Informed Consent Advocacy Letter
Yesterday I posted seven ways you can get involved in the advocacy efforts to reduce routine, medically unnecessary infant circumcision. One of the ideas listed asks you to write letters to your local hospitals, urging them to require physicians to give parents complete information on the risks involved in routine infant circumcision, and to obtain fully informed consent from parents before performing the surgery.
If you have any ideas that might improve on this sample letter, please leave them in the comments.
Following is a sample form letter that you may personalize and send to your local hospitals to ask them to require fully informed consent from parents before conducting routine, medically unnecessary circumcisions on infants.
All underlined text in parentheses should be personalized before sending.
Name of Person You Are Writing to
Title of Person You Are Writing to
Address of Person You Are Writing to
Dear Mr./Ms. (HOSPITAL ADMINISTRATOR/BOARD OF DIRECTORS),
I respectfully write this letter to urge the (NAME OF HOSPITAL) to obtain fully informed consent from parents before performing routine, medically unnecessary infant circumcision. Attached is a Model Consent Form that you are free to use.
The United States is the only Western nation today where doctors routinely circumcise infant boys in medical settings. Although the rate has fallen from above 90 percent 30 years ago to below 40 percent today, more than one million American babies still undergo the surgery every year. And even though infant circumcision is still often referred to as a “routine” aspect of newborn care, as many as 46% of expectant parents are not given any information on the procedure by their doctors.
American parents trust their pediatricians and rely on them for the best advice in caring for their children. Conversely, physicians have fiduciary responsibilities to fully inform patients of the many risks involved in medically unnecessary circumcision – a procedure that has been designated as an elective procedure by the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists.
Doctors have a responsibility to tell parents the truth: circumcision has significant risks, including infection, bleeding, impairment of sexual function, and even death. An Atlanta family was recently awarded $2.3 million because a physician accidentally amputated much of a baby’s penis during a “routine” hospital circumcision. A Canadian baby bled to death in 2004, after being circumcised in a British Columbia hospital. In 2008, a baby from South Dakota bled to death, and his parents have filed suit against the hospital where he was circumcised, as well as the doctor who performed the surgery.
Infrequent though complications may be, because the surgery is performed on healthy babies who have no need for it, each injury and each death is utterly indefensible. And even an “uncomplicated” infant circumcision permanently removes healthy functional tissue from a person who did not consent to it.
Furthermore, the foreskin provides many functions that are lost after circumcision. These functions include: 1) protection – the foreskin protects the glans and keeps its surface soft, moist, and sensitive. It also maintains optimal warmth, pH balance, and cleanliness; 2) immunological defense – glands in the foreskin produce antibacterial and antiviral proteins such as lysozyme; plasma cells in the foreskin’s mucosal lining secrete immunoglobulins, antibodies that defend against infection; 3) antibacterial function – to help fight harmful bacteria, the foreskin supports a rich flora of beneficial bacteria; without these friendly bacteria, the urethra would become an easy entry point for germs and harmful strains of bacteria, which could cause disease; 4) erogenous sensitivity – the foreskin contains a richer variety and greater concentration of specialized nerve receptors than any other part of the penis; 5) other sexual functions – the double-layered foreskin provides a variety of benefits for a rich sexual experience for both the man and his partner.
Many hospitals/doctors do not provide parents with complete information on which to make a truly informed decision about circumcision. Therefore, few American parents are fully informed of the nature of neonatal circumcision and of the known risks and disadvantages associated with infant circumcision.
As long as routine, medically unnecessary circumcision is legal in the United States, it is essential that (NAME OF HOSPITAL) takes steps to ensure that parents know exactly what the risks and supposed benefits of this procedure are. By requiring parents to read, understand, and sign a consent form like the one attached, physicians will be more likely to fulfill their fiduciary and ethical responsibilities regarding informed consent. Furthermore, by requiring such a consent form to be on file, hospitals should be able to avoid the type of tragic situation wherein a child is circumcised against the wishes of his parents.
Thank you for your time and attention to this serious matter.
Informed Consent for Circumcision Form
by R. S. Van Howe, M.D., F.A.A.P.
Male circumcision is a surgical procedure where 25-50% of the skin of the penis is removed. It is important that you understand the well-established known risks of the surgical procedure as well as the possible, but unproven, benefits.
The following inherent risks are iatrogenic (doctor caused), and result directly from neonatal circumcision surgery. Significant complications from neonatal circumcision range from 2% to 10%.
- Hemorrhage (bleeding): Serious hemorrhage occurs in about 2% of infants, resulting in shock and sometimes death. While death is a rare complication of circumcision, it does occur. Boys with unrecognized bleeding disorders are at risk for serious hemorrhage.
- Infections: Localized or systemic infections include bacteremia, septicemia, meningitis, osteomyelitis, lung abscess, diphtheria, tuberculosis, staphylococcal scalded skin syndrome, gangrene of the penis and scrotum, scrotal abscess, impetigo, necrotizing fascitis of the abdominal wall, tetanus and necrosis of the perineum. A realistic infection rate is probably as high as 10%. Serious infections can cause irreparable and lifelong harm.
- Urinary retention: Swelling from the trauma of the surgery, pain associated with attempts at urination, and sometimes the Plastibell device (if used) can cause the infant to retain urine, leading, at times, to acute obstructive uropathy, when the bladder distends to the point of rupture.
- Laceration of penile skin: Results in varying degrees of skin tone variance.
- Excessive penile skin loss: Occurs when so much of the prepuce is drawn forward that the entire penile skin sheath is removed. From puberty on, penile bowing (curvature) and pain occurs at the time of erection. With erection, pubic hair can be pulled forward onto the penile shaft, and bleeding during sex can occur from shaft skin tears. Skin grafts are sometimes required.
- Beveling deformities of the glans (head of the penis): Varying amounts of the glans are shaved off leaving a scarred, beveled surface and, at times, the entire glans is amputated.
- Hypospadias: While more frequently a congenital defect, hypospadias can also result from circumcision. When the frenular area (underside of the penis) is drawn too far forward, the crushing bell may injure the urethra at the time the foreskin is removed, resulting in a urethral opening on the underside of the shaft.
- Epispadias: When one limb of the crushing clamp inadvertently is passed into the urethra and is closed, it crushes the upper portion of the urethra and glans, creating a urethral opening on the dorsum (top) of the glans.
- Retention of the Plastibell ring: The Plastibell, which normally falls off in 10 days, may get buried under the skin, causing ulceration and/or necrosis. Loss of the glans has also been reported.
- Chordee (permanent bowing of the penis): While often congenital, this can also result from circumcision. Dense scarring at the frenular area causes penile bowing upon erection and may require plastic surgery to repair.
- Keloid formation: Prominent scars can occur where the skin-mucous membrane has been incised, crushed or sutured.
- Lymphedema: Chronic swelling of the glans due to infection or surgical trauma, which can block lymphatic return.
- Concealed penis: The circumcised penis becomes hidden in the fat pad of the pubic area, requiring surgery to bring the penis out again.
- Skin bridges and penile adhesions: A common complication consisting of one or more thick areas of scar tissue that form bridges between the coronal edge of the raw glans penis (head) and the raw circumcision wound on the shaft. For some men, these can be quite painful during erection, restricting the free movement of the shaft skin and pulling on the glans.
- Phimosis of remaining foreskin: When only a segment of the foreskin is removed, the remaining tip sometimes becomes tight and non-retractable, requiring a second surgery.
- Preputial cysts: Cysts caused by infection or mechanical distortion blocking the sebaceous glands.
- Skin tags: Can occur at the circumcision line, representing an uneven removal of skin.
- Loss of part or all of the penis: This can be caused by constricting rings, such as the Plastibell, or by use of an electrocautery device. More frequently, the loss is the result of infection, with the penis becoming increasingly necrotic (dead tissue) until finally the entire organ falls off. The proposed solution in many cases is to raise the child as a girl.
- Meatitis: Inflammation of the urethral opening from the loss of protective foreskin, which can lead to ulceration and meatal stenosis (narrowing). Many infants and children suffer this after their loss of protective foreskin.
- Meatal ulceration: Caused by meatitis and/or abrasions from dry diapers and from diapers soiled with urine and feces. Meatal ulceration does not occur in the intact male and occurs in up to 50% of circumcised infants.
- Meatal stenosis: In advanced meatal ulceration, scar tissue can constrict the urethral opening causing urinary obstruction. Meatal stenosis is usually not apparent for several years, occurring in about one-third of all circumcised infants and not at all in intact males.
- Progressive loss of glans sensitivity: This is the most common complaint of adult circumcised men, whereby some men report stimulated needed to the point of pain to achieve orgasm.
- Sexual dysfunction: Includes impotence and premature ejaculation.
- Nonspecific urethritis: This venereal disease is more common in circumcised adults.
- Gastric rupture: Has been reported associated with prolonged crying during circumcision.
- Glans necrosis: The head of the penis can lose its blood supply and begin to rot from the scarring that follows circumcision.
- Tachycardia, heart failure and myocardial injury: Have been reported associated with the procedure.
- Death: Occurs at a rate of 1 in 5,000.
The permanent psychological trauma of having the most sensitive part of a boy’s anatomy removed shortly after birth without anesthesia has not been fully investigated.
Complications From Anesthesia (if used):
- Bleeding: Usually consists of small ecchymoses (bruises) at injection sites at a rate of around 1.2%.
- Loss of blood supply to the genitals: This has been reported following a dorsal penile nerve block where the wrong local anesthetic was used.
Presumed (But Unproven) Benefits
The American Academy of Pediatrics Task Force on Circumcision in 1975 proclaimed that there is no medical indication for circumcision of the newborn. The Task Force met again in 1989 and concluded that the procedure may have some potential medical benefits. To date, none of these benefits have been conclusively proven. The Task Force met again in 1999 and concluded that the potential medical benefits were so slight that neonatal male circumcision could not be recommended.[Potential medical benefits are conjectured benefits that have not been proven to actually exist.]
- Urinary tract infections: A few studies have suggested that boys who are not circumcised may have a 1% chance of developing a urinary tract infection. These studies have all been done either in military or inner-city hospitals and suffer serious methodological flaws. The one study that has not been done in military or inner-city hospitals showed a urinary tract infection rate of 0.12%, which was the same as for boys who were circumcised. The risk of urinary tract infections in Sweden (where none of the boys are circumcised) is 0.5%. There is also some evidence that circumcision may help mask the symptoms of serious urinary tract abnormalities.
The consensus of medical opinion is that circumcision is of little, if any, value in reducing UTI. The most effective way to combat UTIs in boys and girls is by breastfeeding. Studies have shown that breastfed infants have only 38% as many UTIs as non-breastfed infants.
- Penile cancer: There is an assumed association in the United States between not being circumcised and penile cancer, but now it is known that most cases of penile cancer are caused by human papilloma virus, which is acquired through sexual intercourse. In Denmark and Japan (where few boys are circumcised), the rate of penile cancer is the same as the United States. More baby boys die from circumcision than men die of penile cancer.
The American Cancer Society has actually written a letter to combat the myth that circumcision prevents cancer in either men or women. The American Cancer Society’s purpose in writing the letter was “to discourage the American Academy of Pediatrics from promoting routine circumcision as a preventive measure for penile or cervical cancer. The American Cancer Society does not consider routine circumcision to be a valid or effective measure to prevent such cancers.”
- Phimosis (narrowing of the foreskin opening): A condition that occurs in less than 1% of boys. Of these, 80% can be successfully treated with steroid cream. The remaining 20% can be treated with plastic surgery that preserves the foreskin.
- AIDS: Studies out of Africa suggest that HIV infections are more common in men with foreskins. These studies did not account for cultural, economic and religious differences between the two groups of men. Whether this pertains to the United States is debatable. The United States has one of the highest rates of circumcision in the world as well as one of the most rapid increases in HIV infections in the world.
- Hygiene: A recent study showed no significant difference between the number of penile problems experienced by boys who were or were not circumcised. The boys who were circumcised had more problems early in life, while the boys who were not circumcised had more problems later on. None of the problems encountered in the studied population were serious.
I/We have read and understand the risks involved in circumcising my son. I/We grant consent for the circumcision of my/our son.
First Parent _______________________ Witness _______________________
Second Parent _______________________ Date _______________________
 The Model Consent Form was written by R. S. Van Howe, M.D., F.A.A.P. and provided by NOCIRC.org. It is available at http://www.nocirc.org/consent/form.php.
 U.S. Circumcision Rate Falls to 33%, available at http://www.drmomma.org/2010/08/us-circumcision-rate-falls-to-33.html
 Fleiss, Paul, M.D., “What Your Doctor May Not Tell You About Circumcision” at xi
 See, e.g., Medical Informed Consent: General Considerations for Physicians, available at http://www.mayoclinicproceedings.com/content/83/3/313.long; see also The American Congress of Obstetricians and Gynecologists’ position statement on newborn circumcision, available at http://www.acog.org/publications/patient_education/bp039.cfm; American Academy of Pediatrics Circumcision Policy Statement, available at http://aappolicy.aappublications.org/cgi/content/full/pediatrics;103/3/686
 Researching Circumcision, Part 1: What Is the Foreskin?, available at http://codenamemama.com/2010/02/16/researching-circumcision-foreskin/ (and citations therein)
 For more information on routine infant circumcision, see Intact America, available at http://www.intactamerica.org/. For more information on routine infant circumcision and informed consent, see the National Organization of Circumcision Information Resource Center, available at http://www.nocirc.org/consent/index.php.
- Please note: the model consent form was copied and pasted from NOCIRC.org. I added several sentences to the section entitled “Presumed (but Unproven) Benefits.” Under #1, I added the last 3 sentences. Under #2, I added the last 3 sentences. Also, several sentences of this letter are identical to or slightly modified from Intact America’s letter to the AAP. You can sign/send your own version of Intact America’s letter urging the AAP not to recommend routine infant circumcision by visiting Intact America. ↩
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