Expert Statement: Dr med. Wolfram Hartmann, President of “Berufsverband der Kinder- und Jugendärzte” (professional association of paediatricians)
for the Hearing on the 26th of November 2012 Concerning the Drafting of a Federal Government Bill:
“Drafting of a law regarding the scope of child care and custody in the case of male circumcision”and concerning the draft billing by members of parliament: Marlene Rupprecht, Katja Dörner, Diana Golze, Caren Marks, Rolf Schwanitz, additional members of parliament: “Drafting of a law regarding the scope of care, custody and rights of a child in the case of male circumcision”.
1. Preliminary Note
This statement has been written in agreement with the German Academy for Pediatrics and Adolescent Medicine (DAKJ) “Deutschen Akademie für Kinder- und Jugendmedizin (DAKJ)”. The German Society of Paediatrics and Adolescent Medicine “The Deutsche Gesellschaft für Kinder- und Jugendmedizin (DGKJ), which is the umbrella organisation of all paediatric associations in Germany, the Berufsverband der Kinder- und Jugendärzte BVKJ (Association of paediatricians), the Deutsche Gesellschaft für Sozialpädiatrie und Jugendmedizin DGSPJ (The German society for social paediatrics and adolescent medicine), for further cooperating organisations see (www.dakj.de). I would also like to refer to the statement issued by the Deutschen Gesellschaft für Kinderchirurgie (German society for child surgery) (http://www.dgkic.de/index.php/presse/204pressemitteilung-oktober-2012) regarding this subject.
2. Medical Indication
Initially, it should be observed that there is no reason from a medical point of view to remove an intact foreskin from underage boys or boys unable to give consent. Additionally, in pre-school age, there is only very rarely a real medical indication for removing the foreskin (circumcision). At this age the foreskin (praeputium) is physiologically to a greater or lesser extent, strongly fixed to the glans of the penis. Infections and painful tears often occur due improper attempts to pull back the fixed and still immature foreskin.
The male foreskin is a part of the skin of the organ and fulfils important functions that protect the very sensitive glans. It normally covers the glans and protects it from harmful substances, friction, drying out and injuries. It has apocrine sweat glands, which produce cathepsin B, lysozyme, chymotrypsin, neutrophile elastase, cytokine, and pheromone such as androsterone. Indian scientists have shown that the subpreputial wetness contains lytic material, which has an antibacterial and antiviral function. The natural oils lubricate, moisten and protect the mucous membrane covering of the glans and the inner foreskin. The tip of the foreskin is richly supplied with blood by important blood vessel structures. The foreskin serves as a connective channel for Berufsverband der Kinder- und Jugendärzte (BVKJ. e.V.) many important veins. Circumcision can lead to erectile dysfunction as it destroys these blood vessels. Their removal can, as described by many of those who have been affected, lead to considerable limitations to sex life and cause psychological stresses.
The statement from AAP (DOI: 10.1542/peds.2012-1989 Pediatrics; originally published online August 27, 2012) cited over and over again, contradicts earlier statements from the same organisation, without the necessity of referring to new research results. Since then, this AAP statement as been graded by almost all other paediatric societies and associations worldwide as being scientifically untenable. An appropriate counter-statement has been drawn up and will be published at the start of 2013 also in the renowned journal Pediatrics. I have attached an overview of the authors of the international joint statement and an abstract at the end of my reports. These reports are substantiated by extensive literature.
The American legal organisation (Attorneys for the Rights of the Child – www.arclaw.org) has also criticised the AAP statement in a reader’s letter to the journal Pediatrics. Saying that includes errors and contradictions, and infringements against AAP’s own statements concerning bioethics, as well as against several civil and criminal laws in the USA.
Also the WHO recommendation concerning prophylactic circumcision only applies to sexually mature active men in countries with low hygiene standards and can not be used as a reason for the prophylactic circumcision of underage boys who are unable to give consent. The use of condoms for HIV prevention is the most effective way of preventing cancer (with reference also to HPV preventative vaccination) and for prevention against genital infections amongst men and women.
There is no medical society in the world, including the AAP, that sees a significant advantage in the common circumcision of small boys or generally recommend it. Until now, the psychological consequences of an early circumcision (see. Boyle et al., Page et al., Taddio et al., Yilmaz et al.) remain largely undiscussed in the statements of medical societies and have not been incorporated into their recommendations. It was not possible until now to exactly quantify the risks associated with circumcision. The assumption that it has a preventative use is mainly based on data that was collected in Sub-Saharan Africa, which are strongly doubted. In this situation, without medicinal indication for the need to circumcise, a competent clarification of the surgery to the persons concerned or those having custody is not possible in the normal manner before a “prophylactic” or religiously motivated circumcision.
3. Ethnical and Medical Aspects
The Declaration of Geneva was adopted in September 1948 at the 2. General Assembly of the World Medical Association at Geneva in Switzerland. It is intended to be a modern version of the Oath of Hippocrates and has been revised (1968, 1983, 1994, 2005 and 2006) ] it says:
“I will, in my duties as a doctor, not be influenced by patients age, illness or disability, confession, ethnic origin, sex, nationality, political affiliation, race, sexual orientation or social standing. I will respect every human life from its begining and even under threat not carry out my medical practice in contradiction to the laws of humanity.” (end of citation)
Religious rules must not influence doctors in the way they care for their patients – and in this case underage children deserve special care. Boys have, according to our sense of justice, the same basic constitutional legal rights to physical integrity as girls, they must not be disadvantaged due to their sex (Art. 3 GG – of the German Constitution). The parents right to educate and freedom of religion end here, where the rights to physical integrity of an underage person and child who is incapable of giving consent are infringed (Art. 2 GG), without there being a clear medical indication. This is applicable according to the opinion of all paediatric associations in Germany and applies to other injuries to intact body surfaces such as piercing, tattooing and ear piercing.
In the German Federal Government’s draft legislation, consideration of the child’s wishes is being talked about, “provided that it can be established … especially when bearing in mind that the surgery cannot be reversed at a later date”. In the case of an infant, it is in view of the scale of the surgery, not possible to explain the consequences of the surgery comprehensively to the child and get its consent. Especially the consequences of a complete removal of the foreskin cannot be correctly explained to a child, who is not yet sexually active, in order to ask for their consent. Also parents cannot give their consent and act on behalf of the child because surgery in this case is medically unnecessary and parents cannot at all judge, what future needs he will or will not have regarding body surfaces and sexual fulfilment. Personal experiences cannot be used as a yardstick in this case.
In this context I quote from the Statement of the national coalition for implementation of the UN Convention on the Rights of the Child in Germany from September 2012 (Stellungnahme der National Coalition für die Umsetzung der UN-Kinderrechtskonvention in Deutschland):
“However, the National Coalition in this context would like to point out the requirements in Article 3(1) of the UN Convention on the Rights of the Child [welfare of the child], whereby signing countries are obliged to make the well-being of the child their primary consideration. Such a priority is not apparent in the provisions. Rather the impression that the child’s physical and emotional integrity is second class when regarding consent to circumcision. Which means that the suggestion made in the provision, given in the tradition of an understanding of child’s rights in the interests of child protection, does not give enough consideration to the subject status of children. The provisions of the Council of Europe Convention regarding human rights and biomedicine could give orientation, 2 those which cover the protection of persons incapable of informed consent: “In the case of an incapable person an intervention [for health reasons] can only take place if it is for their direct benefit.“ Also if the affected child, due to lack of ability to reason and make judgements, cannot themselves effectively give consent to surgery, it could be emphasised that parents must carefully make their decision in the best interests (for original text in English see Art. 3 UN CRC) of their child. The National Coalition refers in this context to General Comment3 No. 12 of the UN committee for the participation of children4, in which the committee emphasised that Article 3 (the child’s interests are of primary consideration) and Article 12 (observance of the right of a child to freely express their views) should be understood as being mutually complementary. The committee excludes in its commentary even the proper fulfilment of the requirements of Article 3 of the UN Convention on the Rights of the Child, if the requirements of Article 12 are observed5. In addition, regarding the observance of a child’s opinion, the UN committee emphasises that the maturity of the child must not be linked to a certain age but must be examined from case to case.” (end of quotation)
The federal governments draft legislation mentions the rules of medical practice that must be complied with. However, at the same time, it permits an exception for babies up to 6 months old and is not restricted to a qualified medical doctor. However, a qualified medical doctor must be made mandatory especially in the case of babies.
As substantiated by the literature list given below (only a part of an extensive literature list), babies have a pronounced sensitivity to pain and a lasting memory of pain. This means that such surgery must only be carried out under full narcosis. The operation could only be permitted under medical supervision in a room approved for operative surgery with emergency standby personnel. I would, however, like to point out that we don’t have any overall assessment of an 8 day old child, whether or not the child has any medical contraindications against such surgery, for example a congenital coagulopathy (clotting disorder), hemoglobinopathy or an antibody deficiency syndrome. These illnesses are not determined during routine examinations of newly born (U1, U2, supplementary screening of newly born) and can lead to considerable postoperative complications. EMLA® Cream, repeatedly mentioned by the supporters of the administration of an anaesthetic for newly born circumcision, does not nearly provide enough against a newly born’s sensitivity to pain and must not get onto the mucus membrane of the genitals or be used for babies with methaemoglobinaemia or Glucose-6-phosphate dehydrogenase deficiency (G6PD). This also a reason to strictly reject the government’s draft bill.
Referring to the anaesthesiological aspects, I would like to point out the statement made by Ms Dr Birgit Pabst concerning the recommended actions of the German society for aesthesia and intensive medicine’s pediatric aesthesia workgroup (Arbeitskreises Kinderanästhesie der Deutschen Gesellschaft für Anästhesie und Intensivmedizin (DGAI), has been forwarded to the legal affairs committee of the Bundestag (the lower house of German parliament) for this hearing.
4. Consequences of Circumcision and Complications
Unfortunately the consequences of circumcision of affected men were not heard during this debate. Therefore, I would like to refer to the reports of the affected men at: http://mogis-verein.de and http://www.beschneidung-von-jungen.de/home/maennliche-beschneidung.html. That there are even far more unpleasant consequences and complications, which lead to consultations in the practices of paediatric doctors, was proven by a DAKJ survey taken over both the last two months. In an internet based survey about 10% of children have reported the following complications to paediatric doctor’s practices in Germany as a result of circumcision. Data has been recorded since 01.01.2010:
DAKJ survey of complications arising due to the circumcision of male children and newly born (period 01.01.2010 to 10. November 2012) (458 paediatric doctor’s practices have supplied usable results)
Question 1: How many newly burns have been presented in your practice since 01.01.2010 with complications due to a circumcision? 298
Question 2: How many babies have been presented in your practice since 01.01.2010 with complications due to a circumcision? 351
Question 3: How many children, who are older than a baby, have been presented in your practice since 01.01.2010 with complications due to a circumcision? 1209
Question 4: How often have you seen a local infection in this age range (that required a local treatment)? 1204
Question 5: How often have you seen a systematic infection in this age range (that required a systemic antibiotic)? 628
Question 6: How many cases with wound dehiscence (separation of the inner and the outer foreskins with bad cosmetic results) have you seen? 737
Question 7: In how many cases was a re-circumcision necessary? 249
Question 8: How many local bleedings have you experienced? 470
Question 9: How many of these children were circumcised by a circumciser who was not a medical doctor? 82
Question 10: How many of these children were circumcised by a medical doctor? 695
These results speak for themselves and impressively disprove the repeatedly expressed assertion that it only involves completely harmless operation without significant complications. Even a qualified medical doctor can not protect absolutely against complications.
The Federal Governments draft legislation must be firmly rejected from a paediatrician’s point of view. The reasons are given above. The all-party alternative draft by members of parliament Marlene Rupprecht, Katja Dörner, Diana Golze and additional members of parliament represents a compromise proposal, given the high political sensitivity of this issue in Germany. The practice, mentioned, which has already been frequently carried out
within both the Jewish and Islamic religious communities, makes allowances for newly born and small children and carries out only a symbolic act of circumcision without any bodily harm. It postpones the real circumcision until an adolescent is competent enough, due to their intellectual and physical maturity, to be in a position to make their own decision, as to whether or not he agrees, after comprehensive medical clarification of the lasting consequences of this operation, to this change to his body’s surface that will enable him to become accepted as a full member in the religious community.
This practice is maintained in many countries around the world also in Israel and does not lead to non-circumcised children from being excluded from religious life or that Jewish or Muslim life in these countries is no longer possible.
The debate over ritual circumcision shows fundamentalist characteristics. The proponents of circumcision trivialise this form of bodily harm, which can also lead to lifelong physical and emotional injuries and repeatedly accuse the advocates of child welfare with anti-Semitism.
This is not acceptable and I expect the Central Council of Jews in Germany to distance themselves from such accusations. Especially paediatricians many years ago, long before the existence of the German Medical Association, subsequently dealt with injustices done to Jewish colleagues during the Nazi regime, publically apologised and asked the survivors for forgiveness. This is laid down in detailed documentation and corresponds to the current position of all paediatric associations in Germany.
Also we do not discriminate against Muslims. They form a significant part of our patients and we know that the parents are happy to entrust us with their children and are very pleased with our medical care. Next year the Berufsverband der Kinder-und Jugendärzte (association of paediatricians) will fully devote its annual focus to the problems that immigrant children face in our society. In this case the Muslim immigrant children form the largest group.
However, we must be allowed as advocates of child welfare, to question thousand year old religious rites and customs, which permanently impair the physical integrity of an underage person or child who is incapable of consent, and in the 21st century, based on new findings, stimulate people to think about them, asking whether or not it would be also possible for boys to be educated in the religious tradition of their parents without needing to have their foreskins removed.
The current Federal Government’s draft legislation regarding the scope of care and custody of a child in the case of circumcision of male children unintentionally paves the way towards demands for legal circumcision for female children. The Evangelical Central Office for Questions about World Views (die Zentralstelle für Weltanschauungsfragen der evangelischen Kirche in Deutschland) pointed this out in September 2012 in a document: (http://www.ekd.de/ezw/Publikationen_2762.php). Sure enough Mohamed Kandeel (also written ‘Kandil’), professor for gynaecology and obstetrics at the University of Menofiya, Egypt, does demand a worldwide legalisation of female genital mutilation (FGM) types Ia and Ib, which means removal of the clitoral hood (clitoral prepuce) only (type Ia) or together with the clitoris (type Ib). He claims that negative consequences cannot be proven for those women affected. Therefore it is not understandable that circumcision of boys should be allowed but that of girls prohibited worldwide. Male circumcision is basically comparable with FGM types Ia and Ib that the Schafi Islamic school of law supports (http://f1000research.com/articles/female-genitalcutting-
is-a-harmful-practice-where-is-theevidence/#reflist). Kandeel was previously a member of The Geneva Foundation for Medical Education and Research (GFMER) (Genfer Stiftung für Medizinische Ausbildung und Forschung) who work closely with the WHO.
6. Recommendations for Further Reading
International statement regarding the AAP 2012 reports:
Cultural Bias in AAP’s 2012 Technical Report and Policy Statement on Male Circumcision
Morten Frisch1, MD, PhD, Yves Aigrain2, MD, PhD, Vidmantas Barauskas3, MD, PhD, Ragnar Bjarnason4, MD, PhD, Su-Anna Boddy5, MD, Piotr Czauderna6, MD, PhD, Robert P. E. de Gier7, MD, Tom P. V. M. de Jong8, MD, PhD, Günter Fasching9, MD, Willem Fetter10, MD, PhD, Manfred Gahr11, MD, Christian Graugaard12, MD, PhD, Gorm Greisen13, MD, PhD, Anna Gunnarsdottir14, MD, PhD, Wolfram Hartmann15, MD, Petr Havranek16, MD, PhD, Rowena Hitchcock17, MD, Simon Huddart18, MD, Staffan Janson19, MD, PhD, Poul Jaszczak20, MD, PhD, Christoph Kupferschmid21, MD, Tuija Lahdes-Vasama22, MD, Harry Lindahl23, MD, PhD, Noni MacDonald24, MD, Trond Markestad25, MD, Matis Märtson26, MD, PhD, Solveig Marianne Nordhov27, MD, PhD, Heikki Pälve28, MD, PhD, Aigars Petersons29, MD, PhD, Feargal Quinn30, MD, Niels Qvist31, MD, PhD, Thrainn Rosmundsson32, MD, Harri Saxen33, MD, PhD, Olle Söder34, MD, PhD, Maximilian Stehr35, MD, PhD, Volker C.H. von Loewenich36, MD, Johan Wallander37, MD, PhD, Rene Wijnen38, MD, PhD
Affiliations: 1Consultant, Statens Serum Institut, Copenhagen, and Adjunct Professor of Sexual Health Epidemiology, Faculty of Medicine, Aalborg University, Aalborg, Denmark; 2Professor of Pediatric Surgery, Hôpital Necker Enfants Malades, Université Paris Descartes, Paris, France; 3Professor and President of the Lithuanian Society of Paediatric Surgeons, Lithuania; 4Professor of Pediatrics, Landspitali University Hospital, Reykjavik, Iceland; 5Consultant in Pediatric Surgery and Chairman of the Children’s Surgical Forum of the Royal College of Surgeons of England, UK; 6Professor of Pediatric Surgery, Medical University of Gdansk, Gdansk, Poland; 7Consultant in Pediatric Urology and Chairman of Working Group for Pediatric Urology, Dutch Urological Association, The Netherlands; 8Professor of Pediatric Urology, University Children’s Hospitals UMC Utrecht and AMC Amsterdam, The Netherlands; 9Professor and President of the Austrian Society of Pediatric and Adolescent Surgery, Austria; 10Professor and President of the Paediatric Association of the Netherlands, The Netherlands; 11Professor and General Secretary of the German Academy of Paediatrics and Adolescent Medicine, Germany; 12Professor of Sexology, Aalborg University, Faculty of Medicine, Denmark; 13Professor of Pediatrics, Rigshospitalet, Copenhagen, Denmark; 14Consultant in Pediatric Surgery, Landspitali University Hospital, Reykjavik, Iceland, and Karolinska University Hospital, Stockholm, Sweden; 15President of the German Association of Pediatricians, Germany; 16Professor of Pediatric Surgery, Thomayer Hospital, Charles University, Prague, Czech Republic; 17Professor and President of the British Association of Paediatric Urologists, UK; 18Professor and Honorary Secretary of the British Association of Paediatric Surgeons, UK; 19Professor and Chairman of Committee on Ethics and Children’s Rights, Swedish Paediatric Society, Sweden; 20Vice President and Chairman of the Ethics Committee of the Danish Medical Association, Denmark; 21Practicing Pediatrician and Member of Ethics Committee of the German Academy of Pediatrics, Germany; 22Consultant in Pediatric Surgery and President of The Finnish Association of Pediatric Surgeons, Finland; 23Associate Professor of Pediatric Surgery, Helsinki University Children’s Hospital, Helsinki, Finland; 24Professor of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Canada; 25Professor of Pediatrics, Chairman of the Ethics Committee of the Norwegian Medical Association, Oslo, Norway;
26Consultant in Pediatric Surgery and President of the Estonian Society of Paediatric Surgeons, Tallinn, Estonia; 27Consultant in Pediatrics and President of The Norwegian Paediatric Association, Norway; 28Chief Executive Officer of the Finnish Medical Association, Finland; 29Professor and President of the Latvian Association of Pediatric Surgeons, Latvia;30Consultant in Pediatric Surgery, Our Lady’s Children’s Hospital, Dublin, Ireland, 31Professor of Pediatric Surgery, Odense University Hospital, Odense, Denmark; 32Chief of Pediatric Surgery, Landspitali University Hospital, Reykjavik, Iceland; 33Associate Professor of Pediatrics, Helsinki University Children’s Hospital, Helsinki, Finland; 34Professor and President of the Swedish Pediatric Society, Stockholm, Sweden; 35Professor of Pediatric Surgery, Dr. v. Haunersches Kinderspital, Ludwig-Maximilians Universität, Munich, Germany; 36Professor and Chairman of the Commission for Ethical Questions, German Academy of Pediatrics, Frankfurt, Germany; 37Professor and Chairman of the Swedish Society of Pediatric Surgery, Sweden; 38Professor and Chairman of the Dutch Society of Pediatric Surgery, The Netherlands
Abstract (236 words)
The American Academy of Pediatrics (AAP) recently released its new technical report and policy statement on male circumcision, concluding that current evidence indicates that the health benefits of newborn male circumcision outweigh the risks. The technical report is based on the scrutiny of a large number of complex scientific articles. Therefore, while striving for objectivity, the conclusions drawn by the eight task force members reflect what these individual doctors perceived as trustworthy evidence. Seen from the outside, cultural bias reflecting the normality of non-therapeutic male circumcision in the US seems obvious, and the report’s conclusions are different from those reached by doctors in other parts of the Western world, including Europe, Canada, and Australia. In this commentary, a quite different view is presented by non-US-based doctors and representatives of general medical associations and societies for pediatrics, pediatric surgery and pediatric urology in Northern Europe. To these authors, there is but one of the arguments put forward by the AAP that has some theoretical relevance in relation to infant male circumcision, namely the possible protection against urinary tract infections in infant boys, which can be easily treated with antibiotics without tissue loss. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts and penile cancer, are questionable, weak and likely to have little public health relevance in a Western context, and do not represent compelling reasons for surgery before boys are old enough to decide for themselves.
Literature about sensitivity to pain and managing pain amongst newly borns:
Benrath J, Sandühler J (2000): Nociception in newborn and premature babies (Nozizeption bei Früh und Neugeborenen)
Pain 14: 297-301
Bowmeester NJ, Hop WCJ, van Dijk M, Anand KJS, van den Anker JN, Tibboel D (2003): Postoperative pain in the neonate: age-related differences in morphine requirements and metabolism. Intensive Care Med (2003) 29:2009 ・ 2015 Boyle G J, Goldman R., Svoboda J St , Fernandez E (2002): Male Circumcision: Pain, Trauma and Psychosexual Sequelae. J Health Psychology 7:329-343
Boyle GJ (2003): Issues associated with the introduction of circumcision into non-circumcised society. Sex. Transm. Infect. 79: 427-428
Brady-Fryer B, Wiebe N, Lander JA (2004): Pain relief for neonatal circumcision. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004217
Cyna AM, Middleton P: Caudal epidural block versus other methods of postoperative pain relief for circumcision in boys (Review) Reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2010, Issue 11
Fitzgerald M, Koltzenburg M (1986): The functional development of descending inhibitory pathways in the dorsolateral funiculus of the newborn rat spinal cord. Brain Res. 389:261-270
Page, GG (2004): Are There Long-Term Consequences of Pain in Newborn or Very Young Infants? J Perinat Educ. 13(3): 10–17
Paix BR, Peterson SE (2012): Circumcision of neonates and children without appropriate anaesthesia is unacceptable practice. Anaesth Intensive Care 40(3): 511-516
Rosen M (2010): Anesthesia for ritual circumcision in neonates. Paediatr Anaesth.20(12):1124-1127
Sorrells L , Snyder JL, Reiss MD et al. (2007): Fine-touch pressure thresholds in the adult penis. British Journal of Urology International; 99:864–69.
TaddioA, Katz J, Illersich AL, Koren G (1997): Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet 349(9052):599-603
Yilmaz E, Batislam E, Basar MM, Basar H (2003): Psychological trauma of circumcision in the phallic period could be avoided by using topical steroids. Int. J. Urology 10: 651-656
Friedrich Manz: Wenn Babys reden könnten! (if babies could speak!) See: pp. 477 ff. Dortmund 2011, Fördergesellschaft Kinderernährung e.V. (Society for promoting child nutrition)
Additional literature at the German centre for child pain and child palliative care centre in Datteln (Deutsches Kinderschmerzzentrum und Kinderpalliativzentrum Datteln) Mr Prof. Dr. Boris Zernikow, Vestische clinic for children and adolescents (Vestische Kinder- und Jugendklinik Datteln), Witten/Herdecke University, Dr.-Friedrich- Steiner-Str. 5, 45711 Datteln