R.N. Conscientious Objectors to Infant Circumcision: A Model for Nurse Empowerment by Betty Katz Sperlich, Mary Conant and Frederick Hodges. Revolution, The Journal of Nurse Empowerment, Spring 1996: 86-89.

The United States is the only Western nation in the world that routinely circumcises the majority of its male infants. Both Canadian and English medical associations advise against the procedure and Australia strongly condemns it.

Medical circumcision was introduced into the United States in the late 19th century as a method of preventing masturbation in boys, and neonatal circumcision was not made routine in this country until after World War II. New evidence indicates that this surgery, even if properly and uneventfully executed, is not benign and may cause pain that has long-lasting and possibly irreversible detrimental effects in the developing brain.

The complication rate of circumcision surgery is one in 500; the death rate is one in 500,000. Some research has indicated that circumcision entails a permanent reduction in erotogenic response and sexual function. Moreover, the individual who lives with the consequence of this non-therapeutic, amputative surgery has not consented to its performance.

Routine neonatal circumcision is a controversial procedure which, more than most other surgical or medical procedures, elicits powerful emotional reactions. Because it involves questions of sexuality and the penis, it exists in the realm of taboo, even among healthcare professionals.

In addition, the performance of an irreversible surgical amputation in the absence of medical indications on an unconsenting minor raises serious ethical questions. The human-rights violation of forced genital excision of unconsenting minors has been amply demonstrated in medical and legal literature.

At the annual 1994 meeting of the Registered Nurses’ Association of British Columbia, nurse delegates voted not to allow routine neonatal circumcision to be discussed by nurses because it was judged to be too controversial. But following this vote, media coverage and a subsequent educational and consciousness raising campaign by nurses confronted the taboos associated with the procedure. The following year, at the 1995 RNABC convention, the province’s registered nurses passed a resolution condemning routine circumcision.

Nurses working in St. Vincent’s Hospital in Santa Fe, New Mexico, were expected to participate in this procedure. However, when we confronted this difficult issue, we set a historical precedent for nurses in organizing and taking a leadership role in the reform of this medical practice.

Our medical position was that neonatal circumcision was unjustifiable. Our ethical position was that it violated a newborn’s right to a whole, intact body. As patient advocates and nurse-educators working in maternal-child health, we believed that we had a professional duty to dispel myths and offer parents factual information about circumcision, and that we had a duty not to participate in a procedure that surgically altered the normal genitalia of unconsenting minors.

We observed physicians routinely asking parents if they wanted their child circumcised, in effect soliciting the surgery. Uninformed parents not only mistakenly believed that they had a right to make such a decision, but that an immediate decision was necessary.

Our conscientious-objector stand began in October, 1986, when we worked in the newborn nursery and submitted a letter to the nurse-manager and Vice President of Patient Services stating that we no longer wanted to assist with routine circumcision of newborns.

This decision, after much deliberation, was based on the position statements of the American Academy of Pediatrics (1975) and the American College of Obstetricians and Gynecologists (1978); the reading of relevant medical literature, including publications by Edward Wallerstein and Anne Briggs; conversations with respected pediatricians on our staff, and the example of those who refused to perform circumcisions; knowledge of complications suffered by some infants who had been circumcised; personal experiences in seeing the pain and suffering of newborns undergoing the procedure; the prospect of possible litigation regarding complications of the procedure; and lack of informed consent.

In response to this letter, we were told we would not be excused from circumcision duties. But we were unable to drop the matter and actively sought to educate ourselves and the parents about this issue from both a medical and human rights perspective. After six years of internal debate, we came to the conclusion that we did not require the hospital administration’s permission to take an ethical stance.

In October 1992, we declared ourselves conscientious objectors to circumcision and submitted a formal statement to the physicians, hospital administration, and staff, announcing our refusal to assist any further with the procedure. Other nurses came forward to join us and, in the end, a total of 24 maternal-child nurses–nearly 50% of the staff, including every Jewish nurse–declared themselves conscientious objects and agreed to our position statements. It read as follows:

* Neonatal circumcision is a violation of a newborn male’s right to a whole (intact) body.

* There are no compelling medical reasons for amputating the penile foreskin. Indeed, amputating the foreskin deprives the infant a protective and sexually functional part of his body.

*Circumcision is a surgical procedure with risks of complications, including bleeding, infection, and mutilation.

* Neonatal circumcision is painful. Often, inadequate or no anesthesia is used. Post-operative pain management is rare.

*Parental information on this subject is too often incomplete or based on myths.

*The infant is unable, at this vulnerable age, to state his own wishes or protect himself.

Our conscientious-objector stance attracted media attention across the country. In February, 1993, at a local press conference, we welcomed the opportunity to clarify our position and initiate a dialogue with the community.

Because we wanted to have an open debate at our hospital about the issues of circumcision, we organized an education conference on May 8, 1993. Most of the physicians on St. Vincent’s staff boycotted the conference and we learned later that some of them had asked the hospital’s CEO to fire us.

Undaunted, we organized a free monthly class on circumcision for prospective parents. And, believing that existing pamphlets, such as those prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists were inadequate, we invited physicians to cooperate with us in preparing a factual and informative consent form about deleted circumcision, as well as a simple information hand-out for parents.

The physicians on our hospital’s perinatal committee deleted references to the sexual function of the foreskin, and the nursing administration requested we eliminate references to pain. In the end, the hospital’s Forms Committee vetoed the consent form.

But we still had hopes for the hand-out. In July, 1993, we sent a letter to the physicians, asking them to review and approve the distribution of the educational hand-out.Generally, the pediatricians and family-practice physicians had no objection to its distribution, but a few of the obstetricians did object. The hand-out was distributed to parents for several months before the acting nurse-manager informed us, in a letter dated September 17, 1993, that material on circumcision could only be given to parents following a physician’s order.

This “Gag Order” was clearly not in our patients’ best interests, so we consulted our union lawyer and the New Mexico Board of Nursing. At that time, the union lawyer had little support to offer, and the Board of Nursing informed us that they had no jurisdiction over the matter.

In a memo dated April 4, 1994, nurses objecting to circumcision were ordered to assist in all pre- and postoperative stages of circumcision surgery. We responded in May by informing the administration that, as conscientious objectors to circumcision, we would not obtain permits, set up the equipment, get other nurses to assist, clean up the room, dispose of amputated body parts, and restock equipment. As the hospital became increasingly polarized on the circumcision issue, the work atmosphere deteriorated, prompting us to call for professional mediation.

Mediation was a exhausting process that threatened to break down on several occasions. Ultimately, however, St. Vincent’s Hospital had the historical distinction of becoming the first hospital in the world to officially recognize R.N. Conscientious Objectors to infant circumcision.

Nurses play a major role in patient care and are responsible, with physicians, for the ethical treatment of patients. While many physicians oppose forced infant circumcision, nurses have taken the lead in initiating the reform of medical practice and taking a firm stand in support of the internationally recognized principles of medical ethics, patient advocacy,and human rights.

We call upon all nurses to join us in our reformation of medical practice. Collective actions empower nurses to initiate change and empower the public to uphold the basic human rights of body-ownership and self-determination.

[Betty Katz Sperlich, R.N., and Mary Conant, R.N. are co-founders of Nurses for the Rights of the Child. They worked in the neonatal unit at St. Vincent’s Hospital in Santa Fe, New Mexico. Frederick Hodges is a medical historian and researcher.]

References

Phillips, I. Advocacy: rhetoric or practice. Nursing BC 1994; August-September, 1994, 37-38.

Mall, R.”Halt routine circumcisions, nurses urge,” Vancouver Sun, April 10, 1995, p B2.

Canadian Pediatric Society, fetus and newborn committee: Circumcision in the newborn period. CPS News Bulletin Supplement. 1975:8(2).

Williams, N., Kapila, L. Complications of circumcision. British Journal of Surgery, 1993: 1231-1236.

Bellmaine, S.P. Circumcision. Medical Journal of Australia. May 22, 1971: 1148.

Szasz, T.S. The Manufacture of Madness. New York: Harper & Row, 1970.

Denniston, G.C.Unnecessary circumcision. Female Patient, 1992: 13-14.

Dixon S., Snyder J., Holve R., Bromberger P. Behavioral effects of circumcision with and without anesthesia. Journal of Development and Behavioral Pediatrics, 1984; 246-250.

Taddio, A., Goldbach, M., Ipp, M., Stevens, B., Koren, G. Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet, 1995: 291-292.

Fleiss, P.M. Circumcision. Lancet, 1995:345,927.

Gee, W.F., Ansell, J.S. Neonatal Circumcision” A Ten-Year Overview,” Pediatrics, vol. 58, December 1976: 824-827.

Thompson, R.S.Routine Circumcision in the newborn: an opposing view. Journal of Family Practice, 1990: 189-196.

Gearhart, J.P. Complications of pediatric circumcision. Urologic Complications: Medical and Surgical , Adult and Pediatric, ed. Fray R. Marshal. Chicago: Year Book Medical Publishers. 1986: 387-439.

Money, J., Davison, J. Adult penile circumcision: erotosexual and cosmetic sequelae. The Journal of Sex Research, 1983: 289-292.

Warren, J.P. Bigelow, J. The case against circumcision. British Journal of Sexual Medicine, 1994: 6-8.

Brigman, W.E. Circumcision as child abuse: the legal and constitutional issues. Journal of Family Law, 1984-85: 337-357.

Milos, M.F., Macris, D. Circumcision: a medical or a human rights issue? Journal of Nurse-Midwifery, 1992:37 (Supplement): 87S-96S.

Fleiss, P.M. Female Circumcision. New England Journal of Medicine. 1995:189.

American Academy of Pediatrics Committee on Fetus and Newborn. Report of the ad hoc task force on circumcision. Pediatrics. 1975: 610-611.

American College of Obstetricians and Gynecologists. Statement on neonatal circumcision. ACOG Statement of Policy. December, 1978.

Wallerstein, E. Circumcision: An American Health Fallacy. New York: Springer Publishing Co., 1980.

Briggs, A. Circumcision: What Every Parent Should Know. Earlysville, VA. Birth and Parenting Publications, Inc. 1985.

Conant, M., Sperlich, B., McMurray, S., et al., Letter to Physicians of St. Vincent Hospital, October 1992.

Memo of Understanding for Circumcision Procedure, St. Vincent Hospital. January 31, 1995.