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Bismarck State College Philosophy and Ethics Instructor
Rhonda Ketterling, M. D., Rugby physician, former Chair of the ND Board of Medical Examiners (NDBME) and Medical Director for U.S. Healthcare in ND, in a letter, 11/ 20/ 92, to Duane Voskuil: I sympathize with your desire to have infant circumcision become a thing of the past, …
She wrote further, You will not get the medical profession to overwhelmingly alter its practice by coming on with an accusation of child abuse and/or sexual abuse....your best bet in this program [to stop routine infant circumcision] is that of education, not only of the general public, but of physicians...[and to] get insurance companies not to reimburse for circumcision...[since] this is not a medically necessary procedure.
In a phone conversation taped with permission by Jody McLaughlin, 1993, she also said that giving consent for surgery forms to parents to sign, who do not ask for them, could be considered solicitation for elective surgery.
Robert Wentz, M.D., pediatrician and former State Health Officer, now Deputy Insurance Commissioner: Time has come to stop the practice of routine infant circumcision,
He wrote further that the purported medical indications are outweighed by risks and disadvantages and that circumcisions represent an unnecessary health care cost.
Letter to Duane Voskuil, 10/1/92.
Roger Allen, M.D., neonatologist, Minot, during an interview on KMOT TV, November 1992: Parents have usually made a firm decision [whether or not to circumcise] before they ever talk to me. Their decisions are 95% based on emotions and 5% based on fact...There is no compelling reason to do a circumcision, but on the other hand, there is no compelling reason not to.
He repeated essentially the same words again during a TV interview, May 1994. [See Janet Wentz' appropriate response below under Government Officials.
]
Craig Shoemaker, M.D., Director of Neonatal Services and Chairman, Department of Pediatrics, Fargo Clinic, MeritCare during a phone conversation: You're right. We only circumcise healthy babies.
He also agreed that the medical reasons for routine circumcision are not compelling, and also wrote, 11/3/92: I personally do not feel that I have the right to decide for my patients [parents or newborn?] whether or not they should be circumcised.
[Many people have a hard time seeing the patient--the infant--as the patient. Elective surgeries must be elected by the patient to be morally justified.]
Ron H. Miller, M.D., pediatrician, Fargo Clinic, letter to Duane Voskuil, 9/26/92: What risk is acceptable when one is tampering with something that is normal?...Physicians in general are very divided on this....although most pediatricians take a fairly moderate if not anticircumcision approach, most urologists and surgeons in the united States, even ones who trained in Canada, seem to take a position advocating circumcision.
He also tried several years ago to get BlueCross BlueShield to stop covering it.
Shari L. Orser, M.D., Ob-Gyn, Q&R/Women's Health Center and UND medical school graduate in a letter to Duane Voskuil, 11/24/92: I personally am opposed to circumcision....I feel that the evidence is not strong enough to support circumcision as a routine and that the practice should be discontinued.
Shari L. Orser, M.D. Chair, Department of OB/GYN, Medcenter One: It was felt that educating the parents should be the key focus, and the members of the Department of OB/GYN have agreed to make a concerted effort to provide parents with information regarding [the risks of] circumcision. However, if after reviewing the information the parents wish to proceed with the procedure, we will abide by their wishes, and they will be required to provide thehospital with a signed informed consent.
Letter, 10/5/94.
Alan Lindemann, M.D., Ob-Gyn, Fargo, November 1992: If we were to take routine infant circumcision outside the present circumstances, it would clearly be child abuse....Parents should be forced to watch a circumcision before they agree to one....I was taught at UND that it didn't hurt.
Dennis J. Lutz, M.D. Chairman UND Medical School Department of Obstetrics and Gynecology in a letter to Duane Voskuil, 10/30/92: Obviously there are design problems with some of the studies,...[but] Enough studies linking STD's [sexually transmitted diseases] to uncircumcised males have been published to give rise to the often repeated admonition
[I find Dennis Lutz and George Johnson, below, fellow faculty members of the ND University System, to hold intellectually embarrassingpositions.]it doesn't matter what you do with your sons, but don't let your daughters sleep with uncircumcised males.
Charles Severn, M.D., St. Alexius and Robert Grassy, M.D., formerly of Medcenter One, both told Duane Voskuil in phone conversations, fall of 1992, that the surgery is not medically indicated, though they do them because the parents want them.
Daniel Grover, MD. in a letter to the Bismarck Tribune, 1/22/93: I worked in Panama as a doctor for 20 years and saw many, many complications of foreskins not being circumcised....All of these [cancer, adhesions, urinary retention, phimosis and surgical infections] are avoided by the simple process of circumcision. The urologist [who?] informs me that AIDS is more likely to be transmitted to and from non-circumcised men; and urinary tract infections are more likely to occur also.
[Amputating part of one's penis is not simple,
that is, insignificant, and does not decrease sexually transmitted diseases. As for UTIs, even the questionable retropective studies by Thomas Wiswell show a hundred circumcisions would be required to prevent one UTI, and still girls are four times more likely to get a UTI than boys. What about the many botched jobs,
even death, and the loss of half the penis' sensuous nerve endings?]
Robert Roswick, M.D. and Jeffrey Smith, M.D., Family Medical Center, Bismarck, in office visit conversations, 1993: Routine infant circumcisions are not done for medical reasons.
Thomas W. Mausbach, M.D., former ND Chapter President, American Academy of Pediatrics in a letter to Rhonda Ketterling, Chair of the ND Board of Medical Examiners, 1/26/93: ...I think the important issue is that the total complete scientific evidence is just not complete yet [it is for most people in the world, and this is the very reason for a moratorium]....The key issue is that these individuals who are against circumcisions have no significant scientific evidence to justify a moratorium against circumcisions in our state. Personally I do not feel they are going to go very far because of these public and social issues regarding circumcisions in the United States. I guess it is better to have them standing on the soapbox regarding this issue than something that could be a more detrimental issue for medicine. Sorry I could not help you any further but I think philosophically these people do not have much ground to stand on.
[Even the national AAP does not recommend routine infant circumcision. He confuses medicine
with health.
Most MD's do not agree with his view. Even Rhonda Ketterling ,to whom he is writing, does not think routine circumcision is sound medical practice.]
Robert Pathroff, M.D., urologist, Bismarck, ND, verbally, 6/94: Routine circumcisions cannot be justified on medical grounds.
George Magnus Johnson, M.D., Chairman, Department of Pediatrics, UND School of Medicine in a letter to Duane Voskuil, 9/7/92: Urologists stoutly maintain that cancer prevention (squamous cell carcinoma of the penile foreskin) is one of the major reasons for circumcisions. This is a reason above and beyond prevention of urinary infections in the males.
[More babies die from circumcision than old men do from penile cancer (about 200 per year), and Wiswell's UTI correlation's have been shown to be systematically flawed and statistically trivial even if true. 100 healthy babies would need surgery to prevent one treatable UTI. Not all, or even most (hardly any in Europe and Asia), urologists will put their credentials on the line to defend this practice. See Robert Pathroff above.]
Jon Rice, M.D., ND State Health Officer: This [routine infant circumcision] is not a medical issue.
He elaborated in a conversation with Jody McLaughlin, July 1993, that his reluctance to deal with the circumcision issue, was that he was mainly interested in medical issues, not health issues, because even though he is the State Health Officer, he is a physician first.
Wes Borowski, MD, Rugby in a letter to the Minot Daily News, 1/14/95: ...To describe the foreskin as an essential [body] part would be reaching beyond the boundaries of common sense. I agree that infant circumcison cannot be strictly defined as medically essential.
[What other healthy body parts are not essential? Is the female prepuce, e.g., any more essential?]
Joseph Cleary, MD, Medical Consultant for ND Medicaid said Medicaid does not cover circumcision unless there is a medical indication, which includes phimosis [prepuce is too tight] and balanitis [an infection of the prepuce or glans penis]. He said these two conditions can happen the first day after delivery. 1/96 [Phimosis is not a condition diagnosable in newborns, and balanitis is ahighly unlikely condition for neonates.]
Medicaid's present policy statement for ND: Effective for services provided on or after November 1, 1986, the North Dakota Medical Assistance Program will provide payment for circumcisions only when there is documented evidence that the circumcision was performed due to medical necessity. Routine circumcisions that are not medically indicated will no longer be reimbursable through the Medical Assistance Program.
And further, Davis Zentner, Medicaid Director, offered the following policy statement from the ND Department of Humans Services: Medicaid pays for circumcisions only when they are medically necessary. Our medical consultant [Joseph Cleary, MD] reviews all claims with circumcisions and payment is allowed for the diagnoses phimosis and balanitis. If other diagnoses are used, the medical necessity must be documented and approved by the medical consultant. Routine circumcision for newborns are not a covered service. Providers should notify the family before the procedure is performed that Medicaid will not cover routine circumcisions.
Emphasis added. ```[Phimosis and balanitis can hardly ever be a diagnosis for a newborn or even an infant, since whether the prepuce is too tight (phimosis) cannot be known until it physiologically separates from the glans, often not until teen years; and very few babies, especially neonates, could have infection of the glans or prepuce (balanitis orposthistis).]
Julie Weaver, Vice President Planning, Development and Benefit Administration, in a letter to Jody McLaughlin, 11/23/92: Regarding circumcisions-We [the Contract Administration Committee of BlueCross BlueShield of ND] consulted with other Plans and The American Academy of Pediatrics. The majority of these entities do not have an established policy regarding circumcision.... There is recognition by these parties that this [i.e., routine infant prepuce amputation] is an elective service. Board action taken in 1987 in response to this issue provided that payment should continue to be available for circumcisions, based on individual choice [sic], in response to the market demand for this covered service.
[Emphasis added. Letter to Jody McLaughlin, 11/23/92, from Julie Weaver.]
Julie Weaver in a letter 1/16/95: I admire your dedication to the issue you address....there will be no change in our policy or benefit provisions...[based] on much the same criteria noted in the letter from Dr. Fitzpatrick [namely to pay for some elective surgeries requested by consenting patients, like tubal ligations and vasectomies]. While we support efforts to educate the general public on circumcision so that thoughtful and informed decisioins may be made regarding this elective procedure, we are not seeking a visible role in that process at this time...[so we] request that any reference to Blue Cross Blue Shield of North Dakota be deleted.
[Infant circumcision is forced upon nonconsenting patients, and so does not fit the analogies BlueShield gives to justify paying for it.]
ND Public Employees Retirement System Group Health Plan (PERS), July 1, 1993, underwritten and administered by BlueCross BlueShield of North Dakota: You [North Dakota Public Employees] are not covered for: nonmedically necessary circumcision for newborns.
Sister Mary Margaret Mooney, P.B.V.M, R.N., Professor and Chair, Department of Nursing, University of Mary: I used to work with a physician who would ask a mother whether she wanted to mutilate her son. He never did any circumcisions.
She also said the practice continues [to a large extent] because of the financial incentives. Conversation, 1992.
Connie Kalanek, MSN, RNC, Associate Professor, Medcenter College of Nursing,: I am certainly supportive of efforts to try to stop routine circumcision. I have always regarded this procedure as repulsive and a painful experience for the neonate. I agree that the literature does not support routine circumcision of the male. It truly represents an unnecessary health care cost.
Letter, 10/22/92.
Arlene Mack , R.N., Vice President Medcenter One, Support Services. We will inform the parents of the risks [of circumcision].
Phone conversation, 10/3/94.
BSC student and Bismarck nurse: I find it very hard to believe that people, including the medical profession, have been so blind to the fact that male infant circumcision is child abuse. As a student nurse I was taught that these babies feel no pain. How stupid! These doctors taught us this! These poor babies are swaddled on a restraint board and the foreskin torn away and cut off--for what? It makes me very angry to think that we as nurses, parents and the general public have been so misled.
(Also See Those Who Are Physicians and Professors)
Gladys Cairns, Director Child Protective Services, State Capitol: When one considers what is done to the child, it is hard not to consider this child abuse,
verbally while extending an invitation to Duane Voskuil in October 1992 to address, the Alliance for Sexual Abuse Prevention and Treatment, ASAPT, a statewide group of professionals from many areas concerned with sexual child abuse.
Janet Wentz, Republican State Legislator, Minot: If there is no compelling reason to do a circumcision, that is a compelling reason not to do one,
verbally November 1992, responding to Roger Allen's KMOT TV comments of November 1992 (above).
Sandra Holbrook, Ph.D., Director of Equal Opportunity, NDSU in a letter to Duane Voskuil, 8/2/93: Thanks for your letter and for sharing the information regarding various types of sexual [genital] mutilation. This is obviously a significant gender issue....
Mother and member of ND Board of Social Work Examiners: My doctor told me circumcision was necessary to be clean and prevent infection, and besides, the military will do it anyway.
State Legislator: I took my uncircumcised son to the pediatrician for his first checkup. He ripped the foreskin back while my son screamed; I felt sick. When we came back to the clinic for the next checkup, he started crying. I took my son and left, and never went back.
State Representative Cathy Rydell, Executive Director, ND Medical Association and ND Hospital Association: When I first worked at St. Alexius, my office was right next to the circ room. I can still remember the babies' screams.
Conversation, 11/92.
Spokeswoman for the ND Committee to Prevent Child Abuse, appointed by the Governor: It [circumcision] is an issue that is being discussed, but the national level has not yet taken a position, and we tend to follow them.
Conversation, 1994.
Russell Thane, Chair, ND Senate Human Services Committee to Duane Voskuil after the committee voted unanimously to recommend passage of SB2454, the first FGM bill to become law: Thank you for bringing this issue [genital mutilation] to our attention. We needed to deal with this, but it is hard for us to do it.
North Dakota SB2454 , initiated by Jody McLaughlin and Duane Voskuil, sponsored by Senators Scherber, Mathern and Watne and Representatives Kelsh and Margaos, passed by the ND legislature, 3/95 unanimously with backing from the AMA and the North Dakota Medical Association:
Section 1. Surgical alteration of the genitals of females minors - Penalty - Exception.
Roger J. Minch, Attorney, Fargo, letter, 9/27/92: The law does not allow one to mutilate another without consent, and the law, on its face, cannot discriminate between the sexes. However, the law often blindly follows custom and usage without much reflection.
He was responding in a to a question about the legalities of amputating a healthy prepuce without consent and whether a parent or physicians could do the same thing to a female.
Thomas A. Mayer, Assistant Attorney General of North Dakota, 1/12/93: In connection with routine male infant circumcisions, the criminal elements of assault are lacking. There is no purpose to intentionally or knowingly cause bodily injury. Thus, criminal culpability is absent [for the physician]. It is assumed there is informed consent to the surgery.
Parents, guardians, and custodians are authorized to consent to health care on behalf of children.
~ N.D.C.C. Sec. 23-11-13.
Circumcision may also be performed for religious or cultural reasons. In this respect, it may be more akin to elective plastic surgery for cosmetic purposes. Arguably, such surgery does not in many instances serve any medical [i.e. health care] need. This fact would not warrant reporting elective cosmetic surgery under N.D.C.C. Sec. 43-17-41. Presently in our culture a routine male infant circumcision does not violate any North Dakota criminal statute. Emphasis added. Mayer was responding to questions (though not to be considered as a formal legal position of this office
) about culpability of physicians (and others) who perform non-medically indicated surgery on non-consenting male or female children. [He does not make clear how a surgery that does not serve any medical need,
and which is not elected by the patient, can be legally forced on a nonconsenting individual. Is he also saying in the first paragraph that a physician can remove or alter any body part on children if a parent signs a consent form?]
Heidi Heitkamp, Attorney General, State of ND, after a talk at the Unitarian Universalist fellowship, 1994, where she outlined her work to prevent child abuse and violent children: It won't do any good talking to me about it [routine infant circumcision].
[She was asked whether the violence of cirucmcision could be one factor in violent children, since it is common knowledge that those who are violated, violate others.]
Rolf P. Sletten, Commission Secretary, responding to Ramona Goheen's formal complaint (see below) that Manuel Neto, M.D., injured her son's genitals and wanted to circumcise him even thought he had hypospadies, a reason not to circumcise: This is to advise you that the Commission on Medical Competency has completed its investigation regarding your experience with Dr. Neto....In this case the Commission has determined that the circumstances do not give rise to a disciplinary action under current North Dakota law.
Letter, 10/3/94.
Robert Lynne, Bishop ELCA, in an interview fall 1992: The Lutheran Church has no rite of circumcision.
John F. Kinney, former Bishop Bismarck Diocese, who chairs a national committee to investigate sexual abuse by priests, said in a phone conversation, fall 1992: The Roman Catholic Church has taken no stand on circumcision.
Bismarck minister: People don't ask pastors about circumcision. The doctors have become society's high priests.
Conversation, 1992.
Duane Voskuil, Ph.D., former Assistant Professor and Chairman Department of Philosophy, UND, now philosophy instructor, Bismarck State College, and violin maker. Nothing would make me prouder to be a North Dakotan than to have my state lead the nation in outlawing this brutal practice.
1992. [ND was the first state to outlaw the practice of female genital mutilation of minors in 1994.]
Renee Bergstrom, psychologist and health educator now living in Elgin, MN, speaking out publicly for the first time, and videotaped, at the Third International Symposium on Circumcision, University of Maryland, Washington DC, May 1994: I was born and raised on a farm in South Dakota (to very loving parents), and when I was three years old, my mother who was concerned about the fact that I was masturbating (she had read some place that it was the ultimate sin), took me to a doctor in a clinic in [Wahpeton] North Dakota, who took me to a hospital in [Breckenridge] Minnesota and removed my clitoris. My mother was at the end of the table. I remember the pain, and I also remember knowing that I couldn't trust her any more....
[Emphasis added.] She went on to explain how the clitoridectomy has ruined much of her life, and how clergy, counselors and physicians have been no comfort.]
Ramona T. Goheen, in a letter, 9/3/94, to the North Dakota Board of Medical Examiners: I brought my son in to get Dr. Neto's opinion on surgery regarding his hypospadias. He said that my son did not need reconstructive surgery to the urinary hole, but should be circumcised so he, 'Doesn't get picked on by other boys because he won't be urinating straight.' He also stated that 'He won't learn as well in school if he doesn't get circumcised'....He forcibly retracted the foreskin without my permission causing it to redden, bleed, and swell, causing extreme pain to my son. I said to him, ' I thought you were supposed to leave it (the foreskin) alone,' while he was doing this, but he still proceeded to force it back even after I said this. He gave no explanation for forcibly retracting the foreskin from the glans. If anyone else would have done that to my son, I would have them arrested.
[See Roff Sletten's NDBME's reply above under Attorneys
.]
Jody McLaughlin, NA Representative, Primal Health Research Centre, London and editor of the Compleat Mother magazine: Circumcision is institutionalized quackery.
1995.
Female Minot High School student after watching the suffering during three circumcisions in a local hospital as part of a career orientation course in nursing:There must be a very important reason for doing this!
A mother after learning routine circumcision is not medically necessary: I now know why my son who is 28, married, in college in Utah asked me about why I did this to him. I couldn't understand why he even brought the topic up. Now I know....
25 year old Fargo business man when asked whether he was circumcised: I don't know.
A North Dakotan raised as a Jew: I don't think I would circumcise my sons.
Mother and student: I have to tell you that I feel just awful for circumcising my son. I really did think that I was doing him a big favor....This is really hard for me to handle. I can't imagine how other people feel, when they don't even know why they had them circumcised. I honestly thought I was doing him a favor. I would now wait until he was old enough, to see if he even had a problem with it....I feel I owe my son an apologywhen he gets older.
The film was the first time I actually knew exactly what they do when a baby is circumcised. The crying was so bad and just to know that doctors would do such things to a little baby for no [medical] reason is so sick! Just watching and listening to this film made my stomach turn!
The tape was an eye opener and a stomach turner. I definitely would want both my husband and me to have to be informed before making any decisions.
The film I feel was rough to watch but it was worth seeing.
I don't see why such a big fuss is made about circumcision. Women suffer all the time. Their hymen is ripped; they have pain in birth; hot flashes in menopause, etc. Men should have some pain too.
Female BSC student who two months later changed her mind when her girl friend had a baby boy.
Mother and student: I didn't have my son circumcised and the doctor gave me ahard time for years....He said the military will do it anyway.
Pre-med student: My boy friend won't marry me unless I agree to circumcise our sons.
The substitute doctor walked into the room, said he had just mutilated my child and walked out. I wish he had talked to me before he did it, if he felt thatpained about it.
Do medical staff get into trouble for trying to inform parents further about circumcision?
[Yes.]
Female BSC student: I was so ignorant that when the doctor asked me about doing the surgery, I had never really understood what they even did. I would never have even thought to ask for this surgery. She [the nurse with the consent form to sign] came to me. I guess I had only seen circumcised males and didn't even recognized they were circumcised.
No one has the right to do genital mutilations on children. If you were born with it, then let be. I just can't understand why would any one want to torture someone that way for no medical reason at all.
Male student.
I think hospitals should show this film [on infant male circumcision] to parents before they perform the circumcision.
Have you ever suggested that it be shown during Lamaze classes?
The videos were hard to watch but very necessary to give informed consent for the procedures.
BSC ethics student, 11/94: Watching the FGM was even worse the 2nd time...because I knew what was coming. The MGM was bad. I couldn't believe it. That baby goes through hell. I can't believe what I put my son through. No wonder he was crying so hard when they brought him to me. He went through hell. I'm glad you made this video available for us to watch....
I was shocked at how cruel circumcision is.
I was too shocked after watching the video [on infant male circumcision] to be able to write anything coherent on my [daily 3x5] card. But that night, at home, I told my husband about the videos and asked him, 'Why do you still see fit to perform circumcision?' (He is a neonatologist, and that is [one thing] he does for a living.) Our own two boys are not circumcised....
But when I asked him that night after watching the video, 'What good do you as a person and doctor see in this procedure,' he told me, 'The good I see is that it does reduce sensitivity, [and] the full force of sexual drive. Man is not [meant] to be subjected to the full force of his sexual drives, but instead to God.' What he was talking about is Paul and his advices about sexuality (being sinful, of course).
Well, then I asked him, 'What is wrong with being sexual? We are supposed to be, otherwise, God would not have seen fit to give us such a drive.' He insisted that it is the purpose [for sex] that matters. As 'Godly' beings we are called to transform it into something higher. From that point our conversation turned into fighting. I've been his wife for years, but I did not know that sexuality for him is 'lower' and 'lesser,' and that the purpose of it is just offspring, not on its own a joy.
I guess what I am sharing is this: I've discovered, through this topic of yours in class, a can of worms in my intimate sexual relationship that made me more sick than the explicit videos I watched. In a few years I might not remember Anaximenes, but I will my husband's remarks...!' Thanks. [This quotation shows the close tie that can exist between personal religious beliefs and medical practice.]
Male student, 1995: When I first found out about circumcision, I heard that is was done as part of a religious practice. I didn't really understand this at that time. When I got older I found it is still a very common practice. I asked my mother about it, and she said it is something little boys have done [to them] when they are born. I found this extremely disturbing. She said it was for hygiene. The thoughts I had about this [comment on cleanliness] was: What happened before anyone thought of circumcision? Did every male's organ just get diseased and fall off? I found this absurd. It couldn't just happen. I felt very angry for a long time about this misjustice: Feeling that you can be violated as a child in a way you couldn't even imagine was possible, until you learn about it.
[Is it already too late to save the medical profession's prestige and legal culpability?]
Female pre-med student to Dr. Voskuil: I would like to know something, O.K. Now I understand the concern, but if it has been going on for so many years, and it is so bad, then why has it gone on? I mean how can you know so much when our own doctors don't know that much? How can you say this has to be stopped? You can't know everything, yes?! Now, I'm not questioning your IQ. It just seems weird that if this was so painful & and hurtful that it would have gone on for so long. Plus, where do you think the doctors get their information? If not from medical school, then where? It is hard to believe doctors hurting patients for $200 or so. They are suppose to know how to heal--that's what they are taught.
[Will the NDBME answer this woman'squestions?]
I think, as a mother of two boys and a wife, [circumcision] is a good thing to discuss. I found out things today I as a mother was never told. There are harms that last the child's whole life. I have to truly say I'm pissed off I didn't hear these things from my doctor. Maybe, I would have not have had it done to my baby boys, if I would have known half of this!
[Perhaps the reason she didn't hear these things has to do with the silence of our watchdog boards. Are they legally negligent because she did not hear?]
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