(1) why amputating normal, healthy, functioning tissue from someone who has not consented to have the amputation performed does not violate the physician’s duty to act in the best medical interest of his or her patient. I further asked:

(2) why someone who performs medically contra-indicated prepuce amputations is not exhibiting a pattern of inappropriate care as defined by the North Dakota Century Code (NDCC) 43-17.1-07 (Sec. 4) and 43-17-31 (Sec. 6 and 7) because she or he has a history of performing unnecessary surgeries. I also asked you to explain

 (3) why the NDBME does not censure physicians who are defrauding their patients and parents in their practices by failing to explain that circumcision is medically unnecessary, ill-advised and has risks including disfigurement and death, and always actual losses due to the surgical removal of half of the individual’s erogenous tissue, and finally

(4) why physicians, even with parental consent to truncate their son’s penis, can have sufficient ethical and legal grounds in our democracy to perform this nontherapeutic amputation. (For what other operation would physicians defer to the request of parents when making a decision to surgically remove normal, healthy, functioning structures from a child who cannot consent?)

I received no response from you despite repeated requests. The factual evidence and the ethical grounds for the basis of my request have increased in recent years. A point has now been reached where silence on this issue is an affront to the public trust and a clear violation of the NDBME’s responsibility to follow the laws of our state and live up to its charge to protect the public from physicians who perform procedures that harm and defraud. So I’m again asking the question:

Why does the Board continue to allow the physicians it licenses to perform this medically contra-indicated procedure, a procedure which clearly fits the definition of “medical quackery”?  (See the U.S. Congress Select Committee on Aging’s definition of “quackery” in my 3/3/95 letter.)

Among the new developments since I last corresponded with the you are the following:

(1) The American Academy of Pediatrics’ (AAP) March 1999 restatement on circumcision acknowledges that prepuce amputation (their word) is not healthcare:

“...Data [from ‘existing scientific evidence’] are not sufficient to recommend routine neonatal circumcision” Pediatrics, 3/99. Article posted a  >http://www.cirp.org/library/statements/aap1999/

No medical society in the world suggests circumcision be routinely practiced under the guise of medicine.

(2) The AAP's own Committee on Bioethics in 1995 denies a healthcare provider can accept a parent’s request as sufficient grounds for a physician to legally and ethically perform a harmful or unnecessary act on a child-patient:

“‘proxy consent’ poses serious problems for pediatric health care providers. Such providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses....The pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent" Pediatrics, 2/95 emphasis added.

(3) The North Dakota legislature passed a law in 1995 criminalizing the amputation or separation of genital structures, thereby prohibiting a physician from amputating or tearing any healthy tissue of a minor girl’s genitals (whether or not a parent requests it): 

         “NDCC 12.1-36-01. FEMALE GENITAL MUTILATION

              Surgical alteration of the genitals of female minor - Penalty - Exception.

1. Except as provided in subsection 2, any person who knowingly separates or surgically alters normal, healthy, functioning genital tissue of a female minor is guilty of a class C felony.

2. A surgical operation is not a violation of this section if a licensed medical practitioner performs the operation to correct an anatomical abnormality or to remove diseased tissue that is an immediate threat to the health of the female minor. In applying this subsection, any belief that the operation is required as a matter of custom, ritual, or standard of practice may not be taken into consideration.”

The next year a similar federal law was passed. The federal FGM law of 1996 also reads that

“no account shall be taken of the effect on the person on whom the operation is to be performed or any other person, that the operation is required as a matter of custom or ritual” (Ch. 7, title 18, U.S. Code, ¶ 116),

because such a custom or ritual would permit the unnecessary mutilation of others without their consent. Additionally, the U.S. Constitution’s 5th and 14th Amendments guarantee security for individuals in their persons and property, and their right to be treated equally regardless of race, gender or beliefs (so long as one’s beliefs don’t harm others).

(4) In 1998 the AAP’s Committee on Bioethics addressed Female Genital Mutilation (anything from a small nick on the prepuce to infibulation) and correctly stated the affects of genital mutilation. Unfortunately the statement is limited to the mutilation of females.

“The physical burdens and potential psychological harms associated with FGM violate the principle of nonmaleficence, a commitment to avoid doing harm, and disrupt the accepted norms inherent in the patient-physician relationship, such as trust and the promotion of good health. More recently, FGM has been characterized as a practice that violates the right of infants and children to [have] good health and well-being, part of a universal standard of basic human rights” (RE9749). The full statement can be found at: >http://www.aap.org/policy/re9749.html  [link may be dead]

As difficult as it is

•     for men to acknowledge they’ve had a highly erogenous part of their body unnecessarily amputated, a structure required for full, normal feeling and anatomical function––a loss affecting women as well as the mutilated male (see O'Hara K, O'Hara J. “The effect of male circumcision on the sexual enjoyment of the female partner,” BJU, Vol. 83, Supplement 1, Jan. 1999, 79-84; also found at: >http://www.cirp.org/library/anatomy/ohara/), or

•     for parents to acknowledge they have failed to protect their son's sexual and bodily integrity, or

•     for circumcisers to admit they have been acting as practitioners of a ritual amputation, not as physicians carrying out a medical procedure, or

•     for any of us to accept we have failed to recognize this cruelty that has been part of our secular culture for little more than a century, still

the ethical concerns and legal issues are clear:

A. Parents may not amputate, nor allow others to amputate, a normal part of their child’s body (unless there is urgent medical need not treatable by less radical methods).

B. Physicians must act in their patients’ best interest as ethics and laws require, that is, First Do No Harm––“the principle of nonmaleficence” ––even when parents, out of ignorance or malice, fail to do so.

C. Gender discrimination is unconstitutional (even though we’ve become enculturated and ritualized to the injustice of this social practice).

Time has come for the members of the Board of Medical Examiners to protect our sons from a procedure commonly performed by physicians which has no medical justification. Phimosis, a fraudulent excuse for performing circumcision on a minor cannot be diagnosed until one is an adult, and balanitis (the other major excuse for cutting) is treatable with medication and is very rare when not iatrogenically induced by tearing the prepuce from the glans penis. Even manipulating the foreskin is not medical care. Once again to quote the AAP:

“The uncircumcised penis is easy to keep clean; no special care is required. No attempt should be made to forcefully retract the foreskin. No manipulation is necessary. There is no need for special cleansing...external cleansing...is all that is required.... Separation will evolve with time, and it should not be forced....Your boy’s foreskin may not be fully retractable until adolescence” Emphasis is found in original AAP brochure: Newborns: Care of the Uncircumcised [sic., i.e., Intact] Penis.

Worse than simply having no medical basis, circumcision is a harmful procedure that does not fit the legal definition of de minimis  (falling below the concern of the law). It surgically diminishes a man’s normal physiology, and evidence is rapidly accumulating that it can have serious, long-term, negative physical and psychological effects (as the AAP acknowledges is the case with FGM). At the very least the Board must call for a moratorium on the circumcision of minors until it is proven there are no harms (as it did with Fen Phen).

I am a witness, and there are many more also, telling you there are harms, actual harms which no so-called potential benefits can justify. If anyone wants to believe there are benefits, our society allows one to believe it and even to have parts of one’s own penis cut off. But no one has the legal or ethical right to mutilate another because of his or her beliefs, superstitions, standards of practice, financial or social considerations.

Members of the Board of Medical Examiners are appointed by the governor to act responsibly in protecting the citizens of North Dakota from physician ignorance or negative patterns of practice, including unnecessary surgery:

“ND Century Code 43-17-31. Grounds for disciplinary action.

Disciplinary action may be imposed against a physician upon any of the following grounds:

6. The performance of any...unethical...conduct likely to deceive, defraud, or harm the public.

21. A continued pattern of inappropriate care as a physician, including unnecessary surgery.

22. The use of any false, fraudulent, or deceptive statement in any document connected with the practice of medicine.”