Rapid Responses to:

HEAD TO HEAD: Geoff Hinchley Is infant male circumcision an abuse of the rights of the child? Yes BMJ 2007; 335: 1180 [Full text]

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Rapid Responses published:

Medical Propaganda

Thomas Flett   (7 December 2007)

Baloney on 'the snip'

Paul Rosswick   (8 December 2007)

Individual bodily rights and patient autonomy

A. D. Fontain   (8 December 2007)

Re: Medical Propaganda

A. D. Fontain   (8 December 2007)

No reason not to wait

Eleanor Snape   (8 December 2007)

Questionable argument

Jake H Waskett   (8 December 2007)

Infant male circumcision IS abuse

Heather M Longanecker   (8 December 2007)

Hinchley understates his case

George Hill   (8 December 2007)

Re: Medical Propaganda

J D Poff   (8 December 2007)

Parents have the right and obligation to choose what they consider best for their children

Norton Pérez, MD   (9 December 2007)

Psychological damage from circumcision

Janet Menage   (9 December 2007)

circumcision should not be done to any minor.

troy l horenziak   (9 December 2007)

Updating circumcision

David B G Hawker   (9 December 2007)

Is infant male circumcision an abuse of the rights of the child? Yes

NAZAR R DESSOUKI   (9 December 2007)

Re: Baloney on 'the snip'

Ivy Paul, West Bromwich B71 4HJ   (9 December 2007)

Do no harm

Iris B. Fudge   (9 December 2007)

Is infant circumcison abuse?

Tandy Huighes   (9 December 2007)

Circumscision is justified

Mujibur Rahman   (9 December 2007)

Is infant male circumcision an abuse of the rights of the child?

Jan J van der Bank   (9 December 2007)

Re:Questionable argument

A.D. Fontain   (9 December 2007)

Don't do it!

George W Terrell Jr.   (9 December 2007)

Circumcision or retraction?

Oscar Luis Pereira   (9 December 2007)

Circumcision may also be painful for the surgeon

Roger H Armour   (9 December 2007)

Circumcision’s lawfulness is in doubt and there is a conflict of rights

John D Dalton   (10 December 2007)

Male circumcision is cosmetic surgery.

Andras Heijink   (10 December 2007)

Hard to imagine adolescent boys lining up to be circumcised

Trevor Schroder   (10 December 2007)

Circumcision IS a good practice

Anthony B Ainley   (10 December 2007)

Male & Female circumcision

Sikander A Arshad   (10 December 2007)

prophylactic amputation should only be consensual

Laura J MacDonald   (10 December 2007)

Questionable Argument

IRIS B. FUDGE   (10 December 2007)

Better to provide a safe environment

Shalini Pooransingh, Sam Ramaiah   (10 December 2007)

Human Rights either exist or they do not..time for us to decide.

Mark W Savage   (10 December 2007)

Circumcision - an essential surgical 'vaccine'

Brian Morris   (11 December 2007)

What's sauce for the gander.....

Laura J MacDonald   (11 December 2007)

Of course it is

janice page   (11 December 2007)

Parents' rights

Jean Davies   (11 December 2007)

Women's Rights

Dr John Glazebrook   (11 December 2007)

Male Circumcision-way forward?

Babajide O. Olubaniyi   (11 December 2007)

Genital Integrity not Medicalization

Dan Bollinger   (11 December 2007)

Gloves?

Michael Bunbury   (11 December 2007)

Male circumcision

Ishaq Mohammed   (12 December 2007)

A Sensible Solution

Phyllis C Mervine   (12 December 2007)

Human rights are relative

Santosh A Gholkar   (12 December 2007)

Personal evidence

David J Grant   (12 December 2007)

Doctors need to update

David Smith   (12 December 2007)

Ritual circumcision – a service that should be provided by the NHS

Colin R Butler, Simon Clarke   (12 December 2007)

Many circumcised persons have a compulsion to repeat the trauma

George Hill   (12 December 2007)

Circumcision soon after birth, or once they can consent?

Salwa Kamourieh, Eyston Vaughan-Huxley   (12 December 2007)

A surgical 'vaccine'?

A.D. Fontain   (12 December 2007)

Financial issues we should consider

Laura J MacDonald   (13 December 2007)

Commonsense

Richard N Duncker   (13 December 2007)

Infant Male Genital Mutilation Should be Banned

Bradley L Stueber   (13 December 2007)

And later, would you really give him the choice?

Anthony B Ainley MCSD   (13 December 2007)

BMJ circumcision debate continued in the New York Times

Trish Groves   (13 December 2007)

The overwhelming benefits of circumcision

richard a sturdy   (13 December 2007)

May I make this clear?

Van Lewis   (13 December 2007)

Foreskin has important sexual function

Mike Cooper   (13 December 2007)

objectively...it's wrong

Justin A Williamson   (14 December 2007)

An informed choice

janice page   (14 December 2007)

Male Circumcision is a Female Issue

Felicity A Milner   (14 December 2007)

Dangers of male circumcision

Tim J Sladden   (14 December 2007)

Bancroft J. Human Sexuality and its Problems

J D Poff   (14 December 2007)

Whose foreskin is it?

Michael Glass   (15 December 2007)

"uncircumcised penis"

J D Poff   (15 December 2007)

Circumcision is sadistic sexual assault on children

Michael Steffe   (15 December 2007)

The ethics of circumcision

Michael H Mitchell   (17 December 2007)

Qualified rights in conflict with absolute rights

John D Dalton   (17 December 2007)

Medical Activism

Rajesh K Choudhary   (17 December 2007)

Let's Stop Selling Men Back Their Foreskins

Ron J Low   (17 December 2007)

Higher Love Consciousness will ban Circumcision world wide

Michael Steffe   (17 December 2007)

Is infant male circumcision an abuse of the rights of the child?

Lotte Newman   (19 December 2007)

Very uncertain sexual benefits, beware!

Sigi Sigismond   (4 January 2008)

What are the glans and foreskin for?

Kenneth N Wilkinson   (4 January 2008)

Re: What are the glans and foreskin for?

Janet Menage   (7 January 2008)

Effect of circumcision on intromission and sexual satisfaction

John D Dalton   (7 January 2008)

Circumcision and European jurisprudence

Sigi Sigismond   (15 January 2008)

The 2nd commandment forbids circumcision

Sigi Sigismond   (15 January 2008)

Another reference

Sigi Sigismond   (15 January 2008)

Circumsexuals

Rood Andersson   (8 March 2008)

Expert refusal: the physician's right and duty

Hervé M. Sigismond (Navoiseau-Bertaux)   (16 September 2008)

Right to the placenta, right to the foreskin, same fight!

Sigismond (M. H. Navoiseau-Bertaux)   (9 November 2008)

Circumcision has many benefits

Richard A Sturdy   (12 November 2008)

Re: Circumcision has many benefits

Van Lewis   (16 November 2008)

Circumcision entails impotence in the long run!

Sigismond (M. H. Navoiseau-Bertaux)   (26 December 2008)

The "covenant"?

Robert Samson   (7 July 2009)

Circumciseds' foetuses more at risk!

Sigismond (M. H. Navoiseau-Bertaux)   (31 July 2009)

Medical Propaganda 7 December 2007
Thomas Flett, General Practitioner Retired, FY1 2QX Send response to journal: Re: Medical Propaganda	I was a General Practitioner for over 30 years, over which time, I have seen thousands of patients who were circumcised and never once did I hear a complaint from a child or adult who felt assaulted. I think Dr Hinchley has missed the entire rhyme and reason around the controversial issue of consent. Babies undergo a wealth of procedures and endurances, from having their heels pricked for the Guthrie Test, their hips stressed for DDH , vaccinations and even the chore of having to attend Nursery and worse still Kindergaten. None of these activities receive informed consent. To obtain a serum bilirubin for a jaundiced child involves stabbing the foot with a small knife that is quite a horrific experience for the parents and no doubt highly unpleasant for the baby. Nonetheless, I do not see Geoff Hinchley writing to have all these procedures banned. I would strongly recommend that as an A&E Consultant, in one of the UKs worst performing Trusts in infection control, that Geoff Hinchley focus his efforts on his task at hand, rather than trying to spread a frankly irrelevant message. After all, it may be that a child is brought to his department following a circumcision, with a complication. Of course it would be a tragedy if they were to pick up MRSA as a result! Competing interests: None declared
Baloney on 'the snip' 8 December 2007
Paul Rosswick, retired surgeon N3 3EG Send response to journal: Re: Baloney on 'the snip'	As a retired, circumcised,Jewish surgeon I cannot abide the ridiculous argument that my human rights were abused 75 years ago by my parents! I am proud to be a 'cavalier' and have never seen any significant problems in practice except where untrained persons perform.Jewish ritual circumcisors undergo training - so should all whatever their tradition. Let us have less, much less about human rights in this matter and much more about regulating for the safe performance of a traditional procedure. Competing interests: None declared
Individual bodily rights and patient autonomy 8 December 2007
A. D. Fontain, Independent Researcher Toronto, ON. Canada M5S 1A5 Send response to journal: Re: Individual bodily rights and patient autonomy	Is infant male circumcision an abuse of the rights of the child? Yes. In her article defending infant male circumcision as an acceptable practice in medicine, Kirsten Patrick seems to miss the mark. She states: "we cannot know for sure if men who grew up without a foreskin feel that they were assaulted." It does not require "robust research...examining the long term psychological effects of male infant circumcision" in order to be aware that there are a significant enough number of males who are dissatisfied and harmed to varying degrees by this medical custom. A fact made apparent by the existence of sufficiently widespread and sustained calls for it's eradication as a medical practice.[1] The more important question is whether or not it is an acceptable situation in medicine for a male to have genital anatomy removed, contrary to his will, in the absence of not only any medical need, but of even a likeliness (going on the claims off even the most ardent circumcision promoters) that he would have benefited from the procedure in any significant enough way as to justify the surgery. Contrary to Patrick's assertion, recent strong evidence shows that circumcision is medically beneficial only to a small minority of males who are circumcised, as well as carrying both known and unknown risks to a males. The blanket statement that the procedure is 'medically beneficial' is a distortion. Virtual all of the benefits she cites are related to STDs, which are primarily an issue of behavior and are not relevant to male until he would be able to make a decision to be circumcised for himself. There are far more effective and conventional non-surgical means to protect oneself from STDs; it cannot assumed that the surgery will be acceptable to an individual and not infringe upon his rights. It is puzzling indeed that bodily rights and patient autonomy can continue to be so casually disregarded in medicine because of 'cultural reasons'. The fact that there is an unlikely possibility a male may be afforded what amounts to mostly minor compensatory medical benefits is largely irrelevant. The nature of the much debated benefits, or lack thereof, associated with the surgery are such that they are rare and could be achieved far more easily via less invasive and ethically problematic means.[2] Physicians are not acting in accordance to their ethical duties to the patient by performing needless surgeries on a child's genitals simply because the child's parents want them to for the sake of culture, dressed up in medical rationalizations. Rationalizations that would likely not hold if the cultural impetus were not there to prop them up by over- exaggerating the benefits, dismissing the harms, and clouding the ethical/bodily rights implications of performing unnecessary genital surgeries on children. Assuming that circumcision gives men additional protection from becoming infected with HIV as recent research suggests: baby boys and children do not immediately need such protection and can choose for themselves, when they are capable, if they want to be circumcised. Adult male circumcision is a relatively safe minor procedure; pain can be effectively managed; and is associated with relatively short duration of recovery. [3] This inconvenience factor is not nearly too high a price to pay in order for the medical community to give due weight to principles of individual autonomy and bodily rights by preserving a males right to choose the procedure for himself. Placing little importance on individual bodily rights, a more compelling argument for allowing infant circumcision might be made in situations where a child will be raised within a cultural group which possesses stigmas towards natural/un-surgically altered human male genital anatomy.[4] However, what more appropriately ought to be be addressed by the medical community is the fact that these stigmas still exist in the first place, and what to do about them; not how these stigmas ought to be respected and catered to. Technically, circumcision compromises an individual's bodily integrity. It is only the degree to which it does so which is debatable. Nevertheless, circumcision constitutes a permanent removal of genital tissue and alteration of the appearance of the external male genitalia which can not be equated to a vaccination needle any more than male circumcision can be equated to a medicalized FGM/clitorectomy as a cultural practice. Concepts of bodily integrity can be subjective in nature. In cases where the procedure is seen as desirable or unimportant to the individual when he is grown it could be argued this is non-relevant. However, in cases where the procedure is unwanted, circumcision is a clear violation of an individual's bodily rights in which their bodily integrity is compromised - in the absence of appropriate medical/ ethical justification .[5] It can be reasonably argued that this runs counter to several of the ethical principles that govern medicine[6] as it is entirely unknowable if a male would accept or object to the surgery. Given the highly ethically questionable nature of non-therapeutic circumcision of minors, it is difficult to find much validity in Patrick's arguments that doctors would do better by assisting parents in obtaining a circumcision services for their sons. A physician is ethically bound to act in the best interest of the patient - the infant male child. Given that it is highly unlikely he would benefit from the surgery in any substantive enough way to justify genital surgery; and given that it is unknowable whether or not the irreversible procedure performed on a male infant is something he would want done to his body: The most ethically sound course of action for a physician to undertake would be to counsel parents against the procedure, not to have a hand in enabling it. --- [1] W Dekkers, C Hoffer, JP Wils - Bodily integrity and male and female circumcision Medicine, Health Care and Philosophy, 2005 [2] Somerville, M. 2000. "Altering Baby Boys� Bodies: The Ethics of Infant Male Circumcision", The ethical canary: science, society, and the human spirit. New York, NY: Viking Penguin Canada, 202�219. LCCN 2001- 369341. ISBN 0670893021. [3] Halperin DT, Bailey RC (1999) Male circumcision and HIV infection: 10 years and counting. Lancet 354: 1813�1815 [4] Benatar, D., and M. Benatar. 2003. 3:2 Target article authors respond to commentators: How not to argue about circumcision. The American Journal of Bioethics 3(2): W1-W9. [5] Povenmire R. Do parents have the legal authority to consent to the surgical amputation of normal, healthy tissue from their infant children? The practice of circumcision in the United States. Journal of Gender, Social Policy & the Law 1998;7:87-123. [6]George C. Denniston Circumcision and the Code of Ethics, , Humane Health Care Volume 12, Number 2 Competing interests: None declared
Re: Medical Propaganda 8 December 2007
A. D. Fontain, Independent Researcher Toronto, ON. Canada M5S 1A5 Send response to journal: Re: Re: Medical Propaganda	"I was a General Practitioner for over 30 years, over which time, I have seen thousands of patients who were circumcised and never once did I hear a complaint from a child or adult who felt assaulted" It should be noted that knowledge and awareness of circumcision, and sexual health issues in general, is much greater in recent times than it was in the past which might contribute to an 'ignorance is bliss' phenomenon you witnessed. Of course not all males are unhappy about being circumcised, but enough of them are to warrant a change of conduct within the medical profession. Namely - allowing males to make the decision to be circumcised for themselves. The principles of individual autonomy and bodily rights in medicine are not based on majority rules. It is irrelevant what you believe 'most people' you came in contact with in your career who were circumcised may have felt about it - when the procedure is entirely unnecessary and in which all its touted benefits can be achieved in less invasive ways. ie bathing, and practicing safe sex which people should be doing anyways en lieu of surgery. It could be argued that 'most' (whatever that entails) males are not bothered by having the surgery as children - But an individual is not 'most people', and deserves to have their autonomy over their body respected when it comes to genital modification. Removing sexual anatomy without any medical need is not equatable to vaccination. Incidentally how would you be aware if any of you patients were dissatisfied with being circumcised. What would they say to you if they weren't to embarrassed to talk about it? And to what purpose would it serve them to tell you they didn't like it in the first place? I fail to see how ethical issues that need to be addressed in medicine amount to 'Medical Propaganda'. A term which I think could more appropriately be applied to culturally fueled medical justifications given to validate a social custom. Competing interests: None declared
No reason not to wait 8 December 2007
Eleanor Snape, Resource Assistant University of Brighton, BN1 9PH Send response to journal: Re: No reason not to wait	I think the comparison to immunisations and the like is faulty because these 'abuses' of the child are for his or her protection against things which cannot be realistically prevented in other ways. The argument that it may have sexual health benefits adds no weight to the case for infant circumcision as these children will not be sexually active for years to come, by which time they can make a more informed decision of their own regarding whether to be circumcised. Furthermore, there are other and more effective ways of practicing safe sex which are not irreversible, painful and potentially hazardous. I see no good reason why circumcision cannot wait until the child is old enough to make his own decision about it. Competing interests: None declared
Questionable argument 8 December 2007
Jake H Waskett, Founder Circumcision Independent Reference and Commentary Service, M26 1JR Send response to journal: Re: Questionable argument	Hinchley argues that it cannot be in the best interests of a child to perform a procedure "which will provide no medical benefit but which has proved adverse consequences both in terms of potential complications for some and reduced penile sensation in adulthood for all."[1] The evidence, however, does not support his implication that circumcision is such a procedure. The medical benefits of circumcision include reduction in risk of urinary tract infection,[2] penile cancer,[3][4] phimosis,[5-6] balanitis,[5-7] and several sexually transmitted diseases.[8-11] These benefits are recognised in the position statements of several medical organisations, such as that of the American Academy of Pediatrics (AAP).[12] While Hinchley compares female genital mutilation to circumcision, the AAP state that "[the] critical distinction between female genital mutilation and male circumcision is the potential medical benefits of male circumcision. These potential benefits warrant a parental role in decision making about this procedure."[13] Similarly, "the circumcision of male children did not concern the United Nations as only female circumcision was deemed a harmful practice to be eradicated. Consequently, it would seem inappropriate to consider under one head both female circumcision which is harmful to health and male circumcision which has no undesirable effect and [is] even considered to be beneficial."[14] In support of his claim of reduced penile sensation, Hinchley cites indirect evidence in the form of a study which claimed that the foreskin contained the most sensitive parts of the penis.[15] When data from this study were properly analysed, there were in fact no statistically significant differences.[16] Curiously, Hinchley did not consider evidence which directly addressed this issue. A study of adult circumcision patients found that only 18% reported reduced penile sensation, while 38% reported improved sensation.[17] Hinchley is correct, however, in noting that potential complications exist; their incidence is estimated at 0.2% and 0.6%.[12] Hinchley claims that "[far] from being a harmless traditional practice, circumcision damages young boys." If this were so, one would expect to find significant dissatisfaction among circumcised males. Yet in fact, studies of circumcision patients consistently reveal high rates of satisfaction.[8-9,17,19-21] Indeed, one study suggests that circumcised males may in fact be more satisfied than their uncircumcised peers.[22] Hinchley appears to believe that it is sufficient to describe circumcision as 'mutilation', and pretend that the benefits of this procedure do not exist. Yet as Benatar and Benatar observed in 2003, "whether circumcision is a mutilation and, if it is, whether it is an unacceptable mutilation can be established only by argument and not by mere assumption. Potential harms and benefits must be examined and weighed against one another. [...] To think that a moral judgment can be made without considering these is to adopt what sounds like a dogma rather than a reasoned conclusion."[18] References 1. Hinchley G. Is infant male circumcision an abuse of the rights of the child? Yes. BMJ 2007;335:1180 2. Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch Dis Child. 2005 Aug;90(8):853-8 3. Schoen EJ, Oehrli M, Colby C, Machin G. The highly protective effect of newborn circumcision against invasive penile cancer. Pediatrics. 2000 Mar;105(3):E36. 4. Maden C, Sherman KJ, Beckmann AM, Hislop TG, Teh CZ, Ashley RL, Daling JR. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. J Natl Cancer Inst. 1993 Jan 6;85(1):19-24. 5. Fergusson DM, Lawton JM, Shannon FT. Neonatal circumcision and penile problems: an 8-year longitudinal study. Pediatrics. 1988 Apr;81(4):537-41. 6. Herzog LW, Alvarez SR. The frequency of foreskin problems in uncircumcised children. Am J Dis Child 1986; 140: 254-256 7. Fakjian N, Hunter S, Cole GW, Miller J. An argument for circumcision. Prevention of balanitis in the adult. Arch Dermatol. 1990 Aug;126(8):1046-7. 8. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005 Nov;2(11):e298 9. Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, Williams CF, Campbell RT, Ndinya-Achola JO. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet. 2007 Feb 24;369(9562):643-56. 10. Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F, Kiwanuka N, Moulton LH, Chaudhary MA, Chen MZ, Sewankambo NK, Wabwire- Mangen F, Bacon MC, Williams CF, Opendi P, Reynolds SJ, Laeyendecker O, Quinn TC, Wawer MJ. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet. 2007 Feb 24;369(9562):657-66 11. Weiss HA, Thomas SL, Munabi SK, Hayes RJ. Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect. 2006 Apr;82(2):101-9 12. Circumcision policy statement. American Academy of Pediatrics. Task Force on Circumcision. Pediatrics. 1999 Mar;103(3):686-93 13. Lannon CM. Circumcision---The Debates Goes On [authors' reply]. Pediatrics 2000; 105(3):681-4 14. Warzazi HE. The implementation of the human rights of women traditional practices affecting the health of women and children: Follow- up report of the Special Rapporteur on traditional practices affecting the health of women and children. 1997. Available at: http://www.unhchr.ch/Huridocda/Huridoca.nsf/(Symbol)/E.CN.4.Sub.2.1997.10.En?Opendocument 15. Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF, Wilcox N, et al. Fine touch pressure thresholds in the adult penis. BJU Int 2007;99:864 -9 16. Waskett JH, Morris BJ. Fine-touch pressure thresholds in the adult penis. BJU Int. 2007 Jun;99(6):1551-2 17. Masood S, Patel HR, Himpson RC, Palmer JH, Mufti GR, Sheriff MK. Penile sensitivity and sexual satisfaction after circumcision: are we informing men correctly? Urol Int. 2005;75(1):62-6. 18. Benatar M, Benatar D. Between prophylaxis and child abuse: the ethics of neonatal male circumcision. Am J Bioeth. 2003 Spring;3(2):35-48 19. Jensen MK. [Surgery for phimosis with Plastibell. A follow-up study]. Ugeskr Laeger. 1998 Jun;160(26):3920–3923. 20. Sobeh M, Junaid I, Marsh H, Fowler CG. Local anaesthetic circumcision in adults. Int J Clin Pract. 1999 Dec;53(8):637. 21. Stenram A, Malmfors G, Okmian L. Circumcision for phimosis: a follow-up study. Scand J Urol Nephrol. 1986;20(2):89–92. 22. Schlossberger NM, Turner RA, Irwin CEJ. Early adolescent knowledge and attitudes about circumcision: methods and implications for research. J Adolesc Health. 1992 Jun;13(4):293–297. Competing interests: None declared
Infant male circumcision IS abuse 8 December 2007
Heather M Longanecker, Stay at Home Mom Naperville, IL 60540 Send response to journal: Re: Infant male circumcision IS abuse	I would not cut off a perfectly healthy and necessary part of my son's penis for some possible benefits to future sexual health. Circumcised men get AIDS and every other sexually transmitted disease in America, where the circumcision rates are high. I think it more responsible to make a choice as a parent to teach our sons (and daughters) about condoms and safe sex. I wouldn't cut out my daughter's breast tissue at birth to prevent some future possibility of breast cancer either. It is a barbaric practice inflicted on our newborns so they look like daddy. Parents who want what is essentially cosmetic surgery on their son's genitals are either misinformed or out for their own best interests, not the child's best interests. The status of our children's sex organs is not our decision as parents. The whole practice needs to be done away with. Competing interests: None declared
Hinchley understates his case 8 December 2007
George Hill, Vice-President for Bioethics and Medical Science Doctors Opposing Circumcision, Suite 42, 2442 NW Market Street, Seattle, Washington 98107-4137 Send response to journal: Re: Hinchley understates his case	Geoffrey Hinchley understates his case.1 He should have looked at the UN International Covenant on Civil and Political Rights (ICCPR).2 That instrument of international law, now ratified everywhere, clearly states that everyone has a right to security of the person. It should be obvious to everyone, that male circumcision, which amputates and excises significant amounts of nerve-laden, sexually sensitive skin and mucosa from the male phallus,3 does not accord with this very fundamental principle of human rights. Moreover children are to be given special protection.2 What does this mean for medical doctors? Everyone has an ethical duty to respect the rights of others.2 International ethics experts have developed two international instruments with a goal of bringing medical practice into conformity with international human rights law. The Council of Europe’s Convention on Human Rights and Biomedicine (1997), now ratified and in force in 21 European nations, provides: No organ or tissue removal may be carried out on a person who does not have the capacity to consent under Article 54 UNESCO’s Declaration on Human Rights and Bioethics says: Individuals and groups of special vulnerability should be protected and the personal integrity of such individuals respected. 5 No one is more non-consenting and vulnerable than a child. The circumcision of children does not accord with these ethical priniciples. Non-therapeutic circumcision of children is thoroughly unethical under contemporary human rights and medical ethics.6 What does this mean for governments? The ICCPR imposes a duty on governments to protect the human rights of every person. 2. Where not already provided for by existing legislative or other measures, each State Party to the present Covenant undertakes to take the necessary steps, in accordance with its constitutional processes and with the provisions of the present Covenant, to adopt such laws or other measures as may be necessary to give effect to the rights recognized in the present Covenant.2 Every government has a duty to take measures to protect the rights of male children. The GMC exercises a quasi-governmental function and has a duty to act to protect male children from the excesses and abuses of medical doctors under its supervision and control. Its present policy regarding male circumcision, now a decade old, is outmoded and needs re-examination and amendment. George Hill Doctors Opposing Circumcision Web: http://www.doctorsopposingcircumcision.org References Hinchley G. Is infant male circumcision an abuse of the rights of the child? BMJ 2007;335:1180. International Covenant on Civil and Political Rights. Adopted and opened for signature, ratification and accession by General Assembly resolution 2200A (XXI) of 16 December 1966. entry into force 23 March 1976. Available at http://www.unhchr.ch/html/menu3/b/a_ccpr.htm Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-5. Available at http://www.cirp.org/library/anatomy/taylor/ Council of Europe. European Convention on Human Rights and Biomedicine. Adopted at Oviedo, 4 April 1997. Available at http://conventions.coe.int/Treaty/en/Treaties/Html/164.htm Accessed December 4, 2007. UNESCO. Universal Declaration on Human Rights and Bioethics. Adopted by UNESCO General Council on 19 October 2005. Available at: http://portal.unesco.org/en/ev.php-URL_ID=31058&URL_DO=DO_TOPIC&URL_SECTION=201.html Accessed November 24, 2007. Clark PA. To circumcise or not to circumcise. Health Prog 2006;87:30-39. Available at http://www.chausa.org/Pub/MainNav/News/HP/Archive/2006/09SeptOct/Articles/Features/HP0609d.htm Competing interests: None declared
Re: Medical Propaganda 8 December 2007
J D Poff, researcher Auckland 0629, NZ Send response to journal: Re: Re: Medical Propaganda	Thomas Flett's ad hominem response to Dr Hinchley's discussion of circumcision: "I would strongly recommend that as an A&E Consultant, in one of the UKs worst performing Trusts in infection control, that Geoff Hinchley focus his efforts on his task at hand" is about par for proponents of male genital mutilation. I think Dr Flett has missed the entire rhyme and reason around the simple meaning of consent. None of the gallery of tortures and neonatal traumas he mentions involve the pointless amputation of healthy body parts. Babies, like the rest of us, are guaranteed security of person under the Universal Declaration of Human Rights. His construction of this straw man: "I do not see Geoff Hinchley writing to have all these procedures banned" only serves to draw attention to the inadequacy of his case. Equally feeble is his appeal to the failure of circumcised patients to feel satisfactorily assaulted. I suggest to Dr Flett that if Masters and Johnson were unaware of the existence, anatomy and natural function of the male prepuce, it is unlikely that many adults circumcised in childhood will be any better informed. Most will not be conscious of their loss or aware of its significance. Does that make it acceptable? Those of us who are aware of damage done to our bodies feel violated and angry, and will not be silenced by attacks on our personal credibility. The facts are readily available for any who care to face them. _________________________________ Competing interests: None declared
Parents have the right and obligation to choose what they consider best for their children 9 December 2007
Norton Pérez, MD, General Surgeon & Critical Care Medicine Hospital Departamental de Villavicencio, Meta, Colombia, South America Send response to journal: Re: Parents have the right and obligation to choose what they consider best for their children	As parents we take decisions for the best of our children. Vaccination, school, clothes, friends, etc. Some have decided to offer our children the benefits of circumcision without religious considerations. My parents also chose for me and I have always been grateful with them. Besides, I have no memories of the procedure it self. So I took the same decision for my son like my parents did for me. I am sure he will be grateful when he grows up. Competing interests: None declared
Psychological damage from circumcision 9 December 2007
Janet Menage, GP Bulkington Surgery CV12 9JB Send response to journal: Re: Psychological damage from circumcision	Puppies are now protected from tail-docking but human babies can still have a normal, healthy, functioning part of their genitalia amputated at the drop of a hat (1). Loss of a body part is psychologically traumatic (2). When it occurs without consent it is perceived as an assault. When it attacks the penis it constitutes a sexual assault. And when done without anaesthetic it may be experienced as sexual torture. There is much published work on the subject (3). My research into obstetric and gynaecological procedures in women (4) showed that where the patient experiences a genital procedure, without informed consent, in an unsympathetic environment, associated with pain and an experience of powerlessness, there is a risk of Post Traumatic Stress Disorder similar to that experienced by victims of war, rape and childhood sexual abuse. Preliminary research into the psychological effects of circumcision revealed similar findings of PTSD on a clinical scoring system validated on Vietnam war veterans (5). Dr Flett may well not have heard any complaints from circumcised men as they would be reluctant to trust the medical profession, would fear ridicule, and likely feel ashamed of their condition, as per other victims of sexual assault. Genital mutilation of healthy, unconsenting children is an anachronism in the 21st century: balanitis is treatable by antibiotics, phimosis by steroids, vaccines prevent cervical cancer, condoms are prophylactic against HIV, and religious belief is not a valid medical indication to amputate normal healthy tissue. So what is left? – only transgenerational irrationality and tradition. Whatever happened to E.B.M? References: (1) 6 April 2007 in England, and 28 March in Wales, the mutilation of animals is banned under the Animal Welfare Act 2006 (2) Adler, Alfred. (1958) Individual Psychology; Harper & Row (1 Jun 1958) (3) Goldman,R.(1997) Circumcision: The Hidden Trauma; Vanguard, Boston (4) Menage,J. (1993) Post Traumatic Stress Disorder in Women who have undergone Obstetric and/or Gynaecological Procedures, Journal of Reproductive and Infant Psychology (Oct) (5) Menage,J. (1999) Post Traumatic Stress Disorder after Genital Medical Procedures, Male and Female Circumcision: Medical, Legal and Ethical Consideration in Pediatric Practice; Kluwer Academic/Plenum Publishers Competing interests: None declared
circumcision should not be done to any minor. 9 December 2007
troy l horenziak, agriculture 48741 Send response to journal: Re: circumcision should not be done to any minor.	it has been shown to remove pleasure and lower pain thresholds.doing this to a boy or girl is wrong and should be left up to them to decide on their own when they grow up.it should be illegal to perform on a child. Competing interests: None declared
Updating circumcision 9 December 2007
David B G Hawker, retired GP/Anaesthetist PL30 5LA Send response to journal: Re: Updating circumcision	It is good that such an important and misunderstood topic as circumcision is in the open for debate. Malone and Steinbrecher, in their "Clinical Debate" (BMJ 8/12/07) are limited to completed clinical trials, ideally having others to compare with. This standard technique inevitably ignores incompleted trials as well as individual papers and anecdotes. It serves well, but is often a decade out of date for the front line worker. The past 10 years has brought much new evidence to the circumcision debate. No longer is phimosis the prime reason for circumcising infants. Circumcision results in a wide range of disease prevention, ranging from urinary tract infections in infancy, phimotic and infective diseases of childhood, a reduction in the ever growing numbers of STIs in our "liberated" society, through to a reduction in Prostatic cancer and ease of nursing especially incontinent older men. I feel that Dr Hinchly is in danger of repeating the mantras of the anti- circumcision advocates, often quoting out-of-date evidence, and using emotive rather than medically sound arguments. It is an issue, though whether it is right to remove such a personal thing as a foreskin without permission or disease, and parents neeed to be given enough information for them to be able to make an informed choice, as they do with vaccinations, which have far more and serious side effects than circumcision. Dr Patrick seems to me to bring us right up to date. We have to confront major diseases such as HIV (uncommon at present in UK) and HPV (very common). Removal of the foreskin removes the Langerhan cells which are responsible for the spread into the body. The warm moist environment also encourages the spread aand multiplication of these along with syphilis, chlamydia,and rarely chanchroid. A recent IPPR report suggested that 38% of our under15s have had penetrative sex, an alarming pool of infection. We are about to vaccinate our girls, at a cost of at least £200 each, against Human Papilloma Virus (HPV). Infant circumcision has as much protective effect against HPV at a cost of £60, bringing all the other benefits along with it. The South Korean and Phillippino boys arrange their own circumcision at age 12, and have a 90% uptake. That would satisfy those who want the individual to choose. As we have seen, that choice has to be made before sexual activity takes place. In our culture, a 10 minute procedure using a Plastibell or (beloved of Americans) a Gomco clamp with local anaesthetic provides a cheap and simple solution in early childhood, a technique easily learned by a competent GP. Prof Brian Morris of Sydney puts the relative risk of circumcising as 1: 100 compared with lifetime uncircumcision. Personally, I am delighted that my son and grandson were circumcised as infants. I believe that is as responsible a decision as to have them vaccinated. We need to make it easy for those who desire it. Competing interests: None declared
Is infant male circumcision an abuse of the rights of the child? Yes 9 December 2007
NAZAR R DESSOUKI, CONSULTANT SURGEON ST BERNARDS HOSPITAL GIBRALTAR Send response to journal: Re: Is infant male circumcision an abuse of the rights of the child? Yes	The answer is NO Male circumcision has been associated with a lower risk for HIV infection in international observational studies and in three randomized, controlled clinical trials. Male circumcision could also reduce male-to- female transmission of HIV to a lesser extent. It has also been associated with a number of other health benefits. While there are risks to male circumcision, serious complications are rare. Accordingly, male circumcision, together with other prevention interventions, may play an important role in HIV prevention in settings similar to the clinical trials. Male circumcision may also have a role for the prevention of HIV transmission in the United States. With the results of three clinical trials showing that male circumcision decreases the risk for HIV infection, CDC is undertaking additional research and consultation to evaluate the potential value, risks, and feasibility of circumcision as an HIV prevention intervention in the U.S. Competing interests: None declared
Re: Baloney on 'the snip' 9 December 2007
Ivy Paul, A&E doctor (locum) sandwell hospital, West Bromwich B71 4HJ Send response to journal: Re: Re: Baloney on 'the snip'	The debate on the usefulness or the disadvantages of male circumcision has been going on in the western society for a long time, because circumcision is neither culturally mandatory nor a religious practice, therefore still an arguable issue. Without being biased I would like to quote an article in a journal called 'The Aids Reader' under the heading of "Male Circumcision and the Risk of HIV Infection". The article can be found at www.medscape.com and mentions reports about the potential protective effect of male circumcision in the sub Saharan African continent. I believe, in view of providing good health care in any form, it would be better for us to start thinking beyond 'abuse', which is a matter of debate, and strive to take any measures that could possibly decrease the risk of infections like HIV Competing interests: None declared
Do no harm 9 December 2007
Iris B. Fudge, RGN Retired LONDON SE24 0DQ Send response to journal: Re: Do no harm	Any medical practitioner carrying out a surgical operation upon a person must ask himself - what is the necessity and the reason for this procedure and what is the benefit to the patient which justifies any harm that may ensue. Competing interests: Member of NORM-UK and FORWARD.
Is infant circumcison abuse? 9 December 2007
Tandy Huighes, retired 15235 Send response to journal: Re: Is infant circumcison abuse?	Of course it is. And to pretend that there are valid medical reasons for it is fallacious. Studies claiming any benefit for infant circumcision are flawed correlational statistics only. No where in the real world outside of the studies themselves are these benefits ever seen. Many countries that do not circumcise have the same rates (or lower rates) for all claimed beneits as do circumcising countries.. when this is brought up, there is never a rebuttal, just a lot of vague and unproven excuses. SCIENCE does not accept excuses! Science and Circumcision Basic principals of science: These can be used as a litmus test for claimed benefits Conclusions based solely on known flawed data cannot be considered valid All studies have known flaws—flaws of commission and/or flaws of omission Flaws = not scientifically compelling The worth of a theory is determined by its ability to make accurate predictions No predicted reduction or elimination is found in real world Failure to fulfill prediction = not scientifically credible Competing interests: None declared
Circumscision is justified 9 December 2007
Mujibur Rahman, Assistant Professor 5400 Send response to journal: Re: Circumscision is justified	Yes, it is justified to have cicumscision of male infant or child. It not only keeps best sexual life in later life rather prevents many diseases like cancer or other sexual diseases. There are many publications on the matter. Parents have to do many things for the better future of the child. Why should the parents send them to school when they like to play only. It is for their better future. In this way a child should not be exposed to anything that should be exposed to adults only e.g. sex education in school life that is practised in so called most modern western country. It is one of the common causes of HIV or other sexual diseases those prevelent in those people. Many things that should not be exposed to them may make them curious to perform or practise it in inappropriate time and bringing dangerous effect. If parents do not control them or teach them religion they will be worse than animals. I think muslim religion is best in this sense. HIV/AIDS is least among the muslims in the world. Competing interests: None declared
Is infant male circumcision an abuse of the rights of the child? 9 December 2007
Jan J van der Bank, Religious Researcher Pretoria, 0186, RSA Send response to journal: Re: Is infant male circumcision an abuse of the rights of the child?	Yes: Every person is entitled to their own opinion when and how and if. The baby does not have that right to choose. Even the parent may not decide even if it's religious of nature. The ONLY time it may happen is when the child is actually in <b>immediate</b> danger and/or can/will be in danger before the age of adolescence is reached, and even then there are certain procedures and/or rules to work upon. Competing interests: Religion
Re:Questionable argument 9 December 2007
A.D. Fontain, Independent Researcher Toronto, ON. Canada M5S 1A5 Send response to journal: Re: Re:Questionable argument	The AAP holds that the existence of potential benefits associated with male circumcision justifies a parental role in making the decision. However, what the AAP fails to address is the question of how/why the mere existence of potential benefits alone adequately justifies the allowance of parental consent. And consequently, results in the usurping of individual bodily rights in relation to an unnecessary genital modification. Should a male object to the removal of healthy genital tissue from his body, this rational provides little in the way of appropriate justification for the infringement upon his individual bodily rights that has occurred. Policies which fail to adequately address the issue of individual bodily rights in this matter represent more of an artifact of cultural inheritance than they do any kind of sound policy. Compensatory potential benefits which are not compelling enough for the AAP (or any other national medical organization for that matter) to make positive recommendations upon are given far too much weight in the current equation. The AAP position, along with Benatar and Benatar's arguments[1], might more appropriately apply to religious circumcisions performed by a mohel. Physicians, on the other hand, are bound to a specific code of conduct unique to their position as health care providers. They are required to respect a patient's autonomy and act solely in the patient's best interest. It is quite a stretch indeed for a physician to claim that he/she is acting in accordance with his/her ethical duties when removing healthy genital anatomy from a patient before the patient's will regarding this action can be known. Aside from the matter of principle, there is the fact that circumcision is no longer an unquestioned cultural norm within Western society as it once was. - which makes any assumption that a male will have wanted to be/or will be neutral about being circumcised in infancy even more questionable. To justify this conduct by the fact that a male infant's will cannot be known, despite the fact that he will be capable to make this decision at a later date, does not constitute a need for proxy consent to be sought and undermines it's validity. The uncertainty surrounding the best interests of a child when he will be raised in a cultural setting that may possess stigmas towards natural male genital anatomy is not so much a matter of whether or not surgery should be performed on him. - But a question of how to eliminate these unfair and harmful stigmas that are directed towards boys simply because they have not had their genitals surgically altered. In societies where male circumcision has been culturally normalized, it is often simply assumed that the removal of genital tissue from an un- consenting minor is acceptable. From this starting point: if it is not on par with FGM in terms of harmfulness; and if it is associated with a collection of (mostly minor) potential health benefits(that are rare) - it therefore must be an acceptable practice. Unfortunately, this outdated logical tangent continues to be reflected in many of the policies throughout the world. Given the cultural history involved, it is not surprising that the AAP, along with many other medical societies hold confused policy statements on the issue. Benatar and Benatar, merely parrot the AAP position statement as it pertains to ethics. Kirsten Patrick, in her defense of the procedure, does the same; while at the same time cherry picking studies that would paint circumcision in a favorable light - a tactic that is necessary in order to give circumcision advocacy any semblance of credibility. However, even taking these claims at face value, virtually all of the potential health benefits cited are either 1. Not relevant to male until he would old enough to make a choice for himself (STD data).; 2. Are mostly minor and rarely associated with a need for any surgical intervention whatsoever (infection). 3. Can be achieved via more effective, ethically sound and non-surgical means (practicing a modicum of care in relation to hygiene and sexual conduct). And 4. Are exceedingly rare and are associated with far more significant risk factors that are primarily behavior related(penile cancer). Only in some cases would circumcision avert a male having to be circumcised for health reasons - the exact same procedure, only slightly more complicated as the prevention. This is the upside-down logic in the argument of why circumcising infants is acceptable or even desirous. I do believe there might be some truth to George Hill's observation that some circumcised men who are doctors use the medical literature to justify their loss... which results in a voluminous, confused, and chaotic literature as other doctors refute the fantasy claims of circumcised doctors. - There must be at least some degree of psychologically driven fanaticism at play when an advocate of circumcision takes a microscope to statistical data and translates, say, a 0.4%circ versus 0.8%uncirc rate of an adverse health event like a skin infection; Trumpets the study as proof that uncircumcised boys are "twice as likely!" to get said skin infection; Goes on to collect as many circumcision- positive studies that would support their pre-determined hypothesis that they can find; Tally their figures; Omit any conflicting evidence; Weigh the result against the smallest risk figures that can be found within medical literature; And then go on to claim that circumcision is associated with 'significant health benefits' which therefore make it a perfectly acceptable practice. Nevermind the fact that, in reality, whether or not 1% or 10% of males get some small benefit from the surgery is only one consideration - the fact remains that 90%-99% of infant males will not benefit in anyway from having part of their genital anatomy removed. Nevermind the fact that most of the benefits are irrelevant to a child and that in most cases the prevention is more drastic then would be the treatment. And nevermind the fact that there are males (enough at the least to give rise to widespread and sustained calls to put an end to the practice) who strongly object to having their bodily rights infringed upon via the removal of healthy genital tissue by doctors acting as cultural agents. It is far too facile to say that the crux of the matter rests upon: 1. Whether or not it is true that male circumcision reduces a males sexual sensitivity in the remaining anatomy (of which there exists conflicting research). 2. Whether the potential compensatory health benefits outweigh the risks and harms of the procedure. 3. How male circumcision differs from FGM. 4. Whether or not more males than not prefer, or are indifferent towards being circumcised in childhood. Regarding the first point: It should be noted that many men find the foreskin to be a pleasurable part of the penis that a circumcised male will never experience. Conflicting research into the matter aside, to claim that there is not at least some inherent loss in terms of sexual sensory experience, which can be of detriment to the capacity for sexual pleasure in a male, is utter denial. Some men may well claim to enjoy sex more after being circumcised. However, it should be noted that most men who chose to get circumcised in adulthood were likely experiencing a health problem with their foreskin, or felt some psychological desire to be circumcised. Two factors which would strongly contribute to the perception of increased sexual contentment. If a males is unsatisfied with being uncircumcised he can do something about it via a simple minor procedure. A circumcised male does not have any choice in that respect because his autonomy over his body has been taken from him, in the absence of any medical indication. Regarding the second and third point: There are many parts of the anatomy that could hypothetically be removed from a healthy child which might result in some potential compensatory benefits down the road. Nor might it necessarily be considered to be as injurious as FGM. Yet, as a general rule, as per the fundamental ethical principles that govern medicine, physicians do not interfere with a patient's bodily integrity when the patient cannot consent unless there is a clear and pressing medical need(or perhaps in cases of anatomical deformity). In addition, as mentioned earlier, the nature of the medical benefits are such that they are mostly minor and for the most part irrelevant to a male until he would be able to decide. Regarding the fourth point: Principles of individual autonomy and bodily rights in medicine, as they relate to a patient, have little to do with how other people might be culturally inclined to perceive a genital/body modification performed on them in childhood. Waskett states that "studies of circumcision patients consistently reveal high rates of satisfaction". This might be relevant in understanding how circumcision is perceived within a circumcising culture, but does little to address the nature of ethical arguments being put forward by abolitionists. I would not go so far as to equate the practice of FGM with infant male circumcision; but it is worth mentioning that within cultures that practice FGM, similar high rates of satisfaction coming from recipients of the custom can be observed.[2]. This only serves to illustrate that a culturally influenced and widespread favorable perception surrounding a body modification custom does little to provide any significant validity to it's ethical acceptability as it relates to an individual. Patrick and other infant circumcision apologists are apt to describe opposition to the circumcision of minors as being far too nebulous (citing a lack of any large scale studies looking into the matter) to deserve any consideration when it comes to policy. However, it is generally becoming accepted within the medical world that these men do indeed exist in sufficient number as to warrant a re-examination in policy. One recent example can be found in the College of Physicians & Surgeons of British Columbia's Resource Manual for Physicians pertaining to infant male circumcision[3] which states: "Under the Canadian Charter of Rights and Freedoms and the United Nations Universal Declaration of Human Rights, an infant has rights that include security of person, life, freedom and bodily integrity. Routine infant male circumcision is an unnecessary and irreversible procedure. Therefore, many consider it to be “unwarranted mutilating surgery”. "Many adult men are increasingly concerned about whether their parents had the right to give consent for infant male circumcision. They claim that an infant’s rights should take priority over any parental rights to make such a decision. This procedure should be delayed to a later date when the child can make his own informed decision. Parental preference alone does not justify a non-therapeutic procedure." Of course, one must also consider the point which Mr. Rosswick has raised: He is happy that he was circumcised 75 years ago, so all this discourse in the year 2007 on the ethics of neonatal circumcision within the context of health care ought to just disappear. --- [1] Benatar, D., and M. Benatar. 2003. 3:2 Target article authors respond to commentators: How not to argue about circumcision. The American Journal of Bioethics 3(2): W1-W9. [2] Morison et al - The long-term reproductive health consequences of female genital cutting in rural Gambia: a community-based survey. Tropical Medicine & International Health Volume 6 Issue 8 Page 643- 653, August 2001 [3] College of Physicians & Surgeons of British Columbia - Resource Manual for Physicians - Circumcision (Infant Male) Competing interests: None declared Competing interests: None declared
Don't do it! 9 December 2007
George W Terrell Jr., college professor Gadsden State Community COllege 35901 Send response to journal: Re: Don't do it!	Since it can't be easily reversed, circumcision should be the choice of the OWNER of the penis it is to be performed on! SO many nerves are removed that sensation HAS to be significantly diminished as a result. If it is not ok to MUTILATE girls (ie the new US law) then why is it still ok to do it to boys? Let them decide when old enough is my call. I was clipped at birth, as that was the trend at the time in the USA. I would advise parents now to NOT... George W. Terrell Jr. Competing interests: None declared
Circumcision or retraction? 9 December 2007
Oscar Luis Pereira, Pediatrics 10500 Send response to journal: Re: Circumcision or retraction?	When circumcision has a medical indication (very low), I think that it is not a child abuse because it is a treatment, but preputial retraction which is not indicated: yes it is. Competing interests: None declared
Circumcision may also be painful for the surgeon 9 December 2007
Roger H Armour, Retired Consultant Surgeon, Lister Hospital Stevenage 88 Wymondley Road, Hitchin, Hertfordshire SG4 9PX Send response to journal: Re: Circumcision may also be painful for the surgeon	Whatever the pros and cons of circumcision (1, 2), it is a painful business. In my last years as consultant I gave all my day-surgery patients my personal pager and home telephone numbers so they should not feel abandoned. In one typical year*, 130 operations were performed, 64 on children on dedicated paediatric lists. Twenty-three children underwent circumcision under general anaesthesia and a caudal block. To reduce anxiety to a minimum the children entered and left the operating theatre in their outdoor clothes. Circumcision was performed with a microsurgical technique using 5X magnifying loupes, saline drops to keep the wound moist, bipolar diathermy to coagulate blood vessels before they were divided, and the utmost gentleness. That year I received six telephone calls, four from parents of circumcised boys in much pain after operation, and my House Surgeon received two calls, also from parents of distressed circumcised boys. Thus 6/23(26%) of the boys were so upset that their parents had to telephone for help. Surgeons who do not allow their patients direct access to them sleep blissfully unaware of the suffering they are causing. Acknowledgments. I thank Dr Indu Sockalingham, consultant anaesthetist, and the the day-surgery and district liason nurses for their support. *unpublished data available on request 1) Hinchley G, Patrick K.Is male circumcision an abuse of the rights of the child? BMJ 2007;335:1080-1081 2) Malone P, Steinbrecher H. Medical aspects of male circumcision. BMJ 2007;335:1206-1209 Competing interests: Circumcision at age eight
Circumcision’s lawfulness is in doubt and there is a conflict of rights 10 December 2007
John D Dalton, Trustee NORM-UK, PO Box 71, Stone, Staffs ST15 0SF Send response to journal: Re: Circumcision’s lawfulness is in doubt and there is a conflict of rights	The question is not whether circumcision is in breach of the rights of the child but how properly to resolve the conflict in rights between the parents and the child. NORM-UK is a charity established in response to the need to represent the interests of male patients to avoid therapeutically unecessary circumcision. We receive calls daily from patients who have been harmed by male circumcision for which there was little or no therapeutic need. Many of the men who contact us have been profoundly damaged either physically or psychologically. Male circumcision is in all cases harmful since it removes the part of the penis most sensitive to fine touch, destroys the gliding function of the penile skin and removes immunological tissue. As circumcision permanently alters the appearance of the body it meets he dictionary definition of disfigurement. Since it removes a normal functional body part it meets the dictionary definition of mutilation. To claim that the procedure is not harmful would be absurd. Since male circumcision cuts through the full thickness of the skin it would appear to be a wounding for the purposes of the Offences Against the Person Act 1861. This calls into question the lawfulness of the procedure when performed on normal unconsenting children for any reason other than absolute therapeutic need. A defence of reasonable surgery would imply that disease is present for which there is no non-invasive treatment, that circumcision would provide effective treatment of the disease and that there is valid informed consent. We recognise that male child circumcision is a traditional practice within some religious communities. Everyone has the right to manifest religious belief, however that right is not absolute. The right to manifest religious belief may be limited where necessary to protect the rights and freedoms of others.[1] NORM-UK considers that circumcision of normal unconsenting children, when done for non-therapeutic reasons, infringes a child’s rights to autonomy, privacy, dignity and protection from cruel, inhuman or degrading treatment. As such, limitations on religious freedom in order to forbid male child circumcision would appear to be legally admissible. A realistic rate of significant complications for male circumcision lies between 2% and 10%.[2} Given this high rate of complications, NORM-UK considers the practice of male child circumcision to be prejudicial to the health of children. In this case governments would be obliged to act with a view to abolishing the practice if they are to meet their obligations under the 1988 Declaration of the Rights of the Child.[3] The recent death of a child following ritual circumcision in North London (http://www.guardian.co.uk/uk_news/story/0,,2015181,00.html) also raises issues of the right to life.[4] To answer Kirsten Patrick’s question “Where’s the harm?”, NORM-UK retain copies of all the letters received by our charity. These letters have been made anonymous by removal of all personal details which could identify the author. We invite Doctor Patrick to come to our office and read those letters. The evidence of harm is there if she cares to look. NORM-UK considers that the present guidance documents on male circumcision from the BMJ or GMC are no longer supportable in view of the GMC’s new statement that doctors must respect the rights of the child. The UK Government must honour its commitment to the Convention on the Rights of the Child. If HM Government do not have the stomach for this, they must ensure that circumcisers are traceable and can be held accountable for their actions. John Dalton, NORM-UK, PO Box 71, Stone, Staffs ST15 0SF References   1.       European Convention on Human Rights Article 9.2.   2.       Williams N, Kapila L. Complications of circumcision. Br J Surg. 1993; 80:1231-1236.   3.       Convention on the Rights of the Child Article 24.3.   4.       European Convention on Human Rights, Article 2.   5.       http://www.gmc-uk.org/guidance/ethical_guidance/children_guidance/index.asp accessed 08 December 2007. Competing interests: None declared
Male circumcision is cosmetic surgery. 10 December 2007
Andras Heijink, Orthopedic Surgery resident Mayo Clinic Rochester, USA Send response to journal: Re: Male circumcision is cosmetic surgery.	Male cirumcision, if not performed for medical reasons, is a cosmetic procedure and is unnessecary. Parents can consent to medical and surgical procedures to be preformed on their child only when there is a medical necessity, in other words, when the child will benefit from it from a health perspective. Parents can not have their child undergo unnecessary medical or surgical treatment. Hence, parents can not have their child undergo circumcision. Just imagine what an outrage it would cause if one would present at a hospital to schedule a face-lift for his 7 year old daughter; or breast augmentation for his 14 year old; or calf implants for his 10 year old son? These examples may seem completely ridiculous, but are in principle identical to male circumcision. The reasoning is quite simple. The only argument that can be made for male circumcision is that religious people usually do not follow legal and moral principles if they don't suit them well and will resort to non-medically schooled personell to perform the procedure under unhygienic conditions. This, however, should not be a reason to allow male cicumcision. Competing interests: None declared
Hard to imagine adolescent boys lining up to be circumcised 10 December 2007
Trevor Schroder, Research Fellow University of Queensland 4006 Send response to journal: Re: Hard to imagine adolescent boys lining up to be circumcised	I somehow found it very doubtful (and a completely laughable notion) that throngs of adolescent boys will feel the inclination to have their forskins whipped off in order to stave off future STD's. If indeed there is a benefit to circumcision - which the evidence appears to suggest both at an individual AND a population level - then surely there is much less trauma amd discomfort involved for a newborn infant who will have minimal recollection of the event than for a pubescent boy already at heightened sensitivity about his sexuality. Competing interests: None declared
Circumcision IS a good practice 10 December 2007
Anthony B Ainley, Graphic Designer BD21 5RA Send response to journal: Re: Circumcision IS a good practice	Sometimes the onlooker sees more of the game. Although a professional, medicine is not my discipline, but I am happily circumcised since childhood for none other than prophylactic reasons. Due to self interest, I have read widely on this subject and am astonished at the widespread ignorance and prejudice surrounding this time-honoured procedure amongst the UK public and doctors in particular. Ladies and gentlemen, please go back to basic principles of training. You know that the AIDS virus, like that of many STDS, dies quickly when exposed to open air and conversely, thrives in a damp, moist, atmosphere with nutritive fluids and decaying skin cells. A circumcised penis presents the former situation; the permanently exposed head being dry on entering his female partner for intercourse and returning to that state within a minute or two afterwards. There is no foreskin to trap the unedifying cocktail of their combined body fluids, together with any STDs the female may have been hosting. A foreskinned penis may, at best, have gone some hours since the last intimate hygiene routine. Not all personal attention to this area is effective and the foreskin cavity remains moist and disposed to disease. If there has been an intervening sexual liaison, this will have preserved any viruses for onward transmission. After coitus, the preputially intact man re-hoods his penis and retains what he has received under it, preserved until his next opportunity to shower. In many cases that time interval allows any viruses to breed and enter his system. Everyone knows the answer is for men to wear condoms and practice good genital hygiene. In the real world many men are deaf to such exhortation and do neither. The majority of male doctors in the UK today are probably uncircumcised. Many of their female counterparts have no experience of a circumcised partner. How can they know what is best for others? How can the oppose parents where the male is circumcised and both have experienced the benefits it bestows? As well as a degree of protection from disease, outlined above, I cite easier personal hygiene, the elimination of mechanical problems of the foreskin, like phimosis, and yes, enhanced sexual pleasure. Is it any wonder parents want these perceived advantages for their son and want the procedure done when it is not memorable and easiest to perform for him. Circumcision has been around since the dawn of time, arising independently to become embedded in religious faith and cultures both ancient and modern. If it were not found to be beneficial it would never have become so popular. I address all doctors to say, if you can't endorse the validity of circumcision, at least refer parents to those who do. Competing interests: None declared
Male & Female circumcision 10 December 2007
Sikander A Arshad, consultant Stoke on Trent ST6 7Ag Send response to journal: Re: Male & Female circumcision	If male circumcision, which I think is unnecessary on non medical grounds, is to be banned worldwide then there will be very good justification to stop female circumcision. Competing interests: None declared
prophylactic amputation should only be consensual 10 December 2007
Laura J MacDonald, stakeholder in the NHS London N1 5Sl Send response to journal: Re: prophylactic amputation should only be consensual	There is a simple way in which we can test whether the 'benefits' of circumcision are great enough to force this operation on a child. This is to consider whether we would countenance prepuce removal on baby girls if it could prevent some UTIs, some vulval cancer, some cases of HIV-AIDs. The answer (excepting a couple of particularly feverish circumcision agitators in Australia and the US) is a resounding NO. This is not entirely hypothetical. Evidence has emerged in Tanzania (R Stallings research) of a significant reduction in HIV risk through female genital cutting. If FGC had a dedicated group of Western enthusiasts who'd been funded to find justifications for it, we'd likely have a suite of health benefits associated with the practice. We need to take off our cultural blinkers. And as a matter of urgence consider the joy of the foreskin as something to balance against the benefits of prophylactic amputation. As was commented in the furore over CONSENSUAL labia circumcision data in May, "Incision to any part of the genitalia could compromise sensitivity" Competing interests: None declared
Questionable Argument 10 December 2007
IRIS B. FUDGE, RGN Retired LONDON SE24 0DQ Send response to journal: Re: Questionable Argument	Where there is a perfectly healthy child, male or female, with no presenting symptoms to be addressed, no case for surgery exists. The issue is not about comparing whether more or less harm is caused on the basis of gender, but about causing none at all. Intervention cannot be justified. Competing interests: Member of NORM-UK and FORWARD.
Better to provide a safe environment 10 December 2007
Shalini Pooransingh, Locum Consultant in Public Health Medicine Walsall tPCT, Jubilee House Bloxwich Lane , WS2 7JL, Sam Ramaiah Send response to journal: Re: Better to provide a safe environment	Dear Sirs, We agree with Kirsten Patrick that ‘circumcision is a choice that parents will make on behalf of their male children….and regulating its provision is the wisest course of action’ (1). What is important is to provide a safe environment for this in view of the potential complications of this procedure which range in severity from minor complications such as bleeding and poor aesthetic appearance, to major complications such as penile amputation, urethral fistula formation as well as altered or reduced penile sensation (2). In 2000, Walsall set up a service to provide religious circumcision for males aged 2 years and under. Primary care and secondary care are involved – GPs provide a full medical history and obtain consent while the acute trust provides the premises, the surgeon and post operative care. This is provided on a Saturday morning under local anaesthetic. The service is publicised in places of worship, GP surgeries and in the antenatal and delivery wards. A one year evaluation in 2001 showed uptake of just over 20%. A more recent evaluation in 2005 revealed a take up of about 33%. Some may criticise the PCT for providing this service, however we view this as we view the provision of free condoms…people will continue to engage in sexual activity so if we can make it safer then we should; similarly people may continue to marry their close relatives so if we can encourage them to attend antenatal screening we should; its about health education, health promotion and service provision taking into account the varying needs of a diverse society. Dr Shalini Pooransingh Locum Consultant in Public Health Medicine Dr Sam Ramaiah Director of Public Health Walsall teaching PCT, Jubilee House, Bloxwich Lane WS2 7JL References (1) Hinchley G, Patrick K Is infant male circumcision an abuse of the rights of the child? BMJ 2007; 335: 1180-1 (2) Malone P, Steinbrecher H Medical aspects of male circumcision Clinical review BMJ 2007; 335: 1206-9 Competing interests: None declared
Human Rights either exist or they do not..time for us to decide. 10 December 2007
Mark W Savage, Consultant Physician Manchester, M8 5RB Send response to journal: Re: Human Rights either exist or they do not..time for us to decide.	Sir, Geoff Hinchley [1] makes an eloquent and overwhelming case for the obvious fact that male circumcision is an abuse of the child's rights to decide for himself. He even points out the obvious facts that in the religious context a decision of an (uncircumcised) adult male to undergo such a procedure voluntarily will have much more weight in the religious-minded communities. The counter argument, by Kirsten Patrick that we should circumcise male infants to reduce HIV transmission is to denigrate the African and Indian populations to the status of cattle; we in the West are no longer farmers of our fellow man. 1. Geoff Hinchley. Is infant male circumcision an abuse of the rights of the child? Yes. BMJ 2007; 335: 1180 Competing interests: Member of Secular Medical Forum
Circumcision - an essential surgical 'vaccine' 11 December 2007
Brian Morris, Professor of Medical Sciences University of Sydney, NSW 2006 Send response to journal: Re: Circumcision - an essential surgical 'vaccine'	I refer to my extensive review published in the prestigious journal 'BioEssays' Nov issue entitled 'Why circumcision is a biomedical imperative for the 21st century' [BioEssays 29:1147-1158, 2007] and also my extensive internet review with 660 references that can be found at www.circinfo.net. The enormous medical evidence contrasts markedly with the anti-circ diatribe of Geoff Hinchly in the BMJ. It is absolutely appalling that Hinchly feels he can present his nonsense to an intelligent readership. He shows negligible knowledge of the field and his comments do not deserve space in a journal purported to be about evidence-based medicine. The truth is that circumcision of males represents a surgical "vaccine" against a wide variety of infections, adverse medical conditions and potentially fatal diseases over the lifetime of males, and also protects their sexual partners. In experienced hands, this common, inexpensive procedure is very safe, can be pain-free and can be performed at any age. The benefits vastly outweigh risks. The enormous public health benefits include protection from urinary tract infections, sexually transmitted HIV, HPV, syphilis and chancroid, penile and prostate cancer, phimosis, thrush, and inflammatory dermatoses. My calculations reveal that 1 in 3 uncircumcised males will, as a result of not being circumcised, suffer a medical condition over their lifetime that will require medical attention, and many will die from some of these. Since most complications during circumcision are on average seen in only 1 in 500, and these are easily and immediately treated, the benefits outweigh the risks by over 100 to 1. In women circumcision of the male partner provides substantial (over 5-fold) protection from cervical cancer and chlamydia. The latter can result in pelvic inflammatory disease, infertility and ectopic pregnancy. Circumcision has socio-sexual benefits and reduces sexual problems with age. It has no adverse effect on penile sensitivity, function, or sensation during sexual arousal, as now conclusively demonstrated. Credible research shows that most women prefer the circumcised penis for appearance, hygiene and sex. The claims of groups opposed to circumcision have become increasingly outrageous and vitriolic in the face to the medical evidence in favour. Equating male circumcision with female genital mutilation is one such nonsense, as the latter is equivalent to cutting off the penis. The claim that circumcision was advocated in Victorian times as a cure for masturbation, etc is untrue, as this claim was rare and largely rubbished in those days, whereas the Victorians knew well its benefits in prevention of syphilis, phimosis, penile cancer and other problems still recognized today. Moreover, quite surprisingly, some doctors continue to practice ‘ignorance- based’ or prejudiced-based’ medicine’ when it comes to circumcision. They need to update. Given the convincing epidemiological evidence and biological support, any expert such as myself can only conclude in favour of routine circumcision. It should therefore be highly recommended by all health professionals. Brian J. Morris, PhD DSc FAHA Professor of Molecular Medical Sciences, School of Medical Sciences and Bosch Institute, Anderson Stuart Building - F13, The University of Sydney, NSW 2006, Australia Email: brianm@medsci.usyd.edu.au Competing interests: None declared
What's sauce for the gander..... 11 December 2007
Laura J MacDonald, stakeholder in the NHS London N1 5SL Send response to journal: Re: What's sauce for the gander.....	Anthony B Ainley who has never known a foreskin comments that they create a "damp, moist, atmosphere with nutritive fluids and decaying skin cells" where infection can thrive. This is very true Anthony - unfortunately it's also true of the folds and flaps on the genitals of up to 3.2 billion women around the world (excepting those who have been excised). Your comments at least show a degree of consistency not seen elsewhere in this debate - by saying that circumcision would never have become popular if it hadn't been beneficial you automatically validate female genital cutting too. Competing interests: None declared
Of course it is 11 December 2007
janice page, receptionist london n4 Send response to journal: Re: Of course it is	Allow the child to reach 18 years so he can make an informed decision about whether or not he wants to keep his foreskin. The arguments seem to be about whether babies should be circumcised. What is the difference to the pro circ lobby if the boys are allowed to make the decision themselves when they are 18? Competing interests: None declared
Parents' rights 11 December 2007
Jean Davies, retired teacher 35 Pegasus Grange Whitehouse Road Oxford OX1 4QG Send response to journal: Re: Parents' rights	Giving birth to, or being the father, of a child does not give you the right to makes holes in it or chop bits off. The only exception to this is when acting, in accordance with the best medical knowledge available to you, to preserve the child's health. It is obvious why female circumcision is disapproved of in the Western world while excuses are found for male circumcision. Female circumcision is practised in accordance with the religious beliefs/tribal customs of THEM; male circumcision is sanctioned by OURS. Jean Davies. Competing interests: None declared
Women's Rights 11 December 2007
Dr John Glazebrook, veterinarian / research scientist Australia 4054 Send response to journal: Re: Women's Rights	Dr Hinchley's article appears to be full of emotional nonsense and dubious legal argument Has the anti circumcision lobby's position now disintegrated to the extent that they choose to ignore properly designed clinical trials and evidence based medicine ? Fortunately, the last 10 years has seen the development of the polmerase chain reaction which can detect the presence of specific viruses and bacteria on the penis which lead to sexually transmitted diseases This includes under the foreskin, where "washing" was once thought to be adequate Men should be held responsible for the STD's they carry and transmit to women Dr Hinchley, what about women's rights ? Competing interests: None declared
Male Circumcision-way forward? 11 December 2007
Babajide O. Olubaniyi, Surgical Trainee Basset District General Hospital Send response to journal: Re: Male Circumcision-way forward?	The debate on the scientific evidence for/against male circumcision and whether it is in the best interest of the child will continue..at least for now!. Parents will continue to consent for interventional procedures for their children if they judge it beneficial. Their decisions will unavoidably be largely influenced by the religious,cultural or medical background they hail from as every human being has an identity. Our duty as doctors is to educate the parents of these children according to best evidence for practice and allow them to make informed choices on treatment. Competing interests: None declared
Genital Integrity not Medicalization 11 December 2007
Dan Bollinger, International Coalition for Genital Integrity USA 47906 Send response to journal: Re: Genital Integrity not Medicalization	First, I wish to congratulate the BMJ for having the fortitude to delve into the ethical maelstrom concerning the medicalization of male genital cutting. This at a time when the American medical journals seem fit to only publish the status quo. Your courage is refreshing. Male infant circumcision as a prophylactic is unique in medicine. It is the only surgery that is prescribed by the parent, not the physician. Armed with only this information the reader should instantly realize that this is not a necessary or indicated surgery, but rather a cultural imperative. If it weren’t for the fact that so many physicians are circumcised themselves and have a strong cultural bias toward the practice, it would have stopped years ago and went the way of tonsillectomy and adenoidectomy. Another factor at work is income. Physicians and hospital staff persistently ask new mothers if they want their boy circumcised. Circumcision is a $200-360 million dollar industry in the United States and this doesn’t include circumcision repairs for mishap. In the final analysis, this discussion won’t be about medicine, but human rights (you can see that trend in this article and its commentaries). The discussion won’t be circumcision or female genital mutilation, but genital integrity and the rights of the child. It rests upon the shoulders of adults to protect defenseless children from harm and to speak for infants who cannot speak for themselves except by screaming and tugging at their circumcision restraints. Competing interests: None declared
Gloves? 11 December 2007
Michael Bunbury, GP St Vincent Send response to journal: Re: Gloves?	Where does the BMJ find surgeons willing to have their photograph taken of them performing surgery without gloves? Competing interests: None declared
Male circumcision 12 December 2007
Ishaq Mohammed, Clinical Registrar Nevill Hall Hospital NP7 7EG Send response to journal: Re: Male circumcision	Male circumcision has been practised in different geographical areas of the world from times immemorial.So far there hasn't been satisfactory data or studies exhibitng the harmful effects of it.It has proved to be of a great benefit in different aspects. Twelve studies have indicated that neonatal circumcision reduces the rate of Urinary tract infections (UTI's) in male infants by a factor of about 10. Studies have found that boys with foreskins tend to have higher rates of various infections and inflammations of the penis than those who are circumcised. Several studies have shown that uncircumcised men are at greater risk of human papilloma virus (HPV) infection. The World Health Organization (WHO) stated that studies of three trials, one of which was completed, provide compelling evidence that male circumcision provides a 50-60% reduction in HIV transmission from female to male. The American Academy of Pediatrics (1999) stated that studies suggest that neonatal circumcision confers some protection from penile cancer. Circumcision is believed to reliably reduce the threat of Balanitis. A child is responsibility of parents and any parent has the right to choose the best for the child.We can't deny the child of benefits of a procedure simply because it has some disadvantages!We are living in a world where we act with our thoughts and we have to carefully weigh the benefits and risks of any treatment.As far as the male circumcision goes the benefits far outweigh the risks and definitely it must be implemented in the best interest of the newborn males.Ofcourse the parents should be given a choice and all the necessary support should be provided to all parents and newborns irrespective of their views regarding male circumcision.I think proper education and improving the understanding of parents in particular and population in general will result in 100% circumcision rate of male infants.At the end of the day we all as medical professionals are responsible for a healthy future! Competing interests: None declared
A Sensible Solution 12 December 2007
Phyllis C Mervine, Nonprofit director Ukiah CA 95482 Send response to journal: Re: A Sensible Solution	Without going into the health risks and physical and psychological pain and suffering resulting from male infant circumcision, I would argue that if the procedure is not medically indicated, it qualifies as genital mutilation. It’s clear that there are very few cases where circumcision is medically necessary. Infants are not sexually active, therefore the whole HIV-prevention argument does not apply, whether or not it is factually correct. The only reason we circumcise infants is because of convenience (they are already in the hospital) and they can’t fight back. (Intact foreskins are much more common among home-birthed babies.) Babies also forget the trauma of circumcision and grow up not experiencing penile normalcy, so a circumcised father with no religious convictions may choose to circumcise his son so he “will look like me "(or his brothers, or his friends). Ask any uncircumcised man if he would volunteer right now to be circumcised under the same conditions to which we routinely subject tiny infants. I guarantee you would have no takers. Circumcision is a terrible betrayal of helpless babies who depend on the adults around them for everything. The sensible solution is to apply the “treatment” when there is disease. If circumcision actually does reduce the incidence of sexually transmitted diseases, apply the treatment either after the STD is acquired or shortly beforehand. This probably means circumcising teenaged boys. Public health agencies could institute a policy of teenage circumcision that might replace some of the various forms of self-mutilation, piercings, tattoos, etc. already popular among teenagers in the United States and other industrialized countries. Rites of passage have fallen by the wayside in many modern countries. Perhaps circumcision could become the new mark of manhood. Needless to say, insurance should be available for this medically indicated circumcision, while infant circumcision should not be a covered procedure. If we want to escape from barbaric practices passed down from ancient cultures, we have to be prepared to think outside of the box. For more complete discussion of this important topic I recommend the website www.circumcision.org. Competing interests: I declare no competing interests. I am the mother of uncircumcised sons.
Human rights are relative 12 December 2007
Santosh A Gholkar, General Practitioner Manchester PCT Send response to journal: Re: Human rights are relative	Geof Hinchely argues that embodied human rights are an absolute core value to be upheld in deciding whether to offer circumcision. This value, specifically that human rights are inherent to being a person is quite widely held as being a truth, and needs challenging. My experience as a GP and a parent shows quite specifically that this is not true – rather I argue that t human rights exist and evolve from the way that we treat each other, and that there is a subtle difference between the two that renders the initial argument and all arguments based on the first presumption invalid. I work with asylum seekers and the homeless, both in specialised PMS and mainstream practices. I have yet to meet a homeless person that has attended a casualty department and come back extolling the virtues of the treatment and care provided. There are more likely to comment on the humiliating and degrading way that they get treated on virtue of their appearance and state. Having worked in one of the busiest casualty departments in the country (10 years ago), this too was my lasting impression. It is quite apparent to me that for them the only thing that matters on a day to day basis is to be treated as anyone else –this is the context in which they evaluate their rights. On the other hand asylum seekers lack of rights are enshrined in our legal system that treats them as outsiders from the moment of arrival. Like the homeless it is not so much the rights that they do not have which bother them, but the fact that the way society, including the medical profession, treats them that is an abuse of their human rights. The current crisis of refused asylum seekers, soon to worsened by government plans to refuse primary care access, will see the worst case scenario – homeless asylum seekers being denied access to primary care and attending casualty. The argument with children is not dissimilar. My thirteen month boy goes to nursery two days a week – a concept my mother cannot comprehend. I initially had my reservations about it but needs must, and furthermore I tell her, a number of scientific studies have actually said it is better for him. If she used the human rights argument she would argue that I am putting my interests ahead of my child’s - In fact we could write a whole article entitled ‘Nursery: Good or Bad’. Those who think this a banal argument need only to take a step back and reflect on how normalised nursery has become in our society as a result of social and economic factors. It is only then that the relative nature of human rights, and its misuse in this argument becomes apparent. If the human rights argument holds, I a general practitioner would have to in a consultation, tell a parent that actually they don’t treat their child well at all and infact they are abusing their child’s human rights. Please let’s start basing ‘rights’ on the whole picture, not just as isolated ideals to be upheld no matter what. Perhaps the main conclusion that would be drawn is to let general practitioners deal with these issues and let casualty consultants stick to trauma calls. Competing interests: parent of uncircumcised child.
Personal evidence 12 December 2007
David J Grant, Consultant Geriatrician Edinburgh EH16 6UB Send response to journal: Re: Personal evidence	It is regrettable though understandable that debate on circumcision is conducted using language which is highly emotionally charged. The words "sexual assault", "amputation", "mutilation", "violation" and "abuse" flow easily from the pen. Evidence on the psychological risks of infantile circumcision is harder to come by; there has never been and probably never will be a randomised controlled trial of the effect of infantile circumcision on the experience of sexual pleasure in adulthood. However, I wish to document some personal evidence on this subject. As one who was circumcised in infancy, I am thoroughly mystified by the suggestion that my masculinity has been in some way damaged; it simply does not accord with my experience in the world; to me it is counter-intuitive. A local practitioner of psychosexual medicine for fifteen years (my wife) has never encountered a case in which a belief concerning an adverse effect of circumcision has been raised as a cause of male sexual dysfunction. Our edition of Bancroft's textbook on "Human Sexuality and its Problems"1 does not even list circumcision in its index. Reference: 1) Bancroft J. Human Sexuality and its Problems (Second Edition). Edinburgh, Churchill Livingstone, 1989. Competing interests: None declared
Doctors need to update 12 December 2007
David Smith, General Manager, NORM-UK ST15 0SF Send response to journal: Re: Doctors need to update	Brian Morris says ‘Moreover, quite surprisingly, some doctors continue to practice ‘ignorance- based’ or prejudiced-based’ medicine’ when it comes to circumcision. They need to update.’ I agree that they need to update. The BMA also seem to think that doctors need to update as they have issued [The law & ethics of male circumcision - Guidance for Doctors, BMA, 2006] This document states ‘the medical benefits previously claimed, however, have not been convincingly proven, and it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks.’ It is obvious from the messages on this board that a child’s foreskin is not in safe hands with many health professionals. Competing interests: None declared
Ritual circumcision – a service that should be provided by the NHS 12 December 2007
Colin R Butler, SHO Chelsea & Westminster NHS Trust, London, Simon Clarke Send response to journal: Re: Ritual circumcision – a service that should be provided by the NHS	The issues surrounding the ethics of ritual male circumcision is age old and will continue to be debated, however changes in societal attitudes will be less than dynamic, and for now many parents will continue to want their son circumcised be it for religious or cultural reasons. Provision of services towards ritual circumcision however is undergoing rapid change. This is possibly due to shifting attitudes towards an ‘unnecessary’ procedure, but more likely due to financial constraints placed on the NHS in its current climate. Previously, many trusts, including our own, provided a service under the NHS for ritual circumcision, believing it to be a appropriate safe service providing ongoing continuing of care. Many local Primary Care Trusts’ (PCT) are now withdrawing or have already withdrawn funding, and our own survey of 30 UK Trusts performing Paediatric surgery has shown only 10 trusts (33%) continuing with a service.[1] We believe that this has implications in terms of future standards of care particularly ‘where’ the surgery will be done and by ‘whom’. We fear that demand for circumcision in an inaccessible environment will lead to opportunistic unregulated community services, and as such an increase in associated complications. Initial experience, post withdrawal of PCT funding has shown an increase in paediatric admissions for community related circumcision complications. National data is lacking on the origin and extent of morbidity from the community and our trust is currently in the process of setting up a regional web based database to fully assess this potential problem.[2] We agree with K Patrick and other authors views from the rapid responses that ‘regulating its provision is the wisest course of action’.[3] The British Association of Paediatric surgeon’s guidelines towards ritual circumcision advocate standards of care to be identical to any operation for a child.[4] Regardless of the ethics surrounding ritual circumcision, we feel an emphasis should be geared towards allowing access to safe and regulated NHS services. Parents seeking circumcision for their sons remains an accepted norm by many western communities, and we have a duty of care to provide safe services under the NHS in order to reduce unnecessary morbidity and mortality. Butler CR, Clarke S Department of Paediatric Surgery, Chelsea & Westminster, London References [1] Survey of UK Paediatic Surgeons 2007. Unpublished. [2] Chelsea & Westminster Hospital & St Marys Hospital data. 2006- 7. Unpublished. [3] Hinchley G, Patrick K Is infant male circumcision an abuse of the rights of the child? BMJ 2007; 335: 1180-1 [4] British Association of Paediatric Surgeons http://www.baps.org.uk/bapspublications.htm Competing interests: None declared
Many circumcised persons have a compulsion to repeat the trauma 12 December 2007
George Hill, Vice-President for Bioethics and Medical Science Doctors Opposing Circumcision, Suite 42. 2442 NW Market Street, Seattle, Washington 98107-4137 Send response to journal: Re: Many circumcised persons have a compulsion to repeat the trauma	In Africa, older women who were circumcised in childhood are the strongest advocates for circumcising today’s girls. Similarly, in the West, older men who were circumcised in childhood are the strongest advocates for circumcising today’s boys. Some examples of deceased men who were circumcised and became emotional advocates for circumcision are Peter Charles Remondino (1844-1926), author of the highly emotional History of Circumcision from Earliest Times to the Present (1891); Abraham Wolbarst, who authored “Universal circumcision as a sanitary measure” (1914),1 and falsely claimed that male circumcision absolutely prevented penile cancer (1926);2 Abraham Ravich, who falsely claimed that male circumcision would prevent female cervical cancer (1941);3,4 and Aaron J Fink (d. 1990), who authored a procircumcision book entitled Circumcision: A Decision for Life and falsely hypothesized that male circumcision would prevent HIV infection.5 Such men made the most outrageous claims for male circumcision. The general medical ignorance that prevailed allowed these claims to be given credence. There are others with advanced degrees living today who make similar fantastic and incredible claims about circumcision, but today medical science disproves their claims. Male circumcision is highly traumatic6,7 and this factor (among others) partially explains why circumcised women and men argue strenously and emotionally in favour of circumcision. Harvard trauma expert Bessel van der Kolk explains that traumatized persons have a compulsion to repeat and reenact the trauma either on themselves or others.8 These emotional needs could never be satisified even if every female and male on earth were to be circumcised. Their zeal for circumcision knows no bounds. Such authors advocate attacks on the genital integrity of other humans even though such attacks are illegal, unethical, and immoral. The claims of such authors must be taken with a grain of salt and dismissed. George Hill Vice-President for Bioethics and Medical Science Doctors Opposing Circumcision Suite 42 2442 NW Market Street Seattle, Washington 98107-4137 Web: http://www.doctorsopposingcircumcision.org References Wolbarst AL. Universal circumcision as a sanitary measure. J Am Med Assoc 1914; 62: 92–97 Wolbarst AL. Is circumcision a prophylactic against penis cancer? Cancer 1926; 3: 301–10. Ravich A. Herpes simplex virus 2 (HSV2) as the carcinogen in cancer of the cervix. J Am Vener Dis Assoc 1975; 2: 36 Van Howe RS, Hodges FM. The carcinogenicity of smegma: debunking a myth. J Eur Acad Dermatol Venereol 2006;20(9):1046-54. Fink AJ. A possible explanation for heterosexual male infection with AIDS [letter]. N Engl J Med 1986;315:1167. Menage J. Post Traumatic Stress Disorder after Genital Medical Procedures, Male and Female Circumcision: Medical, Legal and Ethical Consideration in Pediatric Practice; Kluwer Academic/Plenum, 1999. Available at http://www.springerlink.com/content/h885378g19128025/ Boyle GJ, Goldman R, Svoboda JS, Fernandez E. Male circumcision: pain, trauma and psychosexual sequelae. J Health Psychol 2002;7(3):329-43. van der Kolk BA. The compulsion to repeat the trauma: re-enactment, revictimization, and masochism. Psychiatr Clin North Am 1989;12(2):389-411. Competing interests: None declared
Circumcision soon after birth, or once they can consent? 12 December 2007
Salwa Kamourieh, F1 general surgery West Middlesex University Hospital, TW7 6AF, Eyston Vaughan-Huxley Send response to journal: Re: Circumcision soon after birth, or once they can consent?	Apart from circumcising in accordance with religious and cultural beliefs, I must agree I do not see the need for circumcision in childhood. However, if the decision to circumcise was made, I feel that by leaving it until the ‘child’ is old enough to consent may cause more psychological damage than if it were done soon after birth. The person in question would be around the age of 16 at this time and to put this young adult through a procedure where he would have to rest after the operation, take time off school, be apart from his friends and possibly even have surgical complications has the potential to be very distressing, not to mention the impact such a procedure may have on the physical and psychological well being of a young man who may well be at the beginnings of his sexual experiences. Young adults at this age often have enough psychological issues to cope with and would probably not appreciate complicating matters further. If circumcision was performed as a baby, he would be unlikely remember the procedure and it would not restrict daily activities. Besides, do we really know how psychologically scarring a procedure like this really is? In my opinion, it is a very difficult aspect to measure accurately. To gain better insight perhaps we should be studying a cohort of men who have been circumcised for religious or cultural reasons, regardless of the age at which it was performed, and who were brought up in a country where it is not routinely performed – is there any evidence of any psychological scarring in this group and do they feel any different to other men? Competing interests: None declared
A surgical 'vaccine'? 12 December 2007
A.D. Fontain, Independent Researcher Toronto, ON. Canada M5S 1A5 Send response to journal: Re: A surgical 'vaccine'?	Responder Brian Morris finds it 'absolutely appalling' that Hinchley feels he can present his argument to an intelligent readership. Yet he expects the same readership to swallow his outrageous argument that circumcision represents an 'essential surgical 'vaccine''? Perhaps Mr. Morris might wish to first join us back in reality, where it has been well established, far beyond any reasonably doubt, that STD risk (as well as the majority of other conditions that circumcision is sometimes said to prevent) is primarily attributable to behavior. Whether or not a baby boy will get any compensatory benefits from being circumcised (or want to be circumcised for that matter) is completely unknowable. This provides little, if any, basis for a doctor to claim to be acting in the best interest of the patient, or adequately respecting a patient's autonomy and bodily rights, when removing genital anatomy from a healthy child. Within his own argument he writes: "In experienced hands, this common, inexpensive procedure is very safe, can be pain-free and can be performed at any age." This only reinforces the argument that a circumcision can wait until the male is old enough to decide, without any significant detrimental effects or undue hardships placed upon those who wish to be circumcised. In addition, he goes on to write that his calculations 'reveal' that 1 in 3 will suffer some ill-effect from not being circumcised. Taking this dubious claim at face value - This still leaves 2 out of 3 males having genital anatomy removed without receiving any benefit to their health whatsoever. Surely, in his analysis (of select studies which support his position), he must have included the most minor health problem to reach such a high a estimate. I assume that within the virtual reality in which this argument resides, the fact that a male may at some time in his life experience a minor skin inflammation is also considered to be a sufficient enough reason to excise genital tissue from a male without consent. It should also be noted that there exists now a vaccine against HPV, which has been associated with cervical cancer and to a lesser extent prostate cancer. Given that HPV risk provides the basis for circumcision advocates to argue that circumcision reduces the risk of these two cancers, the world need not look to their construct of a 'surgical 'vaccine'' - there exists now an English language version of a vaccine that achieves the same ends. While bemoaning the 'outrageous' claims of those who might find some similarities between male and female circumcision, he feels it is sufficient to simply assert that circumcision ( the surgical removal of genital tissue) is equatable to a vaccination (the administration of antigens into the bloodstream by way of a needle). That these that two separate actions raise separate issues entirely in relation to patient autonomy and bodily rights seems to fly completely over his head. I do agree with him in one respect: Despite their similarities, female and male circumcision are not entirely equatable- female circumcision encompasses a much broader range of practices - Some not as drastic as male circumcision but some far more so. Though, I don't believe one would get much argument from anybody there. It appears that Morris would rather argue with a straw man than face the arguments that are being raised in this discourse. Kudos to Brian Morris for collecting as many pro circumcision studies for his website that he could find. However, if he wishes to be taken seriously he will have to do more than present a collection of handpicked studies (that suit his cause) as being representative of consensus among 'experts' and the entirety of medical research on the subject. By contrast, the mainstream scientific community, upon looking at the available data, without seeking a pre-determined conclusion, hold a far more modest view of the benefits that might be associated with circumcision - To the point that virtually every national medical organization, despite ignoring any inherent harm that may be associated with loss of healthy sexual tissue, regard the benefits and risks of the procedure as being essentially nullified by each other. It is also becoming recognized that beyond the narrow range of risks that get entered into the equation, there is a host of other risks who's frequency of occurrence is largely unknown. Upon viewing his website, it appears that Brian Morris provides us with little more than some insight into the degree of spin doctoring and fanaticism behind the medical fringe that is modern day infant circumcision advocacy. If I can also comment on a point made by another responder to this article as well. I find John Glazebrook's argument absurd. What about women's rights? What about women's responsibilities? A baby boy who may grow up to engage in perfectly sound sexual practices (as most males do), owes no part of his body to 'women's rights'. Nor are a woman's rights in any way related to/dependent upon her partner being circumcised. Furthermore, a male, circumcised or not, is equally capable of transmitting STDs to a female partner. Competing interests: None declared
Financial issues we should consider 13 December 2007
Laura J MacDonald, stakeholder in the NHS London N1 5SL Send response to journal: Re: Financial issues we should consider	The current cost of providing for ritual surgery on the NHS is covered above. I wonder however if anyone has carried out due diligence on the FUTURE financial implications of carrying out ritual surgery on non- consenting patients? As a degrading, harmful and painful treatment prescribed on the basis of his gender, his parents religion, or a presumption about his future behaviour, male infant circumcision is a clear violation of many explicit requirements of the Children's Act 2004 and the Equality Act 2006. The loss of highly innervated erogenous tissue is irreversible, and the BMA have accepted this may entail psychological consequences. The compensation awarded to a complainant could run to hundreds of thousands of pounds. Some will consider litigation unlikely but the recent formation of the Council of Ex-Muslims of Britain shows clearly that we cannot rely on the presumption that a man born to a Muslim family will retrospectively approve his circumcision. If GPs, ethicists and surgeons don't care about the consequences of taking a functional and joyful part from an unconsenting boy, NHS finance managers certainly should. Competing interests: None declared
Commonsense 13 December 2007
Richard N Duncker, Yoga Teacher NW1 9NB Send response to journal: Re: Commonsense	There is a simple commonsense test to decide whether it is appropriate or not to amputate a body part without the patient’s informed consent. You just have to ask the question; if we don’t amputate, will the patient die? If the answer is no then you leave them alone. The amputation of the male foreskin before it has fully developed and before the patient is capable of giving informed consent seems to lack all commonsense. Competing interests: None declared
Infant Male Genital Mutilation Should be Banned 13 December 2007
Bradley L Stueber, Accountant Administrator Port Allen, LA 70767 Send response to journal: Re: Infant Male Genital Mutilation Should be Banned	I strongly am opposed to the mutilation of the genitalia of infant males. They have "no" choice concerning the most intimate and important part of the male body at his most vulnerable time in life. I was circumcised. I resent that everybody thought they should make this decision. Nobody asked me. Female genital mutilation has been outlawed in most countries now. It is time for males to have equal rights with females. I also want to say that no female (not mother or doctor) should have any voice concerning this subject no matter how many medical doctorate degrees she has on her office wall. This is a male only subject. I will never know what I have missed by not having the protective skin protecting the extremely nerve packed glans of the penis. The penis is what makes me male. That is what all males identify with for their sexuality. We had our daughter's ears pierced for earrings when she was old enough to decide for herself that she wanted to have this procedure done to her body. We did that out of respect to her as a person and out of love for her. She chose. I did not get that choice over keeping my foreskin or not. My son is married and a father. He and his son are both uncircumcised. If he decides to get his own foreskin removed as an adult male, I would support him in his decision to do so. But not when he was a few days old. I fought for him to have this choice. He is old enough to thank me and say he appreciates what I did to protect him. As far as this procedure being painless, why do the little boys scream bloody murder and sometimes so hard that they cannot make any sound if it didn't hurt? No, this practice should be outlawed. Only by adult consent to have it done to his own body, should this be done, or perhaps a medical complication along the way in life. Competing interests: None declared
And later, would you really give him the choice? 13 December 2007
Anthony B Ainley MCSD, Graphic Designer BD21 5RA Send response to journal: Re: And later, would you really give him the choice?	I feel a need to come back on this issue in consideration of some comments posted. I re-iterate; I'm giving a lay person's opinion, as a happy 'circumcisee' since childhood, not a medical professional view. A few opposers of the procedure have suggested that the decision to be circumcised should be one that is deferred until the boy/youth/man is old enough to make the choice for himself. This is disingenuous - knowing most males will feel deterred by the prospect of pain and embarrassment. Should the individual still decide he would like to be circumcised, he will be further discouraged by the reception he will receive from the average GP. Such a request will be met with scorn and possibly a note on his record of 'a disposition to self harm'. If he has a foreskin problem he will be offered creams and 'wait and see' advice. Circumcision is seen as a last resort, albeit meantime, his difficulty is ruining his sexual experience. If he doesn't have a problem, he will be told that the scarce resources of the NHS cannot be devoted to his 'rather weird preference' and he will be sent off to the private sector, adding considerable expense to his ambition. The present mindset of most UK medical professionals on this issue is appalling! They tell us black is white, denying any benefits can possibly come from prophylactic intervention, whilst we have study after study proving otherwise. The age old mantra of the healthcare sector has always been; 'Prevention is better than cure'. We are urged to adopt healthy lifestyles, not to smoke, drink in moderation, avoid obesity and unhealthy foods. Often with very little cause, we put people on multiple regimes of preventive medication for years and years. Many of these drugs have questionable side effects. The history of pharmaceuticals is punctuated by 'wonder medicines' which have been later withdrawn. Whilst a supporter, vaccination is not without its concerns and can have serious side effects in some cases. Circumcision in competent hands is safe, virtually painless and bestows a range of proven benefits, not just one. Competing interests: happily circumcised
BMJ circumcision debate continued in the New York Times 13 December 2007
Trish Groves, Deputy editor BMJ Send response to journal: Re: BMJ circumcision debate continued in the New York Times	Readers may be interested in the debate on circumcision in the New York Times, prompted by this BMJ Head to Head: http://well.blogs.nytimes.com/2007/12/11/the-rights-of-baby- boys/#more-153 Competing interests: None declared
The overwhelming benefits of circumcision 13 December 2007
richard a sturdy, retired chief executive (plc) Yorkshire UK Send response to journal: Re: The overwhelming benefits of circumcision	Having missed being circumcised as an infant due to the refusal of the nhs to accomodate my mothers wishes in the matter, I finally was circumcised when I was 40. This was with the encouragement of my (then new) wife who is very much in favour of male circumcision and done purely out of choice and for no medical reason. I have to say that the results were overwhelmingly beneficial and after being circumcised I enjoyed better hygiene, comfort, appearance, self-esteem and FAR FAR better sexual sensation during intercourse, both for me and for my wife. It is now 23 years since I was circumcised and there has been no downside whatsoever, only continuing benefit. As far as we are concerned male circumcision should be routinely offered and recommended to parents of male offspring. In addition to the personal and sexual benefits accruing to the circumcised male as an individual, the recently highlighted public health benefits underline the desirability of widespread male circumcision. Competing interests: None declared
May I make this clear? 13 December 2007
Van Lewis, Natural farmer P.O. Box 323, Panacea, Florida 32346, USA vanlewis@earthlink.net Send response to journal: Re: May I make this clear?	I have an English language name for anyone - male, female or otherwise - who believes - and tries to act on the belief - that they have a right to cut off parts of my sex organs without my fully informed, adult, written consent. That name is "Enemy". I also have a name for the terms of our engagement: "War". I choose as an adult to conduct my side of the war, at least, nonviolently, but that does not keep it from being war. The war against human genital mutilation must be victorious if there is ever to be peace on earth. Winning this war against human genital mutilation on the planet is a necessary, although not sufficient, component of world peace. Human genital mutilation is war against the young by the old, against the future by the past. I am on the side of the young and the future. Fortunately, that is the direction that time moves. I believe victory is inevitable, but only if we fight for it as hard as we can. Competing interests: None declared
Foreskin has important sexual function 13 December 2007
Mike Cooper, Writer Los Angeles, CA Send response to journal: Re: Foreskin has important sexual function	Removal of the foreskin makes masturbation more difficult; as a result, many circumcised men have to apply lubricant before pleasuring themselves. (Uncircumcised men can masturbate without problem.) The foreskin also plays a role in the mechanics of intercourse and is a source of sexual pleasure. Why no mention of this? Removing a part of the body that has such a function is madness and an abrogation of an infant child's rights. Competing interests: None declared
objectively...it's wrong 14 December 2007
Justin A Williamson, consultant Hawkes Bay Hospital Send response to journal: Re: objectively...it's wrong	If it was a new procedure, and you had to make a case for funding, you wouldn't get: ethical approval, scientific support, co-operation from your colleagues, any patients for your trial, funding from the government, funding from any large charities. Objectively, it's unacceptable. Competing interests: None declared
An informed choice 14 December 2007
janice page, receptionist london n4 Send response to journal: Re: An informed choice	I am glad Mr Ainley is happy with his status (circumcised), but not everyone is the same, which is why it should be a choice for an informed adult to make. There is enough evidence to suggest that some men have been psychologically and physically traumatised by the procedure. Charities and support groups have been established precisely to help men who have been adversely affected by circumcision. Secondly babies do feel pain when being cut, even if anaesthetic is used. They cannot articulate and communicate their feelings to us. If they could I am sure they would be equally deterred by the prospect of pain and embarrassment. Thirdly, even in the safest of hands babies do die from circumcisions as witnessed earlier this year in London. Finally there is no need to worry about a lack of surgeons willing to remove an important piece of erogenous tissue with thousands of nerve endings. After reading these responses I am sure there are many medics out there only too willing to oblige. Competing interests: None declared
Male Circumcision is a Female Issue 14 December 2007
Felicity A Milner, RGN retired Nottingham NG13 8BG Send response to journal: Re: Male Circumcision is a Female Issue	Infant male circumcision is an abuse of the rights of the child, and it is time that all women made a stand against it. Mothers have a responsibility to protect the rights of their child and that includes protection against any unnecessary trauma that may cause physical or psychological damage,which in turn may result in unforeseen sexual relationship problems for their child in adulthood, both for the male and his female partner. Both female and male circumcision cause lasting physical and psychological damage and are unnecessary procedures. All but a very small percentage of conditions for which male circumcision is recommended can be treated conservatively leaving the foreskin intact as nature intended. Leave the decision to circumcise to the adult male concerned; do not enforce this procedure on him when he is a baby, too young to understand the implications and before he can possibly have any religious viewpoint. My husband was circumcised at 2yrs and has suffered all his life from the effects, carrying on into adult life when the trauma from circumcision infringed upon his sexual life. The capacity for sensation dulled over years which resulted in a need to work harder and longer to achieve orgasm. This resulted in trauma for both of us which almost led to divorce. Fortunately he has now restored his foreskin (which took a number of years) although excised nerves cannot be replaced; and our sexual intimacy has greatly improved. Of cause some men circumcised as babies may argue that they are fine and may think it a bonus to have lengthy intercourse but as the years go by both they and their partners may realize too late that the foreskin was indeed essential for lasting sexual pleasure and intimacy. Competing interests: None declared
Dangers of male circumcision 14 December 2007
Tim J Sladden, STI & HIV Adviser UNFPA Office for the Pacific, Fiji Send response to journal: Re: Dangers of male circumcision	Male circumcision is an abuse of the rights of the child - no informed consent is obtained. Male circumcision is purported to reduce HIV transmission. I think it is early days still to assess this. Even if it provides some protection, it is still only partially protective (around 50%) which is insufficient for a repeated activity like sex. Behavioral disinhibition is likely with circumcised males thinking they are protected so they will be less likely to use condoms. One of the biggest criticisms we repeatedly hear about condoms is loss of sensitivity - even from males with an intact foreskin. I anticipate a backlash of anti-condom sentiment - a refusal to use condoms by dissatisfied, circumcised males who have further loss of sensation owing to keratinised skin on the head of the penis. It will make advocacy to encourage uptake of condoms even harder than it is now. Also women must be at increased risk if males feel protected and reduce their reliance on condoms. Competing interests: None declared
Bancroft J. Human Sexuality and its Problems 14 December 2007
J D Poff, research Auckland 0629, NZ Send response to journal: Re: Bancroft J. Human Sexuality and its Problems	In his response titled Personal evidence, David J Grant comments that... Our edition of Bancroft's textbook on "Human Sexuality and its Problems" [1] does not even list circumcision in its index. A human sexuality textbook which doesn't mention circumcision is probably not the best place to look for a discussion of its negative consequences, but it does say a lot about the state of ignorance. Masters and Johnson also demonstrated total ignorance of the anatomy and function of the uncircumcised penis, in their best selling 'Human Sexual Response'. ____________________________________ 1 Bancroft J. Human Sexuality and its Problems (Second Edition). Edinburgh, Churchill Livingstone, 1989. Competing interests: None declared
Whose foreskin is it? 15 December 2007
Michael Glass, retired - Send response to journal: Re: Whose foreskin is it?	I say that the person with the foreskin is the one who should decide what to do with it. Not his mother, not his father, not his doctor, imam or rabbi: the one with the foreskin should be the one to decide. If all circumcisions were for grown men, much of the controversy would disappear. Competing interests: None declared
"uncircumcised penis" 15 December 2007
J D Poff, research Auckland 0629, NZ Send response to journal: Re: "uncircumcised penis"	And so why do I find myself repeatedly using the tautological construction uncircumcised penis, when in reality it's just a penis? In case we need reminding, circumcised is the modifier, indicating subtraction. Adding un to that forms a double negative, which is a positive and requires no special signature. It's a tedious reflection of the black equals white world we are in here that the 'normal' circumstance involves strapping an infant down with velcro and cutting off parts of his genitals, while the radical departure involves ...not. So let's not call it an uncircumcised penis, let's just call it a penis. Or maybe we could call it a whole penis. _______________________________________ Competing interests: None declared
Circumcision is sadistic sexual assault on children 15 December 2007
Michael Steffe, Special Effects Artist Hollywood, Ca 91609 Send response to journal: Re: Circumcision is sadistic sexual assault on children	There are wondrous things in nature we do not understand yet and they may never be understood by those who are in a state of mind that allows the mutilation of children’s sensory receptors and a state of mind that is not totally disgusted about this ancient circumcision cruelty performed on children. Competing interests: None declared
The ethics of circumcision 17 December 2007
Michael H Mitchell, Consultant Physician HA6 2PX Send response to journal: Re: The ethics of circumcision	Editor - Whether there may or may not be benefits to health as a result of male circumcision is irrelevant. Certainly there is research to support reduced rates of cervical cancer in female partners of circumcised men and lower rates of transmission on HIV infection, but this is not the point. No one would argue that the procedure must be performed by a trained individual registered with an authorized organization. But to advocate banning circumcision, even to defer it until the child is older, goes completely against orthodox Jewish practice and would therefore be unthinkable. The issue is, finally, a religious one and any criticism of a surgical procedure that does not,in safe hands, lead to secondary physical or emotional trauma, comes perilously close to religious intolerance, inevitably associated with horrors one would rather forget. The quality of certified Jewish practitioners of circumcision (Mohelim) is regarded so high, that many Moslems employ the use of such qualified Jews to perform circumcision for their own children. Competing interests: The writer is Jewish
Qualified rights in conflict with absolute rights 17 December 2007
John D Dalton, Trustee NORM-UK ST15 0SF Send response to journal: Re: Qualified rights in conflict with absolute rights	I would like to develop the points made by Santosh A Gholkar about human rights being relative. This statement is certainly true of Article 9 of the European Convention on Human Rights (right to religion). More correctly stated religion is a qualified right. The Convention clearly states a provision for the right to manifest religious belief may be limited to protect the rights and freedoms of others. Some rights however are absolute: Article 2 (right to life) and Article 3 (Freedom from cruel, inhuman or degrading treatment or torture) are absolute rights relevant to this discussion. Thus nontherapeutic child circumcision places the absolute rights of the child in conflict with the qualified rights of adults to demand their circumcision. As such it is clear that the rights of the child should prevail. Reference:- 1.       http://www.niknicol.co.uk/Human/human.html accessed 16 December 2007. Competing interests: None declared
Medical Activism 17 December 2007
Rajesh K Choudhary, Staff Grade Surgeon Darlington Memorial Hospital, Hollyhurst Road, Darlington DL3 6Hx Send response to journal: Re: Medical Activism	Is infant male circumcision an abuse of the right of the child? -yes opinion, expressed by Geoff Hinchley was quiet disappointing.It seems that the article was written by a child right activist rather than a mature professional, in view of strong language and the tone of the article.The article lacks strong scientific evidence.No surgery can be carried out without risk of complication,minor or major.To compare childhood male circumcision with female circumcision is not only improper but highly objectionable.Female circumcision is carried out among certain section of society and only in few countries and has already been made illegal in most parts of the world, whereas male circumcision is carried our throughout the world, from most developed countrirs to the least developed once.It is not illegal anywhere in the world.There are few genuine indications for childhood circumcision and many long term advantages.There is no doubt that large number of circumcisions are being done on relegious grounds.The discussion, whether circumcision should be done only on medical grounds and only in adulthood would not involve only doctors and parents but wider audience.There is no doubt, if we present a rationale view based on strong scientific evidence,that would go long way to stop the practice based on relegious grounds.Society looks upon doctors to give balanced opinion based on sound judgement.The question is whether we want to present ourselves as an activist or scientist?. References; 1.MaloneP,SteinbrecherH.Medical aspects of male circumcision.BMJ2007;335:1206-9 Competing interests: None declared
Let's Stop Selling Men Back Their Foreskins 17 December 2007
Ron J Low, Engineer Chicago, 60062 Send response to journal: Re: Let's Stop Selling Men Back Their Foreskins	I've helped over 9000 men restore their foreskins. This has included men whose desensitized organ prevented them from conceiving a child naturally until they restored. I'd like to stop. Why should a man have to pay me to help him get back a measure of what nature took millions of years to evolve for him. Was surgery or even soap around all those years while the foreskin was proving to give a survival advantage? Cutting in infancy is the worst time to mutilate. The results are very hard to control. The practitioner has no idea how the patient will grow even if a desired level of eventual slack skin was envisioned. Everything is so small that the tiniest irregularity is magnified as the patient grows. Of course, most importantly, the victim can not give informed consent to the cosmetic mutilation. Even a perfect procedure can become a disaster once the patient goes home to recover while wearing fouled diapers under the care of lay persons. The patient is unable to communicate if something doesn't feel just right, and the caregiver is no expert. Circumcision of minors must end, and the medical professionals who might profit from the procedure must answer to their conscience if they are not the loudest voice in the chorus. Competing interests: Marketer of Non-Surgical Foreskin Restoration Devices
Higher Love Consciousness will ban Circumcision world wide 17 December 2007
Michael Steffe, Intactivist and Special Effects Artist Hollywood, Ca 91609 Send response to journal: Re: Higher Love Consciousness will ban Circumcision world wide	A simple projection into the future. 2007 the year of enlightenment and genital integrity. We are living in a time of global awakening. The turning point is happening right now. We witness discussions all over the Internet and in newspapers which discuss the human rights of children to have intact and unaltered genitals. Even those who performed these medical and religious unnecessary surgeries are starting to question this barbaric practice of genital mutilation. Already 30 years ago some people found the courage to express their minds and feelings about the world’s darkest deception which is the mutilation of children’s sex or love organs. Those people went on the streets and held up signs that would raise consciousness. We thank them for their courage. Over the years other individuals recognized the brutality of cutting children’s genitals and they found like minded people on the Internet and in the cities they lived in. New Activity Groups are being formed constantly and we call our selves intactivists as we fight for the rights of children to have an intact body or genital integrity. We had endless discussions that would analyze the motivations of those who perform such cruelty on their own and other people’s children. We found ways to spread consciousness to people of all societies and religions by educating them about the physical and psychological harm that is being done to their children by this cruel and compassionless practice called circumcision. People log on from all over the world to our web sites to find the truth and they will help us to spread more consciousness to bring an end to this ancient barbaric ritual performed on innocence. Publicly burning down a Circumstraint, yearly demonstrations in front of the Capitol in Washington DC and other places, peace signs received from the Washington Police Department as well as being asked for Genital Integrity bumper stickers by them and being told that this is the most significant peace action they have ever witnessed are just signs of a world shifting into higher consciousness where our children will be protected from this most disgusting ancient crime and sadistic assault on their genitals that has been performed on so many throughout history. 2008 People’s consciousness is rising in exponential rates in the United States and all over the world. People are finally waking up. More and more men will restore their foreskins to be whole again and to experience their sexuality the way it was intended by God and Nature. The circumcisers loose all ground to stand on. All medical and religious lies are being debunked by facts. The more ethical and smarter circumcisers who realize the early warning signs can see the consequences of this international awakening and movement and they voluntarily will lay down their knives now and admit that they themselves have been victims of those lies and they will start to protect children as well. They also will realize that circumcision is an invention of the evil that throughout history succeeded to spread lies, fear and chaos into this world to keep us away from the angelic beings we are supposed to be. They will stop repeating the old lies and they also will refuse to spread new ones which we all know were only invented to back up the old ones so their malpractice would not appear all that wrong. As people recognize the physical and psychological harm of genital cutting that has been performed on them and on their own children they will call for an absolute end to it. Anybody who shows good will now by turning against circumcision will eventually be spared from the consequences of people’s outrage. The following years are the years where circumcision will be banned all over this globe. Those who are more resilient and not that smart will insist on keeping up their evil child raping practices as they can not project what this international intactivist movement and the expanded love consciousness of awakening people will hold in store for them. But justice will find its way and those who persisted in performing those cruelties are being recorded and they will have to feel the outrage that is growing to unpredictable dimensions. All circumcisers still struggling to continue their malpractice will have to recognize that no money in the world or any other motivation is worth to be exposed to the outrage of very angry people. Circumcision is war and terror performed on children by adults and it is planting the seeds for more war and terror in this world. How can anybody that has been painfully attacked on his genitals as the first sexual experience in this world be peaceful and subconsciously not afraid of the other? The time to lay down the scalpels and torture clamps to give all boys and children across this world their human rights to grow into a world of peace and to enjoy their whole and intact genitals is now. 2012 the end of the Mayan Calendar, the end of all human sacrifices, a new beginning; human beings enjoying their sexuality without fear, a universe of inner and outer truth and love, an intact world, people in peace with themselves and each other. Warrior of Love Competing interests: None declared
Is infant male circumcision an abuse of the rights of the child? 19 December 2007
Lotte Newman, Retired general practitioner London Send response to journal: Re: Is infant male circumcision an abuse of the rights of the child?	Dear Editor, For several years I worked as a general practitioner. I am also a mother of 4 children, including 3 circumcised sons. I served as elected chairperson of the Brit Milah (Jewish religious circumcision) Committee of the Board of Deputies of British Jews. In none of these roles can I recognise the stereotypes portrayed by Dr Hinchley (335;1180). Obviously one cannot generalise, but most parents of a baby boy are delighted by the birth of a healthy child and hope that he will have the best possible opportunities in life. I would include within this, the opportunity to follow in the Jewish traditions. This loyalty to tradition often manifests itself at times of joy and sorrow. Most of those who perform religious circumcisions, (whether medical or lay), perceive the task very sincerely as a performance of a religious duty, which goes beyond the clinical, as is so clearly summarised in the review article from the same issue (Malone and Steinbrecher; 335; 1206- 1290). I commend Dr Patrick for her helpful comment, that the most important role of the doctor could and should be to help parents find a competent person, rather than force them to navigate the waters of unregulated circumcision. Dr Lotte Newman CBE FRCGP Competing interests: None declared
Very uncertain sexual benefits, beware! 4 January 2008
Sigi Sigismond, researcher in psychoanalysis Paris 75010 Send response to journal: Re: Very uncertain sexual benefits, beware!	Several enquiries (see below) conclude that sexual benefits from circumcision, alleged by several individuals, are much scarcer than sexual impairment. Since these enquiries were most often done in subjects in whom circumcision was necessitated for warranted medical reasons, it is all the more risky to engage in circumcision in the hope of sexual prowess; the contrary is more likely. Richard A. Sturdy's testimony cannot be generalized. Fink K. Adult circumcision outcomes study: effect on erectile function, penile sensitivity, sexual activity and satisfaction. J urol 2002; 167 (5): 2113-2116. http://cirp.org/library/sex_function/fink1 Pang M., Kim D. Extraordinarily high rates of male circumcision in South Korea: history and underlying causes. BJU Int 2002; 89: 48-54. http://www.cirp.org/library/cultural/pang1/ Competing interests: None declared
What are the glans and foreskin for? 4 January 2008
Kenneth N Wilkinson, Consultant Paediatrician Airedale General Hospital Skipton Road, Steeton, BD20 6TD Send response to journal: Re: What are the glans and foreskin for?	The circumcision debate made me think of my neighbour who had a DIY accident. He had put a double folded sheet on the floor; put a ladder on the sheet; climbed the ladder and then the ladder slipped. An accident one might expect from a double layer which can slide and roll. The structure was analagous to a foreskin. Using this analogy it seemed that the foreskin might have a role in helping vaginal penetration. There is also what I will call a "pulley effect" in which there is a ratio of movement. With a circumcised penis (and please assume its covering skin is not stretchy}, for each unit of advance of the glans the skin has to advance an equal distance through the introitus. With an unrolling foreskin the ratio of the advance [glans to foreskin] is 2:1. Elsewhere the glans has been described as having a plunger type action, drawing or forcing vaginal fluid (lubricant)to the exterior. Does the foreskin also help in this fluid transfer by covering the trapped fluid against the glans during withdrawal and releasing it during advance? In conclusion, might the glans and foreskin have a functional, evolutional effect in helping vaginal penetration? I describe three effects: a sliding effect; an unfolding ratio; and assisting lubrication. Removing the foreskin might therefore have disadvantages. Competing interests: None declared
Re: What are the glans and foreskin for? 7 January 2008
Janet Menage, GP Bulkington Surgery CV12 9JB Send response to journal: Re: Re: What are the glans and foreskin for?	For a full explanation visit http://www.noharmm.org/anatomy.htm Competing interests: None declared
Effect of circumcision on intromission and sexual satisfaction 7 January 2008
John D Dalton, Trustee NORM-UK, ST15 0SF Send response to journal: Re: Effect of circumcision on intromission and sexual satisfaction	Author Dalton JD, NORM-UK Stone, Staffs, UK ST15 0SF I am writing to develop the points made by Wilkinson and Sigismond regarding the effects of circumcision on intromission and sexual satisfaction. The intromission function of the foreskin has been documented by Taves.[1] The foreskin also has a sensory function with a possible role in the afferent limb of the ejaculatory reflex.[2] It is no longer acceptable to deny that the foreskin is required for normal sexual function. Four recent studies have previously reported on the effect on sexual satisfaction following adult circumcision for clinical indications.[3-6] The results of these are summarised in the table together with a pooling of the data from the four studies. The four studies reveal a remarkably consistent picture. The pooled data reveal a split into three roughly equal groups of men having circumcision where there is some reason for them to seek treatment. Only one third report improved satisfaction following circumcision with a further third reporting worsened sexual satisfaction and the remaining third reporting no effect. Circumcision can no longer be regarded as insignificant with regard to sexual function. The potential for detriment to sexual satisfaction must now be disclosed if valid informed consent to the surgery is to be obtained. Children should be protected from therapeutically unecessary circumcision without prejudice in respect of race, religion or gender. Table:- Authors Year n No > Sat % > Sat No = Sat % = Sat No > Sat % < Sa End-Point Coursey JW, Morey AF, McAninch JW, Summerton DJ, Secrest C, White P, Miller K, Pieczonka C, Hochberg D, Armenakas N 2001 22 16 73% NR* NR* 6 27% Validated Questionnaire Fink KS, Carson CC, DeVellis RF 2002 123 50 50% 25 12% 48 38% Items taken from various existing questionnaires Masood S, Patel HR, Himpson RC, Palmer JH, Mufti GR, Sheriff MK 2005 88 33 38% 39 44% 16 18% 5-item version of the International Index of Erectile Function (IIEF-5) Solinis I, Yiannaki A 2007 123 20 16% 60 49% 43 35% questionnaire about the quality of their sexual life and the sexual enjoyment before and after circumcision. Pooled data 2008 356 119 33% 124 35% 113 32%   *Coursey and Colleagues pool the results for men reporting Improved satisfaction or no change. For this purpose I have assumed all these to belong to the improved category.   References:- 1.       Taves D. The intromission function of the foreskin. Med Hypotheses. 2002; 59(2):180. 2.       Taylor JR, Lockwood AP, Taylor AJ. The Prepuce: Specialized Mucosa of the Penis and its Loss to Circumcision. BJU Int. 1996; 77:291-295. 3.       Coursey JW, Morey AF, McAninch JW, Summerton DJ, Secrest C, White P, Miller K, Pieczonka C, Hochberg D, Armenakas N. Erectile function after anterior urethroplasty. J Urol. 2001; 166(6):2273-6. 4.       Fink KS, Carson CC, DeVellis RF. Adult Circumcision Outcomes Study: Effect on Erectile Function, Penile Sensitivity, Sexual Activity and Satisfaction. J Urol. 2002; 167(5):2113-6. 5.       Masood S, Patel HR, Himpson RC, Palmer JH, Mufti GR, Sheriff MK. Penile sensitivity and sexual satisfaction after circumcision: are we informing men correctly? Urol Int. 2005; 75(1):62-6. 6.       Solinis I, Yiannak A. Does circumcision improve couple’s sexual life? J Mens Health Gend. 2007; 4(3):361. Competing interests: None declared
Circumcision and European jurisprudence 15 January 2008
Sigi Sigismond, researcher in psychoanalysis Paris 75010 Send response to journal: Re: Circumcision and European jurisprudence	Jurisprudence tolerates limited attacks to the principle of physical integrity committed in the aim of preventive prophylaxis (vaccines) under the condition of being, one, operated for the protection of life, two, proportionate to their aim (European Court of the Rights of Man, 6.10.77; Conseil d'Etat (State Council) of France, 26.11.1), three, submitted to official enquiry. Now physical mutilation is not limited attack but highly pervasive practice. For this reason, elementary ethics considers it unacceptable on prophylactic grounds. Second, considering the risks of the operation and its very doubtful advantages, no medical society in the world recommends circumcision. Therefore, there is no chance for it to fulfil the last two conditions; tolerance for ritual or pseudo-medical circumcision is unwarranted. It has rashly made an exception to the above rules due to sharp claims to the right of liberty of cult and to a respect of cultures ignoring that of the rights of the child. This exception must stop. Striking the specific organs of autosexuality, infantile sexual mutilation must be outlawed whatever the sex of the child may be. And this particularly because no medical neither religious alibi can make forget that customs of marking the human body have a fundamentally discriminative character, of the same nature as racism since founded upon a physical difference supposed to bring superiority and generating reciprocal exclusion. To end with this pleading for the right of the child to physical integrity, it must be reminded that the first great legislator in history was ordered the following: "I am a jealous God who punish the crime of fathers upon sons up to... great-grand-fathers... ". Two cases have illustrated the above principles in European courts. In April 2006, a Finnish magistrate’s court (http://www.hs.fi/english/article/Court+rules+circumcision+of+four-year- old+boy+illegal/1135220958830 and http://www.france.fi/article.php3?id_article=1142 - CIRCONCISION (site of the French embassy in Finland)), followed the requisition of the Prosecution to rank circumcision amongst common law criminality, without a penalty being pronounced. In September 2007, this decision found an echo in Frankfurt where the court of appeal declared circumcision liable to damages for illegal attack to the right of personality and illegal body injury (http://tinyurl.com/2w73d5 and (http://www.jta.org/cgi- bin/iowa/breaking/104271.html). Yet was it necessary, in both cases, that the child be defended by one of his parents, without which nothing would have been done. In absence of clear juridical state policy, the responsibility to ban circumcision mainly weighs upon physicians and their societies. Competing interests: None declared
The 2nd commandment forbids circumcision 15 January 2008
Sigi Sigismond, researcher in psychoanalysis Paris 75010 Send response to journal: Re: The 2nd commandment forbids circumcision	Already in the middle of the 19th century, a German movement of Reform rabbis opposed circumcision on Biblical grounds: the Ten Commandments do not prescribe it, it was not practised during the Exodus (circumcision was set back into practice after Moses's death, in Gilgal) and Moses was opposed to his son's circumcision, were their main arguments. Rabbi Abraham Geiger, their leader, thought circumcision an attempt against the child ("a barbarous and bleeding rite") and that the custom isolates the Jews. This provoked an outcry in the Jewish community, rabbinical authorities answered their arguments and, at the end of twenty years, the German Reform rabbis came back to circumcision. But the "heresy" gained the USA where several rabbis practise a non mutilating ceremony of nomination. Geiger and his friends had perfectly understood that Moses was opposed to circumcision but, unfortunately, they had not made our discovery of the falsification of the meaning of the Second Commandment by orthodox rabbis, from antiquity until now. This falsification hides that this commandment forbids circumcision. Indeed the orthodox interpretation understands the Biblical text: “For I, the Eternal, your God, I am a jealous God, who punish the crime of fathers upon sons up to the third and fourth generation... ” (Exodus, 20: 5), as if it said: “… who punish sons for the crimes of fathers…”, which it does not, merely meaning: "... who punish the crime of fathers upon sons up to... great-grandfathers... " Beyond great-grandfathers, it's true, there is nobody alive to punish. But this means that such a crime must be punished without statute of limitations. Indeed, a crime striking a definite group of the population (male children) is a crime against creation (humanity). It would also be absurd that the Second Commandment would reduplicate the Sixth: "Thou shall not kill". At the contrary, it points out crime against young boys as particularly reprehensible. Besides, it would be preposterous to consider this Commandment a condemnation that would strike irresponsible sons and grand-sons, making God suspicious till injustice. It must be added that, just a few lines below the 2nd Commandment, the Bible enlightens it saying: "If however you build a stone altar for me, do not build it with carved stones for by touching them with the iron, you made them lay.” (Exodus, 20: 21-22). However little medical, Moses's point of view should be taken into account in a discussion about "the rights of the child". Sigismond oldsigismund@hotmail.com Competing interests: None declared
Another reference 15 January 2008
Sigi Sigismond, researcher in psychanalysis Paris 75010 Send response to journal: Re: Another reference	Pang and Kim's enquiry (Pang M., Kim D. Extraordinarily high rates of male circumcision in South Korea: history and underlying causes. BJU Int 2002; 89: 48-54. http://www.cirp.org/library/cultural/pang1/) is missing in Mr Dalton's remarkable publication. Since they assert: "but a man was twice as likely to have experienced diminished sexuality rather than improved sexuality.", it would be useful to add their figures to the ones of Mr Dalton. Cordially yours, Sigismond Competing interests: None declared
Circumsexuals 8 March 2008
Rood Andersson, Designer Goodyear, AZ 85338 USA Send response to journal: Re: Circumsexuals	Those few medical professionals and laypersons, who sincerely promote male genital mutilation (MGM) for its supposed "benefits", typically fail to take into account the complex anatomy and functions of the intact penis and its integral role in sexuality. They also display a profound naivete concerning those few who most avidly support MGM. That support comes primarily from men who characterize themselves with the appellation "circumsexual", a term derived from "circumcision" the euphemistic slang term for MGM. Having myself spent years attempting to overcome the grievous effects of this completely unnecessary procedure, I was astonished to discover the existence of this fringe group. An earnest study of the origins and characteristics of this little examined but aggressive minority has been aided by the remarkable facility of the internet, which has brought the peculiar phenomenon into the light of day. Astonishingly enough, the disorder typically begins in early childhood, most often originating between the ages of three and five. The primary impetus for the disorder seems to be a kind of visually oriented "trauma", varying in individual cause and intensity, during which the child becomes visually and erotically conscious of the exposed glans penis, as contrasted with the appearance of the intact penis. The typical child is usually but not always intact. At least one fellow in my study was circumcised at birth. However, at a very young age he developed a lifelong fascination with the appearance of a normal penis, after observing his intact father. His fascination soon developed into a lifelong conflict, when at age three, during a bath, he was admonished by his mother not to attempt to pull his shaft skin over his glans in imitation of his father's penis. Now in his 50's this fellow restored his foreskin about ten years ago. Three years later he had a second circumcision. Soon afterward he admitted to being fascinated, again, by the intact penis. This propensity to multiple circumcisions is a frequent characteristic of circumsexuals. One fellow in this thread admitted here to having been circumcised as an adult. Elsewhere he has confessed to having had three separate procedures, one at the hands of his wife. One fellow with whom I have had extensive online contact is proud of having had SIX separate circumcisions. One apologist for circumcision discounted the claim that multiple circumcisions among circumsexuals is the rule, rather than the exception. Seeking to counter my allegation, he took a poll at the internet site: Circlist. His poll revealed that the typical "circumsexual" has had two circumcisions, but three and four circumcisions are not at all rare. One fellow claimed having had seven. Therefore, innocent proponents of MGM should never assume that support for their point of view is not biased in the extreme. Furthermore, they risk losing credibility by associating with those who, as circumsexuals, defend Male Genital Mutilation. Rood Andersson Competing interests: None declared
Expert refusal: the physician's right and duty 16 September 2008
Hervé M. Sigismond (Navoiseau-Bertaux), psychoanalysis researcher Paris 75010 Send response to journal: Re: Expert refusal: the physician's right and duty	(Sexual mutilation, the physician’s point of view) Considering on the one hand, that deontology forbids amputations without serious and strict medical motive, on the other hand Foldès’s and Taylor’s discoveries of the importance of the second sex organs of woman and man, the specific organs of autosexuality, however not yet Nobelized these discoveries may be, it is the physician’s duty to turn away requests of cosmetic or religious intervention that might alter the function of sexual organs, whatever the age, sex or religion of the person may be. They must inform them that it is their duty, and right, to do so and will not let them go without having taught them the value of the organ in question. They must not let themselves be caught in the blackmail of their ability in matter of anaesthesia or prevention and treatment of haemorrhages and infections. On the contrary, they must warn the person not to turn towards somebody else and foremost not doing it by themselves. In this aim and in order to protect the patient or their children from likely resorting to either other physicians (and risk spending their money in vain) or taking high risks resorting to non physicians, they must warn them that, since they are themselves now informed, it is their absolute professional obligation, by exception to the principle of privacy of consultation, to inform public authorities (health services, school staff and legal authorities) about the patient’s claim right away, so that further request will not be refunded by private or public insurance, the operation be impeded and parents and the possible operator be prosecuted. In case this would not be the law in some countries, associations of physicians must ask for such laws to be enacted. Expert refusal renders informed consent of the parents or the patient lapsed. Competing interests: None declared
Right to the placenta, right to the foreskin, same fight! 9 November 2008
Sigismond (M. H. Navoiseau-Bertaux), independant psychoanalysis researcher Paris 75010 Send response to journal: Re: Right to the placenta, right to the foreskin, same fight!	Premature cutting of the umbilical cord and development of the brain: psychology or neurology? “Leboyer babies” are particularly peaceful. Gay and lively, they smile from their first day, which was rare before. An enquiry disclosed that between 90% and 100% of them grow ambidextrous (1). Leboyer has announced its publication; he never did it and seems to rely upon word of mouth for promoting the recommendations of his book (2): cutting the cord after the pulsations have ceased (but for cardiac difficulty), never separating the child from the mother, extreme gentleness, filtered lights, a bath, etc. Following him, Karen Strange, a specialist of resuscitation of new-born midwife, brings a river to the validity of the techniques brought back from Gandhi's country by the gynaecologist yogi; she gives lectures but does not publish. She observed that, right before birth, the mother delivers the baby a bolus of blood that is stored in the placenta. This provision is not only heavily burdened in iron; the rise in blood pressure enables the heart to fill in the air cells of the lungs, preparing them for their next task. So, it is demonstrated that nature has forecast everything and that man's meddling into its plans is irrelevant. At all events, being born within gentleness has long-term positive psychological repercussions and, if everything goes well, the only birth trauma is that of the early cut. One does not destroy a functioning organ without lastingly traumatizing the brain. It must be added up to this plea that, the baby being immunized against maternal flora, strictly rooming them in with the mother protects them against UTIs (3), the great pretext of upholders of circumcision. But what is the mechanism of the trauma that forbids ambidextry? Making lateralization a consequence of the normal development of the brain, its explanation by neurology of the brain seems tautological (1) to us. The entire contrary, the existence of ambidextrous proves that lateralization is a pathological consequence, not a cause. Ambidextrous are normal, right-handed and left-handed are not. For the early cut provokes submission (or opposition) to adult norm. Absurd, this submission or opposition does not stem from trust but from the unconscious terror issuing from the brutal extinction of placenta alimentation before its natural, gradual and peaceful stopping. Nature has provided, for a while, a double system of alimentation in oxygen and nutrients; as long as the cord pulses, the placenta allows progressive adaptation, gentle transition between both systems. Cutting by iron does not only deprive the child from natural iron; occurring before natural term, it brutally interferes into the management of their body by the babies. Provoking terrible anguish, it is felt as cruel assault. Intimately and for life terrorised by adults including the mother, the child will foolishly comply with the norm. A first trauma, the early cut creates universal neurosis, its conformism and stream of inhibitions. The placenta is the baby's ownership, nature alone may separate them from it. Leboyer also condemned excision and circumcision (4). What is true for the cord will a fortiori be so for autosexual organs, very rich in erogenous and tactile nervous endings. Much more invasive since destructive, feminine and masculine excision provokes much graver trauma. The same cause: violence, induces the same effect: deep submission, repetition of the absurd crime. Provoked by the premature cutting of the umbilical cord, the symptom of lateralization is a limpid illustration of the Freudian theory of circumcision as technique of submission. Ritual or medical cuts result in separating the child from the mother and make them submitted to a despotic society. Consciously or not, the matter is, from attendants to birth (nurses, mid-wives, gynaecologists), individual or collective appropriation of the baby within compulsive paedophilia. All pretexts are valid in order to have the baby for oneself for a while: “Now for weighing!” but the balance is elsewhere, or the mother catches a cold and the child must absolutely be placed in the nursery, risking nosocomial infection... The mechanism of this appropriation is that of fetishist, infantile or primitive thought that, according to the discoveries of psychoanalysis, likens the part to the whole. It is exploited by the voodoo or other circumciser manipulators; in order to enslave their gullible victims and force them to prostitution, the voodoo robs them a lock of hair, so becoming their master. As observed by Romberg-Weiner, it is useless to have a Leboyer baby if he is to be circumcised later. Leboyer opposes that tyranny. His message can be summarized so: “Let the baby, their placenta and the mother alone.” Violence upon children is the great source of individual or collective mental disease. Correlating birthing techniques with adult behaviour: “obstetric procedures should be carefully evaluated and possibly modified to prevent eventual self-destructive behaviour.”, Jacobsen's enquiry (5) comforts Leboyer's finding. But the examples of Galileo, Copernicus, Freud... etc., have shown that one does not solve the world's problems easily. Like religion, medicine is a universe of dogmas, pride, prejudice and coteries in the hands of all-powerful mandarins. It took it half a century to accept Semmelweiss's discovery (hygiene). So is it for Leboyer's; he did not get the Nobel prize. Sigismond - oldsigismund@hotmail.com Psychoanalysis researcher and a specialist of infantile sexual mutilation (ISM), author of “Sexual mutilation, the child’s point of view”, for free at http://groups.msn.com/circabolition or intactwiki.org. (1) Birth without violence: an evening with Doctor Leboyer. J prim ther 1975, II (4), 289-300. (2) Birth without violence. New-York: Alfred A. Knop; 1975. (3) Winberg J., Bollgren I., Gothefors L., Herthelius M., Tullus K. The prepuce: a mistake of nature? Lancet 1989; i: 598-9. (4) 4.06.1980 letter to R. Romberg-Weiner. http://Sexuallymutilatedchild.org/leboyer.htm (5) Jacobsen B, Eklund G, Hamberger L. et al. Perinatal origin of adult self-destructive behavior. Acta Psychiatr Scand 1987; 76 (4): 364- 71. http://www.cirp.org/library/psych/jacobsen1 Competing interests: None declared
Circumcision has many benefits 12 November 2008
Richard A Sturdy, retired CEO Yorkshire UK Send response to journal: Re: Circumcision has many benefits	To add to what I said in my earlier response, I must emphasise that my "medically unnecessary" adult circumcision was a life-enhancing procedure for me. I cannot understand why the benefits are so readily dismissed by the anti-circumcision activists, many of whom I recognise here. In addition to the better health, hygiene, comfort, appearance, self -esteem etc, the sexual benefits of circumcision are so pronounced as to be invaluable. No one who has not experienced adult life both before and after circumcision can appreciate just how male circumcision improves the sexual pleasure of both the man and his female partner(s). All the nonsense about "reduced sensitivity" is ridiculous - if the young generation knew how much more sexual pleasure they would experience as a result of male circumcision, it would be universal today! Richard Sturdy Competing interests: None declared
Re: Circumcision has many benefits 16 November 2008
Van Lewis, Natural farmer P.O. Box 323, Panacea, Florida 32346, USA vanlewis@earthlink.net Send response to journal: Re: Re: Circumcision has many benefits	Mr. Sturdy's argument for self-chosen adult circumcision is not a valid argument for imposing circumcision/genital mutilation on others without their adult informed consent, especially not on infants and children. Doing so violates their human rights to bodily integrity and recklessly endangers their lives without adequate medical justification. To endanger a child's life with medically unnecessary, elective surgery who is not sick or injured or malformed is madness. Reckless endangerment of children's lives is a crime. Competing interests: None declared
Circumcision entails impotence in the long run! 26 December 2008
Sigismond (M. H. Navoiseau-Bertaux), psychoanalysis researcher Paris 75010 Send response to journal: Re: Circumcision entails impotence in the long run!	Answering in my turn to our friend John D Dalton, we must face the fact that, in the long term, circumcision must have more damaging effects upon sexual sensitivity than reported from static enquiries. We dispose of two observations: - Hughes G., in Circumcision: another look. Ohio medicine 1990; 86 (2): 92. http://cirp.org/library/general/hughes, enquired men married with the same spouse for over 50 years, and suggests "that the uncircumcised male has a more favorable sexual compatibility in his marriage.", which is already astounding. - but Goldman R., in The psychological impact of circumcision. BJU int 1999; 83 (suppl. 1): 93-103. http://www.cirp.org/library/psych/goldman1), confirms that an American enquiry found out that the circumcised are at risk of impotence: "According to a randomized study of 1290 men aged 40 -70 years, 52% reported some degree of impotence, ranging from minimal to complete. This rate varied from ~40% at age 40 to 67% at age 70. (A literature search yielded no comparable European study.)" This seems quite sufficient to assert that circumcision is a terrible threat for virility. One must even think that the circumcised do not even realize their loss, due to its slow progress within time. Competing interests: None declared
The "covenant"? 7 July 2009
Robert Samson, retrired none-15235 Send response to journal: Re: The "covenant"?	I think all here claiming that circumcision is necessary to fulfill the covenant with god need to realize that research into the texts has proven that circumcision was NOT in the original covenant--it was an invention of the priests and inserted into the texts circa 550BCE. This claim of religious necessity is a fallacy and one with proven harm, and cannot be used to justify this violation of the basic right of bodily integrity. Competing interests: None declared
Circumciseds' foetuses more at risk! 31 July 2009
Sigismond (M. H. Navoiseau-Bertaux), psychoanalysis researcher Paris (75010) Send response to journal: Re: Circumciseds' foetuses more at risk!	An enquiry led upon an important random selected sample, recently published by The Lancet, shows that circumcision, which lessens by 50% men's risk of contracting the HIV, worsens it for women in the very same proportion. http://news.bbc.co.uk/2/hi/health/8154134.stm http://www.thelancet.com/journals/lancet/article/PIIS0140- 6736(09)60998-3/abstract Since this study did not include foetuses, then, obviously, circumcision worsens the risk for the whole population. At all events, to complete Mr Hinchley's points, an operation supposedly good for dad but bad for mum and baby does not really seem ethical, does it? Competing interests: None declared