IOTM – Dr. Christopher Guest

JULY 2013: It’s rare that a physician will speak out publicly against circumcision; so many are still afraid of repercussions within the medical establishment. Christopher Guest, MD, however, has taken a courageous route for nearly 20 years.

A vascular and interventional radiologist in Ontario, Canada, Dr. Guest is the founder of the Children’s Health and Human Rights Partnership. He’s been opposed to circumcision since 1994, when he refused to participate in forced infant circumcision during medical school, and has produced several powerful videos aimed at educating the public about the practice,

Dr. Guest’s most recent video, “Circumcision: The Whole Story,” co-produced by the Barrie (Ontario) Midwives, addresses the culture of circumcision. The video (also embedded at the bottom of this page) explores the historical origins of circumcision, explains the physiological functions of the foreskin, and discusses commonly believed myths and scientific truths. Its focus on sexuality and evolution is particularly straightforward and helpful. “Our genitals have an evolutionary track record of efficiency and success,” he explains. “And it’s not just our species—all mammals have a foreskin.”

The video is a fantastic introduction to anyone who’s new to the issue, from newly pregnant parents-to-be, to friends and family who’d never thought about circumcision until you brought it up. Says intactivist videographer James Loewen, “Anyone who would insist upon cutting a male child after seeing this video needs to admit that they are causing serious physical damage to a child based upon misinformation, superstition and/or prejudice.”

Last year, Dr. Guest spoke at the Central Ontario Humanist Association, discussing circumcision history, ethics, and human rights. You can watch his speech on YouTube (Part 1, Part 2).

In a recent interview with Intact America, Dr. Guest told us, “As a radiologist, the continual scientific advancements in medicine never cease to amaze me: CT scanners that image pulsating coronary arteries, fMRI machines that actually watch your brain think, tiny catheters that drill through blockages in arteries. In this age of modern medicine, with all of our technology and knowledge and progress, how is it possible for physicians to promote such a primitive and cruel practice as circumcision? It is difficult to imagine anything more disturbing than the ritualistic mutilation of infant genitalia. The medicalization of this ritual is simply a disgrace to our profession. Forced infant circumcision is medically unethical, it is irrational, it is unscientific and it constitutes a gross violation of human rights. On behalf of many Canadian physicians who oppose circumcision, I commend Intact America for educating health care providers about the sexual and mechanical function of the foreskin, as well as for protecting the human rights of children in the U.S. and throughout the world.”

“Dr. Christopher Guest,” says Georganne Chapin, Intact America’s executive director, “blends a scientist’s observations with a humanitarian’s sensibilities—and the moral courage to speak out against an atrocity so blithely ignored by much of the medical profession in the United States and Canada. Would that more physicians followed his example! Intact America is pleased to welcome Dr. Guest to our Board of Health Professionals, and to share his wonderful new video, which sets the record straight about the normal male body and the harms of surgically altering it.”

You can watch “Circumcision: The Whole Story” here:

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My Letter to the American Academy of Pediatrics

On August 29, Intact America launched an email campaign, inviting our followers to tell the American Academy of Pediatrics what they think about the new Circumcision Task Force’s Technical Report on Circumcision. The Report, which concedes that the purported health benefits of infant circumcision are not great enough to justify recommending it, and that the risks of circumcision have not been adequately documented, somehow concludes that the “benefits” outweigh the risks. The Report also states that the decision to circumcise baby boys, who cannot consent to have this unethical, medically unnecessary surgery performed on their bodies, should be left to the parents, and, that parents’ non-medical decision to have their child’s genitals unjustifiably altered should be abetted by having Medicaid and private insurance companies pay doctors to do the cutting.

Here’s my letter:

Dear AAP Leadership,

What were you thinking?

How can you approve a report that extols the benefits of removing the foreskin, a normal body part, without one single word devoted to the function of that body part, or why it’s there in the first place? How credible is such a report, which neglects to mention that the vast majority of the world’s men are intact (or as the report says, “uncircumcised”), and that these men do just fine?

What were you thinking when you deputized as co-author of the report a doctor who has openly boasted about circumcising his own son?  The American Medical Association’s code of ethics (AMA E8.19) states: “Physicians generally should not treat themselves or members of their immediate families” … “In particular, minor children will generally not feel free to refuse care from their parents.” In 2009, the AAP’s own Committee on Bioethics clearly stated that pediatricians who treat their own children “violate a fundamental professional obligation.”* How can we trust the neutrality or the ethics of a Task Force member who so flagrantly violated his own organization’s bioethical principles?

What were you thinking when you named a specialist in adult sexually transmitted diseases to chair a Task Force to examine infant circumcision? Babies and children don’t have sex, and thus they are not at risk of contracting an STD. It seems to me, by selecting this individual as chair, the Task Force already knew what it was looking to conclude.

Would it not have been relevant for the Task Force to mention the limitations of its recommendations? Specifically, even if circumcision were to confer some protection from HIV for adult heterosexual men, as claimed by the studies cited, it was found to confer none for women, or for men having sex with men, or for intravenous drug users. And, again, it confers no protection for babies and children. Furthermore, shouldn’t the Report have mentioned that if or when an adolescent or adult becomes at risk, there are other nonsurgical ways of avoiding sexually transmitted diseases? Shouldn’t the words “safe sex” or “condom” or “abstinence” have appeared at least once in the Report?

Given the Task Force’s unequivocal conclusion that the “health benefits of newborn male circumcision outweigh the risks,” are you not concerned by the Report’s utter failure to address the risks? Specifically, how do you justify the contradictions and doublespeak in the following statements?

The true incidence of complications after newborn circumcision is unknown, in part due to differing definitions of “complication” and differing standards for determining the timing of when a complication has occurred (i.e., early or late). Adding to the confusion is the comingling of “early” complications, such as bleeding or infection, with late complications such as adhesions and meatal stenosis…. (p. 772)

Based on the data reviewed, it is difficult, if not impossible, to adequately assess the total impact of complications, because the data are scant and inconsistent regarding the severity of complications. (p. 775)

The majority of severe or even catastrophic injuries [such as] glans or penile amputation, … methicillin-resistant Staphylococcus aureus infection, urethral cutaneous fistula, glans ischemia, and death are so infrequent as to be reported as case reports (and were therefore excluded from this literature review).  (p. 774)

Did you not notice any potential liability problems for the AAP and for pediatricians who circumcise that might arise as a result of the Report? For example, while discussing the Mogen clamp in its review of complications from particular circumcision techniques and tools, the Report says:

There were no specific studies of complications … because complications are rare; thus, one can only rely on available case reports of amputation. (p. 775)

No note is made of the fact that the manufacturer of the Mogen is bankrupt, due to lawsuits resulting from these “rare” complications and amputations, and that any doctor sued for an adverse outcome from a Mogen will be on his own (unless, of course, he can implicate the AAP for failing to inform him of the facts).  Also, the review of techniques and tools neglects to cross-reference a mention elsewhere of “devastating burns” that can occur when electrocautery is used in conjunction with the metal Gomco clamp. Sloppy, at best.

Did anybody think to ask why no data has ever been found in the developed world showing a correlation between circumcision and disease? Since when is sub-Saharan Africa, with high rates of poverty, illiteracy, and disease, the gold-standard comparison population for American pediatrics? Did anybody wonder how it can be that Europe, where very few men have been circumcised, has lower rates of STDs and HIV than the U.S. and better overall health status, along with lower per capita health expenditures?

Has the leadership of the AAP, knowing that a Task Force was preparing recommendations about infant circumcision, noticed that medical associations in European countries are increasingly calling for doctors to refuse to perform this surgery, on the basis that it is risky, medically unnecessary, and a violation of the child’s rights? How can you completely ignore the principles and actions of your learned colleagues in other countries?

Did anybody ask the Task Force to make sure its Report was consistent with other AAP policies, including the statement by the AAP’s own Committee on Bioethics on “Informed Consent, Parental Permission, and Assent in Pediatric Practice”? The policy, still in effect, states in part:

Proxy consent poses serious problems for pediatric health care providers. Such providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses… [The] pediatrician’s responsibilities to his or her patient exist independent of parental desires or proxy consent. (p. 315)

In placing the burden of deciding whether to circumcise their sons squarely on the shoulders of parents (who are not medical professionals), is the Task Force Report on Circumcision contradicting this statement on Informed Consent? By referencing religion and culture as valid elements in parental decision-making (p. 759), is the Report attempting to give doctors a free pass? Religion and culture (in the American context) generally lead to circumcisions, but human rights, medical ethics and the mandate to doctors to do no harm clearly lead to leaving a boy intact.

Most important, have you not noticed the growing outcry among parents, complaining that they were duped by doctors into agreeing to allow harmful surgery to be performed on their baby boys? Are you ignoring the growing body of complaints from adult men protesting that they were robbed of an important part of their sexual anatomy, without their consent?

Are any of these considerations not relevant to the pediatrician who would strap down a helpless, screaming baby and cut off part of his penis?

I look forward to your response.


Georganne Chapin, MPhil, JD
Executive Director
Intact America

* Committee on Bioethics, Pediatrician-Family-Patient Relationship: Managing the Boundaries. Pediatrics 124(6), Dec. 1, 2009: 1685-88.

German Court: A Child’s Right to Bodily Integrity Trumps Freedom of Religion and Parents’ Rights

As I write this, I am in Rotterdam (the Netherlands), where tomorrow Marilyn Milos (from NOCIRC) and I will be attending a meeting on infant circumcision, sponsored by the Royal Dutch Medical Association (KNMG). The KNMG, as well as physician organizations from other European countries, are increasingly adopting the position that circumcising children is a bodily assault and a violation of their rights. Yesterday’s German court decision is excellent—in terms of timing and, of course, substance.

Every website that has posted the news is garnering hundreds, even thousands, of comments, this Huffington Post piece being just one example. On the pro-decision side are those who decry forced circumcision as infringing on children’s rights to bodily autonomy. Those who oppose the German court decision defend infant and child circumcision as the right of parents to practice their religion.

Georganne Chapin, Executive Director of Intact America

Georganne Chapin, Executive Director of Intact America

One of the functions of law in a civil democracy is to promulgate a uniform code of conduct. In a pluralistic society, when certain religious practices contradict or violate this code, or the rights of one individual or group interferes with or breaches the rights of another, the law (and any court that upholds it) provides guidance and—it is hoped—protects potential victims’ rights by prohibiting any such harmful practices.

There is no question that, but for the “freedom of religion” claim, holding down a baby boy and cutting off part of his penis constitutes a forcible physical and sexual assault, with visible and permanent consequences. Defending this practice by relying on a literal interpretation of a religious text ignores the fact that democratic law—while tolerating diverse beliefs—must protect those who cannot protect themselves. To label, or even suggest, that those who would protect babies from harm are anti-Semitic (or anti-Muslim) is a tactic of pure intimidation.

Another less explicitly religious—but equally problematic—defense of circumcision relies on parental intent. “We do it for the baby’s own good” (so he’ll be cleaner, so he’ll find a wife, so he won’t be laughed at, etc.).  Sorry. The fact that parents who seek to have their children circumcised may have “benign” motives is irrelevant if the custom inflicts harm on the child.

Cultures or particular groups of people who favor corporal punishment defend it as a legitimate form of shaping behavior, but the courts in countries that recognize individual rights don’t buy this rationale. Cultures too numerous to mention condone child-beating and wife-beating as a means of encouraging better behavior in the future. Individuals from those cultures can believe what they want, but if they live in the United States, they are subject to U.S. law, and will be prosecuted for child abuse or “domestic violence” if they violate the law. Professed non-malignant motives don’t justify acts deemed to harm others.

A huge exception has been the circumcision of children. In the U.S., the fact that doctors adopted the practice as a way of making money (using a series of spurious and serially discredited medical rationales) has served for too long as a cover for religious groups claiming circumcision as their right under religious freedom.

Let us hope that the advocacy of European physicians to abolish infant circumcision, and the court ruling handed down in Germany this week, will lead to a change of consciousness with regard to the rights of children among American physicians and religious groups. The law will—as always—follow suit.

Georganne Chapin

Prostate Cancer? Yet Another Bogus Justification for Circumcision

As more and more Americans realize they’ve been sold a bill of goods about circumcision, and as fewer parents are willing to allow their sons to be tied down and mutilated for a fee, physicians and others with a financial or psychological interest struggle to find new reasons for promoting the Great American Rip-Off .

This week’s example comes via an article published in the journal Cancer, which describes a “statistical sampling” study leading to the conclusion that circumcision may lead to lower prostate cancer rates. “Circumcision,” the study claims, “can hinder infection and inflammation that may lead to this malignancy.”

I could say a lot about this “study,” but in the interest of brevity and timeliness, I will limit myself to the following:

First, the authors relied on self-reporting for circumcision status, history of sexually transmitted diseases (STDs), and age at first intercourse. Self-reports about disease history and sexual behavior are inherently problematic. Self-reports about circumcision status have been shown repeatedly to have a high error rate of +/- 5 percent, or enough to nullify any statistical significance claimed in the study.

Second, the body of medical literature does not support the claim for a lower rate of STDs in circumcised men—either in the United States or abroad. In response to the new study, Medscape News (login required, free registration) interviewed independent physicians regarding the report in Cancer. Siobhan Sutcliffe, PhD, Assistant Professor of Public Health Sciences at Washington University School of Medicine, noted that results from a self-reporting, case-control study are much less reliable than those from a clinical trial. “It is too early to make recommendations about circumcision for prostate cancer prevention,” she said. “More and different types of studies need to be done before a preventive recommendation can be put forward.”  Anthony Y. Smith, MD, Professor and Chief of Urology in the Department of Surgery at the University of New Mexico Cancer Center, also noted that it is “extremely difficult to evaluate the effect of circumcision on a wider geographic scale outside of a controlled clinical trial.” As he mentions, the prevalence of prostate cancer and sexually transmitted infections is similar in the United States, where circumcision is common, to that in Western Europe, where it is not.

Finally, the authors themselves admit that the exact mechanism through which circumcision might prevent prostate cancer remains unknown. Thus, their hypothesis that the foreskin is the cancer-causing culprit requires us to accept that “germs flourishing in the moist environment under the foreskin” somehow make their way into the prostate and cause cancer. Without actual, clinical proof of this, the giddiness regarding one more justification for circumcision is inappropriate—to say the least.

The real lesson here is that current science and news publications set the bar far higher for studies showing the risks and harms of circumcision than they do for lame, unfounded claims touting the “benefits” of removing healthy body parts from babies who are many years away from being sexually active. (And, by the way, whatever happened to condoms, which protect both males and females?) For the promoters of infant circumcision, it appears to be a fact-free, evidence-free environment.

Current estimates of boys leaving the hospital intact range from 33 to 54.5 percent, up from a rate of just 10 percent in the 1960s. It is disheartening that the medical establishment promotes the bogus science, ignores the ethics, and continues to scrape the bottom of the barrel for reasons to keep cutting babies. However, parents are seeing beyond the smoke and mirrors and are getting wise to the Great American Rip-Off.

Georganne Chapin

Talking Points for Intactivists – Part Two

This is the second in a series of talking points for intactivists. As I mentioned in Part One, I know how difficult it can be to have conversations about circumcision with people who defend it – for whatever reason. People often ask me how I deal with certain questions or arguments. The purpose of these talking points is to share some helpful facts and approaches that have worked for me.

Obviously, we each need to find our own voice in talking about why we oppose circumcision. Over time, it’s important to discover what helps you connect with different audiences, and it’s always helpful to try to find some common ground. To avoid triggering immediate defensive resistance, it’s also advisable not to personalize the conversation, at least initially.

You can say, for example, “Most Americans don’t give circumcision a thought; they probably don’t realize that doctors in other countries don’t routinely cut off the ends of baby boys’ penises.” The person you’re talking with might not know this either; but now he’s learned something important, without being told he’s ignorant.

Or you can say, “Most American women have never even seen a normal penis! Isn’t that amazing?” The American woman you’re talking with won’t feel singled out; rather, she can agree with you that most American women have never seen a normal penis. And that’s a good way for her to start thinking about her own biases.

Here are my responses to some of the medical and hygiene arguments often raised to rationalize circumcision.

The circumcised penis is cleaner. If you can teach your child to brush his teeth, you can teach him to wash his genitals. Girls’ genitals have lots of folds, and – by the way – girls have smegma, too! We don’t worry about whether they can learn to keep themselves clean, let alone talk about what to cut off to make it easier for them to wash themselves.

What gives you the right to talk about circumcision? You’re not a doctor. Gee, we talk about all sorts of medical topics all the time, don’t we? Thankfully, “consumer” empowerment is actively transforming the delivery of health care all around us, and for the better. Why shouldn’t circumcision be discussed openly by everyone, especially on behalf of those who don’t have a say in the matter? Even so, and for the sake of argument, if “routine” infant circumcision were a legitimate medical procedure, used to treat a serious or complex illness, then pointing out my lack of medical credentials might be relevant. But no physician organization in the world recommends circumcision. Also, by the way, I am a lawyer and I understand bioethics. I know that cutting off part of another person’s body – a person who has not consented – is legally, morally, and ethically wrong.

Adult foreskin is 15 square inches in sizeNewborn foreskin size of one quarterIt’s just a useless little flap of skin. (Other versions of this are, “it’s just a snip,” or “it’s a skin tag,” as a radio talk-show host once said to me.) With all due respect, these statements reflect Americans’ ignorance about the normal male anatomy. Yes, an infant’s foreskin is small, about the size of a quarter (so are his fingers and toes and his heart, for that matter); but in an adult male, the foreskin comprises 15 square inches (that’s the size of a 3 x5 index card or 15 quarters) of specialized skin, loaded with nerves, blood vessels and muscle. The foreskin is an integral part of the penis. It protects the glans (head of the penis) and keeps it moist and sensitive. It also plays an important role in sexual pleasure for both its owner and his partner. By the way, women have a foreskin, too; it’s called the “preputial hood,” and some cultures that practice female genital cutting remove it. We have thoroughly outlawed this surgery on girls in the United States.

I hear circumcision prevents AIDS.  This one is complex, but it’s important not to be intimidated by this subject. Obviously, the incidences of many diseases could be lessened by proactively removing healthy organs or body parts, but we pretty much don’t do that – and certainly not to people who aren’t old enough to understand and consent. The much-touted “African studies” that showed men to be at a relatively lower risk of contracting HIV from women if the former were circumcised found NO reduction in risk for male-to-male transmission, and circumcision actually increased the risk for male-to-female transmission.

  • There is a lot of evidence that much of the HIV in sub-Saharan Africa is a result of unsafe medical practices – not sex.
  • Most Americans don’t realize that European countries, where circumcision is extremely uncommon, have rates of HIV similar to or lower than the United States where circumcision is common. There is no epidemiological correlation between circumcision rates and HIV rates within the United States, or internationally.
  • There is no evidence that United States saw any benefit from its very high rate of circumcision in mitigating HIV; American cemeteries are full of circumcised men who died from AIDS.
  • The only way to prevent sexual transmission of HIV is to use condoms or practice abstinence.

Sometimes I ask rhetorically, “You’re circumcised, right? Well, would you have unprotected sex with an HIV-positive woman, figuring that you’re protected from getting HIV?” (This one violates my rule about not getting personal, but it’s worth it.)

Have you BEEN to AFRICA? This question – usually asked loudly with a look of great significance, implies that if I had seen first-hand the misery that HIV is causing in sub-Saharan Africa, I would say “try anything and everything” to prevent AIDS.”  Instead, I usually say, “No, I haven’t been to Africa.” But … (I then go to the points on HIV immediately above).

Doesn’t circumcising men prevent cervical cancer in women?  First, keep in mind that cutting off one person’s body part to protect a hypothetical future sex partner is unethical; that’s a straightforward bioethical principle that should not be dismissed. As for the prevention claim itself, this myth arose from observations that Jewish women had lower rates of cervical cancer than some non-Jewish women. No studies were done to determine the circumcision status of Jewish women’s sex partners; it was simply assumed that they were Jewish, and thus circumcised.  However, there is no correlation between a woman’s risk of cervical cancer and her male sex partner’s circumcision status. Human papilloma virus (HPV) and smoking are the leading risk factors for cervical cancer.

What about penile cancer? Penile cancer is exceedingly rare. The rate of penile cancer in the United States, where most adult males have been circumcised, is similar to that in most European countries, where men are intact. Breast cancer is hundreds of times more common than penile cancer. What would you think about a proposal to remove the breast buds of young girls, to prevent them from developing breast cancer in the future?

What about urinary tract infections? UTIs occur in both intact and circumcised boys (and in girls, too). These can be easily treated with antibiotics, a much safer and more humane option than the permanent surgical removal of a body part.

I look forward to getting your feedback on what works for you, when promoting intactivism!

By Georganne Chapin