Comments on KNMG's recent viewpoint on non-therapeutic circumcision

On May 27, The Royal Dutch Medical Association (KNMG) published a viewpoint on non-therapeutic circumcision of male minors.

Comments to that viewpoint follow below.

Prof. Dr. Arie Nieuwenhuijzen Kruseman
Chairman
Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst (KNMG)

June 2, 2010

Re: Non-therapeutic circumcision of male minors

Dear Prof. Dr. Nieuwenhuijzen Kruseman:

The Royal Dutch Medical Association (KNMG) should be praised for advancing the discussion of circumcision and inviting comments.

The most important thing that this document must do and does not do currently is to state clearly at the beginning that circumcision always harms the patient and that any proposal for doctors to circumcise is a proposal for doctors to harm patients.

Because the inherent harm of circumcision is not made clear at the outset, the stated ultimate aim of minimizing non-therapeutic circumcision is allowed to slip to the lesser goal of minimizing complications. Once the harm of circumcision is acknowledged, it follows that the goal sought in the report must be restored from preventing the harm of circumcision’s complications to preventing the harm of circumcision and its complications. Clearly, the way to the minimize these harms is to stop performing circumcisions.

Still a double standard

The religious-cultural justification for circumcising males outlined in the report still sets a double standard. As noted, female genital mutilation is also entrenched in certain cultures and religions but the KNMG manages to set a clear standard against participating in and enabling the abuse of female patients. Male patients deserve and the medical profession is legally obligated to provide the same standard of care and ethical treatment that female patients receive.

Other forms of child abuse have not been eradicated by criminalization but professional associations do not use that fact as an excuse to offer to participate in the abuse. The KNMG’s proposal of offering circumcision because they can do a better job than unsanctioned circumcisers is equivalent to the police offering a child beating service because they can do it more professionally than parents can. Presumably, the criminalization of FGM has led to unsanctioned female circumcisions by non-professional operators with undesirable outcomes but the KNMG does not see this as a reason for proposing to offer FGM services.

Moral Hazards for Doctors

Whenever money is made from an activity a constituency quickly forms who will defend their profitable activity. In the United States, with its fee-for-service system, it is not hard to conclude that the glacial pace of circumcision reduction and the recent backsliding toward offering “sunna light” for females and the re-evaluation of recommending male circumcision based on questionable research have at their root an avoidance of loss of income by the medical profession. As always, there is a conflict of interest when agents stand to profit from the rules they themselves set. The KNMG document must acknowledge the moral hazard to doctors of profiting from harming patients.

There is another moral hazard that’s harder to face. Doctors may discover a sadistic gratification from circumcising and become dependent upon performing circumcisions to fulfill this sadistic urge. Recently a man was arrested in Washington State for posing as a doctor in order to circumcise young men. A knowledgeable source informed the press that his motive was to derive a sadistic thrill from circumcising. Also, some sadomasochistic pornography features performing circumcisions as the central fantasy. Clearly some people do derive a sadistic thrill from circumcising and there is no reason to believe that physicians are immune from this potential response. Any document that proposes to condone the continuation of circumcision must specifically acknowledge the moral hazard to doctors of harming patients for their own sadistic gratification.

Institutionalization of abuse

The institutionalization of a human rights violation is fraught with danger for the participating institution itself and for the society it serves. The institutionalization of circumcision legitimizes the violation of specific human rights and erodes respect for human rights in general. Institutionalization of abuse corrodes the moral standing of the institution itself. Intuitions are notoriously prone to “mission creep,” the continual expansion of justifications and applications for an activity already practiced. Once institutionalized, a practice becomes entrenched and more, not less, difficult to eradicate. Fortunately, the handling of FGM provides a model for escaping from the moral swamp of non-therapeutic circumcision: adopt a clear, unequivocal policy of non-tolerance.

Inherent harm and potential harm

Where is the admission that circumcision harms the boy? The harm of circumcision is not merely a potential side-effect but a certainty inherent in the procedure itself. It is misleading at best to discuss risks of complications, which are potential harms, while not being frank about the unavoidable, certain harm of amputating healthy tissue with unique functions and special erotogenic value to the patient. Whenever risks are discussed they must be presented as potential additional harm to the patient and not simply as potential harm.

At its core, this document proposes a framework for doctors to harm patients. How can this be seen as progress? How can harming patients be part of medicine’s mission?

Risk of death

Death of the patient must be included whenever potential complications are enumerated. The US death rate from circumcision is quoted as 2 per year in this report but other reports estimate it in the 100 - 200 range. This report should include the higher number. Regardless of the true number, the risk of death is always present and should never be left out of any list of risks of additional harm from circumcision.

Lack of patient consent

“Consent” of one or both parents does not constitute consent of the patient. Parents are third parties whose legal right to authorize permanent, non-therapeutic modifications to the bodies of non-consenting minors, even when the minor happens to be the parent’s child, is at best questionable and likely void.

Apologies to victims

Finally, if the KNMG continues to permit male genital mutilation, I would like to suggest that each doctor who circumcises a boy be required to send a letter of apology to the boy on his 18th birthday. The letter must include the doctor’s current home address should the victim wish to discuss the matter with his circumciser personally. If medical professionals are unwilling to deal with their angry, grown patients then they must not harm them while they are still defenseless. If practitioners balk at this requirement they should be reminded of the ethical problem of performing an elective amputation on someone who can’t say no when there is no certainty or even reason to expect that the patient will be happy with the outcome.

No ethical basis for harming patients

When the harm of circumcision is brought to the forefront of the discussion, the conclusion quickly becomes clear. The only ethically supportable position a medical organization can take regarding non-therapeutic circumcision of male minors is to recommend the immediate, total and permanent cessation of the practice as has already been done for female genital mutilation. Halfway measures are not sufficient. Further delay is itself a breach of ethics and a dereliction of professional duty.

Again I would like the thank the KNMG for bringing this vital matter to light and for inviting comments.

Sincerely yours,

Harry Guiremand

Is the American Academy of Pediatrics a Criminal Organization Under Existing Laws?

We usually think of mobsters and people with letters after their names as mutually exclusive groups. And so it's hard to imagine that an association of degreed professionals can be engaging in organized crime. But, as we've seen with pedophile priests, a respected office can be the perfect disguise.

Organized crime is the unlawful activities of a highly organized, disciplined association. The AAP is a highly organized and disciplined organization but are their activities unlawful?

Maimonides and Kellogg both recommended circumcision as a means of intentionally causing extreme pain. The intense pain of circumcision has been documented by others since. Intentionally causing extreme pain is the illegal activity of torture. It is not possible to torture someone without also committing the crime of terrorizing them.

Is a person's body not his property? And is depriving someone of his property against his will not robbery? A baby expresses his will not to be circumcised by the only means available to him when he screams and struggles to kick and flail his arms. He is clearly robbed of his property when part of his body is taken against his will.

Terrorism and robbery are among the crimes singled out for special consideration under the Racketeer Influenced and Corrupt Organizations Act of 1970.

Under RICO, a person who is a member of an organization that has committed any two of 35 specific crimes within a 10-year period can be charged with racketeering.

RICO also permits a private individual harmed by the actions of such an enterprise to file a civil suit.

In addition to racketeering, the AAP has been criminally negligent in failing to adequately inform parents of the harm of circumcision. The most recent AAP statement on circumcision only goes so far as to say that circumcision is "not recommended" in spite of the fact that the harm of circumcision is well documented. After reading the AAP statement most parents are left unaware that by agreeing to circumcision they are permitting significant and irrevocable harm to their new son. Because the harm is well known to the AAP and is significant and irreversible, the AAP's failure to inform constitutes a criminal act.

Is the AAP a criminal organization? The short answer, as far as I can see, is yes.