Options, Ethics, and Moral Imperatives

Vaccinations. Circumcisions. Birthing interventions. These are among the parenting topics that stir up strong feelings and can lead to the exchange of strong words. The recent heated debate over a circumcision post I wrote is one example of this, but there are countless others in fora and on blogs all over the web. In any case, all of this has gotten me thinking about differences in parenting styles. When do philosophical differences become true cases of “right” versus “wrong”?

To illustrate, while discipline styles fall along a continuum, involved parents can generally be classified as authoritarian (strict disciplinarians who don’t display much affection), authoritative (moderate disciplinarians with a warm parenting style), or permissive (non-disciplinarians who display significant affection). Several studies have demonstrated that authoritative parents raise the most well-adjusted, competent children (see, for instance, Lamborn et al, Steinberg et al, Dombusch et al). Furthermore, a recently published study on the topic suggests that authoritarian parenting is associated with future delinquent behavior (Trinkner et al). Still, though the evidence is mounting that children of authoritative parents do best in school and are least likely to engage in risky behaviors of various sorts later in life, parenting style is considered a matter of philosophy, and is left up to the parent (provided the child is not being neglected or abused). Abuse and neglect aside, the overarching social philosophy regarding discipline is that the parent(s) know the child best, and will act in the best interest of the child.

Let’s take another example. As I’ve pointed out here and here, there is neither scientific evidence to support routine infant circumcision, nor is there scientific evidence proving it is harmful in any way. As such, while it’s possible to debate circumcision on moral/ethical grounds (and to feel very strongly about it), the overarching social philosophy is that it’s up to the parent(s) to make the decision regarding circumcision. While there are some who feel very strongly about circumcision (including both those who think circumcision is a violation of the infant’s rights AND those who think that to forgo circumcision is an affront to god), the procedure is not legislated in the United States. Neither is it either supported or opposed by large medical organizations in this country (at this time, at least; there are stirrings that the American Academy of Pediatrics might support circumcision to some extent in the coming years).

Moving on. Vaccination gets a bit trickier, as both camps that feel strongly about the vaccination issue think that there is actual, physical harm being visited upon the child being (or not being) vaccinated. Anti-vaccination advocates think that vaccinating parents are exposing their children to unsafe substances, while proponents of vaccination worry about the children of the anti-vaxers AND about their own children (because the higher the percent of vaccinated individuals in a population, the better EVERYONE, including the vaccinated individuals, is protected). Vaccinations are legislated to some extent; the U.S. Centers for Disease Control and Prevention keeps a database of which vaccinations are required for entry into public school by state. The legislation of vaccinations helps improve compliance among those parents who don’t feel strongly either way about immunizing children, but parents who are fervently anti-vaccination can get an exemption on any one of a number of grounds (philosophical, religious, etc). Nevertheless, some pediatricians feel strongly enough about the dangers associated with children remaining unvaccinated that they won’t accept unvaccinated children into their practice (both to avoid exposing patients to unvaccinated children and to try to motivate parents to vaccinate). Other pediatricians feel that this exclusion of unvaccinated children is unethical. Given that the scientific evidence unequivocally supports childhood vaccination (more articles on this topic archived here), is it ethical to allow a parent who claims that vaccinations are harmful to make a potentially dangerous decision for their child? Is being wrong about the science the same thing as being wrong about the parenting?

Here’s yet another example. There was an ethical discussion written up in the medical journal Pediatrics last year about a case in which parents refused antibiotics and hospitalization for a septic (that is to say, bacterially-infected) newborn (Simpson et al). The mother had been trying for a home birth with a midwife, but had developed a fever and was brought to the hospital. The parents refused fetal monitoring and wanted to continue with their natural birth plan, despite concerns on the part of the medical team that both the mother and newborn had a bacterial infection. The mother eventually accepted IV antibiotics. She refused any treatment for her newborn, however, and asked to be discharged same-day. She and her husband wanted to leave against medical advice because they felt the newborn “didn’t look sick.” The medical team ended up contacting CPS, and the parents agreed to an antibiotic treatment for the newborn. Medical protocol would have been for the newborn to remain in the hospital for 48 hours of monitoring. Instead, however, the parents found another doctor who had privileges at the hospital and who agreed to discharge the baby early. The purpose of the article was to discuss what had been done and what should have been done. The authors of the article, all medical practitioners, agreed that the parents were doing what they (the parents) thought (in the absence of any medical knowledge) was in the best interest of the baby. This was not a case of purposeful abuse or neglect. However, the parents refused to allow the majority opinion of medical experts to guide their decision-making, and instead found a rogue practitioner willing to do what they wanted. Everyone agreed that, given the parents clearly loved the child, it was a shame to have had to bring CPS into the equation Still, the authors further agreed that when it comes to medical decisions, there’s a line between a parent exercising a parental right…and a parent simply being wrong.

With regard to some parenting issues, there’s no clear right or wrong answer. For instance, a few real sticklers on either side of the fence might butt heads over whether a 22-month-old should be allowed to watch TV, but there’s no rational argument that can be made for legislating this issue either way. There are other parenting issues that are clear-cut cases of moral imperative. For instance, it is wrong to keep a child in a kennel. No discussion, no ifs, ands, or buts. It’s wrong. And it’s illegal. Unfortunately, though, the waters are pretty muddy with regard to many other parenting decisions. Sure, the science supports breastfeeding, but what if mama hates it? What if she has to return to work and can’t pump? What if…whatever? Even when science comes down (either weakly or strongly) on one side of an argument, there’s often room for different philosophies. But then again, sometimes there isn’t.

Isaac Asimov, ca 1965

I guess the real question is how do we know what delineates a difference of philosophy and what’s simply a case of right and wrong? Should a set of parents be allowed to feed their newborn nothing but raw vegetable juice — because, say, they’re vegans who further happen to believe that soy is unhealthy due to…whatever — given that this diet would result in massive malnutrition (and eventually death)? Is it the right of a parent who wants a “natural birth experience” to leave the hospital against medical advice with a neonate that the medical staff feel needs antibiotics? If the parents leave and the infant lives, does that make them any less negligent than if they had left and the infant had died? Where’s the line between persevering in a philosophy…and perseverating? When does adherence become obstinance? The availability of free information (much of it erroneous) on the Internet has made many of us feel like armchair Experts In Everything. We tend to turn to the Internet rather than true experts, or we choose to trust only those experts who agree with our preformed, Interwebs-derived conclusions. Further, somehow it has become acceptable — in some circles, even admirable — to defy the medical and scientific establishments, and to refuse to acknowledge the validity of well-performed, oft-repeated, well-accepted research. How did this happen? In the words of Isaac Asimov, who said it so gracefully, “Anti-intellectualism has been a constant thread winding its way through our political and cultural life, nurtured by the false notion that democracy means that ‘my ignorance is just as good as your knowledge.’

 

What do you think a parent should — or should not — be able to choose for their child?

 

References:

Dombusch et al. The relation of parenting style to adolescent school performance. Child Dev. 1987 Oct;58(5):1244-57.

Lamborn et al. Patterns of competence and adjustment among adolescents from authoritative, authoritarian, indulgent, and neglectful families. Child Dev. 1991 Oct;62(5):1049-65.

Simpson et al. When parents refuse a septic workup for a newborn. Pediatrics. 2011 Nov;128(5):966-9. Epub 2011 Oct 24.

Steinberg et al. Over‐time changes in adjustment and competence among adolescents from authoritative, authoritarian, indulgent, and neglectful families. Child Dev. 1994 Jun;65(3):754-70.

Trinkner et al. Don’t trust anyone over 30: parental legitimacy as a mediator between parenting style and changes in delinquent behavior over time. J Adolesc. 2012 Feb;35(1):119-32. Epub 2011 Jun 12.

 

Should I Vaccinate My Child for Chickenpox?

With W’s first birthday behind us, we’ve got 12-month shots in our immediate future. In addition to the panoply of vaccinations she’s been getting at her shot visits for the last year, she’s up for MMR and varicella (chickenpox) this time around. The MMR shot is one I am fervently in favor of, despite the fact that it’s one of the vaccinations most targeted by anti-vaxers. There’s a bit of discussion of the MMR vaccine in this SquintMom post, and there’s quite a bit more information here.

Photo by Jonnymccullagh, from Wikimedia Commons

While my feelings about MMR are unequivocal, I spent the weekend doing some research into the varicella vaccine, as I knew less about it. The anti-vax rhetoric I’ve heard suggests that the varicella vaccine is a bad idea because:

1)   it’s risky

2)   it could wear off in early adulthood

3)   chickenpox is a routine childhood illness

Normally, I don’t put too much stock in anti-vax rhetoric, but I had chickenpox myself (unlike measles), and it (obviously) didn’t kill me, so I’m more predisposed to sympathizing with the argument that chickenpox is a routine childhood illness than I am to agreeing with the same statement about measles. (Though it’s worth noting that since I had chickenpox when I was three, I don’t really remember it. In all likelihood, it was completely miserable, and if I could remember the experience, I’d probably be moved to vaccinate W purely out of sympathy. It’s very easy to sit in an armchair with chickenpox immunity and refer to it as a “routine childhood illness.”) The real sticking point for me — and the reason I did some extensive literature-searching on the topic — was that the vaccine is new (and it might wear off in early adulthood; we don’t know yet), and unlike many other illnesses, chickenpox is actually more serious in adults than in children. I looked into the varicella vaccine to convince myself that I wouldn’t be exposing W to increased risk of chickenpox later in life by vaccinating her now.

The varicella vaccine (sometimes given in combination with the MMR as the MMRV shot) is recommended by the CDC for all children ages 1-12, as well as for anyone over 13 who does not have evidence of chickenpox immunity. Anti-vax rhetoric suggesting that the vaccine is risky is erroneous. The vaccine is a live, attenuated (weakened) virus, and there is a very small chance of getting a mild rash upon vaccination. Serious side effects, including allergic reaction and seizures, are so rare that they can’t be definitively attributed to the vaccine (they’re so rare that they could be due to nothing more than chance). The most common side effect is soreness or redness, which is an indication that the immune system is working. This soreness is mild, and occurs in about 20% of people.

While the risk of a serious reaction to the varicella vaccine is too small to be accurately measured, the risk of death from chickenpox is much more significant. Of every 100,000 infants under 12 months infected with chickenpox, eight will die. Older children have a lower risk of death, but still die at the rate of two in 100,000 (Preblud et al). Far more common complications include bacterial infection of pox sores — which can lead to scarring — and febrile seizures. Chickenpox also typically results in a week or more of lost school time (plus a lot of misery) for children, as well as lost work time (plus sleeplessness and sympathetic misery) for the caregiver. Based upon an analysis of the relative risks, the chickenpox vaccine carries a lower risk of serious complication than acute effects of the chickenpox illness.

It’s also worth noting that anyone who develops chickenpox is susceptible to herpes zoster (shingles) later in life. The chickenpox virus is never fully eradicated from the body. Instead, those who get chickenpox eventually recover from their symptoms, but the virus remains dormant in the nerve cells. Later in life (typically in adults over 60, those under severe stress, and/or those with compromised immune systems), the virus can become active once again. The resulting rash is very painful, and can lead to scarring. It’s also often associated with symptoms of illness, including fever and joint pain. By preventing infection with chickenpox, a vaccinated child is spared the potential for developing shingles later in life.

There have been some popular media reports that the varicella vaccine is responsible for increased shingles incidence. This is true, but only in one sense. Several studies, including Hardy et al, show that as expected, those vaccinated for chickenpox are less likely to get shingles than those who develop the chickenpox infection. However, as more and more young people are vaccinated for chickenpox, the incidence of chickenpox infection falls in the population. Consequently, adults who had chickenpox as children don’t get a natural “immune boost” from being exposed to chickenpox on a regular basis. This makes shingles more likely in these adults (Edmunds et al). Eventually, as the number of vaccinated individuals overtakes the number of individuals who have had chickenpox, the shingles rate will decline. It is a factual misrepresentation to claim that the chickenpox vaccine increases the risk of shingles.

As to the longevity of the vaccine, any “new” vaccine (and it’s worth saying that a vaccine goes through years — even decades — of testing before it’s ever available to the public) is associated with some uncertainty about how long it will last. Some vaccines appear to confer lifetime immunity; adults don’t need MMR boosters, for instance. Other vaccines confer only a few years of immunity, including the Tdap (for tetanus, diptheria, and pertussis), which has to be given every 10 years. Anti-vax rhetoric suggests that since the chickenpox vaccine could wear off in early adulthood, vaccinated children would be at risk for chickenpox infection as adults. This is an erroneous claim, however; the CDC and health organizations worldwide are monitoring the longevity of varicella vaccine-conferred immunity. According to the World Health Organization, studies in Japan indicate that the vaccine is effective for at least 20 years (studies are ongoing), while ongoing studies in the U.S., which started later than the Japanese studies, indicate that the vaccine is still effective after 10 years. In the end, it doesn’t matter whether the vaccine’s effectiveness wears off after a number of years; booster vaccinations will be recommended if health organizations deem them necessary to maintain immunity. Note, too, that since the varicella vaccine has been recommended for all children in the U.S. since 1995, surveillance organizations have had 17 years to observe the first group of vaccinated individuals for waning immunity (and, of course, there’s been even more time to observe the test-case individuals for waning immunity). A child vaccinated for varicella today will know years, if not decades, in advance of the need for a booster shot.

After looking at the research, I’m impressed by the effectiveness of the varicella vaccine. A meta-analysis (study of many studies) by Seward et al revealed that a single dose of the varicella vaccine was 84.5% effective at preventing any chickenpox infection, and was 100% effective at preventing severe chickenpox. Since chickenpox infection is severe in 52% of cases in unvaccinated children (Vazquez et al), this is a significant reduction in risk. Current CDC recommendations are for two doses of vaccine, given at least three months apart, which increases the effectiveness of the vaccine to around 90% (AAP).

The other thing that occurs to me is that, given the tremendous prevalence of the varicella vaccine among US children, parents who don’t vaccinate their children put them at risk of NOT catching chickenpox. Yes, you read that right. Of course, they’re at risk of catching chickenpox, because they’re unvaccinated. But even worse would be to NOT catch chickenpox (as a child), and then catch it as an adult (because while chickenpox incidence is falling in the US, the disease has not been eradicated, and will not likely be eradicated any time soon). It’s essentially incumbent upon parents who don’t vaccinate their children to ensure that the child catches a sufficiently serious case of the chickenpox to help prevent susceptibility later in life. However, in ensuring that the child catches the chickenpox, the non-vaccinating parent also puts that child at risk for serious chickenpox-related complications and later shingles, meaning that the risks associated with not vaccinating are particularly complex in the case of varicella!

 

Science Bottom Line:* The varicella (chickenpox) vaccine is less risky than chickenpox infection, making it an essential childhood vaccination. Despite the relative newness of the vaccine, there’s evidence of at least 10 years of protection (studies ongoing). The CDC continues to monitor immunity of vaccinated individuals, and will recommend booster shots for vaccinated individuals if they are determined necessary.

 

Did you (or will you) vaccinate your child for chickenpox?

 

References:

American Academy of Physicians. American Academy of Pediatrics. Committee on Infectious Diseases. Varicella vaccine update. Pediatrics. 2000 Jan;105(1 Pt 1):136-41.

Edmunds et al. The Effect of Vaccination on the Epidemiology of Varicella Zoster Virus. J Infect. 2002 May;44(4):211-9.

Preblud et al. Deaths from varicella in infants. Pediatr Infect Dis. 1985 Sep-Oct;4(5):503-7.

Seward et al. Varicella Vaccine Effectiveness in the US Vaccination Program: A Review. J Infect Dis. 2008 Mar 1;197 Suppl 2:S82-9.

Vazquez et al. The Effectiveness of the Varicella Vaccine in Clinical Practice. N Engl J Med. 2001 Mar 29;344(13):955-60.

Reflections on a First Birthday — My, How We’ve Grown

This Saturday, my sweet W will celebrate her first birthday. Ok, no, not really. We’ll celebrate her first birthday; she’ll sort of cluelessly enjoy the fact that she’s being handed a cupcake.

It goes without saying that she’s grown and changed so much in the last 365 days. Seriously. It goes without saying. So I’m not going to say it.

Instead, I want to talk about someone else who’s grown and changed in countless ways this last year — me.

A year ago Saturday, my OB plopped a tiny, squirming, mewling, squishy baby onto my chest. I stared deep into her beautiful, soulful eyes, and thought to myself, “Holy shit.* I’m a mother. Whose idea was THAT?” Which, admittedly, is not what I’d envisioned myself thinking at that particular moment.

*Yes, I swore. If you’ve been following this blog since the beginning, you’ll remember I once wrote a post about how I’d never swear on SquintMom, because I wanted it to be a “Gentle Space” where people could come and know in advance that they weren’t going to read anything that could ruin a good mood. Screw it. This blog is as much for me as it is for everyone else, and sometimes, moms need to swear. This is another way in which I’ve changed in the last year; I recognize that now.

Anyway…not what I’d envisioned myself thinking. No, during pregnancy (when my brain was filled with fluffy bunnies and butterflies and all the other sorts of gooey, lovey things that a preggo brain, hopped up on preggo hormones, is filled with), I envisioned myself locking eyes with my newborn and falling deeply, perfectly in love. I imagined I’d immediately feel a sense of “motherishness,” and that I’d, from that moment on, be transformed (in ways more profound than the integrity of my lady parts). I imagined I’d be willing to die for my baby. You know, like that Maureen Hawkins quote goes: “…before you were born, I loved you. Before you were an hour old, I would give my life for you.”

Bullshit. That did not happen for me. Did it happen for you? That’s nice. No, really. I’m happy for you. But it doesn’t make you a better mother than me. Here’s the thing, though…at the time, I thought it did.

I thought, lying there in my hospital bed, holding my newborn W, that there was something wrong with me, because I couldn’t honestly say that I LOVED her, or that I’d DIE for her. Sure, I felt strong and instinctive things toward her. I cried harder than she when they did that PKU heel-stick thing. I wanted to punch the nurse who (I felt) took an excessive amount of blood for her bilirubin re-test. But love? How could I LOVE someone I didn’t know? How could I LOVE someone I’d only just met? How could I LOVE someone who, up until hours ago, had been nothing but an idea, an image on the sonogram, an occasional squirming sensation in my belly.

I realize there are those mothers for whom love comes strong and early. Who truly do love their babies before they’re born. I don’t doubt that. I just wish I hadn’t expected to be one of them. I wish I’d known then what I know now, which is that love comes to some like a hurricane, fast and furious. Forceful, and certain. For some, love blows open the doors to the heart, and storms in. For others, love creeps on silent feet, curls into a corner of the heart, and settles down. It’s not as dramatic, but it’s just as real.

I wondered many times, in those first weeks, whether there was something missing in me. I wondered whether I was “meant” to be a mother. It felt so hard. She wouldn’t sleep unless she was in my arms. She cried All. The. Time. I fumbled through diaper changes, needed step-by-step pictogram instructions to swaddle her, and worried her bobbly head would fall off if I didn’t hold it just so. She couldn’t latch, so we had to use a nipple shield to nurse. My breasts — which had been, shall we say, “fun size” — swelled to beyond Playboy proportions. I looked like a badly drawn pornographic cartoon character. I didn’t recognize myself. I didn’t recognize my life. I felt like someone had made a terrible mistake, trusting me — ME! What were you thinking!! — with this beautiful, helpless human.

Somehow, slowly, things changed. She and I got to know each other. Nursing became easier (though sleep never has, but we’ll get there). My arms learned to cradle her, and my hands learned to diaper her. The muscle memories of these actions became so ingrained that I could perform them in my sleep. I grew accustomed to my new body, and came to appreciate what it could do. Also, at some point — and looking back, I don’t even know when, exactly — I fell in love. Love crept into my heart on silent paws, and now it fills me.

I’ve also realized that “becoming a mother” isn’t something that happens one night on a beach with a six-pack of beer, nor is it something that happens in a delivery room. It happens day-by-day, month-by-month, even year-by-year. Because yes, I’m good at changing diapers now, and I can tell the difference between a “hungry” whine and a “tired” whine, but I am as clueless about the year ahead of me — the first year of her toddlerhood — as I was about the year of her infancy. I’m FANTASTIC at mothering an infant now. Too bad for me, I don’t have one anymore! So off I go to keep becoming a mother.

But here’s the thing, and this makes all the difference. Back then, in the delivery room, I had the expectation that I should “become a mother” instantaneously. That I should feel love right away, have an instinctive sense of what to do. And I judged myself harshly when things didn’t happen that way. Now? I’m perfectly accepting of my cluelessness. I know I’ll screw up, and go to bed at night thinking, “Tomorrow, I’ll do better.” But I also know I’ll figure out how to mother a toddler eventually. Heck, I know I’ll become FANTASTIC at it. Eventually. Like, by the time she’s ready for preschool.

 

How did your first year of motherhood change you?

 

 

What The Science Says About Circumcision: Part 2 — The Risks

There are many different techniques and mechanisms by which circumcision occurs. Since the purpose of this series of posts on circumcision is to address routine infant circumcision in the hospital environment, I will not be addressing alternate circumcision practices, including non-hospital (religious ritual) circumcision.

Photo by Robert Valette, Creative Commons

Last week, I addressed the scientific evidence as it pertained to the benefits of circumcision. My conclusion was that there was no strong scientific evidence to support routine infant circumcision in the United States.

This week, I want to address the issue of harm; that is to say, is there evidence that routine infant circumcision carries significant, scientifically documented risks?

There are four common arguments given in opposition to routine infant circumcision. These are:

1)   It is painful, and therefore cruel and/or damaging to the infant;

2)   It results in diminished sexual function;

3)   It is associated with a high rate of complications;

4)   It results in long-term psychological trauma.

In this post, I will address the evidence for each of these in turn.

At one time, it was thought that neonates didn’t experience pain, didn’t distinguish it from non-painful stimulus, or couldn’t encode it. This was used as a justification for circumcision without analgesic. Later, it was thought that the injection of analgesic would be just as painful as circumcision without analgesia. Many studies have shown these notions to be false, including a study addressed in a previous post (see, for instance, AAP Statement, Fabrizi et al, Taddio et al). Pain-relieving options include a numbing topical cream and a dorsal nerve block (Brady-Fryer et al). However, neither of these completely eliminates pain during the procedure. Another nerve block, called a ring block, appears to be quite effective (Lander et al, Shockley et al). Further, in combination with other pain-relief methods, oral sucrose (sugar) also helps reduce discomfort (Razmus et al). The Lander study points out that not only does the ring block provide very effective analgesia during the circumcision procedure, the block injection itself is significantly less painful than non-anesthetized circumcision. Other analgesic options, including oral sucrose and topical numbing creams, can reduce the discomfort associated with the nerve block injection.

With regard to the notion that circumcision results in lasting damage due to the physical pain, there is some scientific evidence to support this in the case of circumcision with no analgesic. According to Taddio et al, infants circumcised with no analgesia had a greater pain response to subsequent noxious stimulus (vaccination) than infants circumcised with topical cream pain relief, who showed a greater response to the painful stimulus of vaccination than uncircumcised infants. The study did not examine the responses of infants circumcised with a ring block, however. Neither did the study note any effect persisting beyond the neonatal period. A review of the literature suggests that there is no scientific evidence to support the notion that circumcision (with or without analgesia) causes changes to pain response that persist beyond the neonatal period. Further, while some anti-circumcision advocates (sometimes called “intactivists”) suggest that circumcision causes brain damage and/or physical changes to the brain, there is no scientific evidence to support this notion. Studies that show a correlation between neonatal pain and changes in brain structure/function (such as Anand et al) are based upon repetitive exposure to pain, and can’t be generalized to one-time medical procedures.

Some argue that circumcision results in diminished sexual sensation and/or function. This is actually an untestable claim. It’s possible to compare the sexual function of men circumcised as infants with that of men not circumcised as infants, and it’s possible to compare the sexual experience of an uncircumcised adult male with his experience post-circumcision (in the case of a man circumcised as an adult), but it’s not possible to know what a man circumcised in infancy would have experienced had he never been circumcised. As such, none of the scientific evidence regarding sexual function and infant circumcision is particularly relevant or helpful, and can’t be used to support a strong argument either for or against the statement that circumcision affects sexual function.

One study of men circumcised as adults suggests that function may be affected, but finds that more men experience improved function than diminished function after circumcision (Fink et al). Of 123 men circumcised during adulthood, 38% reported harm in the form of perceived diminished function. 50%, however, reported improved function. Unfortunately, since 93% of the study participants underwent circumcision for medical reasons, the results of this study can’t be generalized to the population.

Unbiased studies have uncovered only anecdotal accounts (Moses et al) of sexual effects, which can’t be taken as scientific evidence (see this post for an explanation of why anecdotes aren’t scientific evidence). There are men who attribute their sexual dysfunction to infant circumcision, but there is no scientific evidence to support these claims. Some “intactivist” arguments suggest that female sexual partners of uncircumcised males derive greater sexual pleasure than do the partners of circumcised males. There are no scientific studies to support this. In fact, the few scientific studies that exist suggest the opposite. Ugandan women report greater sexual satisfaction from intercourse with circumcised men, despite the fact that circumcision is not routine practice in Uganda (Bailey et al). Surveys of college-aged American women show overwhelming preference (87%) for the appearance of a circumcised penis (Williamson et al).

There are a few survey studies of sexual function and attitudes about circumcision. One such survey (Hammond) showed strong evidence of sexual dysfunction and psychological trauma as the result of infant circumcision. However, it must be noted that the Hammond study did not sample the population randomly. Instead, study participants were asked to respond to a survey from the National Organization to Halt the Abuse and Routine Mutilation of Males (NOHARMM), an organization whose very name betrays its bias. As such, it’s not reasonable to generalize the findings of the Hammond study to the population at large, since the men most likely to participate in the voluntary survey would have been those who were dissatisfied with their circumcision. A much larger survey by Laumann et al found that of 1400 American men, those who were circumcised were actually less likely than uncircumcised men to report a sexual dysfunction. While the foreskin has sensory function (Taylor et al), there is no scientific evidence to suggest that the loss of these receptors affects sexual satisfaction or the intensity of the sexual experience for men. One study even goes so far as to suggest that while there isn’t currently evidence to support the notion that circumcision somewhat desensitizes men, even if such evidence existed, it wouldn’t necessarily be a bad thing, given that more men (and their partners) complain of premature ejaculation than complain of inability to achieve orgasm (Burger et al). While Burger doesn’t go so far as to suggest circumcision to prevent problems with premature ejaculation, these observations do put into perspective the “intactivist” argument that circumcised men don’t enjoy sex as much as they otherwise would; clearly, for the vast majority of men, enjoying sex isn’t a problem. The scientific evidence does not support the notion that male circumcision diminishes sexual performance in men, nor sexual satisfaction in men or women.

Regarding the notion that routine infant circumcision is associated with a high rate of complication, this does not stand up to scrutiny. The American Academy of Physicians (AAP) has reported a complication rate of 0.2-0.6%, though it’s difficult to accurately assess the rate of complication, since different surveys include different symptoms as complications of circumcision. As such, some studies suggest higher rates of complication, though they define “complication” very differently (including aftereffects that can’t necessarily be attributed to circumcision). On the flip side, Wiswell reports that approximately 10-15% of males who are not circumcised as infants have recurrent balanitis (swelling of the foreskin) or phimosis (foreskin that doesn’t retract), and require circumcision later in life. The adult procedure is a more significant surgery than the infant procedure, leading some practitioners to view circumcision as “preventative medicine.” Not all cases of balanitis or phimosis require surgical treatment, however, meaning that Wiswell’s numbers don’t translate directly into a percentage of uncircumcised men who will require adult circumcision. Based upon the numbers, there is not adequate evidence to suggest that routine infant circumcision is particularly risky.

Finally, with regard to the argument that infant circumcision results in psychological trauma, the support for such a notion is anecdotal and unprovable. “Intactivists” argue that many (some even go so far as to say most) circumcised men are traumatized by their circumcision, and that those who don’t acknowledge the trauma are in denial. This is a spurious claim; one could just as easily make the argument that children born by cesarean section are traumatized by not having experienced a vaginal birth, and that those individuals born by cesarean who don’t acknowledge their psychological pain are “in denial.” The denial argument is a powerful-appearing one for the “intactivists,” since by definition, any man who denies being in denial is categorized as…in denial. Still, we can make an attempt to sort through the science. A very large (5000 individuals) British study showed that circumcised men scored no differently than uncircumcised men on a variety of behavioral and psychological tests (Calnan et al), indicating that if the circumcised men were at all “traumatized,” it was undetectable to psychologists and didn’t affect their behavior. In a position paper, a psychiatrist and anti-circumcision activist compares circumcision to sexual abuse and an assault on the body (Goldman), but there’s no evidence to support the validity of the former, and the latter comes from the statements of young Turkish boys ritually circumcised without analgesic in a public ceremony, so it can hardly be generalized to anesthetized neonates in a hospital setting.

Goldman continues by suggesting that infant circumcision is associated with long-term psychological effects. As evidence for this, he cites the reports of men who contacted the Circumcision Resource Center (CRC). There are two problems with using this group, and their anecdotal reports of psychological harm, as evidence that circumcision has a psychological impact upon the general population. First, the men were “self-selected,” meaning they don’t represent a random selection of the population. To consider these individuals representative of the population is tantamount to making the claim that most Americans believe in extraterrestrials on the basis of those select individuals who contact SETI (Search for Extraterrestrial Intelligence) to report them. As with people who feel strongly enough that they’ve seen an alien to warrant a call to SETI, those who contact the CRC represent the small minority who feel particularly strongly about their circumcision. While it would be wrong to discount the intensity of their individual feelings, neither can one reasonably generalize those strong feelings to circumcised men as a whole. Furthermore, though SETI may claim (or even attempt) to be impartial and scientific in their search for evidence of extraterrestrial life, they are nevertheless predisposed to a particular outcome, and therefore their conclusions may reflect a bias. Similarly, the CRC is predisposed to find evidence that circumcision leads to harm. A second important point with regard to those men who contacted the CRC (and again, this is not meant to downplay their psychological pain) is that since no man has a conscious memory of INFANT circumcision (the brain doesn’t work that way), it’s pure conjecture on the part of a man to suggest that his psychic trauma is the result of his circumcision. He might feel regretful that he was circumcised, or he might wish he hadn’t been, but these feelings could as easily be the result of events he experienced post-circumcision (the emotions conjured by which he falsely attributes to the circumcision in a post hoc ergo proctor hoc fallacy). Even Goldman, who is clearly biased toward showing that circumcision causes harm, can only conclude that “the connection between present feelings and circumcision may not be clear.” In essence, that leaves the psychological trauma argument insufficiently supported from a scientific perspective. While some men may be traumatized by circumcision (though again, whether infant circumcision was the root cause of an individual’s feelings of psychological trauma is impossible to determine), there’s no scientific evidence to suggest that routine infant circumcision has lasting psychological effects.

 

Science Bottom Line:* There is no scientific evidence that strongly links routine infant circumcision with appropriate analgesia to physical or psychological harm.** Because there are many options available for managing pain during infant circumcision, however, there’s simply no justification for medical circumcision without analgesia.

 

**Obviously, this is not to say that no one is ever hurt by circumcision, or that there are not individuals who wish they hadn’t been circumcised. However, the SCIENTIFIC EVIDENCE does not provide support for the argument that routine infant circumcision is harmful. As such, the argument AGAINST circumcision in the U.S. can’t be made on the basis of scientific evidence, and must instead be made on the basis of values and beliefs.

 

What do you think about the risks of circumcision?

 

References:

AAP. Circumcision policy statement. American Academy of Pediatrics. Task Force on Circumcision. Pediatrics. 1999 Mar;103(3):686-93.

AAP. American Academy of Pediatrics: Report of the Task Force on Circumcision. Pediatrics 1989 Nov;84(5):761.

Anand et al. Can Adverse Neonatal Experiences Alter Brain Development and Subsequent Behavior? Biol Neonate. 2000 Feb;77(2):69-82.

Bailey et al. Acceptability of male circumcision as a strategy to reduce HIV infection in Uganda. AIDS Care. 2002 Feb;14(1):27-40.

Brady-Fryer et al. Pain relief for neonatal circumcision. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004217.

Burger et al. Why circumcision? Pediatrics. 1974 Sep;54(3):362-4.

Calnan et al. Tonsillectomy and circumcision: comparison of two cohorts. Int J Epidemiol. 1978 Mar;7(1):79-85.

Fabrizi et al. Electrophysiological Measurements and Analysis of Nociception in Human Infants. J Vis Exp. 2011 Dec 20;(58). pii: 3118. doi: 10.3791/3118.

Fink et al. Adult circumcision outcomes study: effect on erectile function, penile sensitivity, sexual activity and satisfaction. J Urol. 2002 May;167(5):2113-6.

Goldman, R. The psychological impact of circumcision. BJU Int. 1999 Jan;83 Suppl 1:93-102.

Hammond et al. A preliminary poll of men circumcised in infancy or childhood. BJU Int. 1999 Jan;83 Suppl 1:85-92.

Lander et al. Comparison of Ring Block, Dorsal Penile Nerve Block, and Topical Anesthesia for Neonatal Circumcision. JAMA. 1997 Dec 24-31;278(24):2157-62.

Moses et al. Male circumcision: assessment of health benefits and risks. Sex Transm Infect. 1998 Oct;74(5):368-73.

Razmus et al. Pain management for newborn circumcision. Pediatr Nurs. 2004 Sep-Oct;30(5):414-7, 427.

Shockley et al. Clinical inquiries. What’s the best way to control circumcision pain in newborns? J Fam Pract. 2011 Apr;60(4):233a-b.

Taddio et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet. 1997 Mar 1;349(9052):599-603

Taylor et al. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol. 1996 Feb;77(2):291-5.

Williamson et al. Women’s preferences for penile circumcision in sexual partners. J Sex Educ Ther. 1988; 14: 8.

The Stuff in My Head — Random Poetry

Earlier this week I was really frustrated (as evidenced by this post). Truth be told, I’m still really frustrated, but I’ve got some perspective now. One of the wonderful things about motherhood is that even on the days when I want to tear my hair out, there are beautiful moments. Many of them. One night a few months ago, after a really hard day, I watched W sleep and wrote this…and I thought I’d share it…

 

Mama

It’s true that it’s me she kicks

And me she bites

But it’s also me who got her first kiss

Her first smile

The first touch of a starfish hand.

There are days when I just can’t stand another moment of being

Needed and touched…

 

Every.

Single.

Second.

 

And there are moments within every day —

Even the best days —

When I wonder how much more I can take before I crack.

Before I break.

 

There are moments of frustration at the fact that

I am her everything.

But then I realize…

I am her

EVERYTHING.

 

It’s me she turns to for comfort

It’s me she wants when she’s scared

It’s me she reaches for in her sleep

It’s me she watches each morning when she wakes…

She lies quietly beside me and waits…

And waits…

For my eyes to open…

And she grins her big toothless baby grin…

And there is no sunrise so precious.

 

I know it’ll be at me that she yells “I hate you!” when she can’t

Draw on the walls

Have more ice cream

Take the car out.

 

But it will also be me she tells when she

Makes her first best friend

Falls in love

Feels her belly swell with her own sweet baby some day.

 

There are days when I am stretched to breaking,

And I am sure I can’t do this for one more second…

But then I give her a bath

And we nurse

And she hums her going-to-sleep song

And her eyes close

And I look into her beautiful, beautiful, peaceful, sleeping face.

 

In these moments I realize that being Mama is the

Hardest

Sweetest

Most impossible

Most beautiful thing I will ever do.

 

And I would never trade it.

Not for gold,

Not for freedom.

 

She is

My everything.

 

 

Go The #&%$ To Sleep! (So I Can Too)

Many of the more “personal” posts, I’m keeping for W as a sort of journal of her baby/toddlerhood. I thought long and hard about whether to save this one for her, since it’s got some tough stuff in it. In the end, I’ve decided to do so. I know that over time, my memories of the trials of motherhood will fade, and (blessedly) what remains will be mostly the good stuff, the sweet stuff, the stuff that will make me want to say to new moms, “Oh, treasure these days! They go by so fast!” (Which, incidentally, though I’m sure it’s true, is something NO ONE should EVER say to a new mom). When W is a mom herself someday, I want to be able to give her a realistic accounting of how I felt when I walked in those shoes. I want her to know that there’s nothing wrong with her if she feels resentful of her baby (despite loving said baby more than anything), or if she wonders what she’s gotten herself into, or if she sometimes feels like every parenting decision she makes is wrong. I want to show her these posts and say to her, “W, check it out. Here’s what I experienced, and sometimes it sucked royally, but when I look back, I wouldn’t have traded the experience, and everything worked out fine.” Oh, and also? I want to believe that some day, that will be true.

There’s an excellent post on Science Of Mom this week on baby sleep and CIO (cry-it-out). In addition to being well written and informative, I personally find the post very timely. In fact, I find myself holding my breath, hoping and praying that in her next posts on the subject (Alice has promised a series of at least three), she’ll reveal The Secret To Good Sleep (no pressure, Alice!).

I know this isn’t going to happen. I know there is no Secret To Good Sleep. If there were, there wouldn’t be so many damn sleep books out there. There would be one, presumably called “The Secret To Good Sleep.” And the author would be wealthy, venerated, and possibly crowned empress/emperor of the world. Or at least should be.

We have sleep trouble. W sleeps with us; she has from the time she was two days old. We didn’t intend to co-sleep, but quickly realized that it got everyone more blessed shut-eye, since pre-co-sleeping, it was taking 2-3 hours per nursing to get her fed and back to sleep again (at which point she’d sleep for about half an hour, and then cry to be fed once more). Once we moved her into our bed, nursings were quick and easy, and right back to sleep for everyone.

However…

She’s now on the doorstep of her first birthday, and while she goes through short phases (a few days) of only one or two night-wakings, most nights, she’s waking 4-5 times. Each time, she wants to nurse back to sleep, which is a problem for me for two reasons:

1)   I have never been able to sleep while she nurses; the sensation is not compatible with sleep for me.

2)   I worry about nursing cavities, based upon my review of the scientific evidence.

I’m not categorically opposed to the idea of sleep training/cry-it-out in some regard, except that:

1)   I don’t think it will work for W. The one time I tried a modified CIO with her for naptime, she sobbed for a solid two hours, turning herself red and retching.

2)   I know several moms of toddlers with W-like personalities who have to redo CIO every time circumstances change (they go on a trip, new teeth come in, baby gets sick). I might be able to stomach one bout of CIO, but I really don’t see myself being able to handle doing it over and over again.

3)   I would really want to look at the science first, which is why I’m eagerly anticipating Alice’s post (except that I’m still not convinced it’ll work for W).

I’ve read a LOT of sleep books that are gentle/non-CIO, including Elizabeth Pantley’s No Cry books (Sleep Solution and Nap Solution). I’ve read Dr. Jay Gordon’s stuff on gentle night weaning, and I wonder if night weaning would be a good solution for us, except that:

1)   When we tried to do the first night of Dr. Gordon’s plan (nurse baby, but don’t nurse to sleep), W screamed for HOURS. We gave up, because;

2)   Both hubby and I work full time. I have the benefit of being able to work from home at least part of the time, but I still have to be sort of sentient.

As long as I’m listing things that are complicating life right now, I’ll list one more: I’m having mixed feelings about continued nursing (even during the day). Sometimes, I really love nursing her. I love the special relationship, and I love that if she’s upset or scared or she’s just fallen and banged her chin, I can nurse her to comfort her. I love the quiet times when I can just sit and hold her, and we can rock and nurse. However, I resent — frankly, I can’t STAND — having her follow me around whining and making the “nurse” sign when I’ve JUST nursed her, I’ve offered her a snack (“real food,” so she’s not hungry), and I know all she wants is to luxuriate in my lap with a nipple in her mouth. I am not a dairy cow, dammit! Sometimes, I love nursing. Other times — I’ll be honest here — I feel like she’s sucking the life out of me one mouthful at a time.

It’s like the older she gets, the whinier she gets about nursing. She plays with her daddy, she asks my mother’s helper to read to her…but me? She just follows me around making the “nurse” sign and whining nay nay NAY! (her word for nurse). I guess I’m just resentful that sometimes it seems all I am is a giant pair of boobs.

 

So…I’m appealing to the wisdom of the masses. Got any ideas for me? Failing that, want to just make me feel better by sharing your own tale of sleep (or nursing) woe?

 

 

My Birthday

So, rather than trying to write a single, coherent PhPh post today, I’ve got a bunch of stuff rattling around in my brain and figured I’d share it in a series of shorts, in no particular order.

1. It’s my birthday today. I’m 34 29. Yesterday, I had an appointment with the eye doctor for an annual checkup (I wear contacts). Word to the wise: never schedule an appointment with a healthcare professional the week of your birthday (unless you’re pregnant and are hoping to go into labor, which is what I was doing on my birthday last year). Why? Because healthcare professionals have a nasty habit of telling you things that translate to you’re getting older. Which unless you’re under 21, isn’t what you want to hear. For instance, yesterday I got to hear you have presbyopia, which is optometrist-speak for you need {an expensive pair of really cute} glasses on top of your contact lenses so you can see when you read and use the computer. Ok, in fairness, he didn’t say the “expensive and cute” part, but that’s what I chose to hear. That was my aging-eyes consolation prize. I got to pick out my expensive-and-cute frames while W had an I’m-almost-one-going-on-terrible-two tantrum in the frame store. Whadaya think…how’d I do?

2. On a related note, I offered W to a woman at the frame shop. I had finally stopped the tantruming by letting W push her stroller around the store (yes, I have become the annoying mom with the child that pushes her stroller around the store, about whom childless people think things like why can’t she control her kid and Jeezus, just leave her at home next time. I was that childless person. It’s karma that I’ve become the annoying mom. Oh, and to the childless people, I AM controlling my kid. There are two options here — because…leave her at home? With WHOM? — and they are a) let her push the stroller around the store, or b) let her scream. I’ve gone with the option that I assume you prefer, but if you’d rather hear her scream, lemme know. Happy to oblige.) Anyway, so while she was pushing her stroller around, a woman who had not been present for the tantruming commented that she was really, really cute. I said, like I was flattered, Oh, you think? She reaffirmed. I said, You want her? And then I laughed, to convince myself that to show her that I was kidding. Anyway, one of the things I’ve learned about motherhood is that it means loving someone more than anything, but occasionally being willing to sell them to gypsies for the right price.

3. Husband baked me a birthday cake last night so that it could cool and set while we slept. It’s chocolate. Yum. Anyway, I was in bed already (because W holds me hostage every night likes me to lie next to her after she goes to sleep), and when he came to bed, he smelled like chocolate. Best. Birthday. Gift. Ever.

4. I’m starting to wonder whether this blog needs to split into two separate ones. The sciency posts are becoming more sciency and less personal/philosophical than they used to be, while the PhPh posts are becoming more personal and less sciency. I’d love some feedback. Should PhPh stay on SquintMom to “soften” it up, or should SquintMom become strictly resources for evidence-based parenting, while I take my snarky, wish-I-could-swear-in-posts-but-don’t-want-to-on-a-semi-professional-blog self off to another URL dedicated to my random thoughts and observations?

5. Happy birthday to me. Looking forward to a big glass of wine, maybe even two, with dinner. Hooray for being not-pregnant!