10/6/10

The Continuum of Normal Birth: Doulas discussing circumcision?

The Continuum of Normal Birth: An Intact Penis
Anna Marie Nelson, CD(DONA), LCCE, LMT

September 24, 2008
Published in: International Doula, Volume 17, Issue 1, March 2009


ABSTRACT

Oftentimes doulas are asked for information concerning circumcision. Doulas should be educated on this subject and be able to provide information based on scientific evidence without the influence of social biases. The American Academy of Pediatrics does not endorse circumcision. A doula should be educated on the physiology of a normal penis, so she is able to provide the facts associated with the benefits of not performing a cosmetic surgery on a newborn infant. A number of anti-circumcision facts will be presented, so the doula can be informed with evidence-based information on why a penis should be left intact.


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As doulas we discuss many personal subjects with parents, but it seems as though one area is not getting much airtime--circumcision. Perhaps doulas are not mentioning it due to embarrassment; perhaps because they think the decision is too personal and should only be addressed by the parents; perhaps we have a personal bias for or against circumcision; or maybe we think that discussing circumcision is beyond the scope of a doula.

Because circumcision is such a personal and sometimes even embarrassing subject, oftentimes parents will not ask about it during group childbirth classes. Sometimes a doula is the only person parents will ask about it. We should be prepared to give factual information.

Approximately one-half of our clients will be giving birth to boys, and one of the first major decisions parents are faced with is whether or not to circumcise. The decision is a personal one, but if we are asked for information concerning circumcision, we have the responsibility of providing the facts concerning the advantages of leaving a penis intact, and the disadvantages of having a circumcision performed. Parents should at least make an informed decision based on facts, rather than on tradition and social bias.

To effectively teach about circumcision, we must first let go of our own personal biases, especially if we have a male child and chose to circumcise him. As a parent did you make the decision based on facts, or did you do it because ‘everyone else does it’, or perhaps because, ‘he should look like his dad’? Neither of these reasons is evidence-based. They are simply opinions and traditions.

Consider the following scenarios concerning circumcision from a young boy’s point of view: A woman had two sons, one she circumcised because she ‘followed the crowd’, and one she did not because she knew more about it and decided there was no medical reason to have her newborn son undergo surgery. As her two young sons were bathing together they noticed they were not exactly the same. The mom was asked why. She answered that for the older son she and Daddy had decided to cut off a little bit of his penis, but for the younger son they decided not to. The older, circumcised son started crying and asked his mother, “Why did you let someone cut off part of my penis?!”

In another instance, the father was circumcised, but the mother and father chose not to circumcise their son. As their son got older the son noticed that he and his father were different, and the son asked his dad why. The dad answered, “Well, when I was a little baby people thought it was a good thing to cut off a little piece of a baby boy’s pee-pee, but your mom and I read a lot about it and we decided that it wasn’t really a good thing so we didn’t have a little piece of your pee-pee cut off.” The young boy heaved a huge sigh of relief and said, “Thanks, Dad!” Then the son very quietly added, “Daddy, I’m very sorry that you got part of your pee-pee cut off.”

As doulas we seem to constantly struggle with the dilemma of knowing evidence-based facts, yet we observe obstetrical practices performed based on antiquated traditions. To combat that we educate our clients so they can make educated choices. Circumcision should not be the exception. We should give concrete facts, just as we would with any other topic concerning childbirth.
If a doula has a male child that she has circumcised, it is especially hard to teach evidence-based facts concerning circumcision. It is similar to when a nurse almost unknowingly promotes bottle feeding because she bottle fed her own children, and, “…they turned out just fine.” Oftentimes the nurse does not truly embrace breastfeeding because then she would have to admit to herself that she did not do the best thing possible for her own children. That is a bitter pill to swallow.

As professionals we need to keep our own biases out of our discussions with clients. We cannot undo the past, but we can teach the facts so other parents do not blindly follow the crowd simply due to ignorance and a lack of information.

There is also the argument that circumcision is not a part of childbirth. Technically breastfeeding is not a part of birth either, but we certainly talk about that. We also talk about postpartum depression and many other topics that are not technically a part of birth, but they are so closely related that it seems unwise not to educate parents about the subjects.

There is also an argument that Jews must circumcise their sons for religious reasons, thus the subject should not be discussed. However, there are Jews that do not circumcise and instead perform a ceremony which ‘draws blood’ and some Jews feel that it fulfills the religious covenant. A doula should always be respectful of her clients’ personal and religious beliefs, but if asked for information, she should be able and willing to give factual information.

In childbirth education classes is it not appropriate to ‘skip over’ breastfeeding because a woman in the class may have had breast cancer and would not be able to breastfeed, so out of respect for her situation the subject of breastfeeding is completely avoided because the educator does not want to make her feel guilty or uncomfortable. So just as a childbirth educator should not skip over breastfeeding in order not to hurt someone’s feelings, neither is it appropriate for a doula to skip over the subject of circumcision. It is our responsibility to teach the facts in a nonjudgmental manner, and then let the parents make their own educated decisions based on their own set of circumstances.

If asked for information on circumcision, we should answer accurately without ‘playing’ to our audience. We should assume our clients want an accurate, scientifically sound answer without deciding for them what information we think they should have based on our perception of the answer we think they want to hear.
One of the main arguments for circumcision is that a male uncircumcised penis needs to be cleaned. That is true, but not until the foreskin is retractable, which normally does not happen until about the time of puberty. We all brush our teeth, we wash our hair, we wash our hands, we wash our faces, our armpits, and our bottoms. Girls also wash their vaginas. The decision to amputate a body part because it will have to be washed is not based on sound judgment.

Both males and females produce smegma, the lubricating substance a foreskin or clitoral hood and produces. But baby girls do not have their clitoral hood amputated a day or two after birth, we would call that genital mutilation and be highly outraged. There is no difference in amputating an anatomically normal body part of the male body.
In many cultures little girls undergo genital mutilation, and the women that have had the same thing done to them are oftentimes the ones that perform the amputation, while the mother and other women that love the little girl the most are the ones that usually restrain the girl during the amputation. We shudder at the thought and wonder what could possess another woman to not only let it happen, but to act in helping it happen. But in some cultures there is a social bias to do it, it is accepted as a normal part of life for a female, it is perceived as normal and necessary.

Fathers that have undergone circumcision as a baby oftentimes give no thought to their son being circumcised, because just like the mothers of the girls undergoing genital mutilation, circumcision is perceived as normal and necessary. But the practice is based on antiquated tradition, social bias, and myths. There is no logic in that rationale.
Another argument for circumcision is, “I don’t want my son to be the ‘different kid’ in the locker room.” Of course parents are sensitive to their child possibly being ridiculed, but circumcision rates have steadily declined during the past 30 years from about 90% in 1971 to about 60% in 2002, which is the most recent statistics available. However, the downward trend is expected to continue, and currently the circumcision rate in the U.S. is thought to be about 50%. In 2002 the west coast circumcision rate was about 35%.

Although it is highly unethical for profit to be made from unnecessary surgery on a newborn, there are still some doctors and hospitals that promote circumcision. Circumcision is a multi-million dollar industry in the U.S. Parents need to be educated about circumcision well before the birth of their child so they do not fall prey to the many myths surrounding the benefits of circumcision.



Here are the facts concerning circumcision:
Circumcision Information: (Please feel free to reproduce and circulate)
1) In 1999 the American Academy of Pediatrics stated that there is not sufficient data to recommend routine neonatal circumcision (Lannon, 1999).

2) The circumcision rate in the U.S. has steadily dropped from a high of about 90% in 1971 to about 60% in 2002 (Bollinger, 2004).

3) The foreskin is adhered to the glans (the head of the penis) at birth. Retracting the foreskin tears the adhesion of the foreskin to the glans. It is extremely painful, and is comparable to tearing a fingernail away from the finger (Spock, 1998).

4) The foreskin is a useful part of the male anatomy. It protects the glans, and also produces lubrication, sub-preputial moisture containing lytic material, which has anti-bacterial and anti-viral properties. The natural oils lubricate, moisturize, and protect the mucosal covering of the glans and inner foreskin (Cold, 1999).

5) Circumcised male infants are 12 times more likely to get MRSA, (Methecillin-resistant Staphylococcus aureus) an extremely serious antibiotic resistant staph infection, than intact male infants (Klevens, 2007).

6) Circumcision is traumatic to the baby, even if anesthesia is used. If a child stops crying during the procedure it is possibly due to shock, not because it does not hurt. (Wallerstein, 1990).

7) When a child is circumcised, he loses about 240 feet of nerves and between 10,000 and 20,000 specialized erotogenic nerve endings, which decreases his sexual sensitivity. The average size of an adult foreskin is about 15 square inches or more than the size of a 3 x 5 inch index card. The foreskin is the most sexually sensitive part of the penis (Taylor, 1996).

8) Circumcision does not decrease a male’s chances of developing penile cancer. In fact, although penile cancer is rare, in most cases, when it does occur it starts at the circumcision site (Maden, et al, 1993).

9) Circumcision does not decrease the risk of a male’s female sexual partner from developing cervical cancer (Shingleton, 1996).

10) The foreskin contains Langerhans cells, which may provide resistance to HIV infection. (Fleiss, 1998).

11) Circumcision may contribute to erectile dysfunction by destroying blood conduits (Taylor et al, 1996).

12) The foreskin protects the corona (rim of the glans) from direct stimulation during intercourse and helps to prevent premature ejaculation (Zwang, 1997).

13) An uncircumcised penis does not cause the friction that a circumcised penis causes, so it helps in the comfort of sexual intercourse (O’Hara, 1999).

14) Of 138 women who had experience with both circumcised and intact male partners, 85.5% preferred intact male partners (O’Hara, 1999).

15) Circumcision does not prevent a male child from masturbating (Wallerstein, 1990).

16) Circumcision does not prevent sexually transmitted diseases (England, 1998).

17) Circumcision is surgery and carries with it all of the risks of any surgery, including hemorrhage, infection, gangrene, septicemia, ulceration of the exposed urinary meatus, skin grafting, disfigurement, loss of the penis, and albeit a small risk, even death (England, 1998).

18) Although some studies have shown an increased risk for urinary tract infections in uncircumcised males, it is difficult to summarize and compare the results due to many confounders, including: methodology, samples of infants studied, method of urine collection, and urinary tract infection definition. In some studies methods for determining the reliability of the data were not described (Lannon, et al, 1999).

19) While breastfeeding is known to protect against urinary tract infections (Pisacane,1992), the trauma of circumcision often disrupts successful breastfeeding (Howard,1994).

20) Circumcision costs $150-270 million annually, not including complications. And the additional cost of an extra 1/2 day hospital stay, on average, is estimated to be well over $200 million annually (Bollinger, 2004).


Certainly the decision to circumcise or not to circumcise is still a very personal decision, and many couples will decide to circumcise their child. But perhaps when presented with evidence-based facts, some couples that have never really given it any thought will begin to consider the risks of circumcision and the benefits of letting their baby boy stay intact.

As doulas we should be teaching facts, including the often overlooked facts concerning circumcision, because with circumcision, just like birth, there are no ‘do-overs’ and the consequences last a lifetime.

We all want to promote ‘Normal Birth’. It is time we also promote ‘normal’ male anatomy.



REFERENCES

Bollinger D. (2004). Normal versus Circumcised: U.S. Neonatal Male Genital Ratio, white paper. An original publication by the Circumcision Information Resource Pages.

Cold, C.J., Taylor, J.R. (1999). The prepuce. BJU International 83, Suppl. 1:34-44.

England, P., Horowitz, R. (1998). Birthing from Within. Partera Press: 188, 295.

Fleiss, P.M., Hodges, F.M., Van Howe, R.S. (1998). Immunological functions of the human prepuce. Sexually Transmitted Infections, 74:364-367.

Gellis, S.S., (1978). Circumcision. American Journal of Diseases of Children, 132:1168-1169.

Howard CR, Howard FM, and Weitzman ML. (1994) Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics 1994;93(4):641-646.

Klevens, R.M., Morrison, M.A., Nadle, J., et al. (2007) Invasive Methicillin-resistant Staphylococcus aureus infections in the United States. JAMA 2007; 298(15);1763-71.

Lannon, C.M., Bailey, A.G.D., Fleischman, A.R., Kaplan, G.W., Shoemaker, C.T., Swanson,

J.T., Coustin, D., (1999). Circumcision Policy Statement. Pediatrics: Official Journal of the American Academy of Pediatrics. 103:689.

Maden, C., Sherman, K.J., Beckmann, A.M., Hislop, T.G., Teh, C.Z., Ashley, R.L., Daling, J.R. (1993). History of Circumcision, Medical Conditions, and Sexual Activity and Risk of Penile Cancer. Journal of the National Cancer Institute: Vol. 85, 1:19-24

O’Hara, K., O’Hara, J., (1999). The effect of male circumcision on the sexual enjoyment of the female partner. British Journal of Urology: 83, Suppl. 1:79-84

Pisacane A, Graziano L, Mazzarella G, et al. (1992) Breast-feeding and urinary tract infection.

Journal of Pediatrics ;120:87-89.

Shingleton, H., Heath, Jr., C.W., (1996). Letter to Peter Rappo, M.D., February 16, 1996

Spock B., Parker S.J., (1998). Baby and Child Care (7th Edition) New York, Pocket Books, p. 94

Taylor, J.R., Lockwood, A.P., Taylor, A.J., (1996). The prepuce: Specialized mucosa of the penis and its loss to circumcision. British Journal of Urology: 77:291-295.

Wallerstein, E., (1990). The Circumcision Decision. International Childbirth Education Association, Inc.

Zwang, G., (1997). Functional and erotic consequences of sexual mutilations. In: Denniston,

G.C., Milos, M.F., eds. Sexual Mutilations: A Human Tragedy. New York and London: Plenum Press




ANNA MARIE NELSON is a doula and childbirth educator in the Dallas, TX area. She has three teenaged daughters--who all would have been circumcised if they had been males, so she understands the psyche of “following the crowd.” But she is older and wiser now and is trying to spread the word!

3 comments:

  1. Great article! Though I have a question...what research shows that retraction usually happens around puberty? Both my sons are intact, and at almost exactly 3 years old, each of them retracted their own penis without any apparent pain or injury. I'd just like to give accurate information about retraction, and it was my understanding that it could happen anytime from 2 years old up through puberty. Could you clarify?

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  2. Average age of normal retraction is about ten years old......however it may happen earlier or as late as the teen years, and it's all considered "normal". No one should be retracting the foreskin except the owner of the penis and foreskin.

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  3. You are right. I can't remember my first retraction but I can remember being retractable by 5 or 6. A friend didn't retract till puberty - his first sight of his glans coincided with his first adolescent erection. Boy was he surprised!

    But it's probably safer to err on the side of "usually happens around puberty" and have parents surprised by "early" retraction than insist that it must be retractable within a week of birth, as Dr Truby King used to do, probably causing many boys to "need" circumcision.

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