Re: Docket Number CDC-2014-0012
To Whom It May Concern::
We are writing as psychologists who are deeply concerned by the recently announced CDC guidelines promoting circumcision for all males, and in particular children. The CDC guidelines were based on a 2012 policy statement by the American Academy of Pediatrics which was sharply criticized by a large group of physicians, medical organizations, and ethicists from European, Scandinavian, and Commonwealth countries as “culturally biased” and “different from [the conclusions] reached by physicians in other parts of the Western world, including Europe, Canada and Australia” (Frisch et al., 2013). The CDC highlighted methodologically flawed studies from Africa, that have no relevance to the United States, and chose to ignore studies that were conducted in the United States and showed no link between circumcision and the risk of sexually transmitted diseases including HIV (Thomas et al., 2004). Another very troubling fact was that the CDC completely ignored the psychological effects of genital cutting on male children. This letter outlines the psychological research that demonstrates the relationship between circumcision and psychological harm. We are appealing to the CDC as well as Congress to reevaluate this policy in light of the psychological harm it will cause children.
Psychological Effects on Infants
Circumcision Causes Immediate Harm Circumcision is often performed without anesthetic or with a local anesthetic that is ineffective at substantially reducing pain (Lander et al., 1997). In the study by Lander and colleagues (1997), a control group of infants who received no anesthesia was used as a baseline to measure the effectiveness of different types of anesthesia during circumcision. The control group babies were in so much pain—some began choking and one even had a seizure—they decided it was unethical to continue. It is important to also consider the effects of post-operative pain in circumcised infants (regardless of whether anesthesia is used), which is described as “severe” and “persistent” (Howard et al., 1994). In addition to pain, there are other negative physical outcomes including possible infection and death (Van Howe, 1997, 2004).
Pain from Circumcision in Infancy Alters the Brain Research has demonstrated the hormone cortisol, which is associated with stress and pain, spikes during circumcision (Talbert et al., 1976; Gunnar et al., 1981). Although some believe that babies “won’t remember” the pain, we now know that the body “remembers” as evidenced by studies which demonstrate that circumcised infants are more sensitive to pain later in life (Taddio et al., 1997). Research carried out using neonatal animals as a proxy to study the effects of pain on infants’ psychological development have found distinct behavioral patterns characterized by increased anxiety, altered pain sensitivity, hyperactivity, and attention problems (Anand & Scalzo, 2000). In another similar study, it was found that painful procedures in the neonatal period were associated with site-specific changes in the brain that have been found to be associated with mood disorders (Victoria et al., 2013). Most recently, a large study in Denmark found that circumcision performed before the age of 10 was associated with significant increased risk for autism as well as attention-deficit/hyperactivity disorder (.
Infant Circumcision has Psychological Consequences for Men Over the last decade there has been a movement of men who were circumcised as infants and have articulated their anger and sadness over having their genitals modified without their consent. Goldman (1999) notes that shame and denial is one major factor that limits the number of men who publicly express this belief. Studies of men who were circumcised in infancy have found that some men experienced symptoms of post traumatic stress disorder, depression, anger, and intimacy problems that were directly associated with feelings about their circumcision (Boyle, 2002; Goldman, 1999; Hammond, 1999).
Psychological Effects on Children and Adolescents
Medical Procedures in Childhood are Often Experienced as Traumatic
The CDC fails to consider that many medical procedures, even those that are described as routine, are often experienced as traumatic by children and adolescents (Levine & Kline, 2007). Circumcision, for example, clearly meets the clinical definition of trauma because it involves a violation of physical integrity. In fact, research has demonstrated that medical traumas in childhood and adolescence share many of the same psychological elements of childhood abuse, such as physical pain, fear, loss of control, and the perception that the event is a form of punishment (Nir, 1985; Shalev, 1993, Shopper, 1995).
Procedures Involving Children’s Genitals Produce Negative Psychological Effects
The psychological consequences of medical procedures are even greater when they involve a child’s genitals. Studies have examined the psychological effects of medical photography of the genitals (Money, 1987), repeated genital examinations (Money, 1987), colposcopy (Shopper, 1995), cystscopy and catheterization (Shopper, 1995), voiding cystourethrogram (Goodman et al., 1990), and hypospadias repair (INSA, 1994). The studies found that these procedures often produce symptoms which are very similar to those of childhood sexual abuse, including dissociation and the development of a negative body image. The effects often persist into adulthood as evidenced by a study that examined the effects of childhood penile surgery for hypospadias. Men who had this surgery in childhood experienced more depressive symptoms, anxiety, and interpersonal difficulties than men who did not have the surgery (Berg & Berg, 1983).
Circumcision Causes Significant Psychological Harm in Children and Adolescents Circumcision in childhood and adolescence has significant negative psychological consequences. Following a traumatic event, many children experience significant anxiety, depression, and anger; and many others try to avoid and suppress these painful feelings (Gil, 2006). In addition, children often experience a debilitating loss of control that negatively affects their ability to regulate emotions and make sense of the traumatic experience (Van der Kolk, 2005). In a study of adults circumcised in childhood, Hammond (1999) found that many men conceptualized their circumcision experience as an act of violence, mutilation, or sexual assault. Kennedy (1986) detailed the psychological effects of circumcision in a case study describing the psychotherapy of a boy who was circumcised at three years of age. The sense of inadequacy, feelings of victimization, and violent sexual fantasies experienced during this boy’s adolescence were found to be both consciously and unconsciously linked to his experience with losing part of his penis (Kennedy, 1986). In a study examining the psychological effects of circumcision on boys between four and seven years of age, Cansever (1965) used psychological testing to measure boys’ level of distress. The results of the study indicated that circumcision was perceived as an aggressive attack on the body that left children feeling damaged and mutilated (Cansever, 1968). Cansever (1968) also noted that these boys experienced changes in body image (with many feeling smaller and incomplete), feelings of inadequacy and helplessness, as well as a tendency to withdraw psychologically.
The Majority of Boys Circumcised as Children and Adolescents Meet Diagnostic Criteria for Post Traumatic Stress Disorder (PTSD)
The most comprehensive study available that assesses the psychological impact of circumcision on children after infancy was conducted by Ramos and Boyle (2000) and involved 1072 pre-adolescent and adolescent boys who were circumcised in a hospital setting. Using an adapted version of a clinically established PTSD interview rating scale, the study’s authors determined that 51 percent of these boys met the full diagnostic criteria for PTSD and noted that other variables such as age at circumcision (pre-adolescence versus adolescence) and time elapsed since the procedure (months versus years) were not predictive of a PTSD diagnosis (Ramos & Boyle, 2000). As a point of comparison, the rate of PTSD among veterans of the Iraq war is approximately 20 percent (NIH, 2009).
By Encouraging Circumcision, Medical Professionals are Shaming Boys’ Bodies
If the CDC guidance is followed, medical providers will be communicating a psychologically damaging message to boys with intact genitals—that their penises are somehow “bad” or inferior. The negative effects of such communications have been studied with regard to intersex children and have been found to be frightening, shaming, and embarrassing to the child (Rusch et al., 2000). This is a particularly cruel message to send to adolescents, many of whom are already experiencing concerns regarding body image.
As psychologists, we understand that the circumcision of children has myriad negative psychological consequences that the CDC has failed to consider. Removing healthy tissue in the absence of any medical need harms the patient and is a breach of medical providers’ ethical duty to the child. We believe that all people have a right to bodily autonomy and self-determination and deeply respect this fundamental tenet of international human rights law (UNESCO 2005). As children cannot advocate for themselves, they need adults to understand the complexities of their emotional experiences and provide them special protection. We ask that you consider this need and involve experts from the psychological community in revising the CDC circumcision guidelines.
Patrick O’Connor, Psy.D. (firstname.lastname@example.org)
Licensed clinical psychologist specializing in the treatment of trauma, loss, and depression during childhood and adolescence.
Darcia Narvaez, Ph.D. (email@example.com)
Professor of Psychology at the University of Notre Dame studying child flourishing, moral development, and ethics.
George W. Holden, Ph.D.
Professor of Psychology at Southern Methodist University studying child-rearing, parenting, and child maltreatment.
Gwenden Dueker, Ph.D.
Associate Professor of Psychology at Grand Valley State University studying infant and child development.
Anand, K.J., & Scalzo, F.M. (2000). Can adverse neonatal experiences alter brain development and subsequent behavior? Biol Neonate, 77, 69-82.
Berg, R., & Berg, G. (1983). Castration complex: Evidence from men operated for hypospadias. Acta Psychiatrica Scandinavica, 68, 143-153.
Boyle, G.J., Goldman, R., Svoboda, JS., & Fernandez, E. (2002). Male circumcision: Pain, trauma, and psychosexual sequelae. Journal of Health Psychology, 7, 329-343.
Boyle, G.J., & Ramos, S. (2000). Ritual and medical circumcision among filipino boys: Evidence of post-traumatic stress disorder. Humanities & Social Science Papers, 114.
Cansever, G. (1965). Psychological effects of circumcision. British Journal of Medical Psychology, 38, 321-331.
Frisch, M., Aigrain, Y., Barauskas, V., Bjarnason, R., Boddy, S.A., Czauderna, P., de Gier, R.P., de Jong, T.P., Fasching, G., Fetter, W., Gahr, M., Graugaard, C., Greisen, G., Gunnarsdottir, A., Hartmann, W., Havranek, P., Hitchcock, R., Huddart. S., Janson, S., Jaszczak, P., Kupferschmid, C., Lahdes-Vasama, T., Lindahl, H., MacDonald, N., Markestad, T., Märtson, M., Nordhov, S.M., Pälve, H., Petersons, A., Quinn, F., Qvist, N., Rosmundsson, T., Saxen, H., Söder, O., Stehr, M., von Loewenich, V.C., Wallander, J., Wijnen, R. (2013). Cultural bias in the AAP's 2012 Technical Report and Policy Statement on male circumcision. Pediatrics, 131, 796-800.
Frisch, M., & Simonsen, J. (2015). Ritual circumcision and risk of autism spectrum disorder in 0- to 9-year-old boys: National cohort study in Denmark. Journal of the Royal Society of Medicine, January, 2015.
Gil, E. (2006). Helping abused and traumatized children. New York: Guilford Press.
Goldman, R. (1999). The psychological impact of circumcision. BJU International, 83, Suppl. 1, 93-102.
Goodman, G.S., Rudy, L., Bottoms, B.L., & Aman, C. (1990). Children’s concerns and memory: issues of ecological validity in the study of children’s eyewitness testimony. In R. Fivush J.A. Hudson (Eds.), Knowing and Remembering in Young Children (pp. 249-294). NY: Cambridge University Press.
Gunnar, M.R., Fisch, R.O., Korsvik, S. & Donhowe, J. (1981). The effects of circumcision on serum cortisol and behavior. Psychoneuroendocrinology, 6, 269-275.
Hammond, T. (1999). A preliminary poll of men circumcised in infancy or childhood. BJU International, 83, Suppl. 1, 85-92.
Howard, C.R., Howard, F.M., & Weitzman, M.L. (1994). Acetaminophen analgesia in neonatal circumcision: The effect on pain. Pediatrics, 93, 641-646.
Intersex Society of North America (ISNA). (1994). Hypospadias: A parent’s guide.
Kennedy, H. (1986). Trauma in childhood: Signs and sequelae as seen in the analysis of an adolescent. Psychoanalytic Study of the Child, 41, 209-219.
Lander, J., Brady-Freyer, B., Metcalfe, J.B., Nazerali, S., & Muttit, S. (1997). Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision. JAMA, 278, 2157-2162.
Levine, P.A., & Kline, M. (2007). Trauma through a child’s eyes. Berkeley, CA: North Atlantic Books.
Money, J., & Lamacz, M. (1987). Genital examination and exposure experienced as nosocomial sexual abuse in childhood. The Journal of Nervous and Mental Disease, 175, 713-721.
National Institutes of Health. (2009). PTSD: A growing epidemic.. NIH Medline, 4, 1. Retrieved from: http://www.nlm.nih.gov/medlineplus/magazine/issues/winter09/articles/winter09pg10-14.html
Nir, Y. (1985). Post-traumatic stress disorder in children with cancer. In S. Eth R. S. Pynoos (Eds.), Post-Traumatic Stress Disorder in Children (p. 121-132). Washington, D.C.: American Psychiatric Press, Inc.
Rusch, M.D., Grunert, B.K., Sanger, J.R., Dzwierzynski, W.W., & Matloub, H.S. (2000). Psychological adjustment in children after traumatic disfiguring injuries: A 12-month follow-up. Plastic Reconstructive Surgery, 106, 1451-60
Shalev, A.Y., Schreiber, S., & Galai, T. (1993). Post-traumatic stress disorder following medical events. British Journal of Clinical Psychology, 32, 247-253.
Shopper, M. (1995). Medical Procedures as a source of trauma. Bulletin of the Meninger Clinic, 59, 191-204.
Taddio A., Katz, J., Ilersich, A.L., Koren, G. (1997). Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet, 349, 599-603.
Talbert, C. M., Kraybill, E. N., & Potter H.D. (1976). Adrenal cortical response to circumcision in the neonate. Obstetrics and. Gynecology,48, 208-210.
Thomas, A.G., Bakhireva, L.N., Brodine, S., Shaffer, R. (2004). Prevalence of male circumcision and its association with HIV and sexually transmitted infections in a U.S. navy population. Poster Exhibition: The XV International AIDS Conference.
Intergovernmental Bioethics Committee. Universal Declaration on Bioethics and Human Rights. Adopted by the General Conference of the United Nations Educational, Scientific and Cultural Organization on 19 October 2005.
Van der Kolk, B.A. (2005). Developmental trauma disorder: Towards a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35, 401-408.
Van Howe, R..S. (1997). Variability in penile appearance and penile findings: A prospective study. BJU, 80, 776-782.
Van Howe, R.S. (2004). A cost-utility analysis of neonatal circumcision. Medical Decision Making, 24, 584 - 601.
Victoria, N.C., Kiyoshi, I., Young, L.J., & Murphy, A.Z. (2013). Long-term dysregulation of brain corticotrophin and glucocorticoid receptors and stress reactivity by single early-life pain experience in male and female rats. Psychoneuroendocrinology, 38, 3015-3028.