Thursday, June 27, 2013

Factually correct information? Kaiser Permanente flyer on newborn circumcision

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

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

Check out this pdf file from Kaiser Permanente:

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

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

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

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

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

Then the flyer moves to the "benefits of circumcision", and the first one is of course "lowers the risk of cancer of the penis". But how much is the real risk of cancer of penis? Is it frequent? Does it really decrease? The AAP, in spite of touting this same benefit, has to come clean when showing numbers, by saying: "In fact, in men with an intact prepuce and no phimosis, there is a decreased risk of invasive penile cancer (OR: 0.5). When excluding phimosis, the risk disappears, which suggests that the benefit of circumcision is conferred by reducing the risk of phimosis and that the phimosis is responsible for the increased risk." (page 14 of the Technical Report), and again the untold part is that phimosis can often be treated without any excision of tissue, thus making circumcision unnecessary.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The flyer then describes the plastibell method as follows:

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

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

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

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

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

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

There is a section on "care of the uncircumcised penis".

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

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

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

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

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

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