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The hearings for the case of Nibus vs. Hironimus took place between March of 2014 to May of 2014. During these hearings, Pediatric Urologist Charles Flack “testified by telephone upon agreement of the parties’ lawyers even though no notary was present with him to verify the Court’s administration of the oath“.

According to inside sources, Dr. Flack could be the pediatric urologist of choice by the father to perform the circumcision. If that is the case, it must be noted that there would be a conflict of interests as Dr. Flack would stand to profit from a ruling in favor of the father (and from performing an unnecessary surgery on a minor).

According to the order of May 9th, “while Dr. Flack did opine that the procedure was not medically necessary, significantly, he advised the Court and the parties that penile cancer occurs only in uncircumcised males and uncircumcised males have a higher risk of HIV infection than circumcised males. He further testified that the procedure last only 17 minutes and patients experience little post-operative discomfort and few recovery problems. Finally, he testified that performing the procedure on boys up to 10 years of age is medically acceptable, the concern being that with older boys who have reached puberty, an erection could cause tears in the sutures.”

Well, let’s see if Dr. Flack’s assertions are supported by current standards of medicine (whether we agree with them or not).

Penile Cancer

Dr Flack: “penile cancer occurs only in uncircumcised male”

AAP: “A history of phimosis alone confers a significantly elevated risk of invasive cancer (OR: 11.4). In fact, in men with an intact prepuce and no phimosis, there is a decreased risk of invasive penile cancer (OR: 0.5). When excluding phimosis, the risk disappears [...] The clinical value of the modest risk reduction from circumcision for a rare cancer is difficult to measure against the potential for complications from the procedure.” (AAP Technical Report on Circumcision from August 27th of 2012)

So, penile cancer is a rare disease and it occurs mostly on old men. It is usually associated with HPV and with phimosis during adulthood. HPV infection can occur in any sexually active individual. Adult phimosis can often be treated without circumcision. Penile cancer DOES, in fact, occur on circumcised men.

It would make more sense from a social health point of view to remove the breast buds of girls to reduce the risk of breast cancer, than removing the foreskin as a way to prevent penile cancer.

HIV

Dr Flack: “uncircumcised males have a higher risk of HIV infection”

AAP: “40% to 60% for male circumcision in reducing the risk of HIV acquisition among heterosexual males in areas with high HIV prevalence due to heterosexual transmission (ie, Africa). [...] more than 619 000 people in the United States have died of AIDS since the epidemic began.38 In the United States, HIV/AIDS predominantly affects men who have sex with men (MSM), who account for almost two-thirds (61%) of all new infections. Heterosexual exposure accounts for 27% of new HIV infections, and injection drug use accounts for 9% of new HIV cases. In other parts of the world (eg, Africa), heterosexual transmission is far more common.”(AAP Technical Report on Circumcision from August 27th of 2012)

Notice that the text of the ruling does not mention that this “protective effect” is limited to “heterosexual males in areas with high HIV prevalence due to heterosexual transmission”. Given the high rates of circumcision in the United States and the prevalence of the American epidemic of HIV on MSM (men who have sex with men), most of those people who died from AIDS would have been circumcised males.

In 2009, Dr. Ronald Gray, one of the main researchers of circumcision and HIV in Africa and author of some of the studies that found this “consistent” protective effect, said:

“If you were to ask me, should the U.S. be promoting circumcision, my answer would be, ‘no,’ What I do think ought to be the policy is that parents should be informed about the potential protective effects” NYTimes

Studies have failed to find such “protective effect” in the United States due to the different characteristics of the epidemic. Reuters

Complications

Dr. Flack: “patients experience little post-operative discomfort and few recovery problems”

AAP: “The true incidence of complications after newborn circumcision is unknown, in part due to differing definitions of “complication” and differing standards for determining the timing of when a complication has occurred (ie, early or late). Adding to the confusion is the comingling of “early” complications, such as bleeding or infection, with “late” complications such as adhesions and meatal stenosis.” (AAP Technical Report on Circumcision from August 27th of 2012)

CDC’s Charbel El Bcheraoui: the risk of experiencing complications was 20 times higher for boys ages 1 to 9 years. (May 2013)

For an idea of what the complications can be and the different age ranges, see this list at Circleaks and this other list for 2013, at Circwatch.

James R. Robertson, Ed.D., studied the effects of circumcision during childhood. He concluded: “In summary, the 19 letters from men circumcised between ages three and six reveal emotional results in conformity with predicted psychoanalytic consequences for circumcision performed during the phallic stage. These 19 men characteristically feel mutilated, diminished and incomplete. They are preoccupied, if not fixated, with their lost foreskins. They show anger at having been denied the right to choose. When they have attempted to discuss their feelings, they tend to have been met with ridicule, rejection and amusement.” (1989)

Erections

Dr. Flack: “performing the procedure on boys up to 10 years of age is medically acceptable, the concern being that with older boys who have reached puberty, an erection could cause tears in the sutures”

NewKidsCenter.com: “Erection is common among infants and toddlers. (…) Often early erections come for no reason at all (…) Erection could also mean that the boy’s bladder is full and he ‘needs to pee’.”

AAP: An old guideline for parents on care of the uncircumcised penis used to say: “The foreskin may retract spontaneously with erections which occur normally from birth on and even occur in fetal life.” This information is no longer available in the current AAP page on care for the uncircumcised penis.

So, evidently, erections can occur at any age and do not make a difference as to whether a male can be circumcised or not. Over a million baby boys are circumcised in the U.S. every year in spite of erections being also present in neonates.

This is not a valid reason to perform the operation before the patient has the age to consent, but perhaps the reason for this artificial age is the legal precedent of Boldt vs. Boldt, in Oregon, which started when a divorced father decided to convert to Judaism and have his (9 year old) son convert and get circumcised, which the child refused. While the process took several years, the court ruled that a parent could not compel a child to get circumcised against his will.

Conclusion

All the points quoted by the Court from Dr. Flack’s testimony are either partially false, or irrelevant. The only fully true statement is that “the procedure was not medically necessary“.

Dr. Flack may have a conflict of interest in his testimony if he is the doctor that the father is depending on to perform the circumcision, and as the person that stands directly to gain financially from a favorable outcome for the boy’s father, he has incentive to withhold information that could dissuade the judge from ruling in the father’s favor. He may even be inclined to misrepresent, even present false information. In essence, his testimony in court may have been no more than a shameless self-advert.

Were Dr. Flack to perform a circumcision on Chase, not only would he have given a misleading, partially false testimony in Court, but he would also be profiting from the results of his testimony and from causing bodily and emotional harm to a child.