Has anyone here seen this manual from the World Health Organization in affiliation with Johns...

[Crunchy Frog]

http://whqlibdoc.who.int/publications/2010/9789241500753_eng.pdf

I don't know if this is the right place to be posting this, but it looks like they are rolling out a campaign to carry out neonatal circumcision in impoverished areas of Sub-Saharan Africa.

Reading through the whole thing it strikes as me as so wrong and unethical on so many different levels.  They are proposing doing this in extremely primitive facilities, many of which do not even have sterile needles with which to safely inject an infant with Lidocaine.  The people doing the surgeries will largely not even be doctors who are in very short supply, but fairly poorly trained medical functionaries.  It does not appear in most cases that there are easily accessable backup facilities for complications like hemorrhage or infection or surgical mishap, and babies will be sent back to their homes to have their wounds cleaned where the water supplies are unclean.

This is an area of the world where babies die because their umbilical cords were cut with unclean instruments. 

They print an exagerated safety level for the surgery when it is done in American hospitals by well trained medical personell, and then extrapolate that supposed safety to a third world context.

They talk about the process of obtaining "informed consent" from the parents, which basically consists of a highly skilled hard sell campaign to get them to sign the form.

Although they downplay the risks (especially for counselling parents) they actually go through a pretty comprehensive list of severe risks (often illustrated with graphic photographs), presumably to educate the operators rather than the parents.

They even talk about many of the areas in question having very high rates of infant mortality, and trying to make sure than any dead babies get attributed to the general  mortality rates and not to the circs.

If this program is actually carried out, I don't doubt that there will be LOTS of dead babies who wouldn't have died otherwise, and others who will be permanently mutilated beyond what is intended with the surgery.

I don't know if maybe this post belongs in the activism forum, but it seems like it would be of interest to people who are opposed to infant circ to know that this is an ongoing project.

I have no idea where one would begin to approach combatting this, but it seems like something that should be addressed.

Is anyone else as horrified by this as I am?

[Ron_Low]

Originally Posted by Crunchy Frog 

http://whqlibdoc.who.int/publications/2010/9789241500753_eng.pdf

I don't know if this is the right place to be posting this, but it looks like they are rolling out a campaign to carry out neonatal circumcision in impoverished areas of Sub-Saharan Africa.

Reading through the whole thing it strikes as me as so wrong and unethical on so many different levels.  They are proposing doing this in extremely primitive facilities, many of which do not even have sterile needles with which to safely inject an infant with Lidocaine.  The people doing the surgeries will largely not even be doctors who are in very short supply, but fairly poorly trained medical functionaries.  It does not appear in most cases that there are easily accessable backup facilities for complications like hemorrhage or infection or surgical mishap, and babies will be sent back to their homes to have their wounds cleaned where the water supplies are unclean.

This is an area of the world where babies die because their umbilical cords were cut with unclean instruments. 

They print an exagerated safety level for the surgery when it is done in American hospitals by well trained medical personell, and then extrapolate that supposed safety to a third world context.

They talk about the process of obtaining "informed consent" from the parents, which basically consists of a highly skilled hard sell campaign to get them to sign the form.

Although they downplay the risks (especially for counselling parents) they actually go through a pretty comprehensive list of severe risks (often illustrated with graphic photographs), presumably to educate the operators rather than the parents.

They even talk about many of the areas in question having very high rates of infant mortality, and trying to make sure than any dead babies get attributed to the general  mortality rates and not to the circs.

If this program is actually carried out, I don't doubt that there will be LOTS of dead babies who wouldn't have died otherwise, and others who will be permanently mutilated beyond what is intended with the surgery.

I don't know if maybe this post belongs in the activism forum, but it seems like it would be of interest to people who are opposed to infant circ to know that this is an ongoing project.

I have no idea where one would begin to approach combatting this, but it seems like something that should be addressed.

Is anyone else as horrified by this as I am?

The manual is very misleading.  For example it gives a sample parental consent form that cites the rate of complications at 1 in 500, while higher complication rates are discussed elsewhere in the manual.  It conflates forced infant circumcision with adult voluntary circumcision when it talks about published research (in fact NO random controlled trial correlates INFANT circumcision to HIV prevention).  It says "some males may later be unhappy that they were circumcised" without ever noting that most of the world doesn't even do it.  It has lots of footnotes, but it claims WITHOUT a citation that getting circumcised later in life is somehow more dangerous.  In a hundred other ways it seems designed to minimize parental resistance to infant circumcision. 

It's also scary because the practitioners' procedural section contains some info that is vital for doing the best infant circumcision, yet, if the practitioner needs to be told this, they SHOULD NOT be doing infant circumcisions.  For example it says incidentally the frenulum runs parallel to the penile shaft.  It basically says very little about normal penile development, anatomy, or function; nothing about what the foreskin is or does, just how to cut it off. 

Still, it does show lots of snapshots of complications - not for parents, but so the cllinic can recognize them when they occur or are brought back weeks later.  If every parent was made to view and initial every snapshot, the infant circumcision rate would be close to zero.  

[tennisdude23]

Yes, well, unfortunately this is nothing new.  I am not sure that there can much done to address it either.  I can only tell you that the drive behind this manual and several others has mainly come from the advocacy of a small group of researchers, who for a variety of complex reasons, have been quite successful in pushing forward with their circumcision=surgical vaccine campaign in Africa.  This has been a project about 10 years in the making, and we are now seeing the final product taking shape, so to speak. However, from my personal research into the matter, I think the campaign will falter sooner or later.  While there is in fact good evidence to suggest that circumcision might produce some prophylactic benefit, for whatever reason, in female to male HIV acquisition in a 24 month period, it's highly unlikely that we are going to see a large scale population effect in the long run, making this drive yet another waste of funds in combating the African pandemic. 

[Crunchy Frog]

Is there any kind of activism taking place against this?  I didn't even know about it until someone on another group I'm on found it after doing some googling.  It just seems like such a massive breach of ethics, and something that is going to result in multiple infant deaths, and a major American medical and educational institution is involved in it.  It seems like something that the intactivist community should be at least making an effort to publicize. 

[tennisdude23]

Realistically, you can't make a serious ethics case, as the RCTs got through IRBs funded by the NIH and Johns Hopkins University.  While the scientific results of the RCTs are legitimate, there has been much debate as to how they should influence issues of public policy.  In this regard, there have been some very good articles published challenging the specious arguments that circumcision will be a major force in stopping HIV in Africa.  Also keep in mind that JHU's Bloomberg School of Public Health is a leader in HIV research in the Third World.  While its work is to be commanded on all levels, it unfortunately also provides a platform to some very skillful advocates of circumcision.  Unless funding is obtained to carry out long term studies (a combination of RCTs and longitudinal studies) on the HIV-circumcision link (the chances of this are close to zero), it's going to be very hard to seriously challenge the "pro" claims, given the inertia behind the current research.  The best that can be done, in my opinion, is to focus efforts on the United States, where the RCTs don't apply, and be steadfast in pointing out the loopholes concerning the available data. 

[NSmomtobe]

I'm going to have to read the manual later, but right now it's making me physically ill to think about it. This is my hot button issue, and I would very much like to do something to speak up against this blatant racism, but I don't know what to do other than writing letters to WHO (and at this point I don't know where to send the letters either).

[elus0814]

I read through most of it. They do go into how facilities need approval, certain equipment, sterile supplies, etc. to be approved to do this. I certainly doesn't sound like it's unclean procedures performed by untrained people. They even explain how sugar water should not be used when breastfeeding is essential. 

[Ron_Low]

Originally Posted by tennisdude23 

Realistically, you can't make a serious ethics case, as the RCTs got through IRBs funded by the NIH and Johns Hopkins University.  While the scientific results of the RCTs are legitimate, there has been much debate as to how they should influence issues of public policy.  

I disagree.  The legitimacy of the RCTs must never be conceded. 

[Crunchy Frog]

Originally Posted by elus0814 

I read through most of it. They do go into how facilities need approval, certain equipment, sterile supplies, etc. to be approved to do this. I certainly doesn't sound like it's unclean procedures performed by untrained people. They even explain how sugar water should not be used when breastfeeding is essential. 

From my reading of it, it was a description of very minimally equipped facilities (it talks about how Lidocaine should only be administered if there is access to sterile needles, that sounds poorly equipped to me).  These are facilities that do not have the capacity to do real surgery (under GA) should a major complication develop, and almost certainly don't have the capability to provide a safe blood transfusion in the event of hemorrhage.  It was pretty evident to me that they were talking about non-physicians mostly doing the surgery.  They mention things like trying to minimize the need for sutures due to the extra skill required to place them, among other things.

They're not talking about doing it on the floor of a mud hut with a shard of glass, but they are also definitely not talking about anything resembling the standards we have here, either for facilities or for training.  And even we with our advanced and aseptic surgical settings and highly trained doctors have an unacceptably high complication rate.
 

[Crunchy Frog]

Originally Posted by tennisdude23 

Realistically, you can't make a serious ethics case, as the RCTs got through IRBs funded by the NIH and Johns Hopkins University.  While the scientific results of the RCTs are legitimate, there has been much debate as to how they should influence issues of public policy.  In this regard, there have been some very good articles published challenging the specious arguments that circumcision will be a major force in stopping HIV in Africa.  Also keep in mind that JHU's Bloomberg School of Public Health is a leader in HIV research in the Third World.  While its work is to be commanded on all levels, it unfortunately also provides a platform to some very skillful advocates of circumcision.  Unless funding is obtained to carry out long term studies (a combination of RCTs and longitudinal studies) on the HIV-circumcision link (the chances of this are close to zero), it's going to be very hard to seriously challenge the "pro" claims, given the inertia behind the current research.  The best that can be done, in my opinion, is to focus efforts on the United States, where the RCTs don't apply, and be steadfast in pointing out the loopholes concerning the available data. 

Whatever the validity of the RCTs may or may not be, there is nothing there that justifies a mass campaign to circumcise neonates in a third world setting.  It might concievably justify circumcising adult men or even adolescents, but not babies.

While it may not be possible to touch the WHO, I would think that it would be very possible to launch a protest against Johns Hopkins and try to publicize what they're involved in and publicly shame them for it.

[So-Called]

I don't understand how they could say that an advantage to circumcising in infancy is that "the procedure is not complicated by erections". Are they really trying to sell anyone on the idea that infants don't have frequent erections when they're showing color photographs of this very phenomenon occurring when baby boys are being prepped for a circumcision? Or are they simply trying to say that erections aren't a big deal in newly-circ'ed babies because they aren't likely to have stitches?

Either way, I couldn't believe what I was reading. One major effect of the maternal hormones in my newborn ds was crazy erections, and I remember trying to deal with one during a diaper change and thinking, "Wow, I can't imagine if we'd just had him circ'ed and then this happened." After that I could never be convinced that a circ'ed newborn wouldn't experience some kind of erection-related complication, even if it was just an increase in his pain level. :(