UND MEDICAL EDUCATION CENTER
 DEPARTMENT OF PEDIATRICS
1919 NORTH ELM STREET
FARGO. NORTH DAKOTA 58102

October 7, 1992                                                                                                                                                                                    

Duane Voskuil, Ph.D.
Department of Philosophy
Bismarck State College
1500 Edwards Avenue
Bismarck, ND 58501

Dear Dr. Voskuil:

I appreciate your inquiry about circumcision as a pediatric practice. I have personally practiced circumcision on my neonatal patients since 1960. 1 have never regarded this procedure as a very abusive one. There are pluses and minuses to any procedure, including circumcision. In recent months, however, even those opposed to circumcision are accepting the fact that there is a clear cut decrease in urinary tract infections in circumcised males. This is the work of Dr. Wiswell from Hawaii who has for many years conducted prospective studies on this subject. It is also my clinical view that one never sees urinary tract infection in pediatric or adolescent males unless there are previously undiagnosed congenital anomalies of the urinary tract or unless the male are uncircumcised.

Certainly the neonate experiences pain during the circumcision procedure. There was a movement afoot several years ago to do local blocks, such as one would perform before suturing the skin at the time of a laceration. All the members of our pediatric group who enthusiastically espoused doing blocks have dropped this procedure since this turns out to be as painful as doing the circumcision quickly and efficiently and made the circumcision procedure much longer than it would have been otherwise. In short, despite the pain experienced pediatricians do the circumcision quickly and efficiently and there is an extremely small incidence of complications. Furthermore, because of voluminous recent literature on this subject, pediatricians are as aware or more aware of the complications of circumcision than they had been heretofore.

One of the key things that nurses ask the family about at the time of circumcision is whether or not there are any familial bleeding tendencies because one of the worst complications of circumcision relates to an unknown family history of classical hemophilia or Factor 8 deficiency. It is very bad to find out about hemophilia because of continuous massive bleed from the circumcision of a neonate who has this disease.

As you may know circumcisions are generally not practiced in Europe, or practiced about 50% of the time in Canada (the reason for this dichotomy in Canada are certainly unclear to me) and also universally in the United States. As you may know studies on the subject of circumcision in the United States relate to social reasons for circumcisions rather than the medical ones cited above. People in the United States request circumcision because the father is circumcised and "everyone in our family does it." This is precisely the attitude I find in my own practice and on the Neonatal Unit at St. Luke's Children's Hospital.

                                                                                                                                 6/28/94

George Magnus Johnson, M.D.
Professor and Chairman, Department of Pediatrics
UND School of Medicine
Pediatrician, Fargo Clinic--MeritCare
1919 North Elm Street
Fargo, North Dakota 58102

Dear Dr. Johnson:

It has been two years since we exchanged letters. I was somewhat taken back by your response to my questions on circumcision. The information I have found in these two years, however, does not always square very well with what you wrote.

1. Thomas Wiswell’s work has been widely discredited, but the conclusions drawn from his work by Edgar Schoen, AAP board member, and many others are ludicrous. The procedures used to gather samples in his retrospective study can contaminate the samples. The research turned up only a 1% difference, so males, even if the study were sound, would still have half the UTI incidence of females. This is hardly a medical reason to put non-consenting individuals through this painful operation. Other studies do not show his results. Europeans laugh (grimace) at our use of his work to justify amputating parts of infants’ genitals.

2. If pediatricians are aware of the complications of circumcision, few parents I talk to have had this information communicated to them by their physicians. They are seldom told it is even a controversial issue.

3. This operation is, as you say, a hotly debated issue in the medical community, the U.S./Canadian medical community, that is. It is not a debated issue elsewhere. Europe and Japan and most of the non-Moslem world do not do routine infant circumcisions. The Canadian rate, still high at about 30%, is only half our national rate. Non-religious circumcision is definitely a North American ritual that the rest of the world looks at aghast. This I confirmed during a trip to China last fall and in conversations with European physicians.

4. The pain of circumcision is not just the immediate tearing, crushing and cutting of the prepuce. There is irritation of the glans penis (designed to be an internal organ) as it chafes against clothes and is irritated by ammonia for months, until it becomes desensitized.

5. Your so-called medical reasons for circumcision are bogus: Even on conservative estimates, more infants die of circumcision complications than old men die of penile cancer (many deaths are reported as due to the secondary effects of circumcision rather than to the operation itself). And though I’ve been told, as you wrote, “urologists stoutly maintain that cancer prevention is one of the major reasons for circumcisions,” I have yet to find one who will put his credentials on the line in a public forum to defend this stance. (On the contrary, see Robert Pathroth, Bismarck urologist, #54 in the North Dakota Quotations enclosure.) It would make more sense to excise male infants’ mammary glands, since more males die of breast cancer according to the American Cancer Society. The circumcision entry in Mosbys’ Medical Nursing and Allied Health Dictionary, 4th Ed. reads, “Circumcision is widely performed on newborn boys despite the demonstrable lack of medical benefits and small but significant risk as hemorrhage, urethral injury or postoperative infection.”

6. I’m concerned about what you mean by  “careful descriptions of management of the foreskin during the preschool years at routine pediatric visits minimizes this problem.” I hope the description means to do nothing at this age. Tearing a prepuce away from the glans before it has matured and separated on its own or poking anything into the prepuce is not recommended. The AAP pamphlet on care of the intact male says, “Leave it alone.” When the foreskin has separated, the same hygiene that one uses for ears and fingers is all that is required. European physicians do not feel a need to dispense detailed instruction on “management of the foreskin” of intact male infants and children.

7. I’m sorry the literature you have is deficient on the subject of the loss of male sensitivity with the loss of his prepuce. Even Moses Maimonides, 1100 AD, says diminishing pleasure is one of the important reasons it is done to Jewish boys. I have heard many first-hand reports of men being circumcised as adults who say their range of pleasure is reduced. Who has done a study of the effect of circumcision on impotency? If a distinction in the literature is not made between circumcised and intact individuals, it is the literature that is deficient and cannot be trusted. Until a study is made one cannot assume there is no difference. I recently attended a conference in Washington, DC, and attended an hour slide lecture by >John Taylor, M.B., from Canada who with stained tissue slides definitely proves the prepuce is anything but a superfluous piece of skin. (I have his presentation on videotape if you care to see it. He says it will be published in a British medical journal).

8. I was surprised at your vehement denial that infant pain can have any effect on maternal bonding. Even the birthing unit at Medcenter One has given up the newborn nursery. Many physicians and psychologists have looked into the issue of childhood pain and found it has lasting physiological and psychological effects. Often the research does not refer to circumcision specifically, but when asked why not, the reply often cites cultural conditioning as the reason. There is even a society, APPPAH, Association for Pre- and Perinatal Psychology and Health, focusing on the infant’s experience. Their members have many articles in print that document the lasting effects of infant pain. Once again, if you have no evidence, it must be that you cannot find it in the areas you are looking. This, of course, is both a psychological, and a physiological issue. Yet, after your denial of any existing evidence, you acknowledge, to my amazement, that “neonatal intensive care units contribute to an inordinate number of abused children to the total population of abused children.”

9. I am not convinced physicians and medical institutions are aware of the gravity of the legal questions, much less the ethical ones. More than one man has told me he wants to sue a physician because he was unnecessarily mutilated, and there is a movement to pass legislation against these unnecessary genital surgeries. Consider the exposure a physician has who circumcises an infant with Medcenter One’s Authorization for Circumcision form that reads: “I hereby authorized my baby boy to be circumcised if deemed advisable by the attending physician.” My emphasis.

10. I think it ridiculous to dismiss any comparison of female genital surgery with males as “ridiculous.” The removal of the female prepuce [sunna] is very similar to routine infant male circumcision, and at least one physician in the U.S. is in jail for performing such an operation. I have also learned the same rationalizations are given by those who do the female operations as do male circumcisions: cleaner, looks better, etc. (See the enclosed list of quotations from an American woman who has been very active in learning about FGM. Note particularly the identical quotations: “Doctors do it, so it must be a good thing.”) I also understand routine episiotomies fall into the category of unnecessary female genital surgery, another peculiar western custom.

11. After working with my ethics students on this issue for two years, I can tell you a little information goes a long way. The medical profession is rapidly losing credibility over its endorsement of, or failure to speak out against, this unnecessary surgery. Your attempt to trivialize, perhaps as a way to deflect attention from, this issue is unimpressive. Once we understand why we are a circumcising society, we will have a better understanding of the other issues you raised. Since you are also an educator, it is important to reassess your views on this. After all, not long ago the medical school was, indeed, teaching that infants do not feel the pain.

Sincerely yours,

Duane Voskuil, Ph.D.
Philosophy, BSC

Enclosures:

cc: Clayton Jenson, M.D., Dean
Family Practice Division
UND School of Medicine,
Grand Forks, ND

____________________________________

Lutz's 1992 Reply to 1992 Queries about
Medical School Curriculum and Circumcision

Personally, I hope your letters and numerous questions are not antiSemetic. Both of my sons are Jewish and circumcision is really a non-issue but relegated to religious doctrine and biblical and historical precedent contained in the Torah.

Thank you again for your questions and concern, and I would appreciate a copy of your lecture as apparently soon forthcoming.

Sincerely,

Dennis J. Lutz, M.D.

DJL/rh

_______________________________________

Voskuil's 1994 Reply to Lutz' 1992 Letter

November 11, 1994

Dennis J. Lutz, M.D., Chairman
UND School of Medicine, Department of Ob-Gyn
422  Seventh Street N.W.
Minot, ND 58701

Dear Dr. Lutz:

More than two years have passed since our first communication when I asked you about the medical advisability of routine infant circumcision. The more I learn, the less happy I am with your response. Also, I still wait for your response on what materials (texts, research studies, etc.) are used in your classes on this issue.

You suggested I may be verging on anti-Semitism with my activities. That I might be seen to be prejudiced was a concern for me, as it is for most who set out to expose the brutality of circumcision. It is one of the main reasons people are afraid to speak out. You also seemed to be using it as a threat to silence me. But as I learn more, mostly from my Jewish friends, many who are very active in the NOCIRC campaign because they do not want Judaism to be seen as requiring this brutal act, I see the reverse is closer to the truth.

One of the reasons circumcision has become such a major “secular” activity in North America is likely due to the heavy pressure from Jewish physicians to justify their own circumcisions and those they have performed as medically advisable and, therefore, valuable for everyone. Judaism has never tried [until recently] to justify this ritual act on medical grounds. I think the promotion of routine infant circumcision illustrates how religious sympathies are carried over into scientific and secular medical practice.

Circumcision, supposedly done for religious reasons, may present a difficult moral issue. Few realize the rite now performed even by Jews is not the original form of Jewish circumcision that merely caused bleeding by cutting of the tip of the prepuce. But legally, whenever there is a conflict between religious freedom and an individual’s human rights, our society does not allow such religious practice to continue. If religious activity violates human rights, it is not free to exercise such activity. Every child whose body has been irreversibly altered without his consent for nonessential healthcare reasons has had his civil rights violated.

Medical schools should not be preaching nor supporting religious rituals with our tax dollars. Public health insurance should not be paying for them. You must justify routine infant circumcision on medical grounds. I have not been able to find any scientific research that even comes close to justifying this amputation on nonconsenting individuals--males or females.

Until you can prove to me that circumcision is a medical issue rather than a ritual issue, I can only conclude that your advocating or even tolerating circumcision is a misuse of your position in the UND School of Medicine. As a fellow faculty member of the North Dakota University System, I must protest this misuse. If circumcision was a trivial issue, then my concerns would be likewise, but circumcision is seen by many as sexual child abuse. It is mutilating the body of an individual without his consent for reasons that have nothing to do with medicine. A physician’s intervention of any kind can only be ethically justified if the harm caused is less than the benefits. PRIMUM NON NOCERE. When all the issues are examined, circumcision does not come close to being justified, not physiologically, psychologically nor legally.

 I have little hope at this late date you will provide me with what you believe is the basis for circumcision in the medical curriculum. Yet the burden of proof for having it as part of medical education is on those who advocate and do the operations. So until I have such proof, I will continue to believe such activity amounts to incompetence on the part of the educators involved.

There are those concerned enough with this issue to introduce legislation next session. Perhaps you will be called to testify in committee hearings. I have enclosed some items you may find interesting. I think it is unfortunate that so far you have refused to dialogue on this important ethical issue.

Sincerely,

Duane Voskuil, Ph.D.
Ethics and philosophy
Bismarck State College

Enclosures:

      “Quotations and Comments by North Dakotans....”

       Q & R clinic’s “The Circumcision Decision”

      “Assessment of the American Academy of Pediatrics....”

      “Circumcision: A Modern Review of an Ancient Jewish Ritual”

      “Circumcision: A Jewish Feminist Perspective”

      “NOCIRC  Newsletter” (with precedent California case)

      Bismarck Hebrew Congregation Newsletter, 11/30/92

      “Circumcision: A Mother Questions Brit Milah”

      “My Story of Ritual Abuse”

      “From Genetic Cosmology to Genital Cosmetics: Origin Theories of the Righting Rites of Male Circumcision”

      Letter, 6/10/92, from Somerville, Law Professor, McGill Centre for Medicine, to Campbell, Attorney General of Canada

      Videotape: Medical Information presented at the Third International Symposium on Circumcision (includes John Taylor’s slide presentation of the prepuce)

cc: Larry Isaak, Chancellor, North Dakota University System
Kermit Lidstrom, President, Bismarck State College

 

Voskuil's 1993 Letter to Sandy Holbrook
Concerning Equal Opportunity

8/29/93

Dr. Sandy Holbrook
Director of Equal Opportunity
North Dakota State University--University Station
Fargo, ND 58105

Dear Dr. Holbrook:

Thank you for a well-done presentation on sexual harassment. You could have used a couple more hours. Every year what is considered harassment changes as we become more sensitive to the “natural law” of patriarchy (the expression going around during the Thomas conformation hearings [for the Supreme Court]).

I restructured my philosophy classes around the gender issues, not because philosophy is gender-based, but because historically it has been taken to be so, if not explicitly, certainly implicitly. With the new information available in the last 10-20 years on the rise of patriarchy out of the prepatriarchal Neolithic and bronze age Goddess cultures, we are afforded a factual alternative to the world-wide religion of patriarchy. Philosophy, which studies the common aspects of all alternatives, must not be based on one possibility as opposed to others, but most of our religions, which believers say have no true alternatives, are based on the unquestioned and arbitrary assumptions of patriarchy. These assumptions underlie most of the power plays of sexual harassment, even though males can also be harassed

I was shocked into action a couple years ago when I learned of a form of sexual harassment so bad that it can only be called sexual mutilation, namely, female clitoridectomies and infibulations. They are done to 100 million young females by both male and female adults, and are the main cause of death in many African and Near East countries. I was further shocked to learn the rise of gynecology in the U.S.  began with many such mutilations of women by Marion Sims, MD, first on slaves, and then many others.

The shocks continued when I learned that male circumcision (apart from long-standing Jewish and Moslem ritual) began in earnest in the U.S. at the same time a hundred years ago, going from 5% to 85% ten years ago before tapering off to 60% today.

In the last few years, especially with the immigration of Africans to the U.S. and Canada, female genital mutilations have become increasingly common. Most countries and states seem to find statutes to prosecute parents and others who do these mutilations even though there are few laws on the books to forbid it. My attempt during the last legislature to get ND to outlaw FGM was ignored. Any parent can legally circumcise a male child at any age, so far as I can determine, even in a non-medical setting, no matter what the humiliation and pain.

So what’s my point? We must come to recognize that female and male genital mutilation is one of the worst forms of sexual harassment there is. It is also one of the worst forms of child abuse. The North Dakota Alliance for Sexual Abuse Prevention and Treatment (headed by Gladys Cairns) listened to my presentation, but has since ignored the issue. Drs. Johnson and Lutz, UND Chairs of Pediatrics and Gynecology, not only find nothing wrong with male circumcision, they actually advocate it (though they are in the minority of MD’s who think it is to be done for medical reasons), and belittle my questioning of it and refuse to open a dialogue on the issue. Chancellor Treadway did not even acknowledge my letter to him (enclosed) written after he and Kermit Lidstrom exchanged some concern over my bringing on campus the head of NOCIRC (National Organization for Circumcision Information Research Centers), Marilyn Milos and inviting North Dakota physicians to respond to her (no one would).

On the assumption that you, like most of us, have never even thought about this issue and don’t know what the facts are, I’m enclosing some material (sorry it is so voluminous even though it represents only a trifle of what is available). What I am hoping to get from you is some help in opening a dialogue on the issue of circumcision and sexual harassment in the academic environment. If you are at all like me, you will come to see this ritual as one of the more brutalizing, harassing practices our society carries out. Thinking about male circumcision is a very good balance to the present emphasis on female harassment. I hope to have legislation introduced in the next session, since I have two or three legislators who have said they would.

 I have come to appreciate how painful this issue is, not just to the children operated on, but to all of us who are in complicity with this operation. Only episiotomies are a more common operation (another form of sexual harassment, as is the whole dehumanizing American way of birth. See Robbie Davis, Birth as an American Rite of Passage, 1992 and Jessica Mitford, The American Way of Birth, 1992). Anyone working on a doctorate in sociology, etc., would find a gold mine in studying the reaction of people to this issue.

If I can interest you in organizing a forum in the Valley to discuss the history, psychology, physiology, ethics and legality of male and female ritual genital surgery, let me know. I would be glad to talk or lead a discussion group. I can also get MD’s and Marilyn Milos to come in for presentations. Unfortunately, I cannot get any North Dakota physicians to address the issue (Dr. Alan Lindemann, Fargo OB-Gyn may) though several have given me statements indicating their opposition. It really is not a medical issue anyway, though most think it is. I would like to see people from various departments at a roundtable. Perhaps, just informally at first so people can start to think about the ethical, legal, psychological and medical issues involved. (Wiswell’s “research” data was shot down this year when other physicians pointed out that his diagnoses of  UTI’s were taken from a “bagged” urine specimens rather than “in stream” to avoid external contamination of the specimen).

Thank you for your consideration of this unpopular issue. Circumcision not only abuses people but our denial that it is abuse is another, perhaps worse, abuse, like telling a rape victim that she should have enjoyed it.

Sincerely yours,

Duane Voskuil, Ph.D.
Philosophy, BSC