Tag Archives: Lies

Factually correct information? Kaiser Permanente flyer on newborn circumcision

The AAP states that: “Parents are entitled to factually correct, nonbiased information about circumcision and should receive this information from clinicians before conception or early in pregnancy, which is when parents typically make circumcision decisions.

Yet, how much information are hospitals and doctors willing to give to parents?

Check out this pdf file from Kaiser Permanente: http://www.permanente.net/homepage/kaiser/pdf/3558.pdf

It starts with a very common lie: “Circumcision is the removal of the foreskin that covers the tip of the penis“. Actually the foreskin is the tip of the penis, not an attachment, not a fashion accessory. There is no clear line of separation between the foreskin and the penis, and in fact there is no standard as to how much or exactly what tissues need to be removed. The foreskin does cover something, it covers the glans, as much as the lips of the mouth cover the inside of the mouth.

The listed risks of circumcision mentioned by the flyer are: infection, bleeding, pain, injury to the penis.

How severe are these risks? The flyer says these risks are small and “serious complications are very rare (1 in 500)”. I wouldn’t call a 1 in 500 rate to be very rare, when compared to 1.2 million newborns circumcised every year in the United States. That means 2,400 babies every year would experience serious complications.

What the flyer doesn’t state is: bleeding and infections can become fatal. Injuries to the penis can last a lifetime. And exactly what kind of injuries we are talking of? Mild ones, as adhesions (that will be painful and traumatizing for parents), more complex injuries (such as meatal stenosis, fistulas, damage to the urethra, all of which will require additional surgeries to “repair”), to completely damaging injuries (loss of part or the whole glans, loss of the penis, loss of all the skin of the penis, too much skin removed which may result in pain and abrasions during sex in adult life…)

Then the flyer moves to mention the effect on men’s sexual life, saying it “is not fully known. Some studies have reported equal sensation“, but the untold part, implicit by the word “some“, is that some other studies have indeed shown less sensation and decrease on sexual function. One of such studies, which should be enough for doctors to think it twice – and yet it has never been seriously considered by the AAP, is “Fine-touch pressure thresholds in the adult penis” (Sorrells et al, 2007), which states that “The glans of the circumcised penis is less sensitive to fine touch than the glans of the uncircumcised penis. The transitional region from the external to the internal prepuce is the most sensitive region of the uncircumcised penis and more sensitive than the most sensitive region of the circumcised penis. Circumcision ablates the most sensitive parts of the penis“. A slightly similar study by Payne et al., didn’t find a difference, but they never took measurements on the foreskin! In the words on one of the researchers, “[t]he foreskin’s job is to cover the penis and protect it,” she said. “Its job is not to be a part of the sensitivity.” Talk about researcher’s bias.

Then the flyer moves to the “benefits of circumcision”, and the first one is of course “lowers the risk of cancer of the penis“. But how much is the real risk of cancer of penis? Is it frequent? Does it really decrease? The AAP, in spite of touting this same benefit, has to come clean when showing numbers, by saying: “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, which suggests that the benefit of circumcision is conferred by reducing the risk of phimosis and that the phimosis is responsible for the increased risk.” (page 14 of the Technical Report), and again the untold part is that phimosis can often be treated without any excision of tissue, thus making circumcision unnecessary.

Not only that, but this benefit is not proportional to the complications that it would cause. The report again, states that:

It is difficult to establish how many male circumcisions it would take to prevent a case of penile cancer, and at what cost economically and physically. One study with good evidence estimates that based on having to do 909 circumcisions to prevent 1 penile cancer event, 2 complications would be expected for every penile cancer event avoided.121 However, another study with fair evidence estimates that more than 322 000 newborn circumcisions are required to prevent 1 penile cancer event per year.122 This would translate into 644 complications per cancer event, by using the most favorable rate of complications, including rare but significant complications.123 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. In addition, these findings are likely to decrease with increasing rates of HPV vaccination in the United States.

So, 909 to 322,000 circumcisions to prevent a single occurrence of a cancer that takes place in old age, at the cost of 2 to 644 complications. Doesn’t sound that great of a benefits, does it?

The second benefit is a lower risk of UTIs. Other sources (including the AAP) usually say “during the first year of life”. Normally, what they don’t say is that the risk is already lower in males than in females regardless of circumcision status, and that UTIs in females are treated with medicine. Not only that, but circumcised babies still get UTIs. So, does this justify the removal of erogenous tissue?

The third stated benefit is “May help prevent STDS such as HIV“. Notice the words “May help”. We all know that the United States has a high prevalence of HIV and other STDs, compared not only to Europe, but to Latin America, and yet most men in the United States are circumcised and most men in Europe and Latin America are not. So how has circumcision helped, really?

Fortunately, a paragraph later Kaiser states that these long-term benefits are small. It still does not addresses the fact that circumcision DOES NOT prevent STDs and safe sex practices should be encouraged.

Then they state “the decision to circumcise your baby is a personal choice“. Intact-friendly circles strongly oppose this wording, because the personal choice of parents doesn’t take into consideration the personal preference of the person undergoing the procedure. A circumcised baby becomes a forcefully circumcised man, whether he likes it or not, whether he feels it was beneficial or harmful. And in fact, if genital alteration surgery was a personal choice, female circumcision of babies (i.e. labiaplasty or clitoral unhooding) would also be a personal choice of the parents, but it isn’t. In the United States, any non-therapeutic alteration of the genitals of a female minor (except in pregnancy and labor) is a federal crime regardless of the cultural or religious beliefs. We can argue that in both cases, (and not talking of the extreme cases of FGM such as infibulation, clitoridectomy, but of the mild forms, the one that consenting adults can get done at a plastic surgeon, labiaplasty and clitoral unhooding, or even the “ritual nick”) male and female circumcision of minors both remove erogenous healthy tissue without the patient’s consent. Even the AAP stated in 2010 (in a now retracted policy on “Ritual Genital Cutting of Female Minors“) that “Some forms of FGC are less extensive than the newborn male circumcision commonly performed in the West“. So if this is true, why is every form of FGC a crime while male circumcision is “personal choice” of the parents?

The flyer then states that “some parents talk about whether their son will look like his father or like other boys in the locker room”. Both arguments are non-medical and simply fallacious. The boy won’t ever look like his dad, nor like other boys in the locker room. Every circumcision looks different. Parents and sons don’t often sit around comparing genitals, nor boys do. So this is a bullshit reason to appease the sense of conformity and impose a “social surgery” upon non-consenting individuals by brainwashing those who can sign the proxy consent.

The flyer continues: “The American Academy of Pediatrics does not recommend circumcision as a routine procedure” – this is true, and yet people are severely confused about it, thanks to the so touted “benefits outweigh the risks” mantra that the media so gladly parroted on August 27th of 2012.

In deciding, the flyer says: “You may want to talk with your partner, family, or firends to help you decide. Consider your cultural and/or religious values.” – Are there any other excising surgeries that are done for cultural or religious reasons? Is this medicine or religion? Is it ethical to permanently and irreversibly remove part of a person’s body for cultural or religious reasons without that person’s consent?

The flyer then says: “Making a decision about circumcision is more difficult after delivery, when you may be very tired“. Not only tired, but by then the mother may feel protective of the baby and won’t want to hand him for a surgery that is painful. But let’s not talk about that, right Kaiser?

The “How is circumcision done” portion of the flyer is what triggered me to dissect it.

The first phrase: “Infants must be stable and healthy to be circumcised in the hospital“, unfortunately is contradicted in the real world, where premature babies and babies straight out of the NICU are often circumcised, contradicting general medical practices. In March of 2013 I was aware of a case where a baby in California who had shown to have clotting issues (the pinpricks didn’t heal properly), and yet he was circumcised; the baby died two days later, after suffering major loss of blood and seizures, yet the doctors attributed it to an existing bacteria or condition. The non-healing pinpricks should have been enough to suspect that the baby was not in good conditions to undergo an excision.

The flyer says that a shot of pain medicine or an anesthetic cream is used, in addition to a sucrose pacifier, for pain relief. Anesthetic creams don’t stop the severe pain of cutting a densely innervated part of the body. Shots of anesthetic are painful themselves, but are more effective. Sucrose pacifier at most keeps the baby partially distracted (or trying not to choke!).

The flyer then says that your baby may have some mild pain during and after the surgery, which usually does not last more than a day. This is contradicted and you can find reports in social media of babies in severe pain every time the diaper is changed for a week or so. Parents are often unprepared for the pain that their babies will experience.

The flyer then describes the plastibell method as follows:

* A plastic ring is tied around the end of the penis
* The foreskin is removed
* The plastic ring stays on the end of the penis and prevents bleeding after the surgery.

This is highly imprecise. A more realistic description would be:

* The glans and the penis are forcefully separated with a blunt probe.
* A dorsal incision is cut on the foreskin with scissors for easy insertion of the ring.
* The ring is inserted over the glans and tied with a string to cut off circulation to the foreskin (to necrotize the tissue)
* The foreskin may or may not be cut off with a scalpel at that point. The ring keeps the outer and inner layers of the foreskin joined for healing and keeps circulation from the foreskin so it dries and falls off.

Then they describe Gomco and Mogen methods: “The foreskin is removed from the penis using the Gomco or Mogen devices” [clamps! that's what they are]

The Gomco clamp is a slow procedure that forcefully crushes the foreskin between two metal parts, cutting circulation to the foreskin and allowing cutting it with scalpel. A previous dorsal slit is usually done to facilitate insertion of the metal bell used to protect the glans.

The Mogen clamp crushes the foreskin without protecting the glans and allows quick cutting with a scalpel. While generally faster (and probably less painful), it has an added risk of injury because the glans is not protected and may get between the clamp and be amputated.

There is a section on “care of the uncircumcised penis”.

It says: “After 1 to 2 years of age, you can retract the foreskin partially for cleaning“. This is WRONG and PAINFUL. At that age, the glans and the foreskin are likely to still be attached through the balanopreputial synnechia, and retracting it, even partially, may hurt it, may cause bleeding and scarring and acquired phimosis. In fact, it may make circumcision necessary.

When your child is 5 or 6 years old, teach him to do this himself when he takes a shower“. This may be too soon! The percent of boys capable of retracting the foreskin at 5 years is approximately 40%.

Many times the foreskin cannot be fully retracted until your child is a teenager; this is not a reason to worry.” This is true. Over 90% of the boys become capable of retracting by the time they are 17. Those who can’t retract at that age may need to do stretching exercises.

What they also fail to mention is that using soap inside the foreskin can cause irritations. Generally retracting the foreskin (by the person only, and only when he becomes able to do it), rising the glans with warm water, and replacing the foreskin, is all the care that needs to be taken for proper hygiene. The AAP gets this wrong as well.

The flyer does not have a single word about self determination and how circumcising a minor based on parental consent is ethically troublesome, as it is an invasive intervention that is not essential to the baby’s well being. In general the American medical establishment is strongly intent on denying that newborn circumcision violates the bodily integrity and right of self-determination of the person the baby will become, which is perhaps the most important question that parents should ask themselves before making an irreversible decision.

fig2

Circumcision at 5 years: how your doctor gets to lie and collect a check

One of the supposed benefits of circumcision is the “prevention of phimosis“. It is true that phimosis is a condition of the foreskin which may require circumcision, but circumcising babies to prevent circumcision is what I call “prevention by obliteration”: any part of the body that is removed won’t develop any condition or pathology – but won’t serve any functions to the body anymore.

Phimosis occurs when the foreskin cannot retract behind the glans. This condition will make hygiene and sex more complicated, some times even making penetrative sex impossible. Severe cases of phimosis may require circumcision. Milder cases may respond to steroid creams, stretching exercises and stretching devices.

The big confusion however is that there are two different kinds of phimosis:

  • physiological phimosis, which is normal and generally resolves itself in time; and 
  • pathological phimosis, which requires some treatment.

Let’s look deeper into this. At birth, the foreskin and the glans are usually sealed by the “balanopreputial membrane”. This is absolutely normal – this is physiological phimosis. This membrane prevents the foreskin from retracting. Parents of an uncircumcised child do not need to retract his foreskin to wash the penis, and in fact, retracting the foreskin would be painful and harmful.

As the child grows, this membrane desquamates to allow retraction. This can occur in months – or in many years. We will look more into this shortly.

If after puberty, the child cannot retract the foreskin, then we may have a case of pathological phimosis. This often occurs because a ring of skin on the foreskin will not expand enough to allow the glans to glide through. While some men may go their lives without ever retracting their foreskins, some will simply have issues because of this and won’t be able to have normal sexual lives. Phimosis during adulthood is also a risk factor for penile cancer. So it’s better to try to resolve phimosis after puberty.

One important variable here is the age of retraction. A 1999 study by Cold and Taylor shows a graphic of the age of retraction – referring a 1968 study by Jakob Øster. It shows that at 6 to 7 years, approximately 60% of the boys still present adhesions (in other words, they cannot retract the foreskin yet). At 10-11 years, close to 50% of the boys still present adhesions. At 14-15, approximately only 10% of the boys still present adhesions. As we approach 17 years, only a very small percentage will still present adhesions. That means that, left uncircumcised, most boys will be able to retract their foreskin before they are 17 years old.

Incidence of preputial adhesions in various age groups, after Øster

As you can see, there are a lot of details in understanding what is phimosis and when phimosis becomes a problem. But hospitals and doctors often use the ignorance of parents to their benefit, by turning a natural condition into a pathological one.

I often hear parents who during childhood “had to” circumcise the child that they tried to keep intact, because he “had phimosis”, the son was traumatized, and discouraged they have decided that any future son will be circumcised at birth.

This, however, is the result of a lie.

The other day, as I was reviewing the website of the Cincinnati Children’s Hospital, base of some of the researchers in the trial of Gomco vs. Mogen clamp, I ran into an interesting information.

First, I have to admit that their page on circumcision provides some more information than most other clinics do.  For example, this page dedicates one paragraph to the role of the foreskin. While this paragraph is very incomplete (it does not explain at all the sexual function of the foreskin), at least it says that the foreskin “protects the sensitivity of the glans“.

On their section on benefits they also admit that the risks of UTIs, phimosis, balanitis and penile cancer are all low. Very low. And they don’t even try to talk about prevention of STDs. I’m honestly surprised, this page seems more honest than most other hospitals.

However, I also found a referral guide, and this is their guide for circumcision:

Elective circumcisions (outside the newborn period) are performed around 6 to 12 months of age. Therefore we recommend evaluation at age 6 months. 

Neonates who were circumcised at birth should be seen seven to 10 days later in the primary care physician’s office. At this visit, the infant should be checked for the development of adhesions between the glans and the foreskin. These adhesions should he lysed in the office at that time. Children with adhesions that cannot be lysed in the office, or with a sub-optimal initial circumcision, may be seen at age 6 to 12 months for possible surgical revision.  

Children who are uncircumcised should not have their foreskin retracted until 3 to 4 years of age. If adhesions still exist when the child is 5 years old, offer the option of circumcision or recommend waiting until puberty to see if the adhesions resolve spontaneously.

This is the key part: “If adhesions still exist when the child is 5 years old, offer the option of circumcision or recommend waiting until puberty to see if the adhesions resolve spontaneously.” From the graphic, over 65% of the children at age 5 still present adhesions! That means that 65% of the uncircumcised children are at risk of being referred for circumcision at age 5 unless their parents have enough understanding to know that this is not a pathological condition.

Let’s be clear. Diagnosing phimosis on a child is almost always fraud. Retracting the foreskin of a 5 year old child is unnecessary and potentially dangerous, as it can cause pain, bleeding, wounds inside the foreskin, infections and additional adhesions (as wounds inside the foreskin due to forceful retraction may become scar tissue binding the glans to the foreskin!).

Now you know how they do it.

And since we are going at it now, is the AAP Policy on Circumcision any better?

The 9th page of the Technical Report states that:

Parents of newborn boys should be
instructed in the care of the penis
at the time of discharge from the
newborn hospital stay, regardless of
whether they choose circumcision or
not. The circumcised penis should be
washed gently without any aggressive
pulling back of the skin.24 The noncircumcised
penis should be washed
with soap and water. Most adhesions
present at birth spontaneously resolve
by age 2 to 4 months, and the
foreskin should not be forcibly retracted.
When these adhesions disappear
physiologically (which occurs
at an individual pace), the foreskin
can be easily retracted, and the
whole penis washed with soap and
water.

There are several things wrong with this. The use of soap, particularly antibacterial, scented and stronger soaps, on the foreskin and penis in general, may disrupt the pH of the foreskin and damage the beneficial bacteria, causing irritation and infections. It is actually recommended to use just warm water to rinse the penis.

The parents of the child DO NOT need to retract the foreskin at any age. Only the child himself should retract the foreskin, and that only when he becomes able to do it comfortably.

Now, I’m especially concerned with this: “Most adhesions … spontaneously resolve by age 2 to 4 months“. This is definitively not supported by the graphic by Cold and Taylor. It’s only at 17 years of age that most males will resolve their adhesions. This sentence regarding 2 to 4 months will make many people wrongfully think that the inability to retract a child’s foreskin is a pathological condition that merits immediate surgical intervention.

In one occasion someone argued that this document is written for health professionals, not for the typical parents. It is my opinion that even if it is written for health professionals, it should provide more information as this is the one chance to educate them.

So now you know how your doctor gets to lie to you, injure your son and collect a check.