I am Ryan, a friend of Lizzie's. I do bio-physics research at Georgetown University, and I also coordinate two non-profits that deal mostly with supporting families and supporting people in their relationships. Here is my family. So my mission in life basically is to help people get along, and towards that end, I do a lot of workshops with families and I also help families understand medical questions. So I am here to talk with you about circumcision, I am calling it an "Elephant in the Hospital" because it is this huge thing that happens as far as I see in our culture but we have very little discourse about it. It is performed between 500,000 and 1,000,000 million times each year in the U.S., almost entirely on infants within the first three days of life and it is completely unnecessary; and I believe, based on my research, entirely harmful to children. So what we are going to run through, as quickly as I can, is just a discussion what that process is like from the child's point of view, what effects it has on adult survivors, how we get parents to agree to it (what understanding parents have), and how we get practitioners to perform it. So before we do that, I actually just want to get a chance to see what our room is like so we can see each other; therefore, I will ask a few questions and we're gonna use this technology for room assessment that goes back to a before clickers. I am going to ask you, if you are willing, to point in the direction as I ask you about each thing, from beneficial, this wall is the beneficial wall, neutral is the ceiling, and harmful is the wall over there. For Example, what do you think of foot binding? I mean you are anthropologists, most of you have heard of foot binding. Where do you think it goes on the ... okay we have everyone who chose to respond, thinks it is harmful. Good I am pleased with that response. Female Genital Cutting how many people have heard of that? Okay great, we have got universally harmful. Okay what about say we were going to do prophylactic breast bud removal, say we wanted to stop breast cancer and save hundreds of thousands of women's lives per year, and say we just cut all babies' breast buds off? Beneficial? Harmful? Neutral? Okay some neutral and some harmful. Okay. And what about cutting off non-essential tissue from a child, say we just cut off all children's ear lobes because we thought they were an inconvenience, a pain or they looked ugly? Okay, we have got harmful. So what about Circumcision? What is our starting point? We have got every response, that's great; okay, so we have a diverse audience. Now a couple of other questions just to see who we are. Who here thinks that they have a foreskin, anyone? Who here believes that they have a foreskin, which is that part they remove during circumcision, right? Okay, so that is a trick question. Men and women, males and females, are both born with foreskins, the foreskin is just a name for a part of the clitoris or penis, and so probably most of the women here have one and perhaps some of the males also. Who here comes from a culture where female genital cutting is a social norm? No one, okay. Who here comes from a culture where male genital cutting is a social norm? Okay, all of us pretty much, that I can see, okay. And who knows someone who was genitally altered as a child it could be you, it could be a friend it could be your parents, or child? Mostly (all)! Great, so all of that is just to illustrate how it's something that has touched all of our lives in some way. So I am arguing that it is this big thing and that we don't talk about it a lot. So I have to sort of explain why I think that. So I believe that the discourse that we have in our culture about circumcision is one that is used to conceal what the nature of the process is. So you may have heard things like "well, you know, it makes the penis cleaner" and things like that. You may have heard things like "everyone does it," "I am circumcised, I am fine," "It is just a little snip" or "it removes a useless flap of skin," this sort of trivializing language. Well, we have heard all of these things. What I am going to ask you to do is set all that aside, all of that mass of experience in your mind, and to try to come at it from a fresh angle where these sort of illogical arguments of support for it are not part of your way of thinking. I am going to propose that circumcision is this cyclical process in our culture where we do it to children, they grow up to become adult survivors, some of those people become parents, and practitioners engage them in order to perform this surgery on their children, which unlike any other surgery I am aware of in U.S. hospitals, it removes a healthy and unique organ part (actually with the exception of inter-sex genital modification, which bears a lot of resemblance to it by the way). It removes a healthy part of the body. It is not used as a treatment. Doctors don't think they are treating the children; they know it is a social surgery they are performing. It has significant complications. It is performed on minors who cannot give their consent. It is illegal, it is actually a federal felony to perform on girls, but it is actually encouraged and performed on boys. It results in life long function loss, and the tissue is then used commercially. So just a little context piece. I hear you, believe me, and I will show you evidence of that. I won't make such a radical claim without proving it. So let's just finish our context piece with both the geography and the history. So this is a map of the world sort of. As you can see green countries represent places where genital cutting of boys is not practiced, generally speaking. The small, the few yellow countries up in the northern regions are places where it is becoming legally questioned. Circumcision is now rare in Canada, England, and Australia where it used to be practiced on babies also, but stopped. In fact, in England, in the 1950's there was an article published showing it killed a number of children a year, about 14 a year, so they stopped the practice there. And the other places, besides the United States where it is done on babies, in the other regions, most of the time, it is done on adolescents in Sub-Saharan Africa and in Sunni Islamic cultures. Now how did we get here? It has become a medical practice rather than a tribal practice or a cultural practice. And that came about in the late 1800's when people had not the germ theory of disease, but the nervous excitation theory of disease. And people had the Victorian morality, so people see what they expect to see a lot of the time. So you can find a lot of published medical literature showing that circumcision cured things such as, paralysis, epilepsy, hip joint disease, and all sorts of problems that today seem very unlikely for the process to have cured. And people really thought that actually harming, the intention was to harm the genitals of the children. And they thought that it would help in the long term because it would prevent them from having so much sexual excitation that being, in the Victorian model, the most dangerous type of excitation that one could have. So, uhm, oops, I should have given you a caveat, my apologies... There are going to be some graphic slides here, and I certainly welcome you turn away at any point if you don't feel comfortable about looking at what you see. And I will try to more often try to give you a warning when they are about to come up. I would also mention actually another cavea 42I am going to use language differently. I am going to switch now to mostly calling circumcision "genital cutting" because I think that is more of a neutral term, it's a more accurate or descriptive term. I think "circumcision" euphemistically embeds our assumption that it is a fine thing. And the term uncircumcised I am going to replace with the term "intact", because likewise the term "uncircumcised" gives the sense that circumcision is the norm and that those who are not circumcised are simply "not yet" circumcised. And to illustrate that it would be kind of weird if we called women who had breasts"un-mastectomised" right that would be uncomfortable, and, likewise, I hope to sensitize us to the discomfort of calling "intact" "uncircumcised". So the next few slides will have some less-comfortable things to see, and, again, you are welcome to turn away if you want. So this is the section on the Child. The procedure for the child, we will run through what the procedure looks like. That's probably the most graphic section, along with the complications, and what I want you to think about is, it is often times talked about from the parents' perspective,"parents have the right to choose". I want you to question that discourse and think about what the child's point of view is. Who owns the child's body? What rights do they have? Why are we doing it to boys and not girls? What does that say about our views on gender, and so on? So, this slide shows three different representations of people in the genital cutting process. The top left is a young girl being circumcised in her cultural scenario. The top right is a young boy being circumcised in his cultural scenario. And the bottom right is an infant boy in a hospital. Now what I want you to look at is their faces. Just look at their faces because I am asking you to think about their experiences. To me it looks like they are having a very similar experience. And yet in our culture, where I think of us as being kind of imperialist we're very ready to point the finger and say, Oh these terrible things these people do in these other countries where they practice female genital cutting." yet we're silent about the male genital cutting that occurs to children under the same conditions of hygiene and the same death rates in those countries;1 and we promote doing it to boys in our country.1 So how do we do a circumcision? 1 The next bits are going to be the most graphic.1 This is a circumcision restraint;1 they strap the baby down into it,1 and then they proceed with the procedure,1 which I am going to show you a short video of.1 This is going to include sound 1 if I hooked it up correctly.1 and, again, you are welcome to not look; I find this uncomfortable.1 Okay, so I want to encourage you to take a deep breath 1 if you have been having trouble breathing as I have during that. 1 Some things I think to notice is the sort of calm detachment1 of the physician's voice.1 So the physician is not at all distressed by this. 1 And the way the baby is crying.1 I hear the baby's crying as the way I hear babies cry 1 when they are under extreme duress, 1 not you know, "I am hungry."1 So beyond the pain of the procedure itself1 and the pain of the many days it takes to heal,1 there are a number of complications that a circumcision procedure puts a child at risk for. 1 You can sort of divide them into two categories.1 Surgical complications,1 which go from the more minor,1 you know everyone has a scar that has been circumcised. 1 A lot of men don't actually know that the ring around their penis1 is a circumcision scar,1 or they learn it when they hear me talk.1 But that always happens.1 But a number of other complications can be problematic 1 that don't occur all the time,1 like penile adhesions,1 when the healing process goes awry1 and two parts of the penis that weren't supposed to be connected link together. 1 Then these panels show in top left (A)1 (A) that's called a fistula, 1 so its like a doctor induced hypospadias,1 the black line going down is a probe that's entering the meatus, the opening of the urethra 1 and exiting out the additional hole 1 that the physician has caused.1 (B) Top Right is a nearly amputated head of the penis. 1 (C) Bottom Left so much skin of the penis has been removed 1 (C) that the child's corpus cavernosa and head of the penis are lodged down inside the scrotum,1 and in (D) Bottom Right the penis was accidentally amputated entirely. 1 There are also a number of post-operative complications1 ranging from difficulty in breast feeding, 1 which is important because developing the ability to breast feed1 is essential for infants. 1 Bleeding,1 which is another sort of minimizing term, 1 you see that on consent forms, you know like"Oh, bleeding",1 well it turns out an infant only has about 12 ounces of blood1 so bleeding a couple of ounces might cause that child to die 1 or require a blood transfusion.1 Increase in pain response.1 Infection, which is also very serious for a newborn.1 Meatitus, which is an irritation of the opening.1 That also can be problematic because if it gets bad enough1 the child will not be able to pee, and that would require the child to have catheterization. 1 Necrosis1 and even permanent loss of the penis, or death. 1 I have talked with a pediatric urologist.1 He is the type of person who gets the complications to deal with. 1 He said that over a two-year period he had more than 275 children to treat, 1 almost half who required surgery,1 so they were subjected to an additional surgery1 in attempt to correct whatever damage happened.1 Okay, that's most of the graphic stuff, 1 except for in the next few slides we will see pictures of the actual anatomy of adults, 1 so you are also welcome to turn your heads aside for that.1 How many people have seen a penis that was intact? 1 Either your own or a friends, you know? 1 Okay, if you haven't yet, see if you can find someone who is willing to show you. 1 I have talked to hundreds of men,1 both men who have been circumcised and men who have not been circumcised.1 I hear a lot of men who have been circumcised 1 feel upset about that.1 They are aware or have become aware that something has been taken away from them,1 and that their bodies were subjected to something without their choice. 1 I also hear parents talk about their regret from the procedure. 1 So what is the foreskin?1 The foreskin is this sort of socially constructed thing.1 It's really just part of the penis,1 but now that we have cut it off, we have to give it a separate name.1 In fact, a lot of potential complications lists that you get on your informed consent form 1 say that one of the risks is that you might injure the penis.1 So we have constructed a reality in which cutting of the penis is not injuring it; 1 it is if you then cut part that you intended to leave that it is an injury. 1 So I want to show you what the foreskin is.1 I want to spend some time on that.1 The foreskin in the adult male, the part that would have been removed, 1 is about 12 to 15 square inches,1 it is about the size of a 3" x 5" index card.1 It is the most erogenous part of the human male.1 It contains 10 to 20 thousand fine touch nerve endings.1 And it also makes the penis shaft skin motile.1 So it is the difference, you know when you are having sexual intercourse 1 or some kind of interaction,1 it is the difference between this kind of interaction1 or something if you can image a part of your body where the skin moves around nicely 1 (My cheeks are floppy, so I can do that, you know).1 And that is actually a significant thing 1 because there is another kind of nerve that is called a stretch receptor 1 that gets stimulated in that motion,1 and it is the male's contribution to mechanical lubrication during intercourse, 1 either male-male or male-female.1 The foreskin can be broken down into a couple of specialized area :13the frenulum is this sort of...1 my hand isn't really long enough but...1 It is this fanning out region here.1 and there is the ridged band below it, that is were most of the nerves land.1 and the dartos muscle is a cutaneous muscle1 that allows the foreskin to respond to cold or fear 1 by surrounding the penis and pulling it in towards the body.1 In 2007, the first research was done ever1 to attempt to assess where the penis is sensitive.1 So they took a group of males who were intact 1 and a group of men who were circumcised.1 What you see on this color graph here 1 is that the most sensitive regions are that maroon color 1 and the second most sensitive regions are the purplish color.1 If we compare that to a circumcised penis1 what you see is that we have removed most of the most sensitive areas 1 and left just this region around the scar and the remainder of the frenulum 1 is really where most circumcised men are sensitive.1 Therefore, you can compare them this way,1 but you don't have to believe me if you can find a friend or two1 maybe one who is circumcised and one who is not,1 or maybe yourself,1 you can look and can see where the sensitivity actually lies. 1 For most men it is in this region of the frenulum1 or the scar remnant.1 So just to get you a real picture,1 what John here has done, he's a photographer, 1 he has taken a person with a foreskin1 and drawn these lines, so you can see how much tissue it is as it retracts.1 The other difference I want you to note 1 is that the inside what it does it generally surrounds the penis, 1 so it in a sense it invaginates it,1 it gives it an enclosure,1 and it keeps it moist.1 So, if you compare that with the circumcised penis, 1 the tissue looks softer,1 moister and warmer, 1 in addition to there being a lot more of it, 1 and it doesn't have the scar. 1 Those arrows there are pointing to the scar,1 so you can see where that is.1 I did want to invite, if you have any questions,1 it is okay to ask me as we go along 1 because I am giving a lot of information. 1 Okay, then, jumping along to the parent.1 Like I said I have talked with hundreds of parents 1 also especially doing all this work I do with parents, 1 I have talked with many who when they receive their child back, 1 that is the moment at which they understand what they had signed up for. 1 So there is a problem with informed consent 1 both that the information is lacking 1 and that parents are sometimes asked about it at an inconvenient moment, 1 such as when they are in labor, you know.1 And they are also asked about it in this values neutral way.1 Like, would you like a pillow? Would you like a cup of tea?1 Would you like your child circumcised? 1 It carries the same sort of tone, you know,1 and I am concerned about that.1 So I view us as having this sort of manufacturing pseudo informed consent process 1 Where parents need to trust physicians -- 1 The physicians are supposedly the ones1 bringing in the discipline of medicine. 1 So they come in, but they are given this information that is very cursory, 1 it lacks real information about the complications, those are trivialized, 1 the foreskin functions are completely omitted, 1 it's not mentioned that it is actually a sexual organ, 1 and the ethical questions of making decisions about your children's bodies are omitted, 1 and there is also this undeclared conflict of interest1 there is really a lot of commercial use of the tissue.1 So the other thing parents don't know is that it is painful for a week or longer afterwards.1 So the baby is not only in pain during the process, 2 but the wound has to heal, 2 it is a wound on the penis, 2 and babies are very sensitive to pain. 2 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? 2 They are very fragile beings.2 So what we have done is we've put this wound on this child, 2 and now this new parent who is dealing with the healing process 2 and the process of figuring out what it is like to have this new baby; 2 this new parent also has this added complications of having to watch for signs of infection, 2 of having to keep changing the bandage, and having the baby be more upset than he normally would have been. 2 In comparison, for the child who is not circumcised,2 all you have to do is well, almost nothing.2 In fact, you don't even wash the penis.2 Just like you wouldn't was a baby's vagina with soap,2 you just rinse it.2 You don't retract it;2 it becomes retractable on its own.2 You have a baby with fewer health problems, and a child who is more content.2 Now, I promised you that I would show that we actually do use the foreskin tissue.2 We use it for three things2 that I have been able to find.2 We use it for research,2 there are a large number of products you can buy from Invitrogen 2 which is actually a company from which I buy other things that don't contain foreskin 2 cells from for my bio-physics research.2 So there are some of the products they sell using neo-natal foreskins, 2 you can look it up yourselves.2 At a hospital you can get "magic skin treatment" 2 which is cultured, grown foreskin tissue,2 and if you are very wealthy you can buy cosmetics2 that are also derived from foreskin tissue.2 Oh, the cosmetics? 2 Wait, say louder?2 Audience member, "why would people want to use them on their skin?"2 Oh, people think that they will make them less wrinkly. 2 The idea is that baby cells,2 you know they are young, they do their job well, you know...2 And, if you are disturbed by that, I am glad2 because I would like us to be disturbed by that.2 So let's hear from an obstetrician how they frame these sorts of things. 2 This is Lisa Masterson being interviewed on the Craig Ferguson Late, Late Show.2 LISA," Yeah, and again you know what that is a personal choice 2 and as an Obstetrician, I talk to my patients a lot about this. 2 And really there's a lot of health benefits and there are some risk benefits, 2 but it is really a social procedure.2 So you really have to decide, do you want your son to look like you?2 You know it is a cultural thing it is a social thing,2 And there are some health benefits, more for the lady than the man 2 but as far as decreasing STDs and passing on to ah you know other women HPV, which can cause cervical cancer, 2 so decreasing STDs and cancer all that good stuff."2 CRAIG,"But couldn't you achieve the same effect by washing your pee pee on a regular basis?"2 LISA,"You absolutely could."2 CRAIG,"So we're talking, You can have this chopped off, or you can wash it,2 your call?"2 LISA,"Exactly."2 CRAIG, "That's a tough choice there Doctor ... I dunno!"2 So obviously I appreciate Craig's point of view there.2 He is from Scotland, where they coincidentally don't do this to children. 2 And think about her discourse,2 she's saying you have to choose as a parent,2 and I want to question that framing of it.2 Do you have to choose other body modification options for your child?2 Like a nose job, or things like that? 2 And, if the idea of doing things to our children because we want them to look a certain way chills you, 2 I am glad because I want it to chill us.2 I want us to wonder2 why are we so busy making our children look like what we think boys and girls should look like? 2 In this case, we have this idea that boys should look a certain way in their genitals. 2 Okay, so the last section is, how do we get practitioners doing this? 2 So I have a few quotes from practitioners who stopped doing it,2 like Marilynn Milos,2 a nurse who, after seeing it, refused to assist with them 2 and was fired for telling parents they don't need to do it.2 Michelle Storms, who is a very well known Obstetrician [sic, she is a Family Medicine Practitioner]2 who said she was ridiculed and patronized after stopping them in 1988. 2 And I am at Georgetown, so I went and talked to the Head of Obstetrics at Georgetown University Hospital, 2 Obstetricians do most of them, and she says,2 "Medically it doesn't make sense"2 "I don't even like doing the procedure, but I do it well."2 "I have performed thousands of circumcisions."2 She was clear that it is a social procedure,2 she was clear that it doesn't make sense medically,2 And she told me in our conversation that she would not stop doing them. 2 So how do we make physicians into that?2 Well, first we start by pathologizing a healthy organ. 2 Not only is the foreskin absent from most U.S. medical and anatomy texts, 2 There is, therefore, no education of the function.2 It is not viewed as a sexually important organ.2 Physicians are only taught how to remove it as a procedure. 2 and they are mistaught care, they are mistaught this "retract and wash" philosophy, 2 which is problematic because as you can see down at the bottom, 2 the foreskin when you are born is usually attached to the head of the penis.2 What you saw earlier in the circumcision video 2 was the physician running this tool around to break the foreskin loose so that they could cut it off. 2 It is bonded like that to protect babies from, well all the sorts of things that babies do, 2 they might have feces or urine in their diaper, 2 they might get scratched up. 2 The foreskin has a protective function when you are young. 2 Gradually that detaches 2 and the foreskin becomes retractable, 2 but if you forcibly retract it, that tears it up 2 and creates a site for infection, 2 also if you wash with soap that creates a site for infection. 2 And finally, we make this misdiagnosis called "phimosis". 2 There is a true problem called phimosis when there is scar tissue 2 at the opening of the foreskin, so it can't retract 2 and there are treatments for it use steroidal cream to help the scar tissue soften. 2 But when we think that a baby who is three weeks old 2 because you can't pull the foreskin back without making the baby scream, that's wrong.2 It is actually meant to be attached that way, it grew that way and it will become retractable on its own. 2 So, why do we do the circumcisions?2 Well if you look at why parents say they choose the number one reason is appearance. 2 They want their child to look like the other children they'll see or they want them to look like their Dad. 2 They think it looks better, or they think it is easier to keep clean. 2 And I believe it is the solicitation by physicians that reinforces or validates the choice to do this. 2 The fact that physicians do it makes it look like a reasonable thing. 2 Physicians may also give several reasons to collude with this idea,2 they may say it reduces penile cancer rates. 2 That it reduces urinary tract infections (UTIs), 2 Cervical Cancer rates in female partners that your child might have when they grow up. 2 And female to male HIV transmission rate reduction2 is sort of the newest reason.2 So as I showed you in the beginning, we have this sort of cultural baggage 2 a lot of reasons why we used to do circumcisions that don't make sense in today's cultural setting, 2 so we have had to come up with a posteriori reasons in order to feel more comfortable with what we are doing. 2 But I'll analyze those in more depth.2 Besides the social critique that I think they are reasons we made up after the fact, in order to feel comfortable with it. 2 If we think about them carefully, appearance and cleanliness, the number one reason that circumcision is done. 2 Well that argument is used to support both male and female genital cutting 2 in every culture that I am aware of that either of those practices occurs in. 2 And they are just made up arguments, 2 I mean, how can you say that something is cleaner if you do one thing to it or another? 2 Penile Cancer, the American Cancer Society says no, it won't protect you from penile cancer. 2 It is also irrelevant; the rate is 1 in 100,000.2 More people may die from circumcision than penile cancer. 2 Urinary tract infections, 2 well that was based on a big study in 1986,2 done by a fellow, I kid you not, his name was Wiswell.2 And the problem was his instructions caused urinary tract infections, 2 selectively in subjects with foreskins2 because he told the parents to forcibly retract the foreskin and wash with soap. 2 So that is just like if you had a girl and you forcibly douched her, 2 you know a little girl, you would get a higher rate of yeast and urinary tract infections 2 because you have messed up the colonies of protective bacteria. 2 Cervical cancer in female partners, 2 Well, first of all, a surgical preventive measure on an infant2 for a potential female partner when they grow up.2 I mean, how do we know this person is not going to be a monk or gay? 2 And they could do it themselves later. 2 Also, cervical cancer is cause by human papilloma virus (HPV).2 Probably most of you guys know that because you learned that in Sex Ed, right?2 Well the same authors went back and looked at the husbands and wives in that study 2 and they had different strains of HPV.2 So I don't know if there was under-the-table non-monogamy or what. 2 But that throws the results of that study totally into question 2 because the husbands were not carrying the HPV strains that gave the women the cervical cancer. 2 Gesundheit.2 Okay, so the last one is circumcision as an HIV preventative.2 Okay, that idea started in the 2000's mostly.2 The evidence for it is three randomized control trials.2 They were performed in Africa, 2 probably because you couldn't get a human review board to permit such a study in the U.S. 2 They got volunteer men who were willing to be circumcised; 2 they randomly circumcised half of them.2 And they watched to see how quickly they got HIV. 2 They had some problematic methodology that I will get into later. 2 And their claim was that that reduced the rate at which men got HIV by 60%. 2 Now the evidence against circumcision as an HIV preventative 2 are pretty much all the other studies that have been done. 2 The geographic data,2 if you look at correlation between circumcision percentage and HIV rates 2 in populations, it contradicts this conclusion.2 For example, 2 the United States has the highest HIV rate of any industrialized nation, 3 and also has the highest circumcision rate of any industrialized nation. 3 You would expect something different if circumcision were so protective. 3 So, I've got a few minutes left. I am going to quickly run through what I think was wrong with the study. 3 Again, there were three studies, they took a group of intact men, circumcised them and watched how quickly they got HIV. 3 The problems were, each time they came to the clinic they gave them condoms 3 and safe sex counseling. 3 But the circumcised group came at least twice more 3 because they had to come to get circumcised and they had to come to get a follow up study. 3 In addition, if you are circumcised, 3 it will take you about four to six weeks until you are able to have sex again. 3 And the circumcised group was asked to abstain for six weeks. 3 But they didn't start the clock until after waiting for six weeks, 3 they started the clock at the beginning, 3 so the circumcised group had six weeks3 of protection by being unable to have intercourse.3 In addition, they used an anti-body test, which 3 you know, if you go to an STD clinic 3 and they use an antibody test, there is a three-month window. 3 They tell you, you've got to wait until three months after your last exposure 3 if you really want to know if you have HIV. 3 But again, they