heterosexual exposure accounts for 27% of new HIV infections, and injection drug use accounts for 9% of new HIV cases. In other parts of the world (eg, Africa), heterosexual transmission is far more common.”(AAP Technical Report on Circumcision from August 27th of 2012)

Notice that the text of the ruling does not mention that this “protective effect” is limited to “heterosexual males in areas with high HIV prevalence due to heterosexual transmission”. Given the high rates of circumcision in the United States and the prevalence of the American epidemic of HIV on MSM (men who have sex with men), most of those people who died from AIDS would have been circumcised males.

In 2009, Dr. Ronald Gray, one of the main researchers of circumcision and HIV in Africa and author of some of the studies that found this “consistent” protective effect, said:

“If you were to ask me, should the U.S. be promoting circumcision, my answer would be, ‘no,’ What I do think ought to be the policy is that parents should be informed about the potential protective effects” NYTimes

Studies have failed to find such “protective effect” in the United States due to the different characteristics of the epidemic. Reuters

Complications

Dr. Flack: “patients experience little post-operative discomfort and few recovery problems

AAP: “The true incidence of complications after newborn circumcision is unknown, in part due to differing definitions of “complication” and differing standards for determining the timing of when a complication has occurred (ie, early or late). Adding to the confusion is the comingling of “early” complications, such as bleeding or infection, with “late” complications such as adhesions and meatal stenosis.” (AAP Technical Report on Circumcision from August 27th of 2012)

CDC’s Charbel El Bcheraoui:  the risk of experiencing complications was 20 times higher for boys ages 1 to 9 years. (May 2013)

For an idea of what the complications can be and the different age ranges, see this list at Circleaks and this other list for 2013, at Circwatch.

James R. Robertson, Ed.D., studied the effects of circumcision during childhood. He concluded: “In summary, the 19 letters from men circumcised between ages three and six reveal emotional results in conformity with predicted psychoanalytic consequences for circumcision performed during the phallic stage. These 19 men characteristically feel mutilated, diminished and incomplete. They are preoccupied, if not fixated, with their lost foreskins. They show anger at having been denied the right to choose. When they have attempted to discuss their feelings, they tend to have been met with ridicule, rejection and amusement.” (1989)

Erections

Dr. Flack: “performing the procedure on boys up to 10 years of age is medically acceptable, the concern being that with older boys who have reached puberty, an erection could cause tears in the sutures

NewKidsCenter.com: “Erection is common among infants and toddlers. (…) Often early erections come for no reason at all (…) Erection could also mean that the boy’s bladder is full and he ‘needs to pee’.”

AAP: An old guideline for parents on care of the uncircumcised penis used to say: “The foreskin may retract spontaneously with erections which occur normally from birth on and even occur in fetal life.” This information is no longer available in the current AAP page on care for the uncircumcised penis.

So, evidently, erections can occur at any age and do not make a difference as to whether a male can be circumcised or not. Over a million baby boys are circumcised in the U.S. every year in spite of erections being also present in neonates.

This is not a valid reason to perform the operation before the patient has the age to consent, but perhaps the reason for this artificial age is the legal precedent of Boldt vs. Boldt, in Oregon, which started when a divorced father decided to convert to Judaism and have his (9 year old) son convert and get circumcised, which the child refused. While the process took several years, the court ruled that a parent could not compel a child to get circumcised against his will.

Conclusion

All the points quoted by the Court from Dr. Flack’s testimony are either partially false, or irrelevant. The only fully true statement is that “the procedure was not medically necessary“.

Dr. Flack may have a conflict of interest in his testimony if he is the doctor that the father is depending on to perform the circumcision, and as the person that stands directly to gain financially from a favorable outcome for the boy’s father, he has incentive to withhold information that could dissuade the judge from ruling in the father’s favor. He may even be inclined to misrepresent, even present false information. In essence, his testimony in court may have been no more than a shameless self-advert.

Were Dr. Flack to perform a circumcision on Chase, not only would he have given a misleading, partially false testimony in Court, but he would also be profiting from the results of his testimony and from causing bodily and emotional harm to a child.

#SavingChase – follow up on Judge keep your hands off my penis

Judge Jeffrey Gillen

Judge Jeffrey Gillen

Chase

Chase

In May we shared that a Florida judge had ruled that a mother must submit her 3 and 1/2 year old son to circumcision as required by the father, in spite of the mother’s fear of the risk of death related to general anesthesia, and in spite of admitting that the procedure is not medically necessary.

Back then the mother filed an appeal. Last Thursday, November 6th, the Court of Appeals denied her motion. Chase, now 4 years old, is now running out of time, but the mother continues fighting and the case might have to go all the way to the Supreme Court to protect the physical integrity of her son and his right to bodily integrity and genital autonomy.

You can help in any of these places

Fundraiser:
http://www.youcaring.com/other/saving-chase/259991

Photo and video campaign:
https://www.facebook.com/events/357342571110808/358327774345621

Petition:
http://tinyurl.com/l53w9rp

Youtube:
https://www.youtube.com/channel/UCqZFAkBXp5PdpVQ1Rp7cC7A

Facebook Page:
https://www.facebook.com/ChasesGuardians

Twitter:
https://twitter.com/savingchase4