Well, I posted that ‘teaser alert’ in April I see, and then did not follow up! I have been very busy starting my new business with Heather and Kelsey. Please click on over to Open Arms Birth Collective to see what we’ve been up to!
I’m delighted to announce that this year I have begun working as a midwife’s assistant to Kim Smith CNM of Selah Midwifery. I am part of a team, and will be working with Kim at her client’s home births. I am continuing to take my own clients and to teach – it is a full and busy life!
In addition, look out for exciting news about package deals as Heather McLees Frazier, Abigail Winter-Lewis and I continue to deepen our working relationship. In the meantime, you can learn more about their wonderful services at The Healthy Birth and Abigail Winter-Lewis Massage and Doula Services.
It has been almost a year since I made it my choice as a doula not to work with parents choosing circumcision for their baby, and I’ve been thinking a lot about it lately. What are the consequences for me professionally and personally? Was it the right thing to do? Do I stand by it? How will my business look in the future?
The consequences for me professionally have been interesting. I usually set out hoping to work with around twelve families in a calendar year: in the past twelve months I have had nine clients. That dip in business is probably at least partly due to my policy: I have certainly had two or three people cancel interviews with me after learning about it (although of course they might not have hired me anyway). It might also be due to the natural ebbs and flows of this kind of work, or a reflection of just how many talented and in-demand doulas are working in and around Richmond these days. In any case, when I discussed this boundary with my family, we agreed that we would view any resulting drop in numbers as an acceptable cost.
A second professional cost has been the loss of opportunities to provide evidence-based information on circumcision to clients who initially plan on circumcising, in the hope of changing their minds. However, it is not a doula’s job to persuade or advocate for any given choice surrounding birth. It is a doula’s job to support parental choices. I am much freer in my advocacy as an ‘intactivist’ now that I have separated this work from my doula work.
A more interesting professional shift has been the types of families I have worked with this year. Almost without exception, I have worked with Americans having girls, and families in which at least one parent is foreign, having boys. I’ve had clients from England, China, India, Kazakhstan, the Netherlands and Germany. How about that!
The key consequence for me personally has been a light heart. I can serve my clients with total commitment and support their choices as a doula should. I am a better doula for it.
That being so, the answer to my questions ‘was it the right thing to do?’ and ‘do I stand by it?’ should be obvious. For me, yes, absolutely, it was the right thing to do. I have received nothing but support from my community – although some friends and co-workers who shared my original post took some heat, unfairly since they were sharing my views, not their own. I continue to review new research on the practice of routine infant circumcision as it is published, and to participate in activism to end the practice. Increasingly for me it is simply a question of human rights: either we are entitled to the full integrity of our whole healthy bodies, or we are not. If girls are protected, so too should be boys. One indirect critic of my original post said it seemed like I cared more about genital integrity than parental choice, and my response was ‘well yes, of course I do!’ When we replace the words ‘genital integrity’ with ‘human rights’ the relative weight versus ‘parental choice’ is even clearer. I continue to note that no medical association in the world recommends non-therapeutic circumcision. I still reject the flawed research, faulty reasoning and incorrect perception of risk behind the supposed ‘potential medical benefits’ of routine infant circumcision. I continue to advocate for a change in the law to protect our baby boys in their most vulnerable days, just as we protect our baby girls.
For the future: I am working on a class about the foreskin. What it is, how it works, what it means to remove it. I’m tempted to call it ‘The Cons and Cons of Circumcision’, but I think I will find a wider audience with a quieter title. I will offer it wherever I can: hospitals, parents’ groups, doula collectives, individuals. As I continue through my own school (prerequisites, nursing school and midwifery school) I will keep on striving to walk a peaceful, gentle path. When I qualify and find work as a hospital midwife, I likely will not be able to maintain my current boundary – although I will be in a good position to offer evidence-based information. School is going to take me long enough that who knows, by then perhaps the law will have been changed!
I’ve been a certified professional birth doula for over 3 years now, and my goal for this Fall is to increase the professionalism of the business side of my, well, business. Being a doula is such a privilege and honour that it has been easy for me to overlook the fact that actually I own a business! Step one in this process was applying for an LLC. Step two will be introducing new features like a logo and ability to pay for services through this website and by credit card. Watch this space!
I recently worked with a lovely lady who, at our postpartum visit, told me that she was embarrassed by how she had ‘behaved’ during the last few minutes of her (glorious, beautiful, moving) birth. She said that she had felt out of control, like an animal. Two things struck me from this comment and I wanted to share them here.
First, and this sounds like a bit of a no-brainer, we experience our own births differently from our support team. So many times my ladies have remembered screaming or shouting at particular points in their births – at transition, or at starting to push, or at crowning (especially at the notorious ‘ring of fire’). And yet, in my experience of their birth story (which, of course, is theirs to write and tell) there is no screaming or shouting – or very little. There is almost always vocalising of some sort: intense moaning, repetition of a mantra, or expression of a certain ardent desire to be done with the whole thing. But I have actually very rarely heard a mama scream in labour. And yet I have several mamas who remember screaming, even who apologise for it. The only way I can account for this disparity is that we experience birth distinctly inside our own heads, away in labour land, in a manner that trumps the outward physical expression of whatever is going on internally. It is such a powerful experience that it writes a physical memory of an emotional response. This is true of my own births too.
Second, I really believe that that out of control, ‘animal’ feeling, is almost essential to birthing, and certainly to an unmedicated vaginal birth. It’s what Ina May Gaskin refers to as the ‘inner ape’ as she calls on women to ‘Let your monkey do it’ (Birth Matters: a midwife’s manifesta, 2011, p37). It’s a primal, overwhelming negation of intellect and its replacement with instinct and pure physicality. It’s so important that labour can slow or stall if the intellectual brain kicks back in for some reason – for example, if someone turns on the lights in a dark room, or if an unfamiliar person comes in. Some women embrace this finding of a different inner self while some women fight against it, uncomfortable with the loss of inhibition that goes along with it. Some revel in its freedom; others recall it with mortification. In the modern western world, giving oneself over to being out of control, operating on instinct, surrendering to the process of birth – it is really hard. It is a reminder that we are mammals, and that just as cats and dogs seek a quiet, undisturbed place to birth, so too do we need a place where we feel safe, private, and cared for. A place where no one will tell us to be quiet or to stop moving. A place where a lover or doula or nurse or midwife or doctor will say quietly instead ‘yes that’s it, that’s perfect, listen to your body, you are so strong, you are so beautiful, yes yes yes.’ A place where one or all of those people help us float gently back to ourselves, newly anchored by the warm, wet, vital being who has arrived earthside. It’s a place where there is no shame in or judgment of instinctive, animal behaviour, but rather a celebration of the raw and beautiful power of it: what it takes to bring a baby in.
In the land of instant information and where everyone has a blog (like me – ha!) it can be hard to know where to turn for reliable, trustworthy information. This fact is especially true for any hot-button or emotional topic, like circumcision. If you google the word, you get hundreds of thousands of hits, with tones varying across the whole spectrum from dry academic research to heated parental debate to the frankly weird. From my perspective, even the results that seem to be trustworthy can be tricky, because, as with everything involving statistics and medical research, numbers can be read many different ways, and research can be spun. The two key lines of distinction that need to be drawn in reading research and making decisions are first, the difference between relative and absolute risk, and second, the difference between causation and correlation. I’ll come back to this point below. I am rather reinventing the wheel here – all the links I posted last time contain this information. The absolute best thing to read is by an Oxford University ethicist named Brian Earp.
One response to my previous post on circumcision raised the current stance of the American Academy of Pediatrics (AAP), which reads as follows:
‘Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it. Specific benefits identified included prevention of urinary tract infections, penile cancer, and transmision of some sexually transmitted diseases, including HIV.’ You can read the short statement here and the full technical report here. This week the CDC has come out with a very similar statement, claiming the same ‘benefits’.
As a dear friend once asked me, ‘What mother wouldn’t want to protect her son from UTIs and especially cancer and HIV?!’ The question to ask is, DOES male infant circumcision protect against these things, and if so, how much?
Let’s start with UTIs. Certainly some studies have shown that circumcision reduces the risk of UTIs (although other, more recent studies have not) – but let’s look at the numbers. According to one study from 1985, of every 1000 boys who remain intact, 7 will be admitted to hospital for a UTI before the age of 1 year old. Of every 1000 boys who are circumcised, 2 will be admitted to hospital for a UTI before the age of 1 year old. We could look at those numbers in various ways: circumcision reduces the risk of UTIs by more than two-thirds! Or we could look at the absolute risk: 7/1000 is 0.7%. Circumcising reduces the chance of a hospital-bound UTI from one very tiny number to another very tiny number. We can flip that number around and look at it from the other side: of every 1000 boys circumcised, 993 would never have needed hospitalisation for a UTI in any case. Or you could look at it another way, and say that for every hospital-bound UTI prevented by this choice, about 141 circumcisions were performed needlessly (this is the ‘number needed to treat’ to achieve the goal). This point also highlights what we mean when we say that the health benefits of circumcision are potential rather than actual – they prevent (possibly) things that might happen. Before moving on we can also note that girls under the age of 1 have approximately as many UTIs as boys. We treat them with antibiotics.
The second health benefit listed by the AAP is the prevention of penile cancer. Let’s look at the numbers. Of every hundred thousand men who are intact, 3 will develop penile cancer. Of every hundred thousand circumcised men, 1 will develop penile cancer. So, we could indeed say that circumcising a baby boy reduces his risk of penile cancer by two-thirds. Or we could flip the numbers and see that 99,997 circumcisions were performed needlessly. Penile cancer is so incredibly rare that, in fact, more men die of breast cancer in the United States every year than of penile cancer. About 1 in EIGHT women will get breast cancer at some point in their lives. We do not remove the breast buds at birth. This argument for performing circumcision is so ridiculous that decades ago the American Cancer Society actually asked the AAP to stop using it and today the American Cancer Society recommends good hygiene and not smoking as far more effective methods of risk reduction.
Finally, the AAP suggests that circumcision can reduce the transmission of STDs including HIV. The link with HIV came out of three main studies performed in Sub-Saharan Africa about ten years ago. Adult men who chose (please note it was a choice) circumcision were found to have about 60% protection against contracting HIV. However, many scholars have found problems with these studies, mostly around the difference between correlation and cause. The men who chose to be circumcised had more clinic visits and thus access to lectures on safe sex and condoms than the men who did remained intact, for example. The studies were stopped early. The ‘protective effect’, even if considered ‘real’, is still only 60% (and the absolute reduction was just 1.3%), meaning that even the circumcised men should wear condoms to avoid infection or infecting others. We can also draw two national comparisons. Most HIV transmission in Africa is by male-female sex. Most HIV transmission in the USA is by male-male sex and contaminated blood (like sharing drug needles) – circumcision does not protect against these means of transmission and the risk of female to male HIV transmission in the USA is incredibly low anyway. Finally, if this link is causal, we would expect the USA, with its relatively high levels of circumcision, to have low rates of HIV, and countries with low rates of circumcision to have higher rates of HIV. That is simply not the case: Norway, for example, has almost zero male circumcision and much lower rates of HIV than the US – 0.47 per 1000 in the adult population compared to 3.7 per 1000 in the US. Once again ask what is the number of men circumcised for this reason who never would have contracted HIV in the first place – what is the number needed to treat? Some studies have shown that males are less likely to contract other STDs like genital warts if circumcised, while others have shown that they are more likely to infect women if infected themselves. You can read an overview (from an admittedly anti-circumcision site) here. One fundamental point to consider is this: is your baby boy going to be sexually active? Is he going to be engaging in activity likely to land him an STD? Could you teach him how to have sex safely, that is, by using a condom or avoiding promiscuity? Could you let him choose circumcision as a preventative measure if he so desires, in the knowledge that he would STILL need to wear a condom to have sex safely?
To sum up, the health benefits of circumcision are not at all clear. They are disputed. They are potential rather than actual.They are all either treatable by other means or avoidable by methods far less drastic. If any scientist or government committee suggested introducing any new surgical procedure (rather than one entrenched in this country’s culture) on the basis of these kinds of number, they would be laughed at.
One final note: all of these perceived and potential benefits are predicated on the notion that the foreskin is pointless – that there is no advantage to having one and that it serves no function. This is certainly the stance of the committee that prepared the AAP and CDC statements referenced above. That stance could not be further from the truth, but you will have to wait for another blog post to read about the wonders of the male foreskin.
I’ve been thinking about a question, sparked by a new doula friend. A huge part of my job is helping mamas to protect their bodily autonomy – that they make the decisions about what happens to their bodies with genuinely informed consent – and genital integrity – specifically, avoiding episiotomy unless medically indicated and minimising the chance of tearing during birth by following physical cues for positioning and pushing, ‘breathing the baby down’, or perineal support, for example. I hear things like ‘I don’t want to be cut unless it’s an emergency’ or ‘I want my vagina or vulva to be the same afterwards’ or ‘I’m afraid that I will tear and it will hurt’ or ‘I tore last time and it was very painful and took time to heal: how can I avoid that this time?’ Imagine helping a VBAC (vaginal birth after cesarean) mama birth a nearly ten pound baby over an intact perineum. Think of seeing a mama who had had a huge episiotomy (to which she had not consented) that extended to a fourth degree tear with complications, birth her second sweet baby with no tearing at all. It’s incredible. I say, ‘Trust your body. Your body is not broken. Your body was perfectly designed to birth this baby. You will open and stretch. Trust your body. Your body is perfect.’ These are some of the mantras of doula-assisted birth. Again: women want me to help them guard their own bodily autonomy and genital integrity. And I am very, very happy to do so.
How do I hold this role in my mind with some parents’ decision to circumcise baby boys, breaching their bodily autonomy and genital integrity? Recently I have come to the conclusion that I can’t hold both things in my mind at the same time. I hear in my head the same requests and questions above, this time in the voice of a baby boy: ‘Please don’t cut me unless it’s an emergency…Please let me decide…Please let my penis be the same as it is now…Please don’t hurt me.’ In a whisper, so that parents cannot hear, I have told brand new baby boys ‘You are perfect, and whole, and your body is not broken.’ And I have said ‘I’m so so sorry, I tried my best.’ Someone might tell me to mind my own business, that’s it’s not my decision or my place to apologise. To this I can only say: it is this one baby boy’s penis. He has the right to bodily autonomy and genital integrity. Just as his mama does.
Consequently I’ve decided not to offer doula services to mamas who are carrying boys and choose to circumcise. I understand that (male) infant circumcision is seen as a legal right* and a cultural norm in much of the United States. I know that there are a number of spurious health claims about circumcision, myths about cleanliness and frankly offensive ideas about the aesthetics of the intact penis. I believe, most of the time, that parents who choose to circumcise make their decisions out of love and with the best information they have at that time. I recognise that for at least two religions it is an important rite.** But for myself, for my own mental and spiritual well-being, I can no longer reconcile working so hard to help mamas have a gentle birth, a ‘gentle welcome’ into motherhood, and leave knowing that I have failed to secure a ‘gentle welcome’ for a baby into life just because he is a boy, born in a country where routine infant male circumcision is normal and often unquestioned. It is true that this decision may cost me clients: in fact, it already has. But I think that is an easier cost to live with.
If you want to learn more about circumcision, why it’s done and why it’s important to leave all babies, boy or girl, intact, these are some great resources:
* Technically, the Fourteenth Amendment means that laws forbidding female circumcision apply to males too.
** For Jewish people, as part of the Covenant; for Muslims, as a cultural expression rather than a requirement of the Quran.
Hello strangers. I’m delighted to announce that I am now a Certified Lactation Educator with CAPPA. Look out for a post about group and private classes and in-home support coming soon.
In the meantime I was asked in a recent class about resources for pumping and returning to work. As with many issues I really recommend the kellymom website and this huge and helpful list of links from La Leche League.
There is also a wonderful book, available on amazon, called Nursing Mother, Working Mother, with lots of useful tips. This one is on making more milk, a common concern for working mothers – and it’s by Martha Sears!
Do you work outside the home and nurse? How do you do it?
Having disappeared for a time, and had my third baby (another boy! at home!) I’m emerging from the blur and I’m teaching my first breastfeeding class tomorrow. I’m working on certification as a CAPPA Certified Lactation Educator, and as part of my course I have to film myself teaching an hour long class. My good friend Heather McLees-Frazier has given me a spot in her Lamaze Class and I’m excited to work with her. I’m going to show a couple of short films during the class, and I thought I would share them here too, since they are excellent resources. The first is an Indian film of a newborn breast crawl (you can see a really interesting cultural difference too – the mama’s face is blurred out as too personal to share, but her breasts and nipples are fully visible. Which is helpful in a breastfeeding film!). The second is a film made by Ameda about how to achieve a good latch. Enjoy!
Here are another couple of great resources on getting off to a good start with breastfeeding: