Newman. And now this...

[deleted87051]

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Women don’t get clitoral cancer, phymosis, paraphymosis, or balanitis. Being analogous does not make them equal. Not even close. One is done for clear cut medical reasons, the other is done to disempower women.

Most of Europe, Asia, Africa, and Australia get by fine without it. I’m generally against preemptive surgery. What’s the NNT to prevent these complications? At what cost?

Circimcision , both male and female, is more cultural than medical. We are actually fine the way we are born.

 

[miacomet]

Ok since you are so knowledgeable please show me all this magical data.

Also, you didn’t answer my question.

The point is we don't have the data. That is the point.

 

[Hamhock]

Who cares about why they did something 50 years ago or a thousand years ago. I care about the present because I live in the present. If there were no medical benefits to circumcision, I wouldn’t defend it, in fact, I’d probably be arguing against it. But guess what? There are!

Please read my post again. I clearly said "for the past 50 years" not "50 years ago". (straw man)

Yes, there MIGHT be some debatable data showing some small protective benefit...but to argue for circumcision using this data without considering the consequences and risks of the surgical procedure, benign alternatives to prevent infections, and the incidence of the diseases in the population we are discussing shows a lack of understanding of basic epidemiology, statistics, and public health.

HH

 

[miacomet]

Please read my post again. I clearly said "for the past 50 years" not "50 years ago". (straw man)

Yes, there MIGHT be some debatable data showing some small protective benefit...but to argue for circumcision using this data without considering the consequences and risks of the surgical procedure, benign alternatives to prevent infections, and the incidence of the diseases in the population we are discussing shows a lack of understanding of basic epidemiology, statistics, and public health.

HH

Thank you HH!

People forget (or deny) that this is surgery, with all the attendant risks thereof. Why people don't understand the importance of, as you state, cost-benefit and risk-benefit analyses, as well as the absolute reduction in disease burden, is beyond me.

 

[GeneralVeers]

I actually think male circumcision should be outlawed as well, except for medical reasons. There is no legitimate health justification for it.

 

[Tenk]

Please read my post again. I clearly said "for the past 50 years" not "50 years ago". (straw man)

Yes, there MIGHT be some debatable data showing some small protective benefit...but to argue for circumcision using this data without considering the consequences and risks of the surgical procedure, benign alternatives to prevent infections, and the incidence of the diseases in the population we are discussing shows a lack of understanding of basic epidemiology, statistics, and public health.

HH

No. You lack an understanding of basic epidemiology. If a disease is found almost entirely in a patient population you can easily calculate its prevalence by dividing the # affected by total uncircumcised males. Compare that to the 0 you will find with circumcised males and you’ll notice hey, there’s a big difference there! Wow, science!

Like I honestly wonder if any of you are actually doctors because I see balanitis, phymosis and paraphymosis all the time in the ED and have to educate parents on yup, these things happen to uncircumcised males. Anyways, I’m done here because it’s like arguing with a brick wall with an arrow pointing to “data” that is actually a blind alley with an anti-vaccine hobo living in it.

Happy thanksgiving.

 

[miacomet]

I think it's a decision every man should make for himself....

 

[miacomet]

No. You lack an understanding of basic epidemiology. If a disease is found almost entirely in a patient population you can easily calculate its prevalence by dividing the # affected by total uncircumcised males. Compare that to the 0 you will find with circumcised males and you’ll notice hey, there’s a big difference there! Wow, science!

Like I honestly wonder if any of you are actually doctors because I see balanitis, phymosis and paraphymosis all the time in the ED and have to educate parents on yup, these things happen to uncircumcised males. Anyways, I’m done here because it’s like arguing with a brick wall with an arrow pointing to “data” that is actually a blind alley with an anti-vaccine hobo living in it.

Happy thanksgiving.

So, can you address the complication rate? What is it?

Can you address how Europe etc, basically the whole world aside from the ME and the US deal with...balanitis? Not such a big deal IMHO. Do they have significantly higher rates of death from penile cancer? Notably, the HIV infection rate in much of Europe is lower. Are there other interventions that can achieve the same outcome?

 

[Birdstrike]

A lot of people are interpreting this ruling wrong, particularly about the fact the the federal judge dismissed most of the charges on constitutional grounds. His ruling did not favor, legalize, or approve of FGM. In fact, he did the opposite. He called it outright “assault” and said unambiguously FGM is “despicable” and a crime and is already covered under state laws against assault. He also ruled it is not “health care” in any way, shape or form.

It’s basically a technical ruling that says the state of Michigan (and any other state) has every right to arrest and charge this doctor for assault, for cutting off parts of someone’s body, with no accepted medical justification, but under state, not federal law. He’s basically saying, “Yeah, it’s bad. It’s assault. It has no medical justification whatsoever. But you dummies need to charge this doctor under state law, as you would any other assault, and not needlesly make it a federal case.”

In the same way that the federal government would not need to get involved if Billy Bob stabbed Jimbo in the arm at a bar, because local law enforcement is expected to and does handle that, the feds don’t need to get involved if a doctor stabs someone in the genitals. He’s saying it’s a job for local cops and courts, and not to tie up federal courts with every assault case.

I don’t think any reasonable person is arguing FGM is a medically justifiable practice. Even those on the fringes that claim to be in favor of it, are not citing medical reasons, but are claiming religious reasons, cultural reasons, or both. But the bottom line is, if you perform FGM, you’re getting arrested. Maybe not by the FBI, by local police, but arrested, nonetheless.


https://www.google.com/amp/s/amp.th...-mutilation-detroit-michigan-unconstitutional
“As despicable as this practice may be, it is essentially a criminal assault,” Friedman wrote. “FGM is not part of a larger market and it has no demonstrated effect on interstate commerce. The commerce clause does not permit Congress to regulate a crime of this nature.”

Here’s the actual ruling itself:

https://content-static.detroitnews.com/pdf/2018/US-v-Nagarwala-dismissal-order-11-20-18.pdf

 

[deleted87051]

We don’t do preventive tonsillectomies and appendectomies but maybe that’ll become a thing. All the cool kids will walk around with no foreskin, clitoral prepuce, or tonsils.

 

[Vandalia]

A lot of people are interpreting this case wrong, particularly about the fact the the federal judge dismissed most of the charges on constitutional grounds.

Exactly.

Despite what some politicians might tell you, judges - particularly federal judges - hate making substantive decisions. If they can decide a case on procedural grounds, they will. The problem with this case was that the state could not prosecute on ex post facto grounds. The state law was passed after this incident. So they tried to do it based on the existing federal law.

The problem/issue is that the federal government does not have general police powers. For it to be a criminal offense, there has to be federal jurisdiction: If you kill an FBI agent, there is jurisdiction. If you defraud a federal program - Medicare or Tricare - there is jurisdiction. The federal government also has jurisdiction if an act effects "interstate commerce." This was expanded by FDR, but in the last 40 years the Supreme Court has pushed back a tiny bit on the Commerce Clause.

First, Congress needs to make a finding that something effects interstate commerce, "Guns near schools damages a child's education. Education effects interstate commerce, therefore we have jurisdiction in preventing guns near schools." The fundamental problem, I believe, with this law is that Congress did not even make even a hypothetical claim that FGM effects interstate commerce. If they had, the next step would have been for a court to review if the claim was even plausible, as it did when the SC struck down the "Gun Free School Zone Act."

95% of the time courts - particularly federal courts - are not making decisions on whether an idea is good or bad, but on technical issues such as standing, estoppel, time limits, etc.

I recommend the following article - and the Volokh Conspiracy in general - if you are interested in a more technical argument. (Just ignore the "conspiracy" part. It is a group of highly respected, libertarian lawyers.) Why the Federal Law Banning Female Genital Mutilation is Unconstitutional

 

[Birdstrike]

Exactly.

Despite what some politicians might tell you, judges - particularly federal judges - hate making substantive decisions. If they can decide a case on procedural grounds, they will. The problem with this case was that the state could not prosecute on ex post facto grounds. The state law was passed after this incident. So they tried to do it based on the existing federal law.

The problem/issue is that the federal government does not have general police powers. For it to be a criminal offense, there has to be federal jurisdiction: If you kill an FBI agent, there is jurisdiction. If you defraud a federal program - Medicare or Tricare - there is jurisdiction. The federal government also has jurisdiction if an act effects "interstate commerce." This was expanded by FDR, but in the last 40 years the Supreme Court has pushed back a tiny bit on the Commerce Clause.

First, Congress needs to make a finding that something effects interstate commerce, "Guns near schools damages a child's education. Education effects interstate commerce, therefore we have jurisdiction in preventing guns near schools." The fundamental problem, I believe, with this law is that Congress did not even make even a hypothetical claim that FGM effects interstate commerce. If they had, the next step would have been for a court to review if the claim was even plausible, as it did when the SC struck down the "Gun Free School Zone Act."

95% of the time courts - particularly federal courts - are not making decisions on whether an idea is good or bad, but on technical issues such as standing, estoppel, time limits, etc.

I recommend the following article - and the Volokh Conspiracy in general - if you are interested in a more technical argument. (Just ignore the "conspiracy" part. It is a group of highly respected, libertarian lawyers.) Why the Federal Law Banning Female Genital Mutilation is Unconstitutional

You make a lot of great points. To clarify, he wasn’t saying the woman could be prosecuted for the crime. He ruled she couldn’t be prosecuted under the federal law, which he struck down. You’re also right that he ruled she can’t be prosecuted after the fact under the anti-FGM law, which was passed after her acts.

But the crucial factor, is that he did in fact rule that she could be prosecuted under existing assault laws that have been around for centuries. You don’t need a separate law for assault, applying to each separate body part. You chop a piece of someone’s body off with a knife, without consent or medical justification, and you call the cops charge the person with assault. It doesn’t matter what body part, how emotionally charged the act is, or whether you have a special name for it, like FGM. Assault, and therefore FMG, has been illegal forever and remains so. That’s what the judge is saying.

This was absolutely not a good ruling for the people that support FGM, as its being spun by pundits. He clarified that’s its illegal, no new laws against it are needed because its already covered under pre-existing assault laws. He’s essentially ruled that when FGM happens, call your local PD, report the assault, they should prosecute it as such, but just don’t be an idiot and call the FBI.

 

[Vandalia]

I may have misunderstood the factual details of the case then. I thought that the person who was ... mutilated... HAD consented to the procedure. I was under the impression that the physician was prosecuted in the same vein as in an assisted suicide case. But if there was no consent, then you are absolutely correct, this is assault, pure and simple.

 

[Zebra Hunter]

No. You lack an understanding of basic epidemiology. If a disease is found almost entirely in a patient population you can easily calculate its prevalence by dividing the # affected by total uncircumcised males. Compare that to the 0 you will find with circumcised males and you’ll notice hey, there’s a big difference there! Wow, science!

Like I honestly wonder if any of you are actually doctors because I see balanitis, phymosis and paraphymosis all the time in the ED and have to educate parents on yup, these things happen to uncircumcised males. Anyways, I’m done here because it’s like arguing with a brick wall with an arrow pointing to “data” that is actually a blind alley with an anti-vaccine hobo living in it.

Happy thanksgiving.

Such a bizarre response. Again, you can’t claim to know superiority of a procedure when you don’t know the complication rate. It’s whole reason we like RCTs even for things that make sense. For example, stenting coronaries in individuals that aren’t having an MI. I had a colleague who took care of a child who died from a botched circumcision. I’ve seen another nearly die from blood loss.

There are many smart individuals on both sides of this issue. It’s kind of absurd to claim to definitively know better than multiple developed countries’ pediatric societies who say otherwise.

 

[Birdstrike]

I may have misunderstood the factual details of the case then. I thought that the person who was ... mutilated... HAD consented to the procedure. I was under the impression that the physician was prosecuted in the same vein as in an assisted suicide case. But if there was no consent, then you are absolutely correct, this is assault, pure and simple.

Remember though, these cases involve kids. Kids can’t consent. And parents can’t consent for them, to something to their minor child, that is legally considered assault.

 

[miacomet]

Such a bizarre response. Again, you can’t claim to know superiority of a procedure when you don’t know the complication rate. It’s whole reason we like RCTs even for things that make sense. For example, stenting coronaries in individuals that aren’t having an MI. I had a colleague who took care of a child who died from a botched circumcision. I’ve seen another nearly die from blood loss.

There are many smart individuals on both sides of this issue. It’s kind of absurd to claim to definitively know better than multiple developed countries’ pediatric societies who say otherwise.

Tenk has accused several of us of "not being doctors," but I want to know how someone becomes a doc, a faculty doc, without a basic understanding of epidemiology and evidence.

Maybe it is time for the PAs to take over lol.

 

[Vandalia]

Remember though, these cases involve kids. Kids can’t consent. And parents can’t consent for them, to something to their minor child, that is legally considered assault.

The question, I would imagine, is that since it was not specifically illegal under state law at the time of the act, if that analysis would apply. Since parents can provide medical consent for their children, and it was not an enumerated illegal act, then their consent would presumably be valid. For example, piercing an ear has no legitimate medical purpose. I would agree that from the date the state prohibition of the act was in effect, a parent cannot consent to an illegal act, but I still think they are back to the ex post facto problem.

 

[Birdstrike]

The question, I would imagine, is that since it was not specifically illegal under state law at the time of the act, if that analysis would apply.

The judge is saying it's always been specifically illegal under existing assault laws, as much as its been specifically illegal for a parent chopped a kids finger tip off, or to take a child to someone else to have their finger tip cut off, since neither are justifiable as "healthcare." In short, he didn't buy the argument that FGM is "healthcare" or accept any comparisons to any other procedures considered healthcare.

For example, piercing an ear has no legitimate medical purpose.

Yes, but I don't know that a federal judge has ever ruled that ear piercing is, and I'm quoting the judge here (these are not my words, but the judges), "despicable, essentially criminal assault," just like "rape."

Those are pretty strong words to have as precedent. And I think that's the crux of the issue. The pro-FGM people had tried to paint the issue as one with religious and/or medical justification. This federal judge has now thrown that idea out and ruled that it's garden variety assault. Again, those are Judge Friedman's words, not mine. It's my understanding that all along, those trying to prosecute these cases felt the religious and medical angle presented a barrier to prosecuting these cases under existing assault laws. That's why the prosecutors tried to get cute and cook up some "interstate commerce" angle under federal law, to prosecute this case. I'm not a lawyer, but the judges words seems to indicate that they absolutely can prosecute them as general assaults. Although having a portion of the federal charges thrown out for these specific defendants is a short term win for those defendants, I can't imaging how this makes things easier for the FGM crew. It seems to me the judge has given the go ahead to have these cases prosecuted more easily as garden variety assault by local cops and prosecutors. It makes a case a heck of a lot easier, if you can arrest and prosecute quickly and locally, without having to get the slow, lumbering behemoth that is the federal government, involved. Just imagine you see one of these kids in your ED, hurt bad, bleeding and infection. Which is more likely to get quick action, calling local PD and child protective services as you normally do, or calling the federal government and waiting on the FBI?

https://content-static.detroitnews.com/pdf/2018/US-v-Nagarwala-dismissal-order-11-20-18.pdf

 

[KGflyboy]

The question, I would imagine, is that since it was not specifically illegal under state law at the time of the act, if that analysis would apply. Since parents can provide medical consent for their children, and it was not an enumerated illegal act, then their consent would presumably be valid. For example, piercing an ear has no legitimate medical purpose. I would agree that from the date the state prohibition of the act was in effect, a parent cannot consent to an illegal act, but I still think they are back to the ex post facto problem.

The legality of piercing a child's ear does not imply it is legal to cut off part of a child's genitals with parental consent without a medically justifiable reason.

Parents cannot provide consent for a child to be assaulted.

 

[Vandalia]

The law is a strange thing. It is possible for someone to break into a home and shoot the occupant and it not be a "violent" crime under federal law. The law does not work on the basis of common sense or the way "normal" people think. Sure, they could be prosecuted under the common law crime of assault. But I am sure the defense will raise the issue of parental consent and the fact that the act was not specifically illegal under state law at the time the act was committed. They will also likely raise the issue of a lack of fair notice as to precisely what is legal and illegal. I am also sure the defense counsel will raise a ton of "slippery slope" arguments both before the trial judge and if applicable on appeal. Will it work? Maybe, probably not. I will also point out that the federal judge's comments are what lawyers call dicta and are not binding on state courts (or federal courts.)

There is also the obvious fact that the most likely reason state prosecutors did not handle this as a simple assault case was because they were not confident they could get a conviction. There is not a prosecutor in America who does not dream of higher office, and prosecuting this case would provide a ton of free publicity and would look good in a campaign ad. The fact the state prosecutor passed it on to the US Attorney is highly significant. (Remember, the state and the federal government are "separate sovereigns." The state could have prosecuted a simple assault case in parallel with the federal prosecution.)

 

[WilcoWorld]

A lot of people are interpreting this ruling wrong, particularly about the fact the the federal judge dismissed most of the charges on constitutional grounds. His ruling did not favor, legalize, or approve of FGM. In fact, he did the opposite. He called it outright “assault” and said unambiguously FGM is “despicable” and a crime and is already covered under state laws against assault. He also ruled it is not “health care” in any way, shape or form.

It’s basically a technical ruling that says the state of Michigan (and any other state) has every right to arrest and charge this doctor for assault, for cutting off parts of someone’s body, with no accepted medical justification, but under state, not federal law. He’s basically saying, “Yeah, it’s bad. It’s assault. It has no medical justification whatsoever. But you dummies need to charge this doctor under state law, as you would any other assault, and not needlesly make it a federal case.”

In the same way that the federal government would not need to get involved if Billy Bob stabbed Jimbo in the arm at a bar, because local law enforcement is expected to and does handle that, the feds don’t need to get involved if a doctor stabs someone in the genitals. He’s saying it’s a job for local cops and courts, and not to tie up federal courts with every assault case.

I don’t think any reasonable person is arguing FGM is a medically justifiable practice. Even those on the fringes that claim to be in favor of it, are not citing medical reasons, but are claiming religious reasons, cultural reasons, or both. But the bottom line is, if you perform FGM, you’re getting arrested. Maybe not by the FBI, by local police, but arrested, nonetheless.


https://www.google.com/amp/s/amp.th...-mutilation-detroit-michigan-unconstitutional
“As despicable as this practice may be, it is essentially a criminal assault,” Friedman wrote. “FGM is not part of a larger market and it has no demonstrated effect on interstate commerce. The commerce clause does not permit Congress to regulate a crime of this nature.”

Here’s the actual ruling itself:

https://content-static.detroitnews.com/pdf/2018/US-v-Nagarwala-dismissal-order-11-20-18.pdf

And here we are, arguing about it. Someone's being had.

 

[Birdstrike]

.[/QUOTE]

And here we are, arguing about it.

I think a more apt term would be "debating," and respectfully so.

 

[Birdstrike]

The state could have prosecuted a simple assault case in parallel with the federal prosecution.)

And maybe they still will, I don't know. It's alleged she did this 100's of times. If the statute of limitations hasn't run out, that may be their next move. Plus, the federal judge did not throw out the conspiracy and obstruction charges. She's still facing 30 years if convicted. That's much worse than a local assault rap. Even though her legal team is claiming victory, I still wouldn't want to be in her shoes, and especially not in the shoes of her "patients."

"Nagarwala, meanwhile, is still facing a conspiracy charge and an obstruction count that could send her to prison for 20 years, along with the Attars. If convicted of conspiracy, Nagarwala faces up to 30 years in prison.

The case is set to go to trial in April 2019."

 

[VA Hopeful Dr]

There are also complications. There are also mistakes. The data on the effect on sexual pleasure is not clear. They don't do this in Europe. In fact, they aggressively discourage it in many countries. I can't think of another organization aside from the AAP that recommends it, and they don't recommend it that strongly.

If you look at the risk/benefits, worst case they're about equal so its reasonable to leave it up to the parents.

Its disingenuous to compare this to breasts/ovaries as those have defined functions that you completely lose by removing them.

I don't much care for what Europe thinks/does.

As for recommendations: American Urological Association - Circumcision

Properly performed neonatal circumcision prevents phimosis, paraphimosis and balanoposthitis, and is associated with a markedly decreased incidence of cancer of the penis among U.S. males. In addition, there is a connection between the foreskin and urinary tract infections in the neonate. For the first three to six months of life, the incidence of urinary tract infections is at least ten times higher in uncircumcised than circumcised boys. Evidence associating neonatal circumcision with reduced incidence of sexually transmitted diseases is conflicting depending on the disease. While there is no effect on the rates of syphilis or gonorrhea, studies performed in African nations provide convincing evidence that circumcision reduces, by 50-60 percent, the risk of transmitting the Human Immunodeficiency Virus (HIV) to HIV negative men through sexual contact with HIV positive females. There are also reports that circumcision may reduce the risk of Human Papilloma Virus (HPV) infection. While the results of studies in other cultures may not necessarily be extrapolated to men in the United States at risk for HIV infection, the AUA recommends that circumcision should be presented as an option for health benefits

 

[VA Hopeful Dr]

We don’t do preventive tonsillectomies and appendectomies but maybe that’ll become a thing. All the cool kids will walk around with no foreskin, clitoral prepuce, or tonsils.

With appendectomies, we kinda do. How often do surgeons take out appendixes/gallbladders while they are in the abdomen for some other reason?

As for tonsils, we used to do them quite frequently until the data showed that it didn't really help as much as we thought.

 

[VA Hopeful Dr]

I think it's a decision every man should make for himself....

The issue behind that is that neonatal circumcision is a fairly easy procedure with a very short recovery and fairly low complication rate. Doing it to adults is a much bigger procedure with a much longer recovery time.

As for actual numbers, the total rate of any complications was 0.2% in the US based on 2 large studies (admittedly in the 80s-90s). We use safer techniques now than we did then so I suspect the numbers now are lower but have no proof.

Interestingly, there is this from one of the studies: Based on our findings, a complication can be expected in 1 out every 476 circumcisions. Six urinary tract infections can be prevented for every complication endured and almost 2 complications can be expected for every case of penile cancer prevented.

In the other study, we have this: For 100,157 circumcised boys, there were 193 complications (0.19%). These included 62 local infections, eight cases of bacteremia, 83 incidences of hemorrhage (31 requiring ligature and three requiring transfusion), 25 instances of surgical trauma, and 20 urinary tract infections. There were no deaths or reported losses of the glans or entire penis

 

[Hamhock]

With appendectomies, we kinda do. How often do surgeons take out appendixes/gallbladders while they are in the abdomen for some other reason?

As for tonsils, we used to do them quite frequently until the data showed that it didn't really help as much as we thought.

As you mentioned, we don't just take out tonsils anymore. And, unless there's some serious regional differences, I don't think surgeons are removing gallbladders for prophylactic purposes.

And it is likely we will stop removing appedenices in the very near future.

Each of these cases shows how we can become confused by similar to thinking to that proposed by Tenk earlier in this thread.

HH

 

[Hamhock]

Although the circumcision discussion in interesting and informative, I wonder how the EM community should respond to this case.
If Nargarwala is eventually legally exonerated (the FGM law in Michigan was created after her alleged abuses and the state "assualt" charges are far from certain), does the state, medical board, or hospitals have a reason to prevent her from practicing?

Would Henry Ford have a legal reason to prevent her from returning?

HH

 

[deleted109597]

She won't get legally exonerated. She's facing 30 years right now.
If somehow she was pardoned by some future president, Henry Ford would still be able to keep her from working just as others have been fired for much, much less heinous or even verbal online statemnts.

 

[miacomet]

Although the circumcision discussion in interesting and informative, I wonder how the EM community should respond to this case.
If Nargarwala is eventually legally exonerated (the FGM law in Michigan was created after her alleged abuses and the state "assualt" charges are far from certain), does the state, medical board, or hospitals have a reason to prevent her from practicing?

Would Henry Ford have a legal reason to prevent her from returning?

HH

Great questions, but my guess is she will be successfully prosecuted under existing state statutes on assault and federal statutes on transporting minors.

 

[Hamhock]

Great questions, but my guess is she will be successfully prosecuted under existing state statutes on assault and federal statutes on transporting minors.

If there is no crime (and it appears that is more likely to be the case now), does the transporting minors case not fall apart?

She won't get legally exonerated. She's facing 30 years right now.
If somehow she was pardoned by some future president, Henry Ford would still be able to keep her from working just as others have been fired for much, much less heinous or even verbal online statemnts.

Yes, I agree with you from an ethical viewpoint...but the law seems to think differently. She could certainly claim 'religious freedom' and point out that once the law was in place in Michigan she was no longer performing this procedure.

Do you think a Jewish doctor could be fired in this country for Metzitzah B'Peh?

Metzitzah B'Peh
The ancient method of performing metzitzah—metzitzah b'peh, or oral suction[37][38]—has become controversial. The process has the mohel place his mouth directly on the circumcision wound to draw blood away from the cut. The majority of Jewish circumcision ceremonies do not use metzitzah b'peh,[39] but some Haredi Jews use it.[40][41][42] It has been documented that the practice poses a serious risk of spreading herpes to the infant.[43][44][45][46] Proponents maintain that there is no conclusive evidence that links herpes to Metzitza,[47] and that attempts to limit this practice infringe on religious freedom.[48][49][50]

Brit milah - Wikipedia

 

[miacomet]

If there is no crime (and it appears that is more likely to be the case now), does the transporting minors case not fall apart?



Yes, I agree with you from an ethical viewpoint...but the law seems to think differently. She could certainly claim 'religious freedom' and point out that once the law was in place in Michigan she was no longer performing this procedure.

Do you think a Jewish doctor could be fired in this country for Metzitzah B'Peh?

Metzitzah B'Peh
The ancient method of performing metzitzah—metzitzah b'peh, or oral suction[37][38]—has become controversial. The process has the mohel place his mouth directly on the circumcision wound to draw blood away from the cut. The majority of Jewish circumcision ceremonies do not use metzitzah b'peh,[39] but some Haredi Jews use it.[40][41][42] It has been documented that the practice poses a serious risk of spreading herpes to the infant.[43][44][45][46] Proponents maintain that there is no conclusive evidence that links herpes to Metzitza,[47] and that attempts to limit this practice infringe on religious freedom.[48][49][50]

Brit milah - Wikipedia

Multiple cases of herpes in NYC over the years from this practice, but it persists and law enforcement does nothing whatsoever. The city simply sends out an advisory every year. Wonder if that can/would be used as a defense in this case? Law is not my forte, but I don't think anyone can claim this is done for "health."

 

[VA Hopeful Dr]

As you mentioned, we don't just take out tonsils anymore. And, unless there's some serious regional differences, I don't think surgeons are removing gallbladders for prophylactic purposes.

And it is likely we will stop removing appedenices in the very near future.

Each of these cases shows how we can become confused by similar to thinking to that proposed by Tenk earlier in this thread.

HH

I hope not on the appendix issue. I know the new data coming out about antibiotics in place of surgery, but you get a certain amount of treatment failure and a not insignificant amount of recurrences.

 

[Hamhock]

I hope not on the appendix issue. I know the new data coming out about antibiotics in place of surgery, but you get a certain amount of treatment failure and a not insignificant amount of recurrences.

Sorry, I should have been more clear. I was talking about removing apendices for prophylactic purposes; analogous to the "prophylactic" removal of foreskin under discussion.

...but on another topic, there is better and better evidence that antibiotics work for uncomplicated appendicitis. Kinda like how antibiotics and hygiene work many of the diseases of the foreskin we were discussing earlier 😉.

HH

 

[VA Hopeful Dr]

Sorry, I should have been more clear. I was talking about removing apendices for prophylactic purposes; analogous to the "prophylactic" removal of foreskin under discussion.

...but on another topic, there is better and better evidence that antibiotics work for uncomplicated appendicitis. Kinda like how antibiotics and hygiene work many of the diseases of the foreskin we were discussing earlier 😉.

HH

That's the data I was talking about, I'd still prefer surgery if it was me or my kids.

 

[Hamhock]

That's the data I was talking about, I'd still prefer surgery if it was me or my kids.

Right. And in the diseased state (appendicitis), this is a perfectly reasonable request.

However, I doubt you would request the removal a healthy appendix from yourself now or at your children soon after birth. And I soon doubt anyone will be doing it during a lap for an unrelated disease.

Now, may we return to the more challenging FGM/Metzitzah B'Peh cases.

HH

 

[VA Hopeful Dr]

Right. And in the diseased state (appendicitis), this is a perfectly reasonable request.

However, I doubt you would request the removal a healthy appendix from yourself now or at your children soon after birth. And I soon doubt anyone will be doing it during a lap for an unrelated disease.

Now, may we return to the more challenging FGM/Metzitzah B'Peh cases.

HH

Yes because an appendectomy is the same as male circumcision.

 

[Hamhock]

Yes because an appendectomy is the same as male circumcision.

Completely agree with your sarcasm (although it seems to be directed at yourself).

That's why I would never make this comparison and a good chunk of my recent posts have been arguing against this comparison made by you and other posters. The similarities are weak and the underlying theory has been nearly debunked.

There is some very non-linear thinking and "debate" around here recently.

HH

 

[Rendar5]

Maybe we should move on from a discussion about male circumcision to what the original topic is...

 

[deleted87051]

With appendectomies, we kinda do. How often do surgeons take out appendixes/gallbladders while they are in the abdomen for some other reason?

As for tonsils, we used to do them quite frequently until the data showed that it didn't really help as much as we thought.

I’ve never witnessed an incidental appendectomy or cholecystectomy for a normal organ.

 

[RustedFox]

There are also complications. There are also mistakes. The data on the effect on sexual pleasure is not clear. They don't do this in Europe. In fact, they aggressively discourage it in many countries. I can't think of another organization aside from the AAP that recommends it, and they don't recommend it that strongly.

Dude, I generally like your contributions to the forum. We're going to formally and politely disagree.

Tenk is right on.

There are complications and mistakes with... life. Of all stages and varieties. However, you don't find penile cancer in circ'd males. You don't run into phymoses (that's a word, I just made it up) in circ'd males.

I'm circ'd. Its awesome. EXCALIBUR! Lol. Everyone take a hot second to laugh at a dick joke. This is not a a safe space. Did you laugh? Good! Its funny. See how good that feels?

They DO "do" this in Europe. Wife's family is a-lot-of-euro and while I don't like some of the other things that they do... (dude, wear some deodorant, and yes - baseball isn't just "Dumb Americans who can't play Soccer", maybe you should grow some biceps, and in America women can drive and it doesn't mean that they're homosexual) they've got this one right. Being circ'd is awesome. Excuse me while I go wave my wanker around the living room. My wife won't be upset. She'll ask me how much I've had to drink, but that's about it.

 

[deleted109597]

I may be on a limb here as a wilderness doc, but having met many, many people who recieve "prophylactic appys" prior to stints in Afghanistan, or Antarctica, or wherever, I'd be down with geting one during an unrelated surgery. People don't die of appendicitis often now, but when they do, it's in a remote area. As often as I'm in one, I'ld like not to die honestly.
Also, I'm circumcised. I can't argue my parents did it because they are learned as opposed to just doing it for cosmetic purposes, but my children from my pediatric wife are both circumcised as well.
We also vaccinate, and I just got Gardisil as a 38 year old man. Fight me.

 

[Hamhock]

I may be on a limb here as a wilderness doc, but having met many, many people who recieve "prophylactic appys" prior to stints in Afghanistan, or Antarctica, or wherever, I'd be down with geting one during an unrelated surgery. .

Perhaps during an unrelated violation of the peritoneum...but just consider the risk of adhesions and bowel obstruction in a remote area; nevermind peri-operative complications (leaks, wound infection,etc.).

It's much easier to treat uncomplicated appy in remote areas (basically abx, which are mighty portable) than bowel obstruction or localized ischemic gut.

That said, again back to the world of EM and accepting religious physicians who practice -- where legal -- FGM or Metzitzah B'Peh into your residency leadership or community hospital.

HH

 

[VA Hopeful Dr]

I’ve never witnessed an incidental appendectomy or cholecystectomy for a normal organ.

Really? I saw 2 in my fairly short surgery rotation in med school (2008 so not too long ago). And in 3 patients in the last 2 months (though not sure when this happened).

From what I've seen, its generally people getting a full on laparotomy where the likelihood of significant adhesions developing is high (in med school this was trauma patients) so they try to do what they can to reduce the chances of needing to go back into the abdomen or like the last 2 patients I saw where this happened fixing significant abdominal wall hernias where again they are trying to do everything they can to avoid future abdominal surgery.

 

[VA Hopeful Dr]

Completely agree with your sarcasm (although it seems to be directed at yourself).

That's why I would never make this comparison and a good chunk of my recent posts have been arguing against this comparison made by you and other posters. The similarities are weak and the underlying theory has been nearly debunked.

There is some very non-linear thinking and "debate" around here recently.

HH

It boils down to this:

Worst case, the risks/benefits of infant male circumcision are about equal. Best case, the benefits significantly outweigh the risks.

Its a procedure that if done early in life is very well tolerated and heals quickly. If done when the patient is older and can consent on their own, it is much harder technically speaking, more painful, and more expensive (~$200 infants, $2000+ on adults).

The pediatricians, OB/GYNs and urologists all say that the procedure seems to be beneficial and so should be offered to families that desire it.

I fail to see why the status quo of leaving it up to the parents, with informed consent, is a bad idea.

 

[deleted87051]

Really? I saw 2 in my fairly short surgery rotation in med school (2008 so not too long ago). And in 3 patients in the last 2 months (though not sure when this happened).

From what I've seen, its generally people getting a full on laparotomy where the likelihood of significant adhesions developing is high (in med school this was trauma patients) so they try to do what they can to reduce the chances of needing to go back into the abdomen or like the last 2 patients I saw where this happened fixing significant abdominal wall hernias where again they are trying to do everything they can to avoid future abdominal surgery.

I’ve been in PP anesthesia for 20 years and haven’t seen it. Surgeons don’t remove normal organs. The consents generally include a statement about “all indicated procedures” and I have seen them remove an appendix or gallbladder if they find disease during the course of another procedure. But that is exceedingly rare (I’ve seen than maybe 3 times in my career and there was always an effort to contact and inform family members before proceeding) and removing normal organs is not an indicated procedure. Honestly it would be a QA trigger if a surgeon sends a bunch of gallbladders that are described as “normal gallbladder”. They are also opening themselves up to liability if for example they injure the bile duct during an incidental cholecystectomy for a normal gallbladder for which they don’t have consent. Perhaps there are regional differences.

 

[deleted87051]

It boils down to this:

Worst case, the risks/benefits of infant male circumcision are about equal. Best case, the benefits significantly outweigh the risks.

Its a procedure that if done early in life is very well tolerated and heals quickly. If done when the patient is older and can consent on their own, it is much harder technically speaking, more painful, and more expensive (~$200 infants, $2000+ on adults).

The pediatricians, OB/GYNs and urologists all say that the procedure seems to be beneficial and so should be offered to families that desire it.

I fail to see why the status quo of leaving it up to the parents, with informed consent, is a bad idea.

We can give all the medical justifications we like but at its heart, it’s still cultural.

https://www.washingtonpost.com/news...mcision/?noredirect=on&utm_term=.65308dc31564


There are also these guys.

It Takes a Lot of Dick-Tugging to Get Your Foreskin Back

 

[thegenius]

...but where is the outrage?

I maintain Nagarwala's crimes FAR exceed those of Newman in terms of harm to the innocent and to the wisp of trust left between the community and physicians...or at least they should.

Newman admitted to sexually preying on several adult women, this female doctor allegedly multilated several girls genitals. Both are pretty damn terrible, this woman's is probably worse but I can see how it might fall under the rubrick of "numerous countries do this as part of their religion" thus making it a little "less bad."


Edit:....Oh I didn't see that this thread started over a year ago.

 

[VA Hopeful Dr]

We can give all the medical justifications we like but at its heart, it’s still cultural.

https://www.washingtonpost.com/news...mcision/?noredirect=on&utm_term=.65308dc31564


There are also these guys.

It Takes a Lot of Dick-Tugging to Get Your Foreskin Back

Duh?

That's why my last sentence is key.

From a medical standpoint, worst case scenario is the risks and benefits are about equal. That being the case, we leave it up to the parents. If the risks outweighed the benefits, it would be unethical for us as physicians to even offer the procedure.

 

[VA Hopeful Dr]

I’ve been in PP anesthesia for 20 years and haven’t seen it. Surgeons don’t remove normal organs. The consents generally include a statement about “all indicated procedures” and I have seen them remove an appendix or gallbladder if they find disease during the course of another procedure. But that is exceedingly rare (I’ve seen than maybe 3 times in my career and there was always an effort to contact and inform family members before proceeding) and removing normal organs is not an indicated procedure. Honestly it would be a QA trigger if a surgeon sends a bunch of gallbladders that are described as “normal gallbladder”. They are also opening themselves up to liability if for example they injure the bile duct during an incidental cholecystectomy for a normal gallbladder for which they don’t have consent. Perhaps there are regional differences.

Possibly. I know the patients that are currently under my care consented to the procedure during their pre-op visits with the surgeon. The trauma patients in residency, I have no idea as I was barely involved.