Daily Star (Bangladesh)
Sunday, September 17, 2006 (Vol. 5 Num 821)

Doctor jailed for 3 years for negligence in duty

Our Correspondent, Chandpur

A court here on Thursday sentenced a doctor to three years' rigorous imprisonment (RI) on charge of negligence in duty that cost the premature death of a boy in June 2005.

District and Sessions Judge Md Abdul Salam Shikdar handed down the punishment in presence of the convict Dr Abu Taher Md Golam Murtaza, 40, at around 1:00pm.

The court also fined him Tk 1000 [$US15.85] and acquitted four others, including two nurses of the charges as they were found to be innocent.

According to the prosecution, Md Habibur Rahman, 8, son of Jahangir Hossain of Shibpur Bernaiya village in Shahrasti upazila of the district was brought to Grameen Shastha Kalyan Kendra on June 23, 2005 for a circumcision by Dr Golam Murtaza of the health centre.

Just after the circumcision, Habib started to bleed profusely and died on his way to a private hospital in Comilla two hours into the operation.

When the news of the kid's death spread, angry people brought out a procession accusing the doctor. Being informed, police rushed to the spot and brought the situation under control.

A case was filed by police, following which Dr Murtaza and three of his staff were arrested. Another accused staff Sajeda Akhtar surrendered later.

The Chicago Sun Times
August 16, 2006

Boy's parents sue doctors

A Chicago couple filed suit Tuesday against Northwestern Memorial Hospital and five doctors involved in their son's birth, saying negligence cost the boy a testicle. The couple said the doctors failed to perform "an appropriate physical examination" before circumcising the boy.

Their failure to properly diagnose a series of conditions -- including testicular torsion and having a buried penis -- was coupled by the doctors' "failure to disclose the risks and benefits of circumcision" before it was done. The boy, now 2, had his right testicle destroyed during the procedure and it's now removed, according to the suit.

CBS
August 15, 2006

Doctors, Hospital Sued Over Botched Circumcision
Couple Alleges Procedure Was Performed To Son Without Their Consent

CHICAGO In a lawsuit filed in Cook County Circuit Court Tuesday, the parents of a 2-year-old boy say the circumcision performed on him when he was born was not only unwanted and unnecessary, but resulted in the loss of one of the boy's testicles because of the surgical team's negligence.

The boy, [name], was born to [name] and [name] on Aug. 15, 2004, at Northwestern Memorial Hospital, the suit said. The couple never asked doctors to perform a circumcision on [him]. .... The suit seeks damages in excess of $50,000.

Doctor's Guide
August 17, 2006

Male Circumcision May Not Protect Against HIV Infection: Presented at AIDS 2006

By Danny Kucharsky

TORONTO, CANADA -- August 17, 2006 -- HIV prevalence is not necessarily lower in populations that have higher male circumcision rates, according to findings from a study of African countries presented here at the 16^th International AIDS Conference (AIDS 2006).

The study, which examined the association between male circumcision and HIV infection in 8 Sub-Saharan African countries, contradicts the findings of previous research and the opinion of several prominent personalities active in the fight against AIDS, such as former US President Bill Clinton.

While several studies have indicated that male circumcision has a protective effect against sexually transmitted infections (STI), including HIV infection, the evidence is inconclusive, said investigator Vinod Mishra, MD, director of research, ORC Macro, Calverton, Maryland. "We're just questioning that push," he said of the optimism displayed by Clinton and others.

The study used demographic findings from recent demographic and health surveys in Burkina Faso, Cameroon, Ghana, Kenya, Lesotho, and Malawi, and AIDS indicator surveys from Tanzania and Uganda. The surveys were conducted from 2003 to 2005 and sample sizes ranged from 3,300 men in Lesotho to 10,000 men in Uganda.

In survey fieldwork in each country, men aged 15 to 59 gave blood for anonymous HIV testing. Information on circumcision status and on STI/STI symptoms was based on men's responses to questions in survey interviews.

Prevalence of male circumcision ranged from a high of 96% in Ghana to a low of 21% in Malawi. Among the other countries, circumcision rates were 84% in Kenya, 89% in Burkina Faso, and 25% in Uganda.

HIV prevalence was markedly lower among circumcised than uncircumcised men only in Kenya (11.5% among uncircumcised men vs 3.1% among circumcised men). A small protective effect of male circumcision was also seen in Burkina Faso (2.9% vs 1.7%, respectively) and Uganda (5.5% vs 3.7%).

In the other countries, there was either no difference in HIV rates between circumcised and uncircumcised men or circumcised men were more likely to be HIV-positive than uncircumcised men. For example, in Lesotho, HIV was seen in 23.4% of circumcised men compared with 15.4% of uncircumcised men.

"If anything, the correlation [between circumcision and HIV infection] goes the other way," in most of the countries studied, Dr. Mishra said during his presentation on August 15^th.

When adjusted for sociodemographic and behavioral factors, a small protective effect was observed in 6 of the 8 countries, but it was not statistically significant in any country, Dr. Mishra said.

In Kenya, and to a lesser extent, in Ghana, Malawi, Tanzania, and Uganda, circumcised men were less likely than uncircumcised men to report having had an STI or STI symptoms in the 12-month period prior to the survey (2.1% vs 5.4%, respectively). The relationship was reversed in Cameroon (8.0% vs 2.5%) and Lesotho (12.1% vs 7.5%).

With other factors controlled, male circumcision had some protective effect in 5 of the 8 countries, but the effect was statistically significant only in Tanzania.

In addition, "circumcised men tend to have more lifetime sex partners, so there's some [high-risk] behaviors that go with circumcision status," he said.

A study limitation is that it was based on self-reported information on circumcision status and STI/STI symptoms. It also lacks data on age at circumcision and degree of circumcision, which might influence susceptibility to HIV infection.

However, Dr. Mishra said the study is consistent with other research that has failed to find a protective effect of male circumcision on HIV and STIs.


[Presentation title: Is Male Circumcision Protective of HIV Infection? Abstract TUPE0401]

Helsingin Sanomat
Mon, 7 Aug 2006

Court rules circumcision of four-year-old boy illegal
Legal status of nonmedical procedure remains murky

Finland’s first court ruling on male child circumcision was handed down by a Finnish court on Friday. A Muslim mother faced charges of assault in Tampere District Court for having her four-year-old son circumcised.
  The incident was reported to the police by the boy’s father, who had not been consulted.
  The court found that the mother’s action was illegal. However, it did not assign any punishment. The mother defended her action by saying that she thought that circumcisions performed by doctors were legal in Finland.
  The case will now go to the Court of Appeals.

The mother said that the procedure is part of the family’s religion and cultural heritage. The court found that interfering with personal inviolability could be allowed only in cases specifically permitted by law.
  "There is a perception in Finland that only girls’ circumcisions are banned by law. There is no specific legislation about them; both types are illegal under the same criminal law. After all, in both procedures, part of healthy genitalia is removed without medical foundation, or competent consent", says local prosecutor Jouko Nurminen.
  Nurminen says that the "misconception" may have arisen in connection with the drafting of the new constitution, at which time only the circumcision of girls was part of the debate.
  In its decision, the court notes that not even a long religious tradition justifies protecting the bodily inviolability of boys to a lesser degree than that of girls.

A working group of the Ministry of Social Affairs and Health proposed a few years ago that circumcisions performed under medical supervision in hospitals should be allowed.
  The working group wanted to avoid complications from operations performed at home, and to reduce the suffering of the child.

Legislation is somewhat vague on the matter, and practice varies in Finland. For instance, a report drafted by the Ministry of Social Affairs and Health in 2004 notes that male circumcision is permitted in all countries.
  "There is no legislation on male circumcision, but there is also no prohibition. The operations have been performed on the basis of common law", says Riitta-Maija Jouttimäki, a lawyer for the Ministry of Social Affairs and Health.

Association for Genital Integrity
August 6, 2006

Canadian Government ends circumcision funding

Canada has phased out the final remnants of government funding for routine infant circumcision.

The Public Service Health Care Plan (PSHCP), a supplemental health insurance plan sponsored by the Canadian government for the benefit of federal public sector employees, stopped reimbursing routine circumcision of newborns effective September, 2005.

PSHCP management said they ended payments for infant circumcision because "no provincial /territorial health insurance plan covers the procedure."

With over half a million members, the PSHCP is the largest employment-based health insurance plan in Canada.

Manitoba, the last province to fund routine circumcision of infant boys, has ceased coverage for the procedure unless medically required.

Perinatal HIV Research Unit
June 6, 2006

Doubts raised over circumcision-HIV utility

A colloquium on circumcision held in South Africa has raised doubts about the usefulness of the operation in preventing the spread of HIV.

In a paper called "Reality Check" Dr Warren Parker of the Centre for AIDS Development, Research and Evaluation, points out that most men in the Eastern Cape are circumcised, being of the Xhosa people, yet the Eastern Cape does not stand out in its HIV prevalence.

Speaking at the colloquium organised by the Perinatal HIV Research Unit in conjunction with the Department of Surgery at Chris Hani Baragwanath Hospital, he said that while the Orange Farm study found fewer circumcised men contracted HIV in the time-span of the study, the epidemiological impacts of ‘lifetime risk’ - whether circumcised or not - are unclear.

And he warned that widespread promotion of circumcision as a core prevention method may overwhelm the promotion of primary and urgent interventions - reduction in the number of partners and the consistent and correct use of condoms.

"The situation is delicate, risks are high, proceed cautiously," he concluded.

Prof. Haroon Saloojee of the Division of Community Paediatrics presented a cost-benefit analysis of circumcision that concluded, "The perpetuation of neonatal circumcision cannot be justified financially or medically; therefore, any justification for the practice must be based on religion, culture, or aesthetics. A cost utility of circumcision for males living in Africa would require a different set of assumptions but should be undertaken before implementation of any circumcision policy."

The Perinatal HIV Research Unit (PHRU), established in 1996, is one of the largest AIDS research centres in Africa. PHRU is a research unit of the University of the Witwatersrand, based in Soweto at Chris Hani Baragwanath Hospital.

Press Release
July 20, 2006

New weblog to collect Forced Genital Cutting Stories

A new weblog has been created for people to tell their own stories of having been genitally mutilated.

Project: OUCH! is a collection of first hand accounts told by victims, survivors, and participants of forced genital cuttings including stories of male infant circumcisions, female genital mutilations, and gender-norming surgeries.

The purpose of Project: OUCH! is to acknowledge victims' suffering of having had their genitals forcibly cut, altered, or mutilated. The weblog is called blOUCH! It is a place where victims and survivors can tell how they have been physically, spiritually, or emotionally harmed from forced genital cutting.

blOUCH! is the reverse of how most blogs are organized. Typically, one person posts their opinion and the public is invited to comment on it. Here, the public posts their stories, and no one may add a comment.

Anyone who has been negatively affected by forced genital cutting, whether their own or someone else's, is encouraged to contribute their story.

blOUCH! is for the benefit of a:

• Anyone genitally traumatized, injured, scarred, tortured, sexually deprived, or mutilated.
• Anyone forcibly cut in a medical, cultural, religious, or ritual genital cutting.
• Men who were circumcised against their will, even if as an infant.
• Women who were genitally cut against their will.
• Intersexed who were forced to undergo gender norming surgery.
• Anyone with an early recollection that may be from a genital cutting.
• Parents who regret having cut their children. Anyone traumatized by witnessing, participating in, or intervening with a forced genital cutting.
• Anyone in relationship with someone described above.

The College of Physicians & Surgeons of Manitoba

Doctor censured for circumcising wrong baby
- and trying to cover up his mistake

On June 7, 2006, the [College's] Investigation Committee censured Dr. Matthew Howard Lazar:

On November 8, 2005, Dr. Lazar asked for one baby to be brought to the procedure room [of St Boniface Hospital, Winnipeg] for circumcision, but a different patient ("Baby X") was brought. Dr. Lazar - or rather, a trainee with him - proceeded with the circumcision of Baby X without checking the patient identification.

Later that morning, when Dr. Lazar learned of the error, he told Baby X’s parents that he needed to talk to them about circumcision. He says they indicated that they wished to proceed with circumcision, but they deny this occurred.  They say Baby X’s mother was undecided, and was particularly concerned about whether her son would experience pain. All agree that he did not immediately inform them of the error, but instead, discussed the pros and cons of circumcision, provided statistics as to the rate of circumcision, and provided information to them in answer to their questions. They say that it was only after this discussion that they decided to proceed with circumcision.

Dr. Lazar obtained a consent form for the circumcision and presented it to Baby X’s parents to sign.

He then circumcised another baby and carried Baby X to Baby X’s parents, telling them that it was a perfect circumcision and their baby was fine.

Other hospital staff completed a critical clinical occurrence form and notified hospital administration. As a result of discussions between Baby X’s parents and another physician who was aware of the error, it became apparent to that physician that Dr. Lazar had not provided full and candid disclosure to Baby X’s parents.  This was reported to hospital administration. 

At a meeting on November 8, 2005, Dr Lazar apologised to the parents for the deception, but did not mention the trainee.

In an interview with the Investigation Chair Dr. Lazar said he was upset and flustered when he went to see Baby X’s parents, and he was relieved when Baby X’s parents said they wanted the circumcision done. He very much regretted the errors he made and he offered his apology to Baby X’s parents.

The Investigtion Committee has "recorded its disapproval" of Dr Lazar's conduct:

• He failed to promptly inform Baby X’s parents of the error.
• He gave them information about the pros and cons of circumcision, when he knew or ought to have known that this was misleading.
• He obtained consent for the procedure without saying that the procedure had already been done, and thereby misled Baby X’s parents.
• He presented Baby X to his parents, leaving the impression that the circumcision had just been performed.
• He took advantage of the situation for his own purposes, .
• At the evening meeting with Baby X’s parents, Dr. Lazar failed to promptly provide full disclosure of the events.
• [He also failed to tell them a trainee had circumcised their baby - so much for "making sure the operator is experienced".]

press release
July 20, 2006

Circumcision rate plummets in Canada

The rate of infant circumcision in Candian hospitals has halved in the last ten years.

Statistics from the Canadian Institute for Health Information show a total of 15,977 infants (9.2% of male births) were circumcised in hospital settings in fiscal 2005 (the latest year for which data are available), down from 38,062 (20%) in 1996.

The data include circumcision procedures performed in acute-care hospitals on boys up to one year of age, either as part of the birth admission or on a subsequent visit.

Data table

Circumcisions performed outside hospitals are not tabulated by any central authority and are not included in the data. In some communities, the number of circumcisions done in doctors' offices and private clinics may be significant.

The Canadian Institute for Health Information is an independent, not-for-profit organization funded primarily by the federal, provincial and territorial governments.

National Review of Medicine
Wednesday, July 5, 2006

BC man's foreskin op a success
Government pays to repair botched circumcision

By Jennifer Laliberté

In late April Paul Tinari became the first man in Canadian history to have the government pay for surgery to reverse a botched circumcision.

Paul Tirani

Armed with letters from a urologist and psychiatrist, the Vancouver engineer - who says he's been in pain for years - convinced the BC government to pick up 90% of the $12,000 tab. The final piece fell into place when he located Toronto plastic surgeon Dr Robert H Stubbs, the only doctor in Canada who'd ever performed a foreskin restoration.

"This is not something I went into lightly," says 48-year-old Dr Tinari of the complex, multistage procedure he began at the end of April. "I assessed the risks [of the surgery] and was willing to take them. But I certainly wasn't willing to pay for it."

The BC Ministry of Health says requests for funding for unlisted medical procedures are approved only if the care isn't available in the province and if a medical professional has confirmed there's a serious medical or mental health issue. There were no existing rules to deal with Dr Tinari's unusual case. "Obviously, something like that would be granted coverage only in rare or extenuating circumstances," says ministry spokesperson Sarah Plank. "We certainly don't have a billing code for it."

"He got a big chunk because no one in BC does this and he had his urologist and psychiatrist on his side," observes Dr Stubbs, who specializes in genital cosmetic surgery. "Some provinces are willing to do things like that for their citizens."

RESTORATION 101
"Dr Tinari was a good candidate for the surgery," says Dr Stubbs, who says he doesn't know of any other Canadian physicians doing foreskin restoration. "He had sufficient donor skin and was well aware of what he was getting into. I select my patients very, very carefully," he said. In fact, Dr Tinari is only the third patient he's agreed to take on. "This is like climbing Mount Everest," he says. "It's a huge procedure."

First, the skin is cut along the circumcision scar line and stretched open to create a graft site. Then, two parallel incisions are made on the scrotum - the donor site - leaving a sort of bridge with the two ends attached on either side. "The penis is popped through the hole, with the skin bridge covering the defect you created," Dr Stubbs explains. "Then we let that heal for at least three weeks." In stage two, the two ends of the bridge are cut, separating the penis and scrotum. "You tuck those two pieces that are still dangling to the underside and keep your fingers crossed that enough blood vessels have grown in to ensure survival of the graft." Finally, when the swelling has subsided, the new skin is stretched over the penis with tape and traction weights to form a foreskin.

[A scrotal graft like this is likely to be hairy, and to wrinkle in a way unlike a natural foreskin. No mention of the thousands of men worldwide who are restoring or have restored their foreskins non-surgically.]

PERSONAL CRUSADE
Dr Tinari sees this not just as a medical victory but a moral one too. He alleges that his circumcision was forced on him when he was eight years old by priests at his Montreal boarding school as punishment for masturbating. He says the circumcision left him depressed, suicidal and in chronic pain. He says his testicles would pull up onto the shaft of the penis during an erection; a segment of the glans healed to a small amount of remaining shaft skin, forming a skin bridge; stretching of that bridge caused intense pain during erection, occasionally causing tearing and bleeding during sex. He adds that cleaning under the skin bridge was also very difficult, so he suffered from chronic infections for years.

Nowadays, Dr Tinari, who has a PhD in engineering, is the director of an environmental engineering company based in Coquitlam, BC. But he spends a lot of his time campaigning against circumcision and for wider access to foreskin restoration. "People thought that I would go away after the surgery, but that was just the first step," he says. "I did this to restore my own bodily integrity, but also to set a legal precedent."

Given the complexity of the procedure, Dr Stubbs doesn't expect to see a dramatic increase in patients. He's staying out of Dr Tinari's legal pursuits. "I don't ask women why they come in for a breast implant, and I didn't ask him if he had an ulterior motive," says the surgeon. "He may have an agenda that I don't know about, but this isn't something where the success or failure of his surgical procedure should make men consider this an option or not."

Meanwhile, Dr Tinari is still recovering; it's nearly two months since the surgery and his doctor is pleased with the outcome. "We seem to have about an 80-90% graft survival," says Dr Stubbs. "I transferred a strip about 7cm wide, so he should have plenty for an adequate foreskin." The patient is also very pleased. "I've been working towards this for thirty years," says Dr Tinari. "I'm feeling better every day."

[It seems that the hurdles to funding are higher for this than other, comparable operations: the only truly unusual features of this are the small number of men who follow through on their demands for funding of the repair of their botched circumcisions, and the long time-lag between the operation and its repair.]