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Easy Questions/Hard Answers:
Circumcision in American Society

Anne Briggs
Excerpts from Chapter 13 of Circumcision: What Every Parent Should Know

Birthing & Parenting Publications - Earlysville, VA, 1985
[ordering information]

 

During the time that I have been researching the topic of circumcision, I have been asked many questions about my research. Some of the questions are:

#1. If circumcision isn’t such a good idea, why are so many doctors still in favor of it?

#2. Who is to "blame" for the continuance of circumcision?

#3. Does the physicians’ greed play a factor?

#4. What about the question of informed consent?

#5. What about the question of parents’ rights versus children’s rights?

 

#1. If circumcision isn’t such a good idea, why are so many doctors still in favor of it?

...(Parents) honestly believe that no matter what the physician says about circumcision,
if he still offers it as a service, "deep inside", he still supports the practice.

There seems to be a major difference between what physicians frequently think they are communicating to parents and what parents perceive. Many physicians feel that they are communicating an "anti-circumcision" stand to their patients, but patients are not interpreting it this way. They honestly believe that no matter what the physician says about circumcision, if he still offers it as a service, "deep inside", he still supports the practice. Not only does the hospital provide circumcision to those who request it, but they actually market it, volunteering the availability of the procedure to those who have not requested it. Although many physicians and hospital administrators bristle at the choice of the verb "market," any close unbiased scrutiny of the procedure at most hospitals will support the idea that that word choice is correct. Examine the evidence.

1. The procedure is widely acknowledged to have no medical benefits and is performed for reasons that are cosmetic and social.

2. The procedure provides income for the hospital (in the case of public hospitals) and for the hospital and the doctor (in the case of private hospitals).

In most institutions, consent forms are volunteered to the mother regardless of whether they have been requested. The service of circumcision and the consent form even if the parent has expressed no interest in circumcision whatsoever.

Not only does the hospital provide circumcision to those who request it,
but they actually market it, volunteering the availability of the procedure
to those who have not requested it.

Most people would have to agree that when circumcision is considered in this light, the verb "market" is not an inappropriate choice to describe how the service is presented to new parents. The only other service so offered is that of the hospital’s baby photographer, definitely a service that is marketed. If any other cosmetic procedure were routinely offered to parents in precisely the same way (such as ear piercing), critics of medicine would be sure to point out how unethical this was. When considered in this light, it becomes easier to understand what mixed messages parents are getting about circumcision. The hospital supplies the form, unasked, and the doctor volunteers to perform the procedure more or less unasked. In this case, the "actions" are certainly speaking louder than the "words", the words being the physician’s brief attempt to explain that it is not medically necessary.

The idea that the parents will decide against circumcision when the "mixed messages" stop is supported by the further experience from Harris County Hospital. After seeming to fail in their attempts to reduce the circumcision rate through patient education, the hospital made a rather unorthodox decision to drop circumcision as an offered service. Now, in spite of the fact that numerous pediatricians in that area will perform the procedure in their offices and the fact that a circumcision clinic, convenient to the hospital and moderately priced, has opened, physicians at Harris county estimate that less than 15% of male babies born there are ultimately circumcised. Dropping circumcision as a provided service was what it took to get the message out as to how the physicians really felt about the procedure. Once this message was "out", it did convince many parents not to have the procedure performed.

Dropping circumcision as a provided service was what it took
to get the message out as to how the physicians really felt about the procedure.

Another aspect of this misconception is illustrated by the following experience which was related to me by a nursery nurse at a large teaching hospital.

I would say without a doubt that most of the doctors here do not favor circumcision, do not like doing them, wish they did not have to. But they don’t have a choice. The heads of OB and Pediatrics are both two old guys. They both think circumcision is the greatest thing ever to happen to little boys. Every time someone tries to change anything about circumcision (like a better consent form, talking to the parents more, etcetera) these guys have a fit.

(My question: So even though the majority of the doctors at ______ do not agree with the head physicians’ circumcision policies, they must continue to do as these two men dictate?)

Yes. There is no choice. A hospital isn’t a democracy. There was a case last year where a mother asked a pediatric resident point blank if he had a son if he would have him circumcised. The resident said , ‘No.’ and he got in a tremendous amount of trouble. They are absolutely forbidden to say anything about circumcision except what’s in the hospital protocols.

It probably never would occur to a mother that the physician who comes into her room to obtain her consent for circumcision may be telling her things that he is required to say by his medical supervisors and that he may not believe or accept the things he is saying in any way. (This would apply mostly to residents, etc., at teaching hospitals. Private doctors at private hospitals obviously have much more autonomy and could never be "required" to say certain things about circumcision or to perform circumcisions if they did not wish to.)

There is a basic misunderstanding among physicians about how much parents actually know about circumcision. Virtually all practicing physicians have some familiarity with he uncircumcised male organ. Virtually all practicing physicians know precisely how circumcisions are performed. It is easy for them to forget how totally lacking in "practical experience" most of today’s young parents are when it comes to the physiology and function of the uncircumcised penis. I was present on several occasions at a teaching hospital when young residents were obtaining consent for circumcision from mothers. Their initial comment to mothers was always just about the same, "I understand that you have indicated that you would like your son circumcised. Now, he is essentially uncircumcised." Obviously, the young resident giving the talk (who has performed numerous circumcisions) knew what "essentially uncircumcised" meant. His assumption was that the mother did too. I have found that most young women in today’s society have not the vaguest idea of how an uncircumcised penis looks and functions. What the resident is saying (as she interprets it) is "Your baby is now in a state which you regard as totally strange and unusual. Do you want us to leave him that way, or should we turn him into what you consider ‘normal?’" When phrased this way, when viewed this way, is it any wonder that so many women say yes?

Physicians must realize that the parents need to have more information
about the structure, function,
and usefulness of the foreskin.

This type of ignorance about circumcision is partially a result of physicians simply losing perspective on how totally ignorant the average new parent is about the "choice of non-circumcision." Physicians must realize that the parents need to have more information about the structure, function, and usefulness of the foreskin. Without this information choosing not to circumcise is not a possibility for most new parents. Without this information, choosing not to circumcise is not a possibility for most new parents. Without this information, there is absolutely no reason why they would want to choose it.

Among a few physicians, there is a support of circumcision that borders on the fanatical.

Among a few physicians, there is a support of circumcision that borders on the fanatical. Although the number of physicians which this involves is small, frequently it seems that physicians who feel this way are in positions of relative power in the medical community and have the ability to influence other young physicians. This attachment to circumcision is not based on logic or reason. Sometimes it is based on ignorance, but more frequently it is based on a personal and conscious rejection of what is said in the official medical press.

Many researchers have found that simply ignoring new information
is a typical reaction among physicians who strongly support circumcision.

I have spoken with more than one doctor who defends the circumcision practice with zeal and seems totally unconcerned by the fact that he does this without a shred of fact to support his position. In spite of the fact that circumcision is undeniably a medical procedure, some physicians feel no obligation to justify their support of the practice with medical research. A circumcision "mystique" definitely exists. How many doctors this involves is a different question. I think it is safe to say, however, that even though the number of physicians who support circumcision strongly are in the minority, their influence is clearly greater than their minority numbers would indicate. The nurse quoted above made this quite clear. At the hospital where she worked, in spite of the fact that the large majority of physicians did not support the current circumcision policies, "two old guys" had the power to require an adherence to those policies.

...(O)pen hostility is not an uncommon reaction among physicians
when faced with a challenge to circumcision thinking.
Their hostility is further proof that circumcision is an emotional issue to them.

Many researchers have found that simply ignoring new information is a typical reaction among physicians who strongly support circumcision. However there are other responses. Others have found that open hostility is not an uncommon reaction among physicians when faced with a challenge to circumcision thinking. Their hostility is further proof that circumcision is an emotional issue to them. Angry reactions have always been an inevitable response whenever an American medical journal has published an article recommending against circumcision. For example, in 1965 when the Journal of the American Medical Association published a strongly anti-circumcision article entitled "The Rape of the Phallus"(8) many response letters were received from physicians. Virtually all disagreed with the article sharply, but few offered an alternative position based upon research or reason. Most were instead based on emotion. One critic suggested that the author should be taken before the House Un-American Activities Committee.(9) Other anti-circumcision research published in American medical journals has met with similar responses, the letters full of angry emotion. In many cases, the letters’ authors were outraged at the conclusions the researchers had published. However, in no case did these outraged physicians offer to repeat the studies, which would seem the logical response to research whose conclusions one questions. back to initial questions

#2 Who is to blame for the continuance of circumcision in the United States?

The fact is that both lay people (the parents) and physicians must share the responsibility for the continuance of a practice that does not benefit the person to whom it is being done. One writer said, "Mothers blame the doctors for advising them to circumcise. Doctors complained that the mothers insisted on having the operation done! To the reader it may sound like a pair of criminals caught red-handed, each one accusing the other of coercion. Point of fact: NO doctor is obligated to perform an operation that he deems unnecessary. He is at liberty to refuse to operate and have the parents go to another doctor.(10)

To be perfectly frank, lay people are not expected to have enough understanding of medical procedures to be able to decide on their own whether or not they are appropriate. However, physicians are supposed to have both the knowledge and the ability to make decisions about medical procedures based on medical research. When it became obvious that the upper echelon of medicine was moving towards the concept that neonatal circumcision did not make medical sense, it was the responsibility of individual physicians to see to it that this message made it to the American people. This was done in other countries. Britain was the first and most direct. The director of the National Health Service simply decided to stop paying for it. Physicians in Australia, Canada and New Zealand, although not as direct or quick as those in Great Britain, have certainly done more than American physicians. In all of those countries, circumcision rates have dropped from levels which were only slightly lower than the United States’ in the 1960’s to below 30% as of 1981.

...(M)ost American physicians are themselves circumcised and share those same feelings
of emotional discomfort that many young fathers have when faced with the possibility
of admitting that circumcision is no longer medically or socially necessary.

In virtually every "informed consent" talk that I have heard in a public hospital, it was the physician who first mentioned conformity and social factors, not the mother. Why have they accepted this reasoning when their counter parts in other nations rejected it is difficult to say. I feel quite strongly that one reason is that most American physicians are themselves circumcised and share those same feelings of emotional discomfort that many young fathers have when faced with the possibility of admitting that circumcision is no longer medically or socially necessary. This was never the case in the other United Kingdom countries. Circumcision had only been very popular in England for ten to twenty years when coverage for it was dropped. Therefore the majority of British physicians were uncircumcised when coverage was dropped; the decision was not personally threatening to them. The same is true in Australia, New Zealand, and Canada. Circumcision was never as popular in the 1920s, 1930s and 1940s there as it was here. Therefore in those countries there has always been a larger reservoir of uncircumcised physicians who were able to speak out for the choice of non-circumcision based on personal experience.

What other surgery would a physician perform after he has stated that he does not feel it necessary? In any other area this would certainly contradict medical ethics. The fact is that there is no other surgery in American medicine that physicians feel any obligation to provide for social reasons, knowing that it is unnecessary. It is to be assumed that any parent who asked a pediatrician to remove the foreskin of a daughter’s clitoris would be sent packing without delay. A parent who suggested one of the more radical female operations performed in other cultures (such as total removal of the clitoris) might even be reported to child welfare agencies. Physicians do not routinely provide ear piercing, foot binding, head molding, or tattooing. Circumcision is provided solely because it occupies a unique place in American medical and social thinking and the other procedures do not.

When medical groups and medical research began criticizing tonsillectomy,
did parents need to form lay advocacy groups
to pressure physicians into accepting the research?

Again, how or why American physicians have come to believe collectively that parents do not have the right to choose and physicians have an obligation to provide a medically contraindicated procedure is uncertain. The fact is that many do believe it. Recent articles in medical journals discuss physicians’ ambivalence openly. One write commented, "One source of this ambivalence may be the uncertainty surrounding the proper role of the pediatrician in the decision regarding circumcision. Should we act as purveyors of medical information, leaving the decision entirely to parents? Or are we obligated to assume a position of advocacy, actively arguing for or against circumcision?"(12)

Another physician commented, "If circumcision practices are ever to stop, such changes will likely result from organized advocacy of lay groups… rather than the efforts of the medical profession."(13) The incredulous researcher can only ask, "Why?" When medical groups and medical research began criticizing tonsillectomy, did parents need to form lay advocacy groups to pressure physicians into accepting the research? The answer is, of course, "No!" Why circumcision should persist in being so different continues to defy explanation.

...(T)he impetus for real change must come initially from physicians.

The blame for the continuance of circumcision in the United States cannot fall entirely on the physicians. I have talked (or tried to talk) to too many parents who were so vehemently and hysterically supportive of the procedure not to know how intensely some parents do desire circumcision. But because circumcision is not a medical procedure, provided within our medical system, the impetus for real change must come initially from physicians. back to initial questions

#3. Do physicians have monetary motives for desiring to continue the practice of circumcision.

The average obstetrician makes several thousand dollars (at least) each year doing circumcisions, so it would seem greed may be the motivating force in some instances.

There is another, clear cut instance of circumcision being performed solely for profit. In 1983, Harris County hospital near Houston stopped providing circumcision. Within a year, a circumcision clinic had opened across the street from the hospital. In an article(14) discussing the clinic, neither the author nor the physicians interviewed ever assert that the clinic was opened due to the to physicians’ feeling that circumcision was an essential medical service that was unfairly being denied to parents and babies by a misguided hospital. The clinic is described as a "for profit venture launched last August [which] was conceived by professional marketers…" The entire tone of the article makes it very clear that this was conceived as and is being carried out as a money-making enterprise. On one occasion, the author discusses how the clinic is "marketed." On another occasion, the head physician is asked about the possibility of "franchises." (Also, it cannot be claimed that these word choices and implications are the product of an author who is trying to prejudice the reader against this venture, as the whole tone of the article is very positive and implies that these physicians had a really wonderful idea.) In short money making is the primary (if not the only) basis for these physicians performing the procedure. back to initial questions

 

#4. What about the question of informed consent?

Consider the following:

In a 1982 survey in San Diego, pediatricians, family practitioners, general practitioners, and obstetricians were queried as to opinions about circumcision. 67% of responding physicians did not know that the infant’s foreskin is normally not retractable. 47% said that they felt a non-retracting foreskin in the newborn was an indication for circumcision. Pediatricians were most often correct, general practitioners and obstetricians most often incorrect in their responses.(16)

In a 1982 survey in Chicago, only 62% of pediatricians and obstetricians in the sample were aware of the American Academy of Pediatrics’ position opposing circumcision.(17)

In a 1981 survey in Utah, 67% of the sample of pediatricians felt that the foreskin should retract "easily" by the age of one year.(18)

The training of physicians in medical school, in general,
does not contribute to an understanding of the normal uncircumcised penis.

The training of physicians in medical school in general does not contribute to an understanding of the normal uncircumcised penis. As part of my research, I looked in scores of anatomy books to find a clear picture of an uncircumcised penis. When I finally ran across a good clear illustration of the uncircumcised penis of a young baby, I as astounded to see that the caption under the picture was "Phimosis."!(19) In other words, this illustration of the totally normal penis was being presented to these medical students as an illustration of a problem. As was stated above, practicing obstetricians which I interviewed showed virtually no knowledge about circumcision practice in other countries.

Many physicians…have come to believe that it would be actually wrong for them
to include any information that could remotely be considered
anti-circumcision in the discussion.

How can a parent counseled by most doctors give "informed" consent when it is obvious that a majority of physicians do not have themselves a basic rudimentary knowledge of the facts about circumcision themselves?

Many physicians are so convinced that parents have an absolute "right" to choose this procedure that they have come to believe that it would be actually wrong for them to include any information that could remotely be considered anti-circumcision in the discussion at all. It is simply inexplicable how many American physicians have come to believe this, but they have. I have asked one physician why he did not tell patients about the American Academy of Pediatrics Statement on circumcision, why he did not tell patients about his own strong, personal opposition to the procedure, why he did not hand out the AAP publication "Care of the Uncircumcised Penis," which emphasizes strongly how simple it is to care for an uncircumcised baby, and his response was, "Well, people might think I was trying to talk them out of it." My interviews with mothers, however, clearly showed me that they desired the precise opposite of what their physicians assumed. A large number of mothers stated flatly, "If I had known that there was anything that said it shouldn’t be done, I wouldn’t have had it done. back to initial questions

 

#5. What about the question of parents’ rights versus children’s rights?

Parents obviously have the right to choose necessary medical treatment for their children: they may give their consent for surgery, they may administer medication tot heir children, they may give consent for vaccinations. Circumcision, according to many people, does not fall under any known category of needed medical procedures. Many critics of circumcision assert that it is an outmoded ritual performed for social reasons only. Many parents I talked with acknowledged this: they had circumcision performed solely because of social reasons.

Do parents in out society have the right to choose medically unnecessary cosmetic surgery for their sons? At first thought, most parents bristle at the suggestion that they do not have the "right" to choose circumcision. But that is because of the really unique position circumcision holds. About 80 years ago in the U.S., many doctors advocated circumcision of the female clitoral foreskin for reasons identical to the reasons for advocating male circumcision: it was cleaner and the children were less likely to masturbate or to have other sexual diseases. It did not "catch on" like male circumcision. However, there are still a few physicians in the U.S. who believe that female circumcision is sexually beneficial. Let us suppose that a couple would decide to have their newborn girl circumcised for future sexual benefits. Most physicians and parents in the U.S. would assert that parents do not have the right to impose this sort of surgery on their daughter. Most of us would shudder at the strangeness of these parents, yet this is only because female circumcision is culturally unacceptable; male circumcision is culturally acceptable.

Most people would feel that parents do not have the right
to alter their children’s bodies for cosmetic reasons.

What are the primary reasons we would object to female circumcision, tattooing of newborns, or nose alterations on newborns? We would object because these procedures are painful, they carry a physical risk, and the body is the child’s. Most people would feel that parents do not have the right to alter their children’s bodies for cosmetic reasons. Yet when anyone says these precise things about circumcision, American parents become affronted and offended.

The only person in the whole scenario who apparently
has no choice at all is the person whose body is going to be changed.

Another perspective on this can be gained by looking at a simple statistic. Here in the United States, a country where the vast majority are circumcised and many physicians still encourage adult circumcision, the vast majority of uncircumcised men choose to remain the way. Every year in the United States, approximately two or three uncircumcised men in 1000 will choose to be circumcised. This in spite of what would be considerable social and medical acceptance if a man makes the decision to conform. From this, we can extrapolate that the vast majority of newborns who are currently being circumcised, if given the choice, would certainly choose not to be circumcised. As one circumcision researcher has put it, "One of the best reasons not to circumcise your baby is that he will almost certainly be glad you didn't."(22)

Considered from this point of view, the title of the American College of Obstetricians and Gynecologists’ pamphlet on circumcision, "A Personal Choice," becomes quite ironic. The only person in the whole scenario who apparently has no choice at all is the person whose body is going to be changed: the baby.

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Selected References

8. Morgan, Williams, "The Rape of the Phallus," Journal of the American Medical Association, vol. 193, no. 3, July 19, 1965. back to text

9. Morgan, Williams, Reply to Dr. Greenblatt, American Journal of Diseases of Children, vol. 111, no. 4, April 1966, p. 448. back to text

10. Saquet, R., "Circumcision in Social Perspective." Reprinted from "The Country Lady’s Daybook," March, 1976. back to text

12. Boyce, W.T., "Care of the Foreskin," Pediatrics in Review, vol. 5, no. 1, July, 1983, p. 30. back to text

13. Maisels, M. J., et. al.: Circumcision: The Effect of Information of Parental Decision Making, Pediatrics, 71:453, 1983. back to text

14. Personal correspondence. back to text

16. Stein, M.T., et. al., "Routine Neonatal Circumcision: The Gap Between Contemporary Policy and Practice," Journal of Family Practice, 15:45-53, 1982. back to text

17. Patel, D.A. et al: "Factors Affecting the Practice of Circumcision," American Journal of Diseases in Childhood, 136:634-636, 1982. back to text

18. Osborn, L.M., et al: "Hygienic Care of Uncircumcised Infants," Pediatrics, 67:365-367, 1981. back to text

19. Structure and Function in Man , Jacobs, S. et. al., (Saunders: Philadelphia) p. 569. back to text

22. Erickson, J., Personal correspondence. back to text

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