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Lost Boys: An Estimate of U.S. Circumcision-Related Infant Deaths

Authors:
  • Intact America

Abstract

Baby boys can and do succumb as a result of having their foreskin removed.Circumcision-related mortality rates are not known with certainty; this study estimates the scale of this problem. This study finds that more than 100 neonatal circumcision-related deaths (9.01/100,000) occur annually in the United States, about 1.3% of male neonatal deaths from all causes. Because infant circumcision is elective, all of these deaths are avoidable. This study also identifies reasons why accurate data on these deaths are not available,some of the obstacles to preventing these deaths, and some solutions to over-come them.
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Θ
Θ
aBoy’s Health Advisory.
Correspondence concerning this article should be addressed to Dan Bollinger, Boy’s Health Advisory, 1970
North River Road, West Lafayette, IN 47906. Email: danbollinger@comcast.net
THYMOS: Journal of Boyhood Studies, Vol. 4, No. 1, Spring 2010, 78-90.
© 2010 by the Men’s Studies Press, LLC. All rights reserved. http://www.mensstudies.com
thy0401.78/$14.00 • DOI: 10.3149/thy.0401.78 • ISSN/1931-9045 • eISSN/1872-4329
Short Communication Dan Bollingera
LOST BOYS : ANESTIMATE OF
U.S. CIRCUMCISION-RELATED INFANT DEATHS
Baby boys can and do succumb as a result of having their foreskin removed.
Circumcision-related mortality rates are not known with certainty; this study
estimates the scale of this problem. This study finds that approximately 117
neonatal circumcision-related deaths (9.01/100,000) occur annually in the
United States, about 1.3% of male neonatal deaths from all causes. Because
infant circumcision is elective, all of these deaths are avoidable. This study
also identifies reasons why accurate data on these deaths are not available,
some of the obstacles to preventing these deaths, and some solutions to over-
come them.
Keywords: male, infant, death, mortality, neonatal, circumcision, penis, fore-
skin, United States
“The life of man is…nasty, brutish, and short.”
—Thomas Hobbes
Circumcision is a surgical procedure performed upon newborn baby boys in the
United States once every seven seconds,1three thousand times a day, over a million
times a year. The practice is so deeply rooted in American childbirth and medical cul-
ture that the public is largely unaware of two facts: first, that infant circumcision is not
medically necessary in almost all instances, and second, that it carries serious medical
risks, including the risk of death. For some parents, circumcising their son will mean
losing their baby boy to what they have been told is a harmless procedure.
Medical associations fail to warn parents of the very real risk of death from cir-
cumcision. Neither the American Academy of Pediatrics (AAP, 1999), nor the Ameri-
can College of Obstetricians and Gynecologists (ACOG, 2001), nor the American
Medical Association (AMA, 1999) mentions death as a possible outcome of the surgery
in their policy statements on circumcision. The American Academy of Family Physi-
1Based on a workweek of five, 8-hour days.
cians (AAFP, 2002) statement says death is possible, but (according to this study’s find-
ings) significantly underreports the risk as 1/500,000.
Parenting and baby books are equally culpable in failing to mention death as a
possible, if rare, outcome of circumcision. A survey of ten popular infant-care books
found that none warn that circumcision could result in a baby’s death.2Most websites
and literature on circumcision also minimize or ignore the risk of death, and no con-
temporary study has attempted to learn the magnitude of this problem. Perhaps this is
due to the peculiar place occupied by circumcision in American medicine—an elective,
almost incidental, procedure carried out on babies, behind closed doors, and mostly by
residents and obstetricians rather than by the baby’s own doctor (Stang & Snellman,
1998).
This study reviews the few sources that have reported on deaths occurring as a re-
sult of circumcision and attempts to provide a rough estimate for neonatal (first 28 days
after birth) circumcision-related mortality in the United States. Since infant circumci-
sion is elective, this study will consider all circumcision sequelae, not just the proce-
dure itself. Its goal is to promote discussion, encourage solutions, and—most
importantly—save children’s lives.
Background
About 1.3 million boys are circumcised each year in the United States (HCUP,
2007); however, the number of boys who died from those surgeries has not been re-
ported or estimated in any credible way. Some reasons include record-keeping practices,
indifference, and—no doubt—concerns about liability.
Death certificates typically do not list circumcision as the immediate or leading
cause of death and rarely list circumcision as an underlying cause. Incomplete and in-
accurate death certificates for children are a common phenomenon (Cunniff, Carmack,
Kirby, & Fiser, 1995). Thus, many circumcision-related deaths are more often reported
as surgical mishap, infection, hemorrhage, cardiac arrest, stroke, reaction to anesthe-
sia, or even parental neglect.
In recent years, U.S. infant deaths have been infrequently reported in the media
(Rachter, 1982; The State, 1992; Miami Herald, 1993; Lum & Sorelle, 1995; News-
Net5, 1998; Proctor, 2002; Cohen, 2005; Verges, 2009). Reports of circumcision-related
deaths have sporadically appeared in the medical literature beginning in the early 1900s
(Holt, 1913; Reuben, 1916; Sauer, 1943; Scurlock & Pemberton, 1977; Gellis, 1978;
Baker, 1979; Hiss, Horowitz, & Kahana, 2000). In Africa, dozens of deaths from cir-
cumcision initiation rites are reported every year, but, as in America, are often treated
with indifference (Ncayiyana, 2003).
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U.S. CIRCUMCISION-RELATED INFANT DEATHS
2Survey by author of the ten highest ranked books listed on Amazon.com, November 10,
2008.
Lost Boys
Boys have been lost to circumcision in the United States from the time it was first
practiced to the present day, for a variety of reasons, as the following examples illus-
trate. The first known reported circumcision-related deaths were in New York City,
where circumcision was introduced. The first was Julius Katzenstein in 1856 (New
York Times) and the second was one-week-old Myer Jacob Levy in 1858 (New York
Times). Both boys were circumcised by a Dr. Abrahams, and the same coroner re-
viewed both deaths. The coroner found that Abrahams had performed the surgeries
properly, and that the boys died from blood loss as a result of parental neglect. Neither
boy had received a follow-up examination.
Allen Ervin, born 1985, was in a coma for more than six years before he died. He
had been on life support after his brain was damaged from oxygen deprivation during
his circumcision (The State, 1992).
Demetrius Manker was born in 1993 and died soon thereafter from blood loss. The
coroner’s examination found a large, gaping wound on the underside of the boy’s penis
extending almost to the scrotum. The coroner listed cause of death as blood loss due to
penile circumcision (Welti, 1993); however, there is no mention of further action being
taken.
A West Virginia child, whose name was withheld, was born in 1996 without inci-
dence and circumcised prior to hospital release. A few days later, the parents rushed him
to the emergency room because he was having seizures and his penis had turned green
in color. He died the next day from septicemia (Ballad, 1997).
Death sometimes occurs following repair of a circumcision complication. Dustin
Evans, Jr., was circumcised soon after being born in 1998. The surgeon took so much
shaft skin that the scar healed as a tight “collar” around his penis, preventing him from
urinating. When he was later given an anesthetic in order to repair the damage, he im-
mediately died of cardiopulmonary arrest (Giannetti, 2000). His father lamented, “You
think, ‘What could go wrong with a circumcision?’ The next thing I know, he’s dead.”
In a 2004 Vancouver, Canada, incident, one-month-old Ryleigh McWillis was sent
home from the hospital immediately following his circumcision. He later bled to death,
his disposable diapers absorbing the small amount of blood from his circumcision
wound necessary to send him into hypovolemic shock (Newell, 2004).
Because the penis is highly vascularized, blood-loss is a risk even for boys cir-
cumcised past the neonatal period. In 2008, 6-week-old Native American Eric Keefe
died from massive blood loss. Hospital officials claimed his circumcision was not to
blame, but instead faulted the parents because they had administered over-the-counter
pain medication that, they also claimed, thinned his blood. The parents were not told
about this possible complication (Verges, 2009). Since then the hospital has stopped per-
forming infant circumcisions.3
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BOLLINGER
3Personal communication with author at the 2009 AAP national conference, Washington,
DC.
Nor are ritual circumcisions without risk, either. In 2004, an infant twin born to
Jewish parents was circumcised by a mohel, a ritual circumciser who was infected with
Herpes simplex virus 1. He practiced the orthodox version of circumcision called met-
zitzah b’peh (in which the circumciser sucks blood from the wound with his mouth),
thereby transmitting herpes to the boy via his saliva. The baby boy died a few days
later (Cohen, 2005).
Previous Death Estimates
The widely varying results from the handful of researchers that have attempted to
estimate circumcision-related deaths can be explained by their choice of survey crite-
ria. A study by Dr. Douglas Gairdner in 1949 included deaths due both to surgery and
to ensuing complications. He reviewed case histories of 90,000 circumcisions for boys
under five years old from 1942 to 1947 in England and Wales, identifying 95 deaths at-
tributable to circumcision. Of these, he found 16 deaths per 100,000 annually for boys
less than one year old, including postoperative, postrelease deaths. Some of these were
due to reactions to anesthesia; Gairdner nevertheless classified these as circumcision-
related since the boy would not have been administered anesthesia except for circum-
cision. This was considered a definitive study in the United Kingdom, and led the
British government to deem infant circumcision an unnecessary and nonreimbursable
medical procedure. When extrapolated to the present-day United States, Gairdner’s
findings represent an estimated 230 deaths annually. Children’s-rights activists in the
United States often claim this death toll (Baker, 1979), rather than underreport the risk
using lower estimates, in an attempt to portray the gravity of the problem. However, this
rate is misleading because it does not allow for improvements in healthcare from post-
war, pre-penicillin Britain to the present day United States. Thus, this figure is likely
overstated. The question is, How much is it overstated?
In a 1953 letter to the editor of Obstetrics and Gynecology, Dr. H. Speert states that
of 566,483 circumcisions performed between 1939 and 1951, there was one operative
death. Applied to the present U.S. incidence that would equal 2.4 operative deaths per
year. Circumcisionists cite this ratio in order to minimize the death risk. But this esti-
mate reports only those who died on the operating table—it ignores the much larger
number of postoperative deaths both inside and outside the hospital.
Inexplicably, no deaths at all were reported from any cause in a population of
100,157 circumcised, neonatal boys in a survey of U.S. Army hospital records (Wiswell
& Geschke, 1989). However, the national male neonatal death rate from just two
causes—hemorrhage and sepsis—is 30.2 per 100,000 (NCHS, 2004), leaving us unsure
what to make of this discrepancy.
Hospital discharge records reveal that, during the 1991–2000 decade, on average
35.9 boys died from all causes each year during their stay (average 2.4 days) in the
hospital in which both their birth and circumcision occurred (Thompson Reuters, 2004).
These were among the average of 1,243,392 boys circumcised annually during the
same period, but this number is limited to deaths inside the hospital, some of which are
undoubtedly due to circumcision.
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U.S. CIRCUMCISION-RELATED INFANT DEATHS
Complications from circumcision are as high as 55%, according to Patel’s (1966)
circumcised-infant cohort study, which reviewed case histories, examined infants in
the home, and questioned parents on outcomes, making it the most thorough circum-
cision-complication study performed to date. Eight percent of boys in the cohort be-
came infected after being circumcised, and they were 700% more likely to have become
infected after hospital release than before. Bacterial sepsis and hemorrhage are both
frequent fatal complications of circumcision, and circumcised boys are at a higher risk
for streptococcus infection (Cleary & Kohl, 1979). Gairdner reported that one in fifty
circumcised boys returned to the hospital for treatment of excessive bleeding, some re-
quiring transfusions.
Infection has become even more of a factor recently with the epidemic of methi-
cillin-resistant Staphylococcus aureus (MRSA) now under way in the United States.
The medical literature is replete with reports of MRSA infections occurring first in hos-
pitals and now in the community (Rabin, 2003; Klevens et al., 2007). Circumcised boys
are at a higher risk for this “superbug” than intact (not circumcised) boys (Enzenauer
et al., 1985), most likely because of the open circumcision wound. A 2003 outbreak of
MRSA in a Long Island, New York, hospital maternity ward resulted in three new-
borns’ being infected: all were boys; all had been circumcised (Rabin). Circumcision
is a double whammy when it comes to MRSA: the American Medical Association iden-
tified both surgery and young age as risk factors (Zeller, 2007). The mortality rate for
neonates once subcutaneous tissue becomes infected is more than 70% (Sawin,
Schaller, Tapper, Morgan, & Cahill,1994). The risk from MRSA alone would seem to
dictate ceasing the practice of unnecessary surgery such as infant circumcision.
Mortality Estimation
Though the data previously cited are insufficient to establish a definitive death rate
on their own, there is enough available information to calculate an estimate. Not all of
the reported 35.9 deaths out of 1,243,392 circumcisions can be attributed to related
causes. What portion, then, is circumcision-related and how may we extrapolate to the
number of deaths after hospital release? What we can safely assume is that it is un-
likely that any of these infants would have been subjected to the unnecessary trauma
of circumcision if they had been in critical condition, or that they would have been cir-
cumcised after their death.
Gender-ratio data can help extrapolate a figure. Males have a 40.4% higher death
rate than females from causes that are associated with male circumcision complica-
tions, such as infection and hemorrhage,4during the period of one hour after birth to
hospital release (day 2.4), the time frame in which circumcisions are typically per-
formed (CDC, 2004). Assuming that the 59.6% portion is unrelated to gender, we can
estimate that 40.4% of the 35.9 deaths were circumcision-related. This calculates to
14.5 deaths prior to hospital release.
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BOLLINGER
4Selected from ICD-10 codes P21.9-22.9, 29.0-29.1, 29.8-29.9, 36.0-36.9, 37.5, 39.8-38.9,
50.9, 52.3, 54.3, 54.8-54.9, 55.9, 96.8-96.9
But as is often the case with hemorrhage and infection, some circumcision-related
deaths occur days, even weeks, after hospital release. The CDC’s online searchable
database, Mortality: Underlying cause of death, 2004 (CDC), lists causes by various
age ranges and reveals that the percentage of deaths after release, compared with deaths
before, is 772% greater. This ratio is comparable to Patel’s (1966) 700% postrelease in-
fection rate.
Multiplying the 772% adjustment factor for age-at-time-of-death by the 14.5 hos-
pital-stay deaths calculated above, the result is approximately 112 circumcision-related
deaths annually for the 1991–2000 decade, a 9.01/100,000 death-incidence ratio. Ap-
plying this ratio to the 1,299,000 circumcisions performed in 2007, the most recent
year for which data are available (HCUP, 2007), the number of deaths is about 117.
This is equivalent to one death for every 11,105 cases, which is not in substantial con-
flict with Patel’s observation of zero deaths in 6,753 procedures. It is more than some
other estimates (Speert, 1953; Wiswell, 1989), but less than the overstated 230 figure
derived from Gairdner (1949). Breaking this statistic down further, about 40% of these
deaths (47) would have been from hemorrhage, and the remainder (70) from sepsis,
using a hemorrhage-to-sepsis ratio for infant mortality (NCHS, 2004).
In summary: through a thorough review of the literature and the application of
common-sense calculations, this study has arrived at a reasoned estimate of circumci-
sion-related neonatal deaths in the United States: approximately 117 per year.
Ulterior Motives
Many factors combine to explain the lack of reliable mortality data or why this
problem has not received more attention. To ignore or hide the likely cause of so many
infant deaths for so many years requires a significant amount of denial or obfusca-
tion—by: parents, physicians, hospital staff, insurers, medical associations, and legis-
lators. The silence of human-rights, men’s-rights, women’s-rights, and children’s-rights
groups concerning these deaths is shocking. It might indicate that they are unaware of
the problem, or that they wish to appear politically correct in regard to religious cir-
cumcisions, even though more than 96.5% of those performed are not for religious rea-
sons (US Census Bureau, 2008).5The explanation for such lack of concern and
discussion is unknown, but one fundamental reason has to be a lack of information dis-
seminated among people who can correct the situation.
Not only will parents of a dead boy be in shock, but also potentially embarrassed,
by what seems now to have been a whimsical choice for their infant. Their under-
standable reaction is to withdraw into protective silence or to defend their choice de-
spite their loss. They might insist, as parents of one deceased child did recently, that they
would “make the same choice with their next boy” (Fournier, 2004). Parents are some-
times irrational concerning circumcision. Many quickly sign the consent form without
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U.S. CIRCUMCISION-RELATED INFANT DEATHS
5If all Jews, Muslims, and Coptic Christians in the United States circumcise.
first learning more about the physical, psychological, and sexual consequences of cir-
cumcision. Some sign because they take their physician’s mention of the topic as a rec-
ommendation, or because they feel coerced by repeated inquires. Others sign because
they fear being regarded bad parents, rather than considering what is in the best inter-
ests of their son. For instance, nine out of ten parents who chose circumcision did so
knowing full well that the procedure was excruciatingly painful for their newborn boy
(Ahaghotu, Okafor, Igiehon, & Gray, 2009).
To hospital residents, the birth of a boy is celebrated as an opportunity to practice
surgery. A resident’s first surgery upon a live human being does not always go as
planned—especially when the patient is not a sedated, consenting adult, but a scream-
ing, thrashing baby. The resident’s mentor is likely to provide cover for any errors, lest
they reflect poorly on him or her and their institution. Busy residents often have a quota
of interventions to meet in order to qualify in their specialty, which means that they have
a conflict of interest, potentially an unethical stake, in performing the procedure. Thus,
most adult American males can be seen as having been child medical-training draftees,
now sporting a “scalpel practice” penis, carved on by a twenty-something-year-old un-
dertaking his or her first surgery.
The relative simplicity of circumcision means that a charge that it was done poorly
is a glaring indictment of the clinician. The notion that a child died as a result is, of
course, even more embarrassing to them and would call forth some sort of preemptive
defense. This often takes the form of blaming the parents for inadequate postoperative
care, or insisting that it was the child’s fault for being too feeble to withstand the pro-
cedure, turning the medical phrase “failure to thrive” into a euphemism for these ia-
trogenic deaths.
Because of the inadequacies of the death-certificate system and the apparent lack
of investigation, it is easy to see how the medical system could either unwittingly or in-
tentionally obscure the true cause of these deaths. American courts aid the medical in-
stitution by sometimes ruling that the parents signed the circumcision consent form, and
that the parents took their chances even if they were not informed of such a possible out-
come. Thus, medical practitioners have a tactical choice. They can list on a lengthy
consent form every conceivable risk of circumcision, including death, which might un-
dersell the procedure, or, calculating that the danger of failure and detection is low,
soft-pedal the risks in hopes that parents will sign anyway.
Few death cases are ever litigated in court because hospitals recognize that their
defenses are few and expensive to plead, and that the publicity would prove harmful.
Such cases usually result in an offer to the parents of a private, sealed settlement. Sadly,
the death of a child is considered less of a liability than an injury case, and therefore
compensation for a dead infant is rarely substantial. On the other hand, severe injury
cases—loss of all or part of the glans, or, even worse, the entire penis—are intensely
litigated and may produce substantial monetary damages in the millions of dollars. The
crass logic of the law is that the injured male will have to bear his injury for a lifetime,
whereas the dead infant barely sensed his own existence, and so would not even sense
the loss of himself. Invariably such settlements include a confidentiality clause, in-
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BOLLINGER
tended, of course, to protect the reputation of both the individual medical practitioner
and the institution.
Following a death, the coroner or the medical examiner, who is usually a physician,
will rule whether the death was from suspicious causes. In the United States, that coro-
ner (who, if male, is probably circumcised) is not likely to face squarely and on the
record the fact that his or her colleague performed an unnecessary and nontherapeutic
surgery that resulted in the death of an infant. This malfeasance could itself be cause
for an investigation, could have serious repercussions for the circumcising physician
and institution, and therefore seems an unlikely move for coroners, especially if they
are elected officials.
Primary and secondary causes of death are all too easy to conceal because of the
lack of healthcare oversight. There is remarkably little regulation of medical practice
by the Federal government, and little coordination among states to regulate medical
procedures. Ironically, circumcision devices (e.g., restraints and clamps) are more
closely scrutinized than their application.
The American Academy of Pediatrics (AAP) was found to be partially liable in
the death of Dustin Evans, Jr., according to the Iowa Law Review (Giannetti, 2000). It
reached the conclusion that his death was attributable to his circumcision, and that the
AAP should either have labeled circumcision as experimental or proved its worth
through exhaustive scientific testing. Yet the AAP has continued over the past four
decades to issue a string of policy statements regarding circumcision, each one carefully
worded so as to increasingly shift liability from its membership to parents, thereby pro-
tecting their members’ lucrative income stream.
Physicians are less likely to circumcise their sons than the general populace (Topp,
1978), suggesting that they know it is an unnecessary surgery, but don’t relay this valu-
able information to parents. Many physicians say that they prefer not to perform cir-
cumcisions, but do them anyway, rationalizing that the boy will be in better hands with
them than with a physician they might refer the parents to. This may seem a noble po-
sition at first, but there can be no pretending to be a conscientious objector to circum-
cision while simultaneously performing one.
Circumcision is a $2 billion healthcare market, which includes costs for the pro-
cedure itself, dealing with complications, and payment for repairs (Fauntleroy, 2001).
A study of Medicaid records found that a greater number of circumcisions are per-
formed in states where Medicaid pays more for the procedure (Craig & Bollinger,
2006). A busy delivery-room obstetrician will do as many as five circumcisions a week.
Physician reimbursement is at about $167 each6(Van Howe, 2004), which means that
they can potentially make an extra $3,340 per month, or $40,080 per year. That is more
than an entire year’s income for 45% of Americans (US Census Bureau, 2005). One
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U.S. CIRCUMCISION-RELATED INFANT DEATHS
6Adjusted for medical inflation to year 2010, does not include hospital’s portion of $136,
or what they obtain from foreskin sales to laboratories and cosmetic companies.
physician brazenly admitted, “I love doing circumcisions—they make my Mercedes
payments!”7
At the very heart of this problem is a lack of honesty about an entrenched med-
icalized ritual. Circumcisers are quick to sidestep ethics and put their real patient—the
baby boy—at risk. But they are not likely to speak out, simply because calling atten-
tion to their unethical actions would likely jeopardize them or their peers, reduce their
income, and, possibly, have dangerous legal consequences.
Implications
Risk assessment for an unnecessary surgery must be held to a higher standard than
that for a life-saving surgery. We accept that a heart transplant carries with it a sub-
stantial risk of death, but without it there is a certainty of death. On the other hand, the
risk from circumcision, which has no therapeutic value, needs to be zero for the in-
fant’s sake, all the more so because he is never consulted about whether he wishes to
take his chances.
We hear very little in the media about circumcision-related deaths compared with
other causes. For instance, compare the 117 annual deaths from circumcision with those
from other causes for male infants: suffocation (44), mother’s use of addictive drugs
(27), HIV/AIDS (19), homicide (17), automobile accidents (8), drowning (2), and falls
(1) (CDC, 2004). Sudden infant-death syndrome (SIDS) killed 1,216 boys under the age
of one year in 2004; of those, 115 were under the age of 1 month (CDC), which is the
same risk as from circumcision. Approximately 36 teen-aged boys are killed in school-
yard shootings each year (Donohue, Schiraldi, & Ziedenberg, 1998). But there is more
publicity for the SIDS deaths and shootings than for the circumcision-related deaths.
Is male circumcision so ingrained in American masculinity that we are hardened
to its consequences? Have we inherited the recurring theme in religion and mythology
of offering our sons to the gods? Or do we stoically value it as a painful male initiation
rite, requiring sacrifice of blood and a body part (Zoske, 1990)—and therefore believed
to be worth the occasional death-cost?
If a similar number of children were dying from another optional body modifica-
tion—say, tattooing or piercing—would the public be outraged at the people and insti-
tutions benefiting financially? If not, is it then due to gender bias? Imagine the uproar
if a hundred girls were dying from female circumcision each year. Why are so many
adults silent about this atrocity? Adults would be furious and highly vocal, to say the
least, if someone were to forcibly cut their genitals.
Solutions
The problem is this: circumcision is a killer of baby boys. No one, except for some
human-rights activists, is trying to save them. It is unlikely that improving circumci-
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BOLLINGER
7Personal communication at the 2003 AAP national conference, New Orleans, Louisiana.
sion techniques would eliminate these deaths. No matter how skilled the physician is,
some deaths will always occur.
Improving the process of securing informed consent from parents by listing death
as a possible outcome would, at first, seem to be a logical solution, but it would fail to
save lives for two reasons. First, even well-informed parents will sometimes insist on
circumcision (Binner, Mastrobattista, Day, Swaim, & Monga, 2002). Second, health-
care providers cannot be trusted to provide truthful disclosure of the risks involved.
The fact that physicians and nurses are already willing to perform well over a million
of these unnecessary surgeries a year is proof they are generally untrustworthy.
The overwhelming majority of infant circumcisions are nontherapeutic and there-
fore unnecessary; the simple solution is eliminating them. To start with, physicians and
nurses should be prohibited from initiating a discussion with, or soliciting circumcision
from, expectant parents. Circumcision should also be defunded, following the exam-
ples set by the sixteen states that have already eliminated Medicaid coverage.
Physicians regularly give parents information favoring circumcision, but rarely
provide instructions on how to care for the intact penis. Furnishing parents with this
knowledge would alleviate their anxiety concerning a body part unfamiliar to them
(Bollinger, 2008). All medical textbooks and parenting guides should include intact-care
information and mention death as a possible outcome.
Physicians who perform unnecessary surgeries that result in death must be held ac-
countable for their actions in criminal and civil court. Professional associations that
protect their members rather than their patients should be forced to change their poli-
cies. Physicians must talk with their peers about ceasing circumcision, or at the very
least become conscientious objectors. Legislation to protect boys must be passed, be-
ginning with demanding that Congress rewrite the 1996 Federal law prohibiting fe-
male circumcision to make it gender-neutral. A nationwide system that reports all infant
deaths with all contributing factors rigorously listed must be established.
Few human emotions compare with the profound grief that results from the loss of
a newborn child. Adding guilt to that grief—from the realization that you requested
the optional surgery that caused his death—is beyond imagination. Most parents would
likely refrain from talking about it publicly. People affected by a circumcision-related
death must speak up. Parents must be encouraged to talk about why they chose cir-
cumcision, what happened to their son, what they are feeling, what they would advise
other parents to do, and whether they would choose circumcision again. Family mem-
bers and friends must also be involved in the discussion.
Conclusion
It is reasonable to conclude that about 117 circumcision-related deaths occur each
year in the United States—approximately 1 out of every 77 male neonatal deaths—and
that thousands of boys have died since this practice was first medicalized 160 years
ago. These boys died because physicians have been either complicit or duplicitous, and
because parents ignorantly said “Yes,” or lacked the courage to say “No.” Every one
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U.S. CIRCUMCISION-RELATED INFANT DEATHS
of these boys would have had a chance at life had he not been circumcised. Circumci-
sion can no longer be called either a beneficial surgery or a beneficent rite of passage,
but by its true designation: an unrecognized sacrifice of innocents.
References
AAFP Commission on Science. (2002). Position paper on neonatal circumcision. American
Academy of Family Physicians.
AAP, American Academy of Pediatrics Task Force on Circumcision. (1999). Circumcision pol-
icy statement. Pediatrics, 103(3), 686-693.
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... In the West, it would generally be adolescence, precisely because of the characteristics of the relationship between victim and aggressor, which in the case of children may be oriented by other power dynamics and would therefore need separate analysis. This, at least hypothetically, excludes deaths from infibulations from the count of femicides, given the difficulty in establishing a prevalence of female victims regarding these practices: the estimates regarding child victims of male circumcision (Bollinger, 2010), in fact, show a problematic picture also for males. Despite this, if infibulation were found to be much more practised in some countries than male circumcision, there would be nothing to prevent female victims of this practice from being included among the femicides. ...
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Despite the widespread use of the term “femicide”, there are no agreed guidelines to define the phenomenon. This has led to frequent statistical contradictions. In recent years, two main approaches have emerged: the broad-range one, in which victims are often defined by the mere fact that the murderer was male, while motives are only auxiliary; in the second, instead, gender motives play the main role, following middle-range theory perspective. The aim will be to provide a new set of indicators to identify victims of femicide more precisely, distinguishing them from other female murders. The use of precise indicators is not limited to the classification of victims, as it can also enable more appropriate prevention programmes and more respectful communication.
... According to Bollinger, the actual number is higher than stated and the amount in 2010 could have been 47. [20,21] The relationship between diapers and bleeding is not mentioned in the American Academy of Paediatrics and European Urology Association guidelines. [22][23][24] Newborns' blood volumes are the reason they are more susceptible to the consequences of bleeding. ...
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Background: The most common complication of circumcision is bleeding. Monitoring bleeding by visual assessment of the diaper can cause errors due to the high absorbency of diapers. The patient may have had significant problems before the visible changes. The amount of liquid that wets the cloth does not necessarily lead to a visual change consistent with the amount, and the nature of the liquid contaminating the diaper may cause difficulties in terms of visual evaluation. Making a decision based on the visual changes in the patient's diaper cannot be considered as reliable. Methods: We planned to evaluate the visual changes that are caused by liquids of various volumes and contents that wet the diaper, according to measurable criteria. We aimed to emphasise the importance of the subject in circumcision practices of diapered children. Wetting of diapers with different volumes and variable blood load was performed utilising blood with different haematocrits and fluids. One hundred and sixty different diapers in four groups were moistened utilising the drip method. Visual changes in the soaked diapers were evaluated with the colorimetric method and five different colour criteria. The saturation and lightness values, which indicate the colour value, were obtained by using the numerical equivalents of the three main components, red, green and blue. Analysis was carried out by subjecting statistical evaluation within and between groups. Results: There was a significant difference between the control group and the study group. It was observed that visual changes caused by the moistened cloths with linear increase did not make the same linear interaction. There was not a significant difference between Group II and Group IV, which were soaked with the same amount of blood and different volume of fluid. In Group III, colour saturation changes were found to have a parabolic effect instead of a linear change. In two different analyses of moistened diapers in terms of volume and blood load; it was not determined that the expected linear changes between the groups were not observed. Conclusion: Visual changes in diapers related to volume or blood load effects of fluids may not be compatible with the amount of bleeding. Mistakes may occur when super absorbent wipes are used when determining the amount of bleeding from the use of colour changes in the diaper. Visual changes should not be relied on in bleeding due to circumcision. Rather, vital signs follow-up and measurable laboratory tests should be used as a basis.
... One study from Iran did not report any circumcision related death [34]. Bollinger et al reported 9 deaths per 100, 000 circumcisions performed in United States of America [35]. Mortality following newborn circumcision was more likely to be associated with co-morbidities such as cardiac disease, coagulopathy or pulmonary disorders [36]. ...
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Background: Circumcision is the oldest surgical procedure in history and is a frequently performed procedure in neonates. The aim of this study was to evaluate the profile of complications seen in neonates following circumcision. Materials and Methods: This was a retrospective study of neonate (aged 28 days and below) who developed complications arising from circumcision. The following information was evaluated: age, weight and height of the neonate, presence/absence of congenital anomalies, indications and contraindications for the circumcision, method and complications of circumcision, and outcome of treatment. Results: A total of 3640 circumcisions were performed during the study period but 182 patients developed complications. This gave a complication rate of 5%. Cultural reason was the most common indication for circumcision and about 10% of the neonates were noticed to have congenital anomalies. Majority of the circumcisions were performed by nurses and plastibell method of circumcision was the predominant modality. Urethrocutaneous fistula was the most common complication arising from the circumcision but there was no mortality. Conclusion: Neonatal circumcision is a frequently performed procedure in infants. As much as 5% of the neonates developed complications following circumcision. Most of the circumcisions were performed by nurses and cultural reasons were the most common indication for circumcision. Urethrocutaneous fistula was the most common complication recorded and better training is recommended for nurses to minimize these complications.
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Background: Evaluation of circumcision bleeding cannot depend on the visual change in the diaper. Diapers have different product features and absorbency capacities. The apparent changes in the diapers may vary according to their absorbent capacity and may not be in parallel with the amount of bleeding. Before significant visual difference occurs, the patient's hemodynamics may be impaired. Aim: Aim of the study is to evaluate better circumcision bleeding. Patients and methods: Patients were divided into groups according to 12 different brand diapers of the same size, containing super-absorbent material. The study started by 15/01/2022, and finished by end of 01/03/2022. Diapers with concealed brands were soaked with blood with equal hematocrit value in 100 ml with increments of 5 ml. 252 images were obtained by taking 21 images of each diaper with the same method. The diapers were evaluated colorimetrically, and numerical values were obtained showing the color differences in red, green, and blue and saturation and lightness. Working groups were formed according to 12 different brands of diapers of the same size, containing super-absorbent material. Standard statistical tests were performed using obtained values. Result: : Dry diapers had different weights, volumes, and specific gravities; the diapers with the lowest unit weight were ranked ninth in terms of volume; the diapers with the highest specific gravity were ranked third in terms of thinness. There were significant differences in the blood on the diaper, and significant differences between some groups (p < 0.005); on the other hand, there was not any difference between some other groups (p > 0.05). There was a significant relationship in terms of Analysis of Variance (ANOVA) (P < 0.05 and P < 0.01). Visual graphic examination showed that linear but non-parallel color changes occurred. As the blood load increased, the visual and statistical differences between the diapers became more pronounced, and the curves diverged. Conclusion: Visual evaluation of the color change of the diapers may not give accurate results for bleeding follow-up. If necessary to use diapers after circumcision, it is more appropriate to prefer those with low absorbency capacity. Using fabric or cotton products in cases with bleeding risk may be recommended. If bleeding is suspected, hemogram control is the most appropriate option. Diaper manufacturers should warn consumers of the risk. In conclusion, we should be on the safe side for mortality and morbidity.
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The United States Medicaid Program funds over one-fourth of the 1.2 million unnecessary infant circumcisions performed each year at a cost exceeding $145 million, including doctor's fee, circumcision repair, and extended hospital stay. Additional lifetime costs bring the annual total to $443 million, about $11.6 million per state. The incidence of infant circumcision has been steadily declining over the past twenty-five years, from a time where almost all boys were circumcised to the present day, when about half are. During that same time period, costs have risen dramatically. With the exception of the United States, those few countries that adopted mass circumcision have already abandoned the practice. Medicaid budget shortfalls demand that only medically valid procedures be funded, and funding for cultural and cosmetic niceties be cut. Sixteen states do not fund infant circumcision, more are discussing defunding, and many private insurers do not cover infant circumcision.
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The practice of routine medical circumcision of newborn male infants remains the norm in the United States, occurring to more than one million baby boys annually. This article examines the history and continuing debate surrounding this surgery, and places it within the context of gender identity. The rise of the activist anti-circumcision movement is described, as medical, moral, psychological, and legal issues surrounding this controversy are identified. The continuing practice of male circumcision is framed as an abusive wounding of males, which holds lifelong implications. A differentiation is made between the conventional medical amputation of the foreskin, from that which is solely ritual, religious-based. Further, a societal double standard is noted between the moral outcry against female circumcision and the relative silence toward male circumcision.
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Tuberculosis by direct wound inoculation while not a frequent method of contracting the disease has yet occurred often enough to demonstrate the fact that this is a real danger. In 1887 Willy Meyer collected reports of a number of such instances and added a report of a case of his own of tuberculosis acquired through ritual circumcision. Since that time many additional observations on this subject have been published but only two, so far as I am aware—one by Ware and one by Sara Welt-Kakels—in this country. From inquiries, however, I am led to the opinion that many cases occur which do not find their way into print.REPORT OF CASE The report herewith presented is of more than ordinary interest by reason of the virulence of the infection as shown by the wide-spread lesions and the fact that the death occurred at an earlier age than in any case
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The most recent policy statement by the American Academy of Pediatrics suggests there are insufficient data to recommend routine newborn circumcision. Nevertheless, circumcision rates have not declined in the United States. Some studies suggest that African Americans are less likely to be circumcised. In blacks that choose to circumcise their males, we sought to examine the factors that drive parents to favor circumcision. The Parental Attitudes on Circumcision questionnaire was utilized to obtain demographic information and attitudinal responses to circumcision during urology clinic sessions at Howard University Hospital, a major teaching hospital located in an urban setting. Parents and caregivers of male children aged 3 months to 7 years participated. Valid responses from 146 participants were collected. Ninety-six percent of our respondents believe that circumcision is healthy. Forty-one percent indicated health reasons as the most important influencing factor for choosing to circumcise their child, while 25% selected maternal preference. Eighty-one percent of all respondents indicated that 1 or more health care providers asked about their decision to circumcise their child. The mother was 12 times more likely than the father to make the final decision for circumcision, especially when her personal preference played a role. Eighty-eight percent of respondents felt that circumcision is painful, but 87% considered the procedure safe, and another 72% believe that it is a necessary procedure. African American parents strongly believe that circumcision is essential for a healthy state and are willing to opt for the procedure despite the belief that it may be painful for the child. The mother primarily made the final decision to circumcise her child, largely based on the perceived health and hygiene benefits. In blacks, the mother yields considerable influence in the decision to circumcise the child, with maternal preference as the main reason for seeking circumcision in as much as a quarter of cases.
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This paper presents four cases of fulminating neonatal sepsis with meningitis. In each infant, there was evidence of an infected circumcision wound. Two infants had Escherichia coli and two had Group B haemolytic streptococcus cultured from the cerebrospinal fluid. One infant died. The risk of introducing infection through iatrogenic portals of entry is a definite problem in the neonate. Circumcision is an unnecessary routine procedure, which puts the infant at risk.