Letter from Duane Voskuil, PhD,
to the North Dakota Board of Medical Examiners
and the Commission on Medical Competency



March 3, 1995 (resubmitted May 21, 1997)

North Dakota Board of Medical Examiners
Rolf Sletten, Executive Director
418 East Broadway, Suite C10
Bismarck, ND 58501

To the North Dakota Board of Medical Examiners and the Commission on Medical Competency:

We place the following Accusation before the Board: Routine infant circumcisers (if individuals need be cited: Roger Allen, MD and Manuel Neto, MD, Minot) are practicing quack medicine, namely, a pattern of inappropriate and fraudulent care.

Request: that the NDBME discipline circumcisers (namely, Roger Allen, MD and Manuel Neto, MD, Minot) for practicing quackery (request made under NDCC 43-17.1-05: "All residents have the right to make or refer complaints to the commission...").

Accusation's Legal Basis: NDCC 43-17.1-07 (Sec. 4) and 43-17-31 (Sec. 6 and 7):
    "The board of medical examiners may revoke or suspend a physician's license to practice medicine in this state or may attach conditions or restrictions thereto on any one or more of the following grounds:... 4. A continued pattern of inappropriate care, including unnecessary surgery, in the performance of his duties as a physician." (emphasis added)
     "The board may refuse to grant a license to practice medicine in this state or may suspend or revoke such license...upon any of the following grounds:... 6. The performance of any dishonorable, unethical, or unprofessional conduct likely to deceive, defraud, or harm the public. 7. The use of any false or fraudulent statement in any document connected with the practice of medicine." (emphasis added)

Basis for Board's Authority and Need for Action: A. Michael Booth, MD, PhD, in testimony, 2/13/95, that helped defeat ND HB 1381 (1 endnote) argued this Bill would "cripple the State Board of Medical Examiners" by restricting its ability to "act against a physician by suspending or revoking his or her license on the simple finding of a continued pattern (2 endnote) of inappropriate care." (3 endnote)

We must assume Dr. Booth, as a member of NDMA and its Commission on Legislative Affairs, and as President of the ND Chapter of the American College of Surgeons, has a good sense for the powers of the NDBME. One of these is the power to determine what "appropriate care" means.

Dr. Booth pointed out that quackery is inappropriate care. He quoted the U.S. Congress Select Committee on Aging's definition of a "quack" in its 1984 report on quackery. A quack is "anyone who promotes medical schemes or remedies known to be false, or which are unproven, for profit." (emphasis added) He pointed out North Dakota has not been free of quacks, but "the Board has acted appropriately to remove them." This is fortunate, according to Booth, or the expected and needed trust in physicians would have been seriously eroded. "Indeed, had the Board failed to act, the public would have had every reason to believe that the relationship of trust between patient and physician had been knowingly violated." (emphasis added)

Dr. Booth pointed out that "These practitioners of quack medicine [have] always been difficult to deal with." They are successful
     (a) because of their ability to "take a bit of scientific fact and then extrapolate [it] to incredible proportions to justify the use of their therapy, oftentimes ignoring the very real toxic potential that their treatments involve..." and
     (b) because "too often, the victims of these practitioners fail to take action, out of embarrassment..."

Summary of Accusation

A. Circumcision is quack medicine. Routine infant circumcision meets every definition of "quack medicine" and is, therefore, "inappropriate care." It is:
     (1) based on "a bit of scientific fact" which is "extrapolate[d] to incredible proportions to justify the use of their therapy, oftentimes ignoring the very real toxic potential that their treatments involve...." When all the evidence is examined, it is seen to be physically and psychologically harmful to the infant, his parents and society at large.
     (2) fraudulent since the circumciser fails to provide full information, either from lack of knowledge or deliberate misrepresentation.
     (3) at least a quarter billion dollar business in the U.S.
     (4) a subject that embarrasses people, so corrective action is not taken.

B. Circumcision violates human rights. Infant circumcision, however, is more than just the usual form of quack medicine. Circumcision does not just defraud the person who is persuaded by misleading information to consent to the procedure for him or herself. The patient, in this case, has no say at all. The amputation is forced upon a completely non-consenting individual. No one has the right to unnecessarily alter an infant's physical integrity.

Supporting Arguments for Accusations

A (cont.): Support for Statements that
Circumcision is Quack Medicine:

Support for point (1)-Harmful, not beneficial, care based on inadequate evidence:

Published studies, considering all the known so-called physiological and cost benefits, show no positive balance of actual benefit can be determined, even when these studies ignore the negative weight of psychological damage and human rights violations. (4 endnote)

For example, in an article in Family Medicine, "Circumcision: A Decision Analysis of its Medical Value," Oct-Dec 1991, Dr. Lawler writes, "We conclude there is no medical indication for or against circumcision. The decision may most reasonably be made on non-medical factors such as parent preference."
     We would like to suggest that the child's preference is the only one that counts.

In another article in Medical Decision Making, Oct-Dec 1991, Dr. Ganiats states: "Circumcision has essentially no effect on either dollar costs or health. For this reason, personal factors could justly be brought into the decision process."
     Even though those doing these studies have not faced the human rights issue, nor long-term psychological or sexual effects, they make clear, that circumcision is not a procedure to be justified on medical grounds.

Thomas Wiswell's urinary tract infection studies is a typical example of those who take "a bit of scientific fact and then extrapolate to incredible proportions to justify the use of their therapy." He even claims God made a mistake providing men with this erotic and protective tissue. One has to circumcise 99 infants to prevent one UTI, even if Wiswell's retrospective study on military babies is accurate, which other researchers question because catherization was used to gather urine samples and may have contaminated them, and because of invalid statistical analyses. Girls are four times as prone to UTIs as boys in any case.

100,000 infants must be circumcised to prevent one penile cancer. Who explains to parents that more infants die of circumcision complications in the U.S. than older men are saved from penile cancer (about 200)? We still hear about the cervical cancer study--proved invalid decades ago. This is just some of the persistent misleading information the quacks dispense or fail to correct. Their approach allows them to hood-wink a trusting public into a procedure with "very real toxic potential."

In fact, all national and international healthcare and medical organizations, including the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, say these amputations are not medically necessary. How can they, therefore, be defined as "preventive medicine" when imposed upon a non-consenting person? They are unnecessary surgeries, and as such must be censored by Board action pursuant to NDCC 43-17.1-07 (Sec. 4).

Surgical amputation of normal tissue can only be called "mutilation." Perhaps we do have a right to mutilate ourselves, but not others. As Ron Miller, MD, Fargo, says, "What risk is acceptable when one is tampering with something that is normal?" The following is a list of a few more North Dakota people and organizations that have recognized the non-necessary nature of routine infant circumcision: (5 endnote)

* Rhonda Ketterling, MD, Chair, ND Board of Medical Examiners, Medical Director for U.S. Healthcare, Bismarck, and practicing physician, Rugby.
* Arlene Mack, RN, Vice President, Medcenter One, Support Services (speaking for Medcenter One, she said their physicians have agreed not to recommend circumcisions and will explain the risks).
* Shari Orser, MD, Chair, Department of Ob/Gyn, Medcenter One, Bismarck.
* Robert Wentz, MD, pediatrician, former ND State Health Officer, now Deputy Insurance Commissioner.
* Jon Rice, MD, ND State Health Officer.
* Sister Mary Margaret Mooney, PBVM, RN, Professor and Chair, Department of Nursing, University of Mary.
* Gladys Cairns, Director, ND Child Protective Services and Chair of the Alliance for Sexual Abuse Prevention and Treatment.
* Craig Shoemaker, MD, Director of Neonatal Services and Chair, Department of Pediatrics, Fargo Clinic MeritCare.
* Ron H. Miller, MD, pediatrician, Fargo Clinic MeritCare.
* Alan Lindemann, MD, Ob/Gyn, Fargo.
* Thomas W. Mausbach, MD, former President, ND Chapter of the American Academy of Pediatrics (in a letter to the NDBME).
* Charles Severn, MD, Chair, Department of Neonatology, St. Alexius Medical Center, Bismarck.
* Connie Kalanek, MSN, RNC, Associate Professor, Medcenter One College of Nursing.
* Robert Roswick, MD, and Jeffrey Smith, MD, Family Medical Center, Bismarck.
* Judy Haynes, PhD, UND Counseling Center and clinical psychologist, Grand Forks.
* Robert Pathroff, MD, urologist, Bismarck.
* Roger Allen, MD, neonatologist, Minot.
* BlueCross BlueShield of North Dakota.
* Medicaid (does not pay for this unnecessary surgery).

Even Roger Allen, MD, Minot, cited above as being a circumciser, said parents make up their minds about circumcision, not on any scientific or medical basis, but on emotion, one of the hallmarks of quackery. In a television interview (KMOT, 11/92) he said "There is no compelling reason to do a circumcision, but on the other hand, there is no compelling reason not to." The only adequate response to such a self-serving statement was made by Janet Wentz, North Dakota Republican Legislator, "If there is no compelling reason to do a circumcision, that is a compelling reason not to do one." This, we hope, will be the appropriate response of the NDBME.

Since science, not custom, must be the final arbiter of appropriateness for procedures forced upon non-consenting individuals, circumcisers must scientifically justify their practice, or it simply stands as a quack procedure. We ask you, where are the studies to justify this painful, disfiguring and sexually de-sensitizing practice?

Support for point (2)-Fraudulent or incompetent practitioners and practices:

Perhaps there are circumcisers who do not know the facts. But ignorance can no longer justify the continuation of this practice. It certainly cannot be a basis for not censoring them. It is a reason that makes Board action more imperative, since well-meaning practitioners, who believe in their own quack procedures, may work their damage even more insidiously on society.

The prestige of the medical profession is truly at stake here. Numerous and angry people can be brought before the Commission to testify to how little information they were given, or how misleading it was, before giving uninformed consent to maim their sons. They know they were defrauded, and some are even looking into law suits. Some did not provide written consent to the unnecessary surgery.

Support for point (3)-Financially self-serving at amputee's expense:

Journals providing medical statistics use the quarter billion dollar figure. It does not include the multi-million dollar law suits arising out of "botched jobs" nor the reconstructive costs to the 1 in 500 which are seriously botched, according the American Academy of Pediatrics. (6 endnote) Of course, any unnecessary amputation is a "botched job," as so well put by the obstetric nursing staff at St. Vincent Hospital, Sante Fe, NM, who refuse to participate in the procedure. Their conscientious objector status has just been negotiated into a legally binding agreement.

Support for point (4)-Embarrassment prevents exposure:

Discussion of genitals is taboo in our society. Acquiring and dispensing accurate information on any taboo subject is difficult. Circumcisers, and all quacks, profit from lack of exposure. The media has a hard time providing information from fear of offending the public. Once someone has been circumcised, has allowed it or done it, the ritualization of the act often keeps one from publicly admitting a wrong. Passing an act on to the next generation is often easier than admitting the act was wrongfully done to oneself.

B (cont.): Support for Accusation that
Circumcision Violates Human Rights.

Parental rights do not extend to unnecessary genital amputations. Now, it is true that "Parents, guardians, and custodians are authorized to consent to healthcare on behalf of children" (NDCC Sec. 23-11-13, emphasis added), but routine infant circumcision is not a healthcare issue. No study with its "bit of scientific fact" (Booth) offered to support the purported positive effects of prepuce amputation, has ever been able to establish that the negative physiological effects are not more significant, not to mention other physiological and psychological effects that result from functioning with a violated body.

Historically, medical rationalizations are a recent approach used by quacks. Except for the last hundred years in the U.S., circumcision has never been done for health reasons. The appeal to scientific evidence to justify it as a healthcare issue is major healthcare fraud. (7 endnote) Since most men in the developed and underdeveloped countries of the world are intact and do not have the dire problems circumcisers threaten will occur, the procedure in the U.S. is obviously a non-medical ritual. This is understood by many North Dakota physicians.

Medical ethics clearly requires physicians to decline to do follow a parent's wish to alter a child surgically for non-medical reasons. The physician is even required to prevent others from doing so! (see NDCC 50-25.1-03-Persons required to report child abuse and neglect). No one in our society can morally (and we believe, legally) alter another surgically against his will for non-medical reasons, even if he is one's own son. Property rights do not extend to one's son or daughter (8 endnote).

Sexism is inherent in the present practice. The physician's responsibility to protect a helpless patient is recognized when it comes to all other operations and for genital amputations on female children (9 endnote) (which has now been formalized in ND SB2454, 1995) along with NDCC 50-25.1-03.

Summary and Request for Action

Information and testimony to support this allegation will be gladly provided. (10 endnote) However, we ardently maintain the evidence is such, despite the cultural conditioning and prevalence of prepucial amputations, that circumcisers are the ones who must justify their actions to the Board on sound medical and scientific evidence. They must prove routine infant circumcision is in line with the physician's oath: First Do No Harm. This justification must not be the little piece of scientific evidence that quacks use. It must be the whole spectrum, including the physical injuries and deaths as well the increasing evidence of negative long-term psychological effects and diminishment of sexual function.

The citizens of North Dakota have a right to expect the Board is monitoring and preventing unnecessary surgical procedures and fraudulent practices. Amputations of healthy prepuces from non-consenting individuals is unnecessary surgery, or more accurately, contraindicated, surgery. It harms our children and violates their human rights. It is a practice international community views as abhorrent as we do female genital mutilations. Now that North Dakota is taking the lead nationally in outlawing FGM, a move supported by the ND Medical Association, citizens and legislators are asking why male circumcisers are allowed to traumatize our male infants. They want to know why our appointed state officials and medical associations do not advocate for protection of male infants.

Yet, with the recognition that in some way we are all victims of the anti-masturbation hysteria which established the practice of routine infant circumcision a hundred years ago, we ask not that circumcisers (namely, Neto and Allen) be harshly disciplined for past acts, but we do ask the Board to declare the procedure to be inappropriate care and to warn potential circumcisers that future amputations of a healthy prepuces will be treated by the Board for what they are: quack medicine.

If the Board or Commission does not declare routine infant circumcision to be inappropriate care, the citizens of North Dakota deserve a point by point explanation why not, giving scientific evidence to support the points. We trust the Board will act to protect those who are too helpless to protect themselves.

History will not be kind to us in our perpetuation and tolerance of this grave violation of human rights and dignity.

Sincerely,

Duane Voskuil, PhD
Philosopher

and other signatories.

Enclosures:
"Quotations and Comments by Some North Dakotans"
"Circumcision as Child Abuse: The Legal and Constitutional Issues"
"A Review of Medical Literature." NOHARMM.
"Parents' Religion and Children's Welfare: Debunking the Doctrine of Parents' Rights," California Law Review.
"Routine Neonatal Circumcision: An Update," Robert S. Van Howe, M.D. FAAP.

Endnotes:

(1) Defeated HB 1381 read: "A physician's use of complementary or alternative therapies does not constitute a continued pattern of inappropriate care, unless there is demonstrable physical harm to patients."

(2) Ralph Kilzer, MD, in response to a question, 2/27/95, from the ND House Human Services Committee as to why the state needed a bill outlawing FGM when this seems like an issue the NDBME should be able to handle, responded that the NDBME generally looks for a pattern of inappropriate care, whereas one unnecessary amputation of normal female genital tissue would be grounds for criminal action. He said "for normal tissue there is no useful medical purpose for amputating [female?] genital tissue." Circumcisers who do prepuce amputations routinely have such a pattern of inappropriate care.

(3)In this regard, the letter from the ND Commission on Medical Competency to Ramona T. Goheen, 11/29/94, responding to her complaint against Manuel Neto's inappropriate handling of her son's genitals, fails once again to address the real issue. Even if it were true that the Commission could, somehow, find no law (such as battery) under which to discipline Neto for a single act of forcibly separating the immature preputial tissue from the glans (against the express wishes of Ms. Goheen) and recommending circumcision for a child with hypospadias (contrary to textbook recommendations), and doing so while saying it must be done so he doesn't get picked on by other boys and so he will to do better in school, still Neto has been following "a pattern of inappropriate care" in forcible retraction of immature prepuces and in surgically removing healthy functioning tissue from non-consenting people. The law is clear enough on this. What is at issue here is not whether a law exists, but whether the Commission has the will to apply it. No law gives physicians the right to remove healthy functioning tissue from non-consenting people, be it the male genitalia or any other tissue. Circumcision, in Neto's mind, it seems, as in many others, is surgical alteration to accomplish psychological ends.

(4) See, for example, "Birth Complications Combined with Early Maternal Rejection at Age One Year Predispose to Violent Crime at Age 18 Years," Achieves of General Psychiatry, Adrian Raine, DPhil; Patricia Brennan, PhD; Sarnoff A. Mednik, PhD, Vol. 51. No. 12. Dec. 1994, pp. 984-988.

(5) See appended list of North Dakota Quotations.

(6) These figures are likely at the low end. The following quotation is from the Journal of Family Law (copy enclosed), Vol. 23, No. 3, 1985, by William E. Brigman, PhD: "Not only is routine surgery unwarranted, but an article published in 1966 in The Canadian Medical Association Journal ['The Problem of Routine Circumcision'] reported a complication rate running as high as 55% for hospital-performed routine neonatal circumcision. Other studies showed that approximately 10% of all circumcisions had to be repeated [Id.]. While most of the surgical complications were minor, Dr. Robert L. Baker, writing in a 1979 issue of Sexual Medicine Today calculated that 229 infants died in the United States per year as a result of circumcision [Baker, 'Newborn Male Circumcision: Needless and Dangerous,' Sexual Medicine Today, Nov. 1979].

(7) The fraud began over a hundred years ago as people were persuaded to mutilate genitals in many ways in order to discourage masturbation. Quacks played on people's fear that "self-pleasuring" would cause nearly every known ailment. Circumcision was actually thought to be one of the least painful ways prescribed to "cure" masturbation. Females were also genitally maimed, one we know of had her clitoris excised by a Wahpeton, ND, physician forty-some years ago.

(8) Rights of parents to do what they will with their children must be limited, testified Burleigh County States Attorney Patricia Burke opposing HCR3036, otherwise the law would not be able to do anything about the father "who initiated this teenaged daughter into sex because he wanted her to learn about it from 'someone who really cares.'" Quoted from the Bismarck Tribune, 3/2/95, Sec. B. Also see an excellent article in the California Law Review, "Parents' Religion and Children's Welfare: Debunking the Doctrine of Parents' Rights," Dec. 1994. The notion that a person can own another only survives in some court judgments (since the freeing of slaves and wives) in the parent/child relationship to the child's detriment.

(9) Ralph Kilzer, MD, speaking for the ND Medical Association in support of SB 2454 said the NDMA endorsed the AMA's Policy Recommendations which read:
     "1. That the AMA support legislation to eliminate the performance of female genital mutilation in the United States and to protect young girls and women at risk of undergoing the procedure.
     "2. That physicians who are requested to perform female genital mutilation on a patient provide culturally sensitive counseling to educate the patient and her family members about the negative health consequences of the procedure, and discourage them from having the procedure performed. Where possible, physicians should refer the patient to social support groups that can help them cope with changing societal mores."
     The AMA's policy statement ends with an Action Recommendation: "That the AMA join other organizations, including the World Health Organization, the World Medical Association, interested national medical societies, UNICEF and the International Federation of Gynecology and Obstetrics in strongly opposing all forms of medically unnecessary surgical modification of the female genitalia, promoting awareness of female genital mutilation to the public and health care workers, and education health professionals around the world to eliminate the practice of female genital mutilation." (emphasis added) No reasons were given for the exclusion of males in this formal statement.

(10) See the enclosed, "A Review of Medical Literature Exposes Circumcision Myths."


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