 Our next speaker today will be Dr. Paul Helft. Paul is an associate professor of medicine and the director of the Fairbank Center for Medical Ethics at Indiana University. Paul completed his medical degree and his residency in internal medicine and his fellowship in He-Munk and in clinical medical ethics here at the University of Chicago. Paul's clinical work is based in the Gastrointestinal Oncology Program at Indiana University where he co-chairs the Ethics Consultation Committee. His research is focused on the ethical aspects of doctor-patient communication. Today, Dr. Helft will talk to us, the title of his talk is No More Circumcision How an Ancient Procedure Violates Medical Ethics. Please join me in welcoming Dr. Paul Helft. I'm not really sure why I'm talking about this topic except I must have been thinking about it when I got Mark's ubiquitous email saying, what do you want to talk about at the McLean Center conference eight months from now? I had been noodling on the topic sort of indirectly having seen the 2012 AAP guidelines which actually changed the view of the American Academy of Pediatrics after and this table actually just traces the history of those recommendations. I'm also, I have sort of a latent interest in how, in our invisible practices, why we do certain things not thinking very carefully about them. So, and as Mark mentioned, I'm not either a urologist or a pediatrician so in some ways I'm not really qualified to talk about this so this is more a series of thoughts. But here's the main argument that I'd like to propose. Modern American medicine has tried to map medical purposes onto circumcision but it remains profoundly tied to ritual purposes and because ultimately it has to be viewed as a ritual with no other analogies in medicine or surgery, it's really outside of the scope of medicine. So I'm not going to come at this either from an advocacy perspective or which is out there if you're interested in it certainly. In fact, I think it's sometimes outside the University of Chicago on some days. This is the oldest known image of circumcision from the Necropolis at Sakara in Egypt, circa 2400 before the Common Era and you can see, if you can just see and outline the two young boys who are undergoing their ritual circumcisions, one of whom is having his arms held back by somebody who accompanies him. That was probably unearthed by members of the Oriental Institute from the University of Chicago ironically in 1934 from that same dig in fact. Circumcision is a surgical practice which goes farther back than anybody knows in fact. There's evidence that it was done at least 4000 BCE in Egypt because we've done CT scans on mummies in fact and it's been practiced at various times and in various cultures all the way across the world. So it's sort of fascinating to think about many millennia of the practice. The Belgian scholar Arnold van Genep studied this across Africa and the Far East and found that it was a pivotal rite of passage in every case he could find across the African cultures that he studied and marked a symbolic transition from one state to another linking this physical change to a change in social position. Van Genep was very interested in finding kind of a universal explanation for the practice of circumcision and didn't really do that. He found in fact that the age of circumcision varied quite widely from a few years of age to puberty to past puberty to a few months in various cultures and like a whole array of other bodily transformations such as ritual hair cutting, knocking out of teeth, tattooing, scarring, perforating and stretching the ear lobes, the septum, the lips, etc. Circumcision symbolized this sort of permanent inclusion in a distinct tribal community. And this is a picture of an Australian Aboriginal circumcision ceremony and you might just stop and think for a minute that to go through this much work on the part of a ceremony must mean that the ceremony has a great deal of significance for that culture. This is true also of the Marina people of Madagascar. This is the only picture I could find in fact but this is a many-day ceremony that takes place village-wide when young boys are circumcised in this part of Madagascar. So Durkheim wrote about religion and ritual and I just don't have time to go into the theories in detail but wanted to make a few points which I think are relevant from his thinking about this. So ritual is usually organized around sacred objects or practices as a focal point and participation in such rights integrates individuals into that particular social order. So the veneration of an object that's held sacred by a community is this powerful affirmation of collective conscious and a call to obey communally defined morality and to distinguish one from other groups in fact. So this is just a brief timeline of the history of circumcision going back to ancient Egypt where it seemed to signify purification, refinement and distinction from other cultures. Through ancient Palestine and the Hebrews where it really was in some ways the special covenant with God was a rite of passage and distinguished Jews from non-Jewish neighbors. In Islam after the 6th century it became a almost universally practice ritual. The Quran is actually silent about the practice but the hadith or the sayings of Muhammad attribute several comments to him and also has been used to distinguish Muslims from other cultures. We get a clue about one of its cultural meanings from Maimonides in 1100 when he says that the bodily pain caused is the real purpose and the wish to bring about a decrease in sexual intercourse and the weakening of the organ so that this activity may be diminished and the organ being as quiet a state as possible. We see that later in about 19th century in the United States. In 1500 the Renaissance anatomist Fallopio says that God must have imposed circumcision so that Abraham and his progeny would concentrate on serving him rather than pursuing the pleasures of the flesh. And we get into the 19th century and we start to see the psychoanalytical meanings in Freud and later in Bettelheim here at the University of Chicago. And then finally the medicalization of circumcision really with the great proponent Louis Serre, one of the founders of the Journal of the American Medical Association in the late 19th century, who began to advocate it as a cure for dozens of disorders. George Beard, Ed Heard, J. Hoffminer, and then Ricketts who found all of these both local and systemic indications for circumcision most of which we don't any longer believe in. Circumcision then comes to be reviewed in the United States anyway as a hygienic procedure. This follows in the wake of the germ theory of coke and pastor in the late 19th century and then America gets its obsession with cleanliness which of course according to John Wesley is next to godliness. So circumcision then becomes a way in the views of many to prevent masturbation. So in 1860 a Lancet article reports that masturbation and bedwetting are rare among Jewish children. And so I thought this is the... I don't know any statistics to back that up by the way. But Abraham Jacobian Moses actually crusade against the foreskin as a primary cause of masturbation and the great founder of the Kellogg Serial Company, J.H. Kellogg recommended performing circumcision in his words without administering an anesthetic as the pain attending the operation of a salutary effect on the mind. So again I go back to the AAP guidelines which really changed its tack on this in 2012 having really found no absolute indication before. And it was based on really this is a summary table of the evidence that they bring forward. There's a very well done comprehensive review and I've tried to summarize it here. One of the main prophylactic benefits appears to be at least according to the research reviewed STI prevention including HPVHSV and bacterial adgenosis. Most of that evidence actually comes from randomized trials. Most of them are either not a big deal like HSV2 certainly from a health standpoint or are now preventable actually with using vaccines. HIV transmission which has been extraordinarily heavily studied there clearly is a relative risk reduction to be obtained with circumcision but mostly in endemic areas with high HIV prevalence such as sub-Saharan parts of sub-Saharan Africa. Syphilis the balance is sort of in favor of circumcision although at least one large randomized controlled trial was negative there seems to be no correlation with Shankroyd or other ulcer forming diseases LGV, Chlamydia or gonorrhea. A lot has been made about its preventative effects on UTI with about a tenfold risk reduction tenfold reduction overall excuse me however the calculated number needed to treat on the basis of that is a hundred circumcisions to prevent a single UTI we'd have to argue about whether UTI is really a significant problem as is penile cancer which is a very rare cancer at least in the United States about half of those are probably due to HPV which again is now preventable and may actually be preventable entirely with good hygiene. This is the only major decision analysis I could find of its medical value trying to estimate the overall benefit of circumcision although the data are now old as you can see this paper was from 1991 finding a 105 day survival advantage for men who undergo circumcision at birth. I want to shift gears for just a moment to talk about the cultural significance which is really the core of what I'm trying to say. Richard Dawkins coined the term meme which is a wonderful term in 1973 in his book The Selfish Gene and he so he makes an analogy with the gene which is the unit of transmission in biological evolution the meme is the unit of transmission in cultural evolution so an idea that has passed from one brain to the next brain and therefore undergoes a similar type of evolution. So you might think about circumcision which goes back thousands of years across cultures all across the world as a meme and you know one way of considering it or tracing it through history is that it's a cultural ritual and originally associated with sexual maturity group identity it becomes then associated with decreased sexual pleasure increased focus on God and the sacred it's then viewed as a cultural or subconscious symbol we then medicalize it in the US especially it's a medical procedure to treat all manner of diseases and then for the sake of hygiene and then as a moral prophylaxis and then finally in our current age as a medical procedure for medical prophylaxis. So is circumcision like any other medical intervention and I would love it if the audience could come up with a perfect analogy for circumcision because I couldn't in thinking about this I couldn't find a perfect analogy so I started to think about what is it like that we do accept. Vaccination for example is a prophylaxis provides population-based risk reduction however is very low risk and non-permanently body altering. Cosmetic surgery we don't do that on babies only people with decision-making capacity. What about prophylactic cancer procedures such as mastectomy or frectomy, which we do that only really in cases of known and identified genetic risk it's hard to assign those same known risks to things like STI and UTI. Gender assignment surgery with ambiguous genitalia in children that's really only in cases of abnormal genitalia which is clearly not the case in the case of the uncircumcised young male infant. So in conclusion I would like to argue that circumcision is a deeply significant human ritual which has arisen for thousands of years independently across cultures and over time and if you start to think about it as a meme as a culturally evolving idea it's easy to see that its meanings for individual cultures have evolved over time and that's why anthropologists have not actually been able to find a central explanation for it. Modern American medicine has tried to map medical purposes that is disease prevention onto the meme of circumcision but it remains profoundly tied to those ritual purposes and despite our efforts to find those medical purposes for the ritual it's a procedure which falls outside the scope of medicine with no other adequate and analogies amongst other procedures. Thank you. My son's pediatrician. And I'm not allowed of course by HIPAA to say. That's right. What we did in this regard but if I understand your argument it's that there's nothing wrong with circumcision per se just that doctors shouldn't do it. That as a ritual, as a deeply important deeply culturally embedded ritual that's been used in cultures since at least the Egyptians you're okay with it. You just want lay circumcision. I never said I was okay with it. That would be a separate discussion though about whether it would be okay outside of the scope and so if your moll wanted to do this I would feel like that's a separate discussion but you're correct what I am saying is that it's outside of the scope of medicine and so doctors shouldn't be performing it. Thank you. Yes sir. I wonder why you didn't mention the response commonly called the European response to the 2012 AAP policy. It was signed by 38 major doctors more than half of them presidents of national medical organizations who said the American Academy of Pediatrics was biased and they didn't agree with the conclusions and also the AAP finally had to admit that they had no statistics on the complications and therefore how could they possibly say that the benefits outweigh the risks. So I'm wondering why you didn't mention that when you know about it. Yeah so that's absolutely true. It was difficult to include everything in 12 minutes. Hello Mary. Hi Paul. Thanks very much for a really interesting topic but as you could guess I couldn't help but think of some of the similarities despite the differential differences between male and female circumcision or correctly put female genital utilization. Certainly the ritual aspects the purest component to prevent or curb sexuality those are so obvious in both cases and it is interesting that although there certainly have even been laws in this country against female circumcision there's been no counterpart with regard to male circumcision so you're surfacing an argument that could be made and could be applicable in both contexts. Yeah great point. I made a conscious decision not to go to female circumcision for a couple of reasons. It seems like a slam dunk argument actually you know we have no if I pulled the room nobody would have any objections to banning female circumcision I suspect. It turns out however that the procedures that we call female circumcision are actually quite variable and so to make a neat analogy with the procedure which at least medically we call male circumcision it actually is much more complicated than that so I decided to omit that because of those complexities. Yes sir. Awesome Pedella University of Chicago thank you for your thought-provoking talk I just have a question about the fact you mentioned there may not be analogies for this practice so I think about a lot of different things doctors do that may not be for medical reasons from botox injections that emergency medicine doctors do at times or dermatologists or breast augmentation or other such things and even some procedures which in other countries they would like to avoid they would like to make it professional and have safety so they take it from outside the scope of medicine and put it within the scope of medicine so I just want to get a sense that why would those analogies not work here or can we actually have a scope of practice of medicine that we think everybody would agree upon I'm not quite sure we can across countries and boundaries but I just want to get a sense from you So I did mention the analogy at least the two procedures that you referred to I did mention and cosmetic surgery I didn't have those on my table and the reason why I think they're not analogous is because we only allow people who have the ability to consent to those procedures to do that and we don't do that we would never do that on a baby we would never do cosmetic surgery on a baby No, I saw that but my point is that while the ethical argument of consent is one that is valid the point remains that people do procedures which may or may not be and so is there an argument to take all of those out and say that this is the scope of medicine and we define it or is that just a few extra sides I see your point now I think you'd have to look at each one of those independently I can remember a McLean Center conference about cosmetic surgery when I was in college here in the late 1980s where folks debated whether cosmetic surgery was within the scope of medical and surgical practice in fact but I think one would have to take each of those in turn yes, thank you for the question thank you so much Paul, thank you so much that was a sterling review of a complicated topic