the controversy

I've been on my obstetrics rotation. I love it. The intern with whom I am working is pretty nice and cooperative. The ever popular hot topic of circumcision comes up a lot with him. We have discussed it. I feel that I am fairly tolerant of others' different perspectives. Clearly, I cannot argue that all newborn males be circumcised compulsively and routinely as if it were an immunization (though I have some misgivings about compulsively doing even that). The act is ethically similar to both vaccination and also to tattooing or piercing, however.
There are many arguments that opponents of neonatal circumcision employ. However, many of the opponents are not content to just not circumcise their own children. They often argue that the procedure not be offered at all; not be covered by insurance; or, as in San Francisco in recent years, even lobby that it be legally banned. Opponents condemn the process as some form of medically unnecessary painful mutilation. They suggest that the preference among women for the circumcised penis is socially biased and that any self-consciousness that the boy has about being uncircumcised is only because of the fair-weather fashion trends of our times. It has been proposed that the autonomy of the child is threatened by the will of the parents. They argue that any benefit that the procedure might convey could easily be achieved with good hygiene and safe sexual practices and that the problems that having a foreskin may actually cause are so rare that they can be ignored. They sometimes argue that it is cosmetic in nature and compare it to female genital mutilation, which is not practiced in the United States and is not taught to medical students or offered in American hospitals. Female circumcision can mean a lot of things, however, and seldom is analogous to the male circumcision.
But, why do Westerners circumcise despite the negative media? Some, like me, belong to a culture that routinely circumcises male infants. For Jews, it is considered to be a covenant with G-d. It represents our faith. Parents who choose circumcision join thousands of years worth of parents who also put faith in the fact that circumcision is beneficial. They performed the procedure without their children's consent, often in defiance of the majority culture and opinion, and it made them cry and the baby cried and was sore for a week. Most boys who have undergone the <40 minute procedure have uneventful urogenital childhoods with respect to infections and physical trauma. They have fewer UTIs and yeast infections. If, in the "intact" boy the foreskin is not retracted regularly by a certain age and after it may be unable to retract beyond the glans and on occasion can become stuck behind- which is quite dangerous. It is actually dangerous for the child not to masturbate if uncircumcised, but serious phimosis is still relatively rare. Irritation of the glans, however, is not uncommon in uncircumcised boys. An accumulation of smegma and microorganisms may be a gift to the uncircumcised boy's first sexual conquest. May she be pure and virtuous or else, he may also be carrying away a foreskin full of chlamydia or syphilis. The foreskin adds infect-able surface area and provides environmental protection for microorganisms and viruses. Circumcised boys have lower rates of several STIs, both contracted and transmitted and; as a consequence have way fewer cases of penile cancers and partners plagued by GU complaints. It seems that even our ancestors recognized these problems enough to try to prevent them.
Neonatal circumcision was of limited risk even four thousand years ago and now is done under local anesthesia so pain is significantly reduced. In the early 1900's the US took on circumcision for non-religious reasons, as a plot to end masturbation in children, an utter failure. While uncircumcised boys must retract their foreskins in order to clean beneath them, removal of the skin doesn't necessarily dissuade them from touching or playing with the penis! However, circumcision may increase time from erection to orgasm during sex, therefore allowing the partner to reach climax prior to a her partner's orgasm. There is much anecdotal evidence that the friction of the foreskin against the glans in the intact male can lead to over-stimulation and premature ejaculation. Why do women prefer circumcised?
But, as for autonomy... We are a civilized country. Shouldn't we get permission from the child first? If as an an adult, he wants it done or if he needs it done for some medical reason, he can do it. Right? This thinking, disregards the expense, trauma, and associated healing time of doing the procedure later in childhood or in adulthood. It also may not convey as much benefit if the man is already sexually active. Also, speaking from a purely anecdotal standpoint, few circumcised men are dissatisfied that the procedure was performed in infancy. There are much more uncircumcised men who feel embarrassment about their extra skin.
I was recently out in the YK Delta where there is a low incidence of neonatal circumcision and a high incidence of pelvic inflammatory disease. Hygiene is poor and some of the people don't even change their underwear regularly. They don't have indoor plumbing. Everything is expensive, if available at all. Winters are long. It is unreasonable to think that sex won't happen and that people will always have access to sanitation and medicine. The truth is that we cannot predict what our child will be exposed to and that is why we vaccinate and that is why I believe in parents' right to choose circumcision. It is a small procedure that can improve the child's health and overall quality of life and improve public health. 

Last week I did two peri-tonsillar abscess needle aspirations, delivered two babies, and did a paracentesis. I also became more comfortable with Radio Medical Traffic ( RMT). This is an important, often stressful part of delivering healthcare in Rural AK. Health aides in the villages, who have consulted their manuals and either cannot provide more treatment without consulting us, or are unsure of what to do, send us patient encounter forms and then call ( or we call) to get further guidance. Often this involves knowing the weather pattern in the village and the flight schedules for that day. We also have guidelines to follow on our end, though not always is it straight forward.
I went to the Subway restaurant yesterday. My 6" was just under $8 and it was quite possibly the worst Subway sandwich I had ever eaten I happen to already hold Subway in the lowest esteem of all fast food joints, lower even than McDonald's. This perhaps dates back to my UAA days, in which that was the only restaurant/food source near the "spine," the sky-bridge connecting the science building to the engineering building, where the chemistry clubbers like myself used to hang. I suppose I just got tired of it, but it was unreliable food at best. I walked around and went to the AC store too. I bought some fruit and the only frozen vegetables they seemed to have. This too seemed expensive. I am, otherwise, living on carbohydrates, the cheapest food here.
My car still doesn't work and they didn't bring the water this week, but I have been exceptionally conservative so am not worried yet. Last night, however, the electricity was out for over a half hour. In that time, the house became quite cold, as it sank in that everything in this place runs on electricity, even the cooking stove... which only has two functioning burners ( the small ones in the back). I couldn't call anybody as the phones are electric. I couldn't heat the place as there is no wood stove, or gas stove to my knowledge. I couldn't even see... no stinking candles. I'll need to remedy that. I have to admit, I panicked a little and had some very unsavory words with G-d. It was a pretty one-sided conversation, but it seemed to do the trick, for no sooner had I started to break down, the power came back. I spent the rest of the night online shopping ( sorry Nick, but there will be a package or two arriving for me) and listening to my computer's store of music.
This morning, however, was not a good one. I spent it cleaning as I am expecting a roommate this week. This disappoints me because I had a pretty bad experience with my last roommate. Directly after that, my parents called.

My family has just suffered a tragic and unexpected loss, you see. My cousin was killed in a car accident this morning. I have spent the rest of the day today feeling awful, helpless, isolated, and alone. We don't have a huge family like some people and my parents moved to Alaska in the late 1970's so my brothers and I weren't as close to our extended family as we might have been, but we always kept up through our parents and visited many summers. Chad was the only son of my aunt Betty, the eldest son of my uncle Paul. He was my eldest cousin, of which I only have five biologically (I also have three step-cousins on my mom's side, and one adopted). He was married to a girl a little older than myself.
I was seventeen when they got married, but remember it well. Mandy, his wife, and I were friends when I lived in Little Rock for medical school. They lived in Benton, my dad's hometown. I had many meals at their home, comfort food. They were always so kind, but also truthful and a very real loving family. They were among the first relatives I told when I discovered my unplanned pregnancy four years ago. They came to the hospital to see Ezra when he was first born. I went to the hospital when their twins were born a year earlier. I am so grateful now that we had these times together.
I can't imagine the pain... well I can, but don't want to think of it, of losing one's father as a child. Perhaps the twin girls are too young to understand, but Cole, their oldest child is in my thoughts. He has always been a bright, well mannered, and charming boy. He's so sweet, always wanting me to play with him in his room. Then their are my uncle and my aunt, who divorced around the time that Chad married. I empathize deeply with their loss.

The loss of my cousin seems distant right now, perhaps like it isn't real. I am still processing it. More than anything, I wish that I could hug my dad. I wish I could support my family and that we could all be together to reminisce and to grieve. But I am here and they are where they are and I pray, but it seems futile now.

Since my big brother decided to start blogging, I decided to get on the band-wagon. I am stranded in a barren wasteland anyway and my writing is a bit rusty. That being said, a " a cold day in Hell" never seemed so pleasant. Bethel has been fairly kind to me, despite my constant concerns about the water supply and the non-functional YKHC vehicle I have parked outside and plugged into the outlet on the porch. This house even has cable television. I don't even have that in Anchorage. Never watched so much Little House on the Prairie in my life! I think they took some creative liberties as I don't remember many of these stories being in the book series. Now I remember why we don't have cable in Anchorage, hah! Yesterday I started walking to and from work in the -30-40 degree weather. Glad I had my scarf! It takes me about 15 minutes if I hustle, which I do because it's really F---ing cold. It reminds me of the days back in Aniak when I would walk to the high school/junior high in the winter except that it's way windier here. The ice under my feet is nicely polished from the wind and I am appreciative also that my Sorels have decent traction. About mid-day yesterday I noticed that I had developed a rash on my face in the pattern of where my hat had hung. It's a wool cap with a fleece lining, with ear flaps. The rash is exactly where the wool would hit my face so I suspect, though I have worn this cap before, that I am developing yet another adult onset sensitivity. Again I was grateful; this time that I had Benadryl with me. I am taking it prophylactically prior to wearing my hat now and after I get home. The house also is a bit smelly, like wet dog. I am told that the place is well insulated and so there is not much ventilation. My eyes and nose itch a lot.

I was born in Bethel, a factoid few know and few would care to admit. However, this is the first time that I have actually been here since. Despite it being relatively close to Aniak, the terrain is totally different and so, it seems, is the culture. I have to say, I much prefer Aniak. But for now I am here and am looking forward to another interesting Bethel day at YKHC doing in and out-patient pediatrics. Next week I do adult inpatient medicine. I should be getting the full spectrum experience. Orientation was okay. I met a traveling male nurse who will be here for three months and is rooming with a giant from Brazil who has only been here a month...and is now orienting us to the foreign concept of team work. I got to explain rosehips to a Gussuk from down in the lower 48. He couldn't wrap his head around that particular fruit... "is it a berry, a flower?"