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I am Ryan, a friend of Lizzie's.

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I do bio-physics research
at Georgetown University,

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and I also coordinate two non-profits
that deal mostly with supporting families

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and supporting people in their relationships.

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Here is my family.

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So my mission in life basically 
is to help people get along,

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and towards that end,
I do a lot of workshops with families

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and I also help families
understand medical questions.

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So I am here to talk with you about circumcision,

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I am calling it an "Elephant in the Hospital"

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because it is this huge thing that happens
as far as I see in our culture

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but we have very little discourse about it.

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It is performed between 500,000 and 1,000,000
million times each year in the U.S.,

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almost entirely on infants within
the first three days of life

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and it is completely unnecessary;
and I believe, based on my research,

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entirely harmful to children.

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So what we are going to run through,
as quickly as I can,

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is just a discussion what that process is like
from the child's point of view,

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what effects it has on adult survivors,

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how we get parents to agree to it
(what understanding parents have),

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and how we get practitioners to perform it.

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So before we do that, I actually just want
to get a chance to see what our room is like

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so we can see each other; therefore, I will ask a few questions
and we're gonna use this technology for room assessment

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that goes back to a before clickers.
I am going to ask you, if you are willing,

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to point in the direction as I ask you about each thing,

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from beneficial, this wall is the beneficial wall,

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neutral is the ceiling,
and harmful is the wall over there.

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For Example, what do you think of foot binding?

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I mean you are anthropologists,
most of you have heard of foot binding.

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Where do you think it goes on the ...

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okay we have everyone who chose to respond,
thinks it is harmful.

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Good I am pleased with that response.

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Female Genital Cutting

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how many people have heard of that?

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Okay great, we have got universally harmful.

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Okay what about say we were going
to do prophylactic breast bud removal,

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say we wanted to stop breast cancer

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and save hundreds of thousands of women's lives per year,

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and say we just cut all babies' breast buds off?

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Beneficial? Harmful? Neutral?

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Okay some neutral and some harmful.

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Okay.

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And what about cutting off non-essential tissue from a child,

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say we just cut off all children's ear lobes

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because we thought they were an inconvenience,
a pain or they looked ugly?

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Okay, we have got harmful.

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So what about Circumcision?

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What is our starting point?

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We have got every response,

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that's great; okay, so we have a diverse audience.

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Now a couple of other questions

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just to see who we are.

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Who here thinks that they have a foreskin,

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anyone?

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Who here believes that they have a foreskin,

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which is that part they remove during circumcision, right?

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Okay, so that is a trick question.

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Men and women, males and females, are both born with foreskins,

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the foreskin is just a name for a part of the clitoris or penis,

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and so probably most of the women here have one

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and perhaps some of the males also.

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Who here comes from a culture where

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female genital cutting is a social norm?

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No one, okay.

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Who here comes from a culture where

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male genital cutting is a social norm?

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Okay, all of us pretty much, that I can see, okay.

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And who knows someone who was genitally altered as a child

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it could be you, it could be a friend it could be your parents, or child?

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Mostly (all)!

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Great, so all of that is just to illustrate how it's something that has
touched all of our lives in some way.

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So I am arguing that it is this big thing and that we don't talk about it a lot.

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So I have to sort of explain why I think that.

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So I believe that the discourse that we have in our culture about circumcision

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is one that is used to conceal what the nature of the process is.

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So you may have heard things like "well, you know,
it makes the penis cleaner" and things like that.

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You may have heard things like "everyone does it," "I am circumcised, I am fine,"

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"It is just a little snip" or "it removes a useless flap of skin,"

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this sort of trivializing language.

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Well, we have heard all of these things.

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What I am going to ask you to do is set all that aside,

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all of that mass of experience in your mind,

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and to try to come at it from a fresh angle where

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these sort of illogical arguments of support for it are not part of your way of thinking.

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I am going to propose that circumcision is this cyclical process in our culture

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where we do it to children, they grow up to become adult survivors,

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some of those people become parents,

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and practitioners engage them in order to perform this surgery on their children,

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which unlike any other surgery I am aware of in U.S. hospitals,

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it removes a healthy and unique organ part

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(actually with the exception of inter-sex genital modification,

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which bears a lot of resemblance to it by the way).

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It removes a healthy part of the body.

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It is not used as a treatment.

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Doctors don't think they are treating the children;

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they know it is a social surgery they are performing.

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It has significant complications.

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It is performed on minors who cannot give their consent.

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It is illegal, it is actually a federal felony to perform on girls,

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but it is actually encouraged and performed on boys.

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It results in life long function loss,

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and the tissue is then used commercially.

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So just a little context piece.

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I hear you, believe me, and I will show you evidence of that.

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I won't make such a radical claim without proving it.

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So let's just finish our context piece
with both the geography and the history.

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So this is a map of the world sort of.

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As you can see green countries represent places where
genital cutting of boys is not practiced, generally speaking.

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The small, the few yellow countries up in the northern regions

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are places where it is becoming legally questioned.

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Circumcision is now rare in Canada, England, and Australia

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where it used to be practiced on babies also, but stopped.

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In fact, in England, in the 1950's there was an article published

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showing it killed a number of children a year,

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about 14 a year,

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so they stopped the practice there.

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And the other places, besides the United States where it is done on babies,

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in the other regions, most of the time, it is done on adolescents

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in Sub-Saharan Africa and in Sunni Islamic cultures.

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Now how did we get here?

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It has become a medical practice rather than a
tribal practice or a cultural practice.

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And that came about in the late 1800's

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when people had not the germ theory of disease,

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but the nervous excitation theory of disease.

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And people had the Victorian morality,

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so people see what they expect to see a lot of the time.

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So you can find a lot of published medical literature
showing that circumcision cured

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things such as, paralysis, epilepsy, hip joint disease,

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and all sorts of problems that today

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seem very unlikely for the process to have cured.

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And people really thought that actually harming,
the intention was to harm the genitals of the children.

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And they thought that it would help in the long term

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because it would prevent them from
having so much sexual excitation

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that being, in the Victorian model, the most dangerous
type of excitation that one could have.

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So, uhm, oops,

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I should have given you a caveat,

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my apologies...

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There are going to be some graphic slides here,

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and I certainly welcome you turn away at any point
if you don't feel comfortable about looking at what you see.

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And I will try to more often try to give you a warning
when they are about to come up.

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I would also mention actually another caveat:

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I am going to use language differently.

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I am going to switch now to mostly
calling circumcision "genital cutting"

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because I think that is more of a neutral term,

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it's a more accurate or descriptive term.

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I think "circumcision" euphemistically embeds
our assumption that it is a fine thing.

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And the term uncircumcised
I am going to replace with the term "intact",

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because likewise the term "uncircumcised"
gives the sense that circumcision is the norm

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and that those who are not circumcised are
simply "not yet" circumcised.

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And to illustrate that it would be kind of weird
if we called women who had breasts"un-mastectomised"

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right that would be uncomfortable,

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and, likewise, I hope to sensitize us to the discomfort
of calling "intact" "uncircumcised".

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So the next few slides will have some
less-comfortable things to see,

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and, again, you are welcome to turn away if you want.

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So this is the section on the Child.

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The procedure for the child, we will
run through what the procedure looks like.

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That's probably the most graphic section,
along with the complications,

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and what I want you to think about is,

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it is often times talked about from the parents'
perspective,"parents have the right to choose".

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I want you to question that discourse and think
about what the child's point of view is.

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Who owns the child's body?

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What rights do they have?

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Why are we doing it to boys and not girls?

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What does that say about our views on gender, and so on?

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So, this slide shows three different representations
of people in the genital cutting process.

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The top left is a young girl

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being circumcised in her cultural scenario.

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The top right is a young boy being
circumcised in his cultural scenario.

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And the bottom right is an
infant boy in a hospital.

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Now what I want you to look at is their faces.

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Just look at their faces

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because I am asking you to think about their experiences.

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To me it looks like they are having a very similar experience.

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And yet in our culture,

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where I think of us as being kind of imperialist

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we're very ready to point the finger and say,

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Oh these terrible things these people do in these other
countries where they practice female genital cutting."

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yet we're silent about the male genital cutting

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that occurs to children under the same conditions of hygiene

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and the same death rates in those countries;

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and we promote doing it to boys in our country.

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So how do we do a circumcision?

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The next bits are going to be the most graphic.

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This is a circumcision restraint;

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they strap the baby down into it,

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and then they proceed with the procedure,

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which I am going to show you a short video of.

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This is going to include sound

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if I hooked it up correctly.

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and, again, you are welcome to not look;
I find this uncomfortable.

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Okay, so I want to encourage you to take a deep breath

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if you have been having trouble breathing
as I have during that.

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Some things I think to notice is the sort of calm detachment

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of the physician's voice.

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So the physician is not at all distressed by this.

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And the way the baby is crying.

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I hear the baby's crying as the way I hear babies cry

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when they are under extreme duress,

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not you know, "I am hungry."

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So beyond the pain of the procedure itself

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and the pain of the many days it takes to heal,

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there are a number of complications that a
circumcision procedure puts a child at risk for.

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You can sort of divide them into two categories.

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Surgical complications,

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which go from the more minor,

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you know everyone has a scar that has been circumcised.

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A lot of men don't actually know that
the ring around their penis

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is a circumcision scar,

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or they learn it when they hear me talk.

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But that always happens.

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But a number of other complications can be problematic

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that don't occur all the time,

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like penile adhesions,

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when the healing process goes awry

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and two parts of the penis that weren't supposed
to be connected link together.

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Then these panels show in top left (A)

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(A) that's called a fistula,

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so its like a doctor induced hypospadias,

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the black line going down is a probe that's 
entering the meatus, the opening of the urethra

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and exiting out the additional hole

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that the physician has caused.

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(B) Top Right is a nearly amputated head of the penis.

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(C) Bottom Left so much skin of the penis has been removed

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(C) that the child's corpus cavernosa and head of the penis
are lodged down inside the scrotum,

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and in (D) Bottom Right the penis was accidentally amputated entirely.

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There are also a number of post-operative complications

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ranging from difficulty in breast feeding,

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which is important because developing the ability to breast feed

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is essential for infants.

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Bleeding,

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which is another sort of minimizing term,

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you see that on consent forms,
you know like"Oh, bleeding",

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well it turns out an infant only has 
about 12 ounces of blood

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so bleeding a couple of ounces
might cause that child to die

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or require a blood transfusion.

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Increase in pain response.

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Infection, which is also very serious for a newborn.

238
00:13:19,031 --> 00:13:21,550
Meatitus, which is an irritation of the opening.

239
00:13:21,750 --> 00:13:24,345
That also can be problematic because if it gets bad enough

240
00:13:24,556 --> 00:13:27,788
the child will not be able to pee, and that
would require the child to have catheterization.

241
00:13:29,000 --> 00:13:30,034
Necrosis

242
00:13:30,260 --> 00:13:32,760
and even permanent loss of the penis, or death.

243
00:13:35,723 --> 00:13:37,809
I have talked with a pediatric urologist.

244
00:13:38,087 --> 00:13:40,829
He is the type of person who gets the complications
to deal with.

245
00:13:41,708 --> 00:13:44,978
He said that over a two-year period he had
more than 275 children to treat,

246
00:13:45,257 --> 00:13:48,117
almost half who required surgery,

247
00:13:48,545 --> 00:13:50,831
so they were subjected to an additional surgery

248
00:13:51,363 --> 00:13:53,103
in attempt to correct whatever damage happened.

249
00:13:55,489 --> 00:13:57,546
Okay, that's most of the graphic stuff,

250
00:13:58,078 --> 00:14:01,651
except for in the next few slides we will see
pictures of the actual anatomy of adults,

251
00:14:02,004 --> 00:14:04,270
so you are also welcome to turn your heads aside for that.

252
00:14:04,597 --> 00:14:07,037
How many people have seen a penis that was intact?

253
00:14:07,494 --> 00:14:09,102
Either your own or a friends, you know?

254
00:14:12,849 --> 00:14:15,977
Okay, if you haven't yet, see if you
can find someone who is willing to show you.

255
00:14:19,781 --> 00:14:21,818
I have talked to hundreds of men,

256
00:14:23,380 --> 00:14:26,850
both men who have been circumcised 
and men who have not been circumcised.

257
00:14:27,504 --> 00:14:30,248
I hear a lot of men who have been circumcised

258
00:14:30,700 --> 00:14:31,883
feel upset about that.

259
00:14:32,362 --> 00:14:36,010
They are aware or have become aware
that something has been taken away from them,

260
00:14:36,514 --> 00:14:39,230
and that their bodies were subjected
to something without their choice.

261
00:14:41,141 --> 00:14:43,953
I also hear parents talk about
their regret from the procedure.

262
00:14:46,303 --> 00:14:48,034
So what is the foreskin?

263
00:14:48,512 --> 00:14:52,815
The foreskin is this sort of socially constructed thing.

264
00:14:53,016 --> 00:14:54,373
It's really just part of the penis,

265
00:14:54,576 --> 00:14:57,417
but now that we have cut it off,
we have to give it a separate name.

266
00:14:58,828 --> 00:15:02,855
In fact, a lot of potential complications lists
that you get on your informed consent form

267
00:15:03,484 --> 00:15:06,730
say that one of the risks is that you might injure the penis.

268
00:15:07,962 --> 00:15:12,112
So we have constructed a reality in which
cutting of the penis is not injuring it;

269
00:15:12,498 --> 00:15:15,460
it is if you then cut part that you intended to leave
that it is an injury.

270
00:15:18,360 --> 00:15:20,447
So I want to show you what the foreskin is.

271
00:15:20,647 --> 00:15:22,153
I want to spend some time on that.

272
00:15:22,357 --> 00:15:25,000
The foreskin in the adult male,
the part that would have been removed,

273
00:15:25,200 --> 00:15:27,430
is about 12 to 15 square inches,

274
00:15:27,630 --> 00:15:29,992
it is about the size of a 3" x 5" index card.

275
00:15:30,192 --> 00:15:32,115
It is the most erogenous part of the human male.

276
00:15:32,315 --> 00:15:35,261
It contains 10 to 20 thousand fine touch nerve endings.

277
00:15:35,790 --> 00:15:39,187
And it also makes the penis shaft skin motile.

278
00:15:39,935 --> 00:15:42,065
So it is the difference, you know when
you are having sexual intercourse

279
00:15:42,268 --> 00:15:44,339
or some kind of interaction,

280
00:15:44,540 --> 00:15:47,000
it is the difference between this kind of interaction

281
00:15:47,200 --> 00:15:50,880
or something if you can image a part
of your body where the skin moves around nicely

282
00:15:51,080 --> 00:15:54,044
(My cheeks are floppy, so I can do that, you know).

283
00:15:54,244 --> 00:15:56,340
And that is actually a significant thing

284
00:15:56,540 --> 00:15:59,500
because there is another kind of nerve
that is called a stretch receptor

285
00:15:59,700 --> 00:16:01,439
that gets stimulated in that motion,

286
00:16:01,639 --> 00:16:05,640
and it is the male's contribution
to mechanical lubrication during intercourse,

287
00:16:07,000 --> 00:16:09,889
either male-male or male-female.

288
00:16:10,563 --> 00:16:13,260
The foreskin can be broken down into a couple of specialized areas:

289
00:16:13,834 --> 00:16:14,949
the frenulum is this sort of...

290
00:16:15,565 --> 00:16:17,752
my hand isn't really long enough but...

291
00:16:18,256 --> 00:16:20,700
It is this fanning out region here.

292
00:16:20,900 --> 00:16:24,592
and there is the ridged band below it,
that is were most of the nerves land.

293
00:16:24,792 --> 00:16:26,852
and the dartos muscle is a cutaneous muscle

294
00:16:27,052 --> 00:16:30,165
that allows the foreskin to respond to cold or fear

295
00:16:30,369 --> 00:16:33,186
by surrounding the penis and pulling it in towards the body.

296
00:16:35,917 --> 00:16:39,586
In 2007, the first research was done ever

297
00:16:40,015 --> 00:16:42,732
to attempt to assess where the penis is sensitive.

298
00:16:44,394 --> 00:16:47,312
So they took a group of males who were intact

299
00:16:47,615 --> 00:16:48,969
and a group of men who were circumcised.

300
00:16:49,778 --> 00:16:51,953
What you see on this color graph here

301
00:16:52,252 --> 00:16:55,005
is that the most sensitive regions are that maroon color

302
00:16:55,260 --> 00:16:57,993
and the second most sensitive regions are the purplish color.

303
00:16:59,130 --> 00:17:02,012
If we compare that to a circumcised penis

304
00:17:02,408 --> 00:17:07,044
what you see is that we have removed
most of the most sensitive areas

305
00:17:07,476 --> 00:17:12,362
and left just this region around the scar
and the remainder of the frenulum

306
00:17:12,865 --> 00:17:15,132
is really where most circumcised men are sensitive.

307
00:17:15,900 --> 00:17:17,731
Therefore, you can compare them this way,

308
00:17:18,093 --> 00:17:21,544
but you don't have to believe me
if you can find a friend or two

309
00:17:21,936 --> 00:17:23,549
maybe one who is circumcised and one who is not,

310
00:17:24,884 --> 00:17:26,121
or maybe yourself,

311
00:17:26,645 --> 00:17:28,881
you can look and can see where
the sensitivity actually lies.

312
00:17:30,590 --> 00:17:32,696
For most men it is in this region of the frenulum

313
00:17:33,234 --> 00:17:34,919
or the scar remnant.

314
00:17:38,650 --> 00:17:40,468
So just to get you a real picture,

315
00:17:40,930 --> 00:17:42,907
what John here has done,
he's a photographer,

316
00:17:43,302 --> 00:17:45,568
he has taken a person with a foreskin

317
00:17:45,926 --> 00:17:49,233
and drawn these lines, so you can see
how much tissue it is as it retracts.

318
00:17:50,498 --> 00:17:52,463
The other difference I want you to note

319
00:17:52,797 --> 00:17:57,254
is that the inside what it does it generally surrounds the penis,

320
00:17:57,454 --> 00:17:59,003
so it in a sense it invaginates it,

321
00:17:59,303 --> 00:18:00,340
it gives it an enclosure,

322
00:18:00,540 --> 00:18:01,846
and it keeps it moist.

323
00:18:02,093 --> 00:18:04,197
So, if you compare that with the circumcised penis,

324
00:18:04,557 --> 00:18:06,420
the tissue looks softer,

325
00:18:06,746 --> 00:18:08,281
moister and warmer,

326
00:18:09,413 --> 00:18:10,671
in addition to there being a lot more of it,

327
00:18:11,049 --> 00:18:12,205
and it doesn't have the scar.

328
00:18:12,601 --> 00:18:14,471
Those arrows there are pointing to the scar,

329
00:18:14,671 --> 00:18:16,122
so you can see where that is.

330
00:18:18,286 --> 00:18:21,306
I did want to invite, if you have any questions,

331
00:18:21,591 --> 00:18:23,618
it is okay to ask me as we go along

332
00:18:23,818 --> 00:18:25,785
because I am giving a lot of information.

333
00:18:27,825 --> 00:18:29,367
Okay, then, jumping along to the parent.

334
00:18:31,310 --> 00:18:33,147
Like I said I have talked with hundreds of parents

335
00:18:33,347 --> 00:18:35,647
also especially doing all this work I do with parents,

336
00:18:35,913 --> 00:18:38,213
I have talked with many who
when they receive their child back,

337
00:18:38,536 --> 00:18:42,425
that is the moment at which
they understand what they had signed up for.

338
00:18:43,137 --> 00:18:46,087
So there is a problem with informed consent

339
00:18:46,733 --> 00:18:48,316
both that the information is lacking

340
00:18:48,522 --> 00:18:51,891
and that parents are sometimes
asked about it at an inconvenient moment,

341
00:18:52,091 --> 00:18:53,300
such as when they are in labor, you know.

342
00:18:54,499 --> 00:18:56,621
And they are also asked about it in this values neutral way.

343
00:18:56,944 --> 00:18:59,595
Like, would you like a pillow?
Would you like a cup of tea?

344
00:18:59,800 --> 00:19:01,454
Would you like your child circumcised?

345
00:19:01,824 --> 00:19:03,371
It carries the same sort of tone, you know,

346
00:19:07,673 --> 00:19:08,715
and I am concerned about that.

347
00:19:09,410 --> 00:19:13,615
So I view us as having this sort of
manufacturing pseudo informed consent process

348
00:19:14,552 --> 00:19:17,102
Where parents need to trust physicians --

349
00:19:17,608 --> 00:19:21,531
The physicians are supposedly the ones

350
00:19:23,547 --> 00:19:27,546
bringing in the discipline of medicine.

351
00:19:27,873 --> 00:19:30,488
So they come in, but they are given
this information that is very cursory,

352
00:19:30,688 --> 00:19:32,112
it lacks real information about the complications,
those are trivialized,

353
00:19:32,312 --> 00:19:34,338
the foreskin functions are completely omitted,

354
00:19:34,677 --> 00:19:36,511
it's not mentioned that it is actually a sexual organ,

355
00:19:37,589 --> 00:19:42,119
and the ethical questions of making decisions
about your children's bodies are omitted,

356
00:19:42,553 --> 00:19:45,346
and there is also this undeclared conflict of interest

357
00:19:45,605 --> 00:19:48,445
there is really a lot of commercial use of the tissue.

358
00:19:51,944 --> 00:19:57,276
So the other thing parents don't know
is that it is painful for a week or longer afterwards.

359
00:19:57,476 --> 00:19:59,732
So the baby is not only in pain during the process,

360
00:20:00,932 --> 00:20:02,402
but the wound has to heal,

361
00:20:02,602 --> 00:20:04,004
it is a wound on the penis,

362
00:20:04,204 --> 00:20:06,295
and babies are very sensitive to pain.

363
00:20:06,695 --> 00:20:11,615
How many people have gotten to play with a baby, you know you
had a friend with a baby or you have had a baby a few days old?

364
00:20:12,369 --> 00:20:13,663
They are very fragile beings.

365
00:20:14,900 --> 00:20:17,000
So what we have done is we've put this wound on this child,

366
00:20:17,200 --> 00:20:20,701
and now this new parent who is dealing with the healing process

367
00:20:20,960 --> 00:20:23,787
and the process of figuring out what it is like to have this new baby;

368
00:20:24,471 --> 00:20:28,427
this new parent also has this added complications
of having to watch for signs of infection,

369
00:20:28,784 --> 00:20:33,207
of having to keep changing the bandage, and having
the baby be more upset than he normally would have been.

370
00:20:34,929 --> 00:20:37,265
In comparison, for the child who is not circumcised,

371
00:20:38,235 --> 00:20:40,679
all you have to do is well, almost nothing.

372
00:20:41,110 --> 00:20:43,446
In fact, you don't even wash the penis.

373
00:20:43,679 --> 00:20:46,378
Just like you wouldn't was a baby's vagina with soap,

374
00:20:46,578 --> 00:20:47,762
you just rinse it.

375
00:20:47,963 --> 00:20:49,446
You don't retract it;

376
00:20:49,650 --> 00:20:51,303
it becomes retractable on its own.

377
00:20:51,641 --> 00:20:54,184
You have a baby with fewer health problems,
and a child who is more content.

378
00:20:56,345 --> 00:21:01,050
Now, I promised you that I would show
that we actually do use the foreskin tissue.

379
00:21:01,265 --> 00:21:02,738
We use it for three things

380
00:21:02,953 --> 00:21:04,677
that I have been able to find.

381
00:21:05,076 --> 00:21:06,561
We use it for research,

382
00:21:06,761 --> 00:21:09,701
there are a large number of products
you can buy from Invitrogen

383
00:21:09,924 --> 00:21:13,548
which is actually a company from which
I buy other things that don't contain foreskin

384
00:21:13,748 --> 00:21:15,624
cells from for my bio-physics research.

385
00:21:16,312 --> 00:21:19,188
So there are some of the products they sell
using neo-natal foreskins,

386
00:21:19,367 --> 00:21:21,848
you can look it up yourselves.

387
00:21:22,783 --> 00:21:26,380
At a hospital you can get "magic skin treatment"

388
00:21:26,681 --> 00:21:28,981
which is cultured, grown foreskin tissue,

389
00:21:29,182 --> 00:21:31,604
and if you are very wealthy you can buy cosmetics

390
00:21:31,934 --> 00:21:35,608
that are also derived from foreskin tissue.

391
00:21:36,556 --> 00:21:37,637
Oh, the cosmetics?

392
00:21:40,901 --> 00:21:42,224
Wait, say louder?

393
00:21:42,864 --> 00:21:44,893
Audience member,
"why would people want to use them on their skin?"

394
00:21:45,093 --> 00:21:47,104
Oh, people think that
they will make them less wrinkly.

395
00:21:47,378 --> 00:21:49,345
The idea is that baby cells,

396
00:21:49,545 --> 00:21:51,334
you know they are young, they do their job well,
you know...

397
00:21:53,910 --> 00:21:56,102
And, if you are disturbed by that, I am glad

398
00:21:56,461 --> 00:21:58,508
because I would like us to be disturbed by that.

399
00:22:02,067 --> 00:22:06,052
So let's hear from an obstetrician
how they frame these sorts of things.

400
00:22:06,447 --> 00:22:10,190
This is Lisa Masterson being interviewed
on the Craig Ferguson Late, Late Show.

401
00:22:10,843 --> 00:22:12,743
LISA," Yeah, and again
you know what that is a personal choice

402
00:22:13,066 --> 00:22:15,522
and as an Obstetrician,
I talk to my patients a lot about this.

403
00:22:15,645 --> 00:22:19,194
And really there's a lot of health benefits
and there are some risk benefits,

404
00:22:19,349 --> 00:22:21,120
but it is really a social procedure.

405
00:22:21,479 --> 00:22:24,749
So you really have to decide,
do you want your son to look like you?

406
00:22:25,110 --> 00:22:27,591
You know it is a cultural thing it is a social thing,

407
00:22:28,021 --> 00:22:31,797
And there are some health benefits,
more for the lady than the man

408
00:22:32,319 --> 00:22:38,173
but as far as decreasing STDs and passing on to ah
you know other women HPV, which can cause cervical cancer,

409
00:22:38,574 --> 00:22:41,382
so decreasing STDs and cancer all that good stuff."

410
00:22:41,968 --> 00:22:45,058
CRAIG,"But couldn't you achieve the same effect
by washing your pee pee on a regular basis?"

411
00:22:46,744 --> 00:22:47,972
LISA,"You absolutely could."

412
00:22:48,725 --> 00:22:51,328
CRAIG,"So we're talking,
You can have this chopped off, or you can wash it,

413
00:22:51,724 --> 00:22:52,659
your call?"

414
00:22:53,521 --> 00:22:54,390
LISA,"Exactly."

415
00:22:55,589 --> 00:22:58,321
CRAIG,
"That's a tough choice there Doctor ... I dunno!"

416
00:23:01,119 --> 00:23:03,198
So obviously I appreciate Craig's point of view there.

417
00:23:03,809 --> 00:23:06,973
He is from Scotland,
where they coincidentally don't do this to children.

418
00:23:08,446 --> 00:23:10,095
And think about her discourse,

419
00:23:10,327 --> 00:23:13,061
she's saying you have to choose as a parent,

420
00:23:13,830 --> 00:23:16,219
and I want to question that framing of it.

421
00:23:17,066 --> 00:23:21,644
Do you have to choose other
body modification options for your child?

422
00:23:22,220 --> 00:23:24,218
Like a nose job, or things like that?

423
00:23:25,871 --> 00:23:29,542
And, if the idea of doing things to our children
because we want them to look a certain way chills you,

424
00:23:29,742 --> 00:23:31,250
I am glad because I want it to chill us.

425
00:23:31,454 --> 00:23:32,880
I want us to wonder

426
00:23:33,040 --> 00:23:37,946
why are we so busy making our children look like
what we think boys and girls should look like?

427
00:23:38,483 --> 00:23:42,474
In this case, we have this idea that boys
should look a certain way in their genitals.

428
00:23:44,202 --> 00:23:47,502
Okay, so the last section is,
how do we get practitioners doing this?

429
00:23:48,928 --> 00:23:51,974
So I have a few quotes
from practitioners who stopped doing it,

430
00:23:52,175 --> 00:23:53,275
like Marilynn Milos,

431
00:23:53,475 --> 00:23:55,975
a nurse who, after seeing it,
refused to assist with them

432
00:23:56,175 --> 00:23:59,379
and was fired for telling parents
they don't need to do it.

433
00:23:59,918 --> 00:24:02,610
Michelle Storms, who is a very well known Obstetrician
[sic, she is a Family Medicine Practitioner]

434
00:24:03,334 --> 00:24:07,432
who said she was ridiculed and patronized
after stopping them in 1988.

435
00:24:08,405 --> 00:24:13,001
And I am at Georgetown, so I went and talked
to the Head of Obstetrics at Georgetown University Hospital,

436
00:24:13,220 --> 00:24:15,302
Obstetricians do most of them, and she says,

437
00:24:15,660 --> 00:24:17,361
"Medically it doesn't make sense"

438
00:24:17,561 --> 00:24:20,067
"I don't even like doing the procedure, but I do it well."

439
00:24:20,728 --> 00:24:22,881
"I have performed thousands of circumcisions."

440
00:24:23,239 --> 00:24:24,678
She was clear that it is a social procedure,

441
00:24:25,108 --> 00:24:26,866
she was clear that it doesn't make sense medically,

442
00:24:27,225 --> 00:24:30,387
And she told me in our conversation
that she would not stop doing them.

443
00:24:33,524 --> 00:24:37,741
So how do we make physicians into that?

444
00:24:39,894 --> 00:24:42,015
Well, first we start by pathologizing a healthy organ.

445
00:24:42,627 --> 00:24:47,657
Not only is the foreskin absent
from most U.S. medical and anatomy texts,

446
00:24:48,198 --> 00:24:50,566
There is, therefore, no education of the function.

447
00:24:50,890 --> 00:24:52,974
It is not viewed as a sexually important organ.

448
00:24:54,951 --> 00:24:57,430
Physicians are only taught
how to remove it as a procedure.

449
00:24:58,156 --> 00:25:01,595
and they are mistaught care, they are mistaught
this "retract and wash" philosophy,

450
00:25:02,352 --> 00:25:06,177
which is problematic because as you can see
down at the bottom,

451
00:25:06,572 --> 00:25:09,229
the foreskin when you are born
is usually attached to the head of the penis.

452
00:25:09,733 --> 00:25:11,746
What you saw earlier in the circumcision video

453
00:25:12,069 --> 00:25:16,488
was the physician running this tool around to break
the foreskin loose so that they could cut it off.

454
00:25:17,673 --> 00:25:21,519
It is bonded like that to protect babies from,
well all the sorts of things that babies do,

455
00:25:22,100 --> 00:25:24,473
they might have feces or urine in their diaper,

456
00:25:24,760 --> 00:25:26,342
they might get scratched up.

457
00:25:26,733 --> 00:25:29,034
The foreskin has a protective function
when you are young.

458
00:25:29,803 --> 00:25:31,163
Gradually that detaches

459
00:25:31,487 --> 00:25:33,931
and the foreskin becomes retractable,

460
00:25:34,182 --> 00:25:36,504
but if you forcibly retract it, that tears it up

461
00:25:36,785 --> 00:25:38,531
and creates a site for infection,

462
00:25:38,762 --> 00:25:41,958
also if you wash with soap
that creates a site for infection.

463
00:25:42,756 --> 00:25:46,028
And finally,
we make this misdiagnosis called "phimosis".

464
00:25:46,732 --> 00:25:49,250
There is a true problem called phimosis
when there is scar tissue

465
00:25:49,450 --> 00:25:52,525
at the opening of the foreskin, so it can't retract

466
00:25:52,725 --> 00:25:55,948
and there are treatments for it use steroidal cream
to help the scar tissue soften.

467
00:25:56,995 --> 00:26:00,233
But when we think that a baby who is three weeks old

468
00:26:00,558 --> 00:26:03,432
because you can't pull the foreskin back without
making the baby scream, that's wrong.

469
00:26:04,402 --> 00:26:09,572
It is actually meant to be attached that way,
it grew that way and it will become retractable on its own.

470
00:26:12,729 --> 00:26:15,239
So, why do we do the circumcisions?

471
00:26:15,527 --> 00:26:18,834
Well if you look at why parents say they choose
the number one reason is appearance.

472
00:26:19,232 --> 00:26:23,544
They want their child to look like the other children
they'll see or they want them to look like their Dad.

473
00:26:25,100 --> 00:26:28,107
They think it looks better,
or they think it is easier to keep clean.

474
00:26:28,647 --> 00:26:33,788
And I believe it is the solicitation by physicians
that reinforces or validates the choice to do this.

475
00:26:34,255 --> 00:26:39,037
The fact that physicians do it
makes it look like a reasonable thing.

476
00:26:39,869 --> 00:26:44,088
Physicians may also give several reasons
to collude with this idea,

477
00:26:44,288 --> 00:26:46,497
they may say it reduces penile cancer rates.

478
00:26:46,697 --> 00:26:49,129
That it reduces urinary tract infections (UTIs),

479
00:26:49,451 --> 00:26:53,729
Cervical Cancer rates in female partners
that your child might have when they grow up.

480
00:26:54,843 --> 00:26:57,838
And female to male HIV transmission rate reduction

481
00:26:58,063 --> 00:26:59,629
is sort of the newest reason.

482
00:27:00,029 --> 00:27:02,625
So as I showed you in the beginning, 
we have this sort of cultural baggage

483
00:27:03,178 --> 00:27:08,356
a lot of reasons why we used to do circumcisions
that don't make sense in today's cultural setting,

484
00:27:09,039 --> 00:27:13,604
so we have had to come up with a posteriori reasons
in order to feel more comfortable with what we are doing.

485
00:27:14,359 --> 00:27:15,759
But I'll analyze those in more depth.

486
00:27:16,154 --> 00:27:20,210
Besides the social critique that I think they are reasons
we made up after the fact, in order to feel comfortable with it.

487
00:27:20,532 --> 00:27:25,873
If we think about them carefully, appearance
and cleanliness, the number one reason that circumcision is done.

488
00:27:26,159 --> 00:27:30,256
Well that argument is used to support both
male and female genital cutting

489
00:27:30,651 --> 00:27:34,963
in every culture that I am aware of
that either of those practices occurs in.

490
00:27:35,436 --> 00:27:37,088
And they are just made up arguments,

491
00:27:37,412 --> 00:27:40,396
I mean, how can you say that something is cleaner
if you do one thing to it or another?

492
00:27:41,727 --> 00:27:45,697
Penile Cancer, the American Cancer Society says no,
it won't protect you from penile cancer.

493
00:27:46,291 --> 00:27:49,383
It is also irrelevant; the rate is 1 in 100,000.

494
00:27:49,693 --> 00:27:51,995
More people may die from circumcision than penile cancer.

495
00:27:52,474 --> 00:27:54,183
Urinary tract infections,

496
00:27:54,559 --> 00:27:56,825
well that was based on a big study in 1986,

497
00:27:57,184 --> 00:27:59,658
done by a fellow, I kid you not, his name was Wiswell.

498
00:28:01,444 --> 00:28:05,449
And the problem was his instructions
caused urinary tract infections,

499
00:28:05,676 --> 00:28:07,017
selectively in subjects with foreskins

500
00:28:07,217 --> 00:28:10,530
because he told the parents to forcibly
retract the foreskin and wash with soap.

501
00:28:10,940 --> 00:28:14,005
So that is just like if you had a girl
and you forcibly douched her,

502
00:28:14,251 --> 00:28:17,441
you know a little girl, you would get 
a higher rate of yeast and urinary tract infections

503
00:28:17,641 --> 00:28:20,893
because you have messed up
the colonies of protective bacteria.

504
00:28:21,926 --> 00:28:24,372
Cervical cancer in female partners,

505
00:28:25,414 --> 00:28:28,002
Well, first of all, a surgical preventive measure on an infant

506
00:28:28,290 --> 00:28:31,291
for a potential female partner when they grow up.

507
00:28:31,499 --> 00:28:34,942
I mean, how do we know this person
is not going to be a monk or gay?

508
00:28:35,515 --> 00:28:37,708
And they could do it themselves later.

509
00:28:38,319 --> 00:28:41,885
Also, cervical cancer is cause by human papilloma virus (HPV).

510
00:28:42,088 --> 00:28:44,569
Probably most of you guys know that because you
learned that in Sex Ed, right?

511
00:28:45,072 --> 00:28:49,212
Well the same authors went back and looked
at the husbands and wives in that study

512
00:28:49,487 --> 00:28:52,363
and they had different strains of HPV.

513
00:28:52,614 --> 00:28:57,390
So I don't know if there was
under-the-table non-monogamy or what.

514
00:28:57,930 --> 00:29:00,628
But that throws the results
of that study totally into question

515
00:29:00,915 --> 00:29:06,306
because the husbands were not carrying the HPV
strains that gave the women the cervical cancer.

516
00:29:07,367 --> 00:29:08,442
Gesundheit.

517
00:29:09,984 --> 00:29:13,255
Okay, so the last one is circumcision
as an HIV preventative.

518
00:29:13,938 --> 00:29:17,390
Okay, that idea started in the 2000's mostly.

519
00:29:17,713 --> 00:29:20,271
The evidence for it is three randomized control trials.

520
00:29:20,471 --> 00:29:21,612
They were performed in Africa,

521
00:29:21,899 --> 00:29:25,925
probably because you couldn't get a
human review board to permit such a study in the U.S.

522
00:29:26,284 --> 00:29:28,751
They got volunteer men
who were willing to be circumcised;

523
00:29:29,065 --> 00:29:30,765
they randomly circumcised half of them.

524
00:29:30,965 --> 00:29:33,280
And they watched to see how quickly they got HIV.

525
00:29:34,393 --> 00:29:37,637
They had some problematic methodology
that I will get into later.

526
00:29:38,247 --> 00:29:42,813
And their claim was that that reduced
the rate at which men got HIV by 60%.

527
00:29:44,251 --> 00:29:47,522
Now the evidence against circumcision
as an HIV preventative

528
00:29:47,846 --> 00:29:50,003
are pretty much all the
other studies that have been done.

529
00:29:50,578 --> 00:29:51,971
The geographic data,

530
00:29:52,171 --> 00:29:55,320
if you look at correlation between
circumcision percentage and HIV rates

531
00:29:55,520 --> 00:29:58,186
in populations, it contradicts this conclusion.

532
00:29:58,503 --> 00:29:59,543
For example,

533
00:29:59,878 --> 00:30:03,796
the United States has the highest HIV rate
of any industrialized nation,

534
00:30:04,262 --> 00:30:07,139
and also has the highest circumcision rate
of any industrialized nation.

535
00:30:07,851 --> 00:30:10,404
You would expect something different
if circumcision were so protective.

536
00:30:12,848 --> 00:30:17,434
So, I've got a few minutes left. I am going to quickly
run through what I think was wrong with the study.

537
00:30:17,900 --> 00:30:23,811
Again, there were three studies, they took a group of intact men,
circumcised them and watched how quickly they got HIV.

538
00:30:24,710 --> 00:30:28,466
The problems were, each time they came
to the clinic they gave them condoms

539
00:30:28,728 --> 00:30:31,280
and safe sex counseling.

540
00:30:31,480 --> 00:30:33,973
But the circumcised group came
at least twice more

541
00:30:34,424 --> 00:30:36,958
because they had to come to get circumcised
and they had to come to get a follow up study.

542
00:30:38,180 --> 00:30:39,801
In addition, if you are circumcised,

543
00:30:40,001 --> 00:30:43,082
it will take you about four to six weeks
until you are able to have sex again.

544
00:30:44,112 --> 00:30:48,066
And the circumcised group was asked
to abstain for six weeks.

545
00:30:48,927 --> 00:30:51,262
But they didn't start the clock
until after waiting for six weeks,

546
00:30:51,462 --> 00:30:52,895
they started the clock at the beginning,

547
00:30:53,099 --> 00:30:55,813
so the circumcised group had six weeks

548
00:30:56,136 --> 00:30:57,506
of protection by being unable to have intercourse.

549
00:30:58,782 --> 00:31:00,769
In addition, they used an anti-body test, which

550
00:31:01,020 --> 00:31:03,533
you know, if you go to an STD clinic

551
00:31:03,733 --> 00:31:06,079
and they use an antibody test,
there is a three-month window.

552
00:31:06,280 --> 00:31:08,886
They tell you, you've got to wait
until three months after your last exposure

553
00:31:09,087 --> 00:31:10,587
if you really want to know if you have HIV.

554
00:31:10,788 --> 00:31:12,983
But again, they didn't start the clock after three months

555
00:31:13,306 --> 00:31:16,239
and most the benefit or half the benefit
occurred during those first three months.

556
00:31:16,527 --> 00:31:19,582
So those infections occurred prior
to the start of the trial,

557
00:31:19,585 --> 00:31:21,562
prior to the randomization and intervention.

558
00:31:22,603 --> 00:31:24,801
There were a lot of problems concerning controls,

559
00:31:25,001 --> 00:31:28,308
including blood exposure
and receptive anal intercourse.

560
00:31:30,751 --> 00:31:32,795
I am also concerned because the authors of that study

561
00:31:33,046 --> 00:31:36,317
likened circumcision to an effective vaccine.

562
00:31:37,719 --> 00:31:40,799
Now all they are saying is that,
if their results are accurate,

563
00:31:41,000 --> 00:31:42,079
which I don't believe,

564
00:31:42,279 --> 00:31:44,365
that it would reduce
your likelihood of getting HIV,

565
00:31:44,565 --> 00:31:47,202
you know each time you had sex, by 60%.

566
00:31:47,402 --> 00:31:50,507
So, if you have sex enough, you will 
et HIV anyway with enough risky behavior.

567
00:31:51,335 --> 00:31:52,216
The measles vaccine,

568
00:31:52,502 --> 00:31:56,608
if you took that and its boosters,
99% of you become immune to measles.

569
00:31:56,808 --> 00:31:58,133
Probably you are actually.

570
00:31:58,423 --> 00:32:00,400
So that is what an effective vaccine looks like.

571
00:32:00,796 --> 00:32:02,377
Ninety-nine per cent permanent immunity.

572
00:32:02,577 --> 00:32:06,143
Not sixty per cent less likelihood
to become infected each time you are exposed.

573
00:32:06,343 --> 00:32:09,958
And real human beings think they are immune
to HIV because they have been circumcised

574
00:32:10,200 --> 00:32:11,287
in African countries,

575
00:32:12,985 --> 00:32:15,321
and I am very concerned about that.

576
00:32:15,835 --> 00:32:17,485
But anyway, so to re-cap,

577
00:32:17,839 --> 00:32:20,791
I think we have a social bias
toward cutting children,

578
00:32:21,506 --> 00:32:22,766
particularly boys.

579
00:32:22,966 --> 00:32:24,983
I think that it is very harmful to children.

580
00:32:25,183 --> 00:32:26,885
It also hurts survivors.

581
00:32:27,085 --> 00:32:29,785
It hurts parents, who really want
the best for their children.

582
00:32:30,269 --> 00:32:31,430
And it also hurts practitioners

583
00:32:31,716 --> 00:32:34,736
because I believe that medical students
come into school wanting to help people,

584
00:32:35,183 --> 00:32:38,414
and they get taught about this procedure
in an out-of-context kind of way.

585
00:32:40,210 --> 00:32:43,429
Most of the people I talk to think it is
not their responsibility to do anything about it,

586
00:32:43,629 --> 00:32:47,665
including professional organizations
like the American Academy of Pediatrics,

587
00:32:47,897 --> 00:32:50,454
the American College of Obstetricians and Gynecologists,

588
00:32:50,738 --> 00:32:51,640
the practitioners, you know,

589
00:32:51,817 --> 00:32:54,764
because their job is to keep the practitioners looking good.

590
00:32:55,016 --> 00:32:59,401
So, if you say something is bad that your practitioners
are doing, that doesn't look so good.

591
00:33:00,227 --> 00:33:04,180
The administrators of the hospital
and the practitioners there don't want to stand out.

592
00:33:04,575 --> 00:33:07,522
The obstetricians don't even think
the child they are operating on is their patient.

593
00:33:07,800 --> 00:33:09,900
The ethics committee of the hospital

594
00:33:10,100 --> 00:33:12,586
told me that they are not
the appropriate venue for this concern.

595
00:33:14,063 --> 00:33:18,017
And I think all of these organizations
are neglecting parents, children, and us.

596
00:33:20,300 --> 00:33:22,274
So I am hopeful
that I have engaged you with some interest

597
00:33:22,541 --> 00:33:24,283
and that maybe you will go and tell people about this.

598
00:33:24,483 --> 00:33:28,219
Because, if they are not going to take responsibility,
I hope that we will.

599
00:33:28,419 --> 00:33:29,877
So tell your friends.

600
00:33:30,077 --> 00:33:32,434
I am going to give a link to this slide show to your professor.
[A link to the files is available in the description.]