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Circumcision and the American Academy of Pediatrics: Should Scientific Misconduct Result in Trade Association Liability?
... The surgeon took so much shaft skin that the scar healed as a tight "collar" around his penis, preventing him from urinating. When he was later given an anesthetic in order to repair the damage, he immediately died of cardiopulmonary arrest ( Giannetti, 2000). His father lamented, "You think, 'What could go wrong with a circumcision?' ...
... Ironically, circumcision devices (e.g., restraints and clamps) are more closely scrutinized than their application. The American Academy of Pediatrics (AAP) was found to be partially liable in the death of Dustin Evans, Jr., according to the Iowa Law Review ( Giannetti, 2000). It reached the conclusion that his death was attributable to his circumcision, and that the AAP should either have labeled circumcision as experimental or proved its worth through exhaustive scientific testing. ...
Baby boys can and do succumb as a result of having their foreskin removed.Circumcision-related mortality rates are not known with certainty; this study estimates the scale of this problem. This study finds that more than 100 neonatal circumcision-related deaths (9.01/100,000) occur annually in the United States, about 1.3% of male neonatal deaths from all causes. Because infant circumcision is elective, all of these deaths are avoidable. This study also identifies reasons why accurate data on these deaths are not available,some of the obstacles to preventing these deaths, and some solutions to over-come them.
... When undertaking research into MC, full disclosure of personal beliefs indicative of likely biases should include professional, religious, political, and cultural affiliations, as well as one's own circumcision status (Goldman 2004). Making unwarranted recommendations in relation to circumcision policy raises the vista of future legal litigation (Giannetti 2000). WHO/UNAIDS has uncritically accepted the African FTM reports as conclusive and have recommended MC as an HIV-preventive measure despite substantial contradictory evidence, including the Wawer et al. ...
On the basis of three seriously flawed sub-Saharan African rand-omized clinical trials into female-to-male (FTM) sexual transmission of HIV, in 2007 WHO/UNAIDS recommended circumcision (MC) of millions of African men as an HIV preventive measure, despite the trials being compromised by irrational motivated reasoning, inadequate equipoise, selection bias, inadequate blinding, problematic randomization, trials stopped early with exaggerated treat-ment effects, and failure to investigate non-sexual transmission. Several questions remain unanswered. Why were the trials carried out in countries where more intact men were HIV+ than in those where more circumcised men were HIV+? Why were men sampled from specific ethnic subgroups? Why were so many men lost to follow-up? Why did men in the intervention group receive additional counsel-ling on safe sex practices? The absolute reduction in HIV transmission associ-ated with MC was only 1.3 % (without even adjusting for known sources of error bias). Relativereduction was reported as 60 %, but after correction for lead-time bias alone averaged 49 %. In a related Ugandan RCT into male-to-female (MTF) transmission, there was a 61 % relative increase (6 % absolute increase) in HIV infection among female partners of circumcised men, some of whom were not informed that their male partners were HIV+ (also some of the men were not informed by the researchers that they were HIV+). It appears that the number of circumcisions needed to infect a woman (Number Needed to Harm) was 16.7, with one woman becoming infected for every 17 circumcisions performed. As the trial was stopped early for “futility,” the increase in HIV infections was not statistically significant, although clinically significant. In the Kenyan trial, MC was associated with at least four new incident infections. Since MC diverts resources from known preventive measures and increases risk-taking behaviors, any long-term benefit in reducing HIV transmission remains dubious.
... 59 Commentators have suggested that the AAP changed its stance on female circumcision to make it more in line with its view of male circumcision in order to protect the flows of money derived from male circumcisions to its members due to it being a trade organization aimed at increasing its member's business profits rather than a non-partisan health organization. 60 Courts throughout the United States have taken a variety of stances, and often conflict with each other, on the issue of male circumcision. In State v. Baxter, 61 the Washington Court of Appeals held that while a parent has a right to control the upbringing of their son that right does not include using circumcision as a form of corporal punishment or as part of a religious or cultural ritual. ...
... However, the deaths occurred sometime after the hospital discharge and so would not be included in our data set (please note that Charlie and David are modelled on real-life cases: the deaths of Allen A. Ervin and Dustin Evans, Jr., respectively). 22,23 To summarize, our figure of 10.2 early deaths per 500,000 newborn inpatient circumcisions may (1) include some deaths that were not caused by circumcision, as well as (2) exclude some deaths that were caused by circumcision. It is not possible to determine how many instances of each of these is represented in our data set. ...
We sought to quantify early deaths following neonatal circumcision (same hospital admission) and to identify factors associated with such mortality. We performed a retrospective analysis of all patients who underwent circumcision while hospitalized during the first 30 days of life from 2001-2010 using the National Inpatient Sample (NIS). Over 10 years, 200 early deaths were recorded among 9,833,110 subjects (1 death per 49,166 circumcisions). Note: this figure should not be interpreted as causal but correlational: it may include both under-counting and over-counting of deaths attributable to circumcision. Compared to survivors, subjects who died following newborn circumcision were more likely to have associated co-morbid conditions, such as cardiac disease (OR: 697.8 [378.5-1286.6] p<0.001), coagulopathy (OR: 159.6 [95.6-266.2] p<0.001), fluid and electrolyte disorders (OR: 68.2 [49.1-94.6] p<0.001), or pulmonary circulatory disorders (OR: 169.5 [69.7-412.5] p<0.001). Recognizing these factors could inform clinical and parental decisions, potentially reducing associated risks.
... 174 3. liability for misleading parents They refer to the case of an anesthesia-related death of a boy operated on for a blocked urethra and whose earlier MC failed to heal. 175 The AAP policy states that parents should be advised that newborn MC carries risks, which, although usually minor, on rare occasions can be serious. Similarly, doctors are required to inform parents of the risks, some serious, associated with vaccination of their child. ...
We critically evaluate arguments in a recent Journal of Law, Medicine & Ethics article by Svoboda, Adler, and Van Howe disputing the 2012 affirmative infant male circumcision policy recommendations of the American Academy of Pediatrics. We provide detailed evidence in explaining why the extensive claims by these opponents are not supported by the current strong scientific evidence. We furthermore show why their legal and ethical arguments are contradicted by a reasonable interpretation of current U.S. and international law and ethics. After all considerations are taken into account it would be logical to conclude that failure to recommend male circumcision early in infancy may be viewed as akin to failure to recommend childhood vaccination to parents. In each case, parental consent is required and the intervention is not compulsory. Our evaluation leads us to dismiss the arguments by Svoboda et al. Instead, based on the evidence, infant male circumcision is both ethical and lawful.
... When undertaking research into MC, full disclosure of personal beliefs indicative of likely biases should include professional, religious, political, and cultural affiliations, as well as one's own circumcision status (Goldman 2004). Making unwarranted recommendations in relation to circumcision policy raises the vista of future legal litigation (Giannetti 2000). WHO/UNAIDS has uncritically accepted the African FTM reports as conclusive and have recommended MC as an HIV-preventive measure despite substantial contradictory evidence, including the Wawer et al. ...
On the basis of three seriously flawed sub-Saharan African randomized clinical trials into female-to-male (FTM) sexual transmission of HIV, in 2007 WHO/UNAIDS recommended circumcision (MC) of millions of African men as an HIV preventive measure, despite the trials being compromised by irrational motivated reasoning, inadequate equipoise, selection bias, inadequate blinding, problematic randomization, trials stopped early with exaggerated treatment effects, and failure to investigate non-sexual transmission. Several questions remain unanswered. Why were the trials carried out in countries where more intact men were HIV+ than in those where more circumcised men were HIV+? Why were men sampled from specific ethnic subgroups? Why were so many men lost to follow-up? Why did men in the intervention group receive additional counselling on safe sex practices? The absolute reduction in HIV transmission associated with MC was only 1.3 % (without even adjusting for known sources of error bias). Relative
reduction was reported as 60 %, but after correction for lead-time bias alone averaged 49 %. In a related Ugandan RCT into male-to-female (MTF) transmission, there was a 61 % relative increase (6 % absolute increase) in HIV infection among female partners of circumcised men, some of whom were not informed that their male partners were HIV+ (also some of the men were not informed by the researchers that they were HIV+). It appears that the number of circumcisions needed to infect a woman (Number Needed to Harm) was 16.7, with one woman becoming infected for every 17 circumcisions performed. As the trial was stopped early for “futility,” the increase in HIV infections was not statistically significant, although clinically significant. In the Kenyan trial, MC was associated with at least four new incident infections. Since MC diverts resources from known preventive measures and increases risk-taking behaviors, any long-term benefit in reducing HIV transmission remains dubious.
... There is also mounting anxiety about issues of legal liability (see Boyle, Svoboda, Price, & Turner, 2000;Richards, 1996;Smith, 1998;Somerville, 2000;Svoboda, Van Howe, & Dwyer, 2000;Van Howe, Svoboda, Dwyer, & Price, 1999). Moreover, Giannetti (2000) has pointed to psychosexual sequelae that appear to go well beyond those acknowledged in the recent American Academy of Pediatrics (1999) circumcision policy statement. The present paper recounts many of these concerns. ...
Infant male circumcision continues despite growing questions about its medical justification. As usually performed without analgesia or anaesthetic, circumcision is observably painful. It is likely that genital cutting has physical, sexual and psychological consequences too. Some studies link involuntary male circumcision with a range of negative emotions and even post-traumatic stress disorder (PTSD). Some circumcised men have described their current feelings in the language of violation, torture, mutilation and sexual assault. In view of the acute as well as long-term risks from circumcision and the legal liabilities that might arise, it is timely for health professionals and scientists to re-examine the evidence on this issue and participate in the debate about the advisability of this surgical procedure on unconsenting minors.
... The AAP wants physicians to get paid for unnecessary surgery, but if the AAP were to call it necessary surgery and recommend it, then it would potentially bear responsibility for any complications or harm resulting from the surgery. xv 96 Thus, presumably, the attempt to walk a fine line. ...
The American Academy of Pediatrics recently released a policy statement and technical report on circumcision, in both of which the organisation suggests that the health benefits conferred by the surgical removal of the foreskin in infancy definitively outweigh the risks and complications associated with the procedure. While these new documents do not positively recommend neonatal circumcision, they do paradoxically conclude that its purported benefits 'justify access to this procedure for families who choose it,' claiming that whenever and for whatever reason it is performed, it should be covered by government health insurance. The policy statement and technical report suffer from several troubling deficiencies, ultimately undermining their credibility. These deficiencies include the exclusion of important topics and discussions, an incomplete and apparently partisan excursion through the medical literature, improper analysis of the available information, poorly documented and often inaccurate presentation of relevant findings, and conclusions that are not supported by the evidence given.
... In the meantime, medical organizations should be aware of the potential legal implications associated with a flawed policy. A law journal article (47) claimed that the failure to act in a scientifically responsible manner could make a medical society liable for trade association misconduct connected with publishing negligent recommendations on circumcision. ...
The debate about the advisability of circumcision in English-speaking countries has typically focused on the potential health factors. The position statements of committees from national medical organizations are expected to be evidence-based; however, the contentiousness of the ongoing debate suggests that other factors are involved. Various potential factors related to psychology, sociology, religion and culture may also underlie policy decisions. These factors could affect the values and attitudes of medical committee members, the process of evaluating the medical literature and the medical literature itself. Although medical professionals highly value rationality, it can be difficult to conduct a rational and objective evaluation of an emotional and controversial topic such as circumcision. A negotiated compromise between polarized committee factions could introduce additional psychosocial factors. These possibilities are speculative, not conclusive. It is recommended that an open discussion of psychosocial factors take place and that the potential biases of committee members be recognized.
... The circumcision rate is declining in the US, especially on the west coast; 89 the two North American national paediatric organisations have elected not to endorse the practice, and the practice's legality has been questioned in both the medical and legal literature. 50,[90][91][92][93][94] 'Playing the HIV card' misdirects the fear understandably generated in North Americans by the HIV/AIDS pandemic into a concrete action: the perpetuation of the outdated practice of neonatal circumcision. ...
The objective of this study was to determine whether the justifications given for promoting mass circumcision as a preventive measure for HIV infection are reasonable and whether mass circumcision is a feasible preventive measure for HIV infection in developing countries. The medical literature concerning the practice of circumcision in the absence of medical indication was reviewed regarding its impact on HIV infection and related issues. The literature was analysed with careful attention to historical perspective. Our results show that the medical literature supporting mass circumcision for the prevention of HIV infection is inconsistent and based on observation studies. Even if the two ongoing randomised controlled trials in Africa show a protective benefit of circumcision, factors such as the unknown complication rate of the procedure, the permanent injury to the penis, human rights violations and the potential for veiled colonialism need to be taken into account. Based on the best estimates, mass circumcision would not be as cost-effective as other interventions that have been demonstrated to be effective. Even if effective, mass circumcision as a preventive measure for HIV in developed countries is difficult to justify.
The foreskin is a complex structure that protects and moisturizes the head of the penis, and, being the most densely innervated and sensitive portion of the penis, is essential to providing the complete sexual response. Circumcision—the removal of this structure—is non-therapeutic, painful, irreversible surgery that also risks serious physical injury, psychological sequelae, and death. Men rarely volunteer for it, and increasingly circumcised men are expressing their resentment about it.
Circumcision is usually performed for religious, cultural and personal reasons. Early claims about its medical benefits have been proven false. The American Academy of Pediatrics and the Centers for Disease Prevention and Control have made many scientifically untenable claims promoting circumcision that run counter to the consensus of Western medical organizations.
Circumcision violates the cardinal principles of medical ethics, to respect autonomy (self-determination), to do good, to do no harm, and to be just. Without a clear medical indication, circumcision must be deferred until the child can provide his own fully informed consent.
In 2012, a German court held that circumcision constitutes criminal assault. Under existing United States law and international human rights declarations as well, circumcision already violates boys› absolute rights to equal protection, bodily integrity, autonomy, and freedom to choose their own religion. A physician has a legal duty to protect children from unnecessary interventions. Physicians who obtain parental permission through spurious claims or omissions, or rely on the American Academy of Pediatrics' position, also risk liability for misleading parents about circumcision.
The practice of infant male circumcision has been debated by legal and medical experts for years. The practice, once seen as a social norm, has come under opposition by children's rights, legal, and medical organisations around the world. In order to meet the requirements of international treaty law and allow infant male children the fullest opportunity for self determination, infant male circumcision must be treated under the law and by medical practitioners with the same degree of opposition that female genital mutilation has received.
As parents and young men become more aware of their rights, an increasing number of circumcision-related lawsuits have been filed. In the past, these suits have not always fared well in the courts but the situation seems to be changing in the United States and in other English-speaking countries. Young men for the first time are suing for damage done to them as infants. New theories of law are being advanced and old ones are being dusted off, although the success of these theories remains to be seen. What is the prospect for the future of genital injury litigation as the public becomes more aware of the damage caused by circumcision?
The objective of this study was to determine whether the justifications given for promoting mass circumcision as a preventive measure for HIV infection are reasonable and whether mass circumcision is a feasible preventive measure for HIV infection in developing countries.
The medical literature concerning the practice of circumcision in the absence of medical indication was reviewed regarding its impact on HIV infection and related issues. The literature was analysed with careful attention to historical perspective.
Our results show that the medical literature supporting mass circumcision for the prevention of HIV infection is inconsistent and based on observation studies. Even if the two ongoing randomised controlled trials in Africa show a protective benefit of circumcision, factors such as the unknown complication rate of the procedure, the permanent injury to the penis, human rights violations and the potential for veiled colonialism need to be taken into account. Based on the best estimates, mass circumcision would not be as cost-effective as other interventions that have been demonstrated to be effective.
Even if effective, mass circumcision as a preventive measure for HIV in developed countries is difficult to justify.
In 2007, WHO/UNAIDS recommended male circumcision as an HIV-
preventive measure based on three sub-Saharan African randomised clinical
trials (RCTs) into female-to-male sexual transmission. A related RCT
investigated male-to-female transmission. However, the trials were compro-
mised by inadequate equipoise; selection bias; inadequate blinding; problem-
atic randomisation; trials stopped early with exaggerated treatment effects;
and not investigating non-sexual transmission. Several questions remain
unanswered. Why were the trials carried out in countries where more intact
men were HIV-positive than in those where more circumcised men were
HIV-positive? Why were men sampled from specific ethnic subgroups? Why
were so many participants lost to follow-up? Why did men in the male
circumcision groups receive additional counselling on safe sex practices?
While the absolute reduction in HIV transmission associated with male
circumcision across the three female-to-male trials was only about 1.3%,
relative reduction was reported as 60%, but, after correction for lead-time
bias, averaged 49%. In the Kenyan trial, male circumcision appears to have
been associated with four new incident infections. In the Ugandan male-to-
female trial, there appears to have been a 61% relative increase in HIV
infection among female partners of HIV-positive circumcised men. Since male
circumcision diverts resources from known preventive measures and
increases risk-taking behaviours, any long-term benefit in reducing HIV
transmission remains uncertain.
An incremental, rational, inexpensive, risk-free plan is proposed for curbing circumcision. It avoids the risk of legal sanctions for filing frivolous lawsuits. Adapted for local use, this plan may hold the key to hobbling, and eventually eliminating, all unconsented genital mutilations.
The BJC is owned by Cancer Research UK, a charity dedicated to understanding the causes, prevention and treatment of cancer and to making sure that the best new treatments reach patients in the clinic as quickly as possible. The journal reflects these aims. It was founded more than fifty years ago and, from the start, its far-sighted mission was to encourage communication of the very best cancer research from laboratories and clinics in all countries. The breadth of its coverage, its editorial independence and it consistent high standards, have made BJC one of the world's premier general cancer journals. Its increasing popularity is reflected by a steadily rising impact factor.
This paper presents four cases of fulminating neonatal sepsis with meningitis. In each infant, there was evidence of an infected circumcision wound. Two infants had Escherichia coli and two had Group B haemolytic streptococcus cultured from the cerebrospinal fluid. One infant died. The risk of introducing infection through iatrogenic portals of entry is a definite problem in the neonate. Circumcision is an unnecessary routine procedure, which puts the infant at risk.
In human studies, the possible long-term effects on behavior of early physical insult or pharmacological agents have received little attention. We present both circumstantial and direct evidence that circumcision of male infants leads to behavioral changes. In some American studies using circumcised infants, reported gender differences may instead be the result of the altered behavior of circumcised males. We suggest that circumcision requires more study in its own right, and that it requires description if not control in all neonatal and infancy studies.
The sixth case of carcinoma of the penis occurring in a Jewish male circumcised eight days after birth is reported. The rarity of this disease in circumcised males confirms the efficacy of circumcision as a reliable preventive measure against the subsequent development of squamous carcinoma of the penis.
There is no absolute medical indication for routine circumcision of the newborn. The physician should provide parents with information pertaining to the long-term medical effects of circumcision and noncircumcision, so that they make a thoughtful decision. It is recommended that this discussion take place before the birth of the infant, so the parental consent to the surgical procedure, if given, will be truly informed.
A program of education leading to continuing good personal hygiene would offer all the advantages of routine circumcision without the attendant surgical risk. Therefore, circumcision of the male neonate cannot be considered an essential component of adequate total health care.
Routine neonatal circumcision has long been controversial. Presented here is a cost-effectiveness analysis of the consequences of the treatment choices (circumcision versus no circumcision) using a decision tree model. For a simulated 85-year life expectancy, routine neonatal circumcision had an expected lifetime cost of $164.61 per patient circumcised and a quality-adjusted survival of 84.999 years. Conversely, for the noncircumcision approach, the expected average lifetime cost was $139.26 per patient, and the quality-adjusted survival was 84.971 years. The net cost-effectiveness ($919.87 per quality-adjusted life year) is within the range usually considered worthwhile for public health policy. However, because of the minor differences in lifetime cost ($25) and benefit (10 days of life) for an individual and the tenuous values available for disease incidence and surgical risk, we conclude that there is no medical indication for or against circumcision. Additional analyses suggested that reported benefits in preventing penile cancer and infant urinary tract infections are insignificant compared to the surgical risks of post neonatal circumcision. The decision regarding circumcision may most reasonably be made on nonmedical factors such as parent preference or religious convictions.
Practice guidelines are standardized specifications for managing particular clinical problems and are intended to improve the outcomes of medical care by increasing adherence to standards of care. They are also meant to make medicine more cost-effective by eliminating unnecessary procedures. A relatively recent phenomenon, the practice guidelines now emerging will have implications for malpractice, which also intends to bring about better care. They will probably not revolutionize the procedures that courts use to determine negligence, but judges will integrate guidelines into their decision-making process. This development should be welcomed. Guidelines should prove to be useful as either inculpatory or exculpatory evidence of negligence. They are unlikely to generate much new litigation, although there is some potential for suits against those who issue guidelines, especially if guidelines are not revised as the technology of medical care changes.
The article by Drs Wiswell and Roscelli (Pediatrics 1986;78:96-99) was an attention grabber, because it suggested a "medical" justification for circumcision. There are, however, several unanswered issues in the paper. Because circumcision was not randomly applied to the male babies, the reader needs to be reassured that the two groups (circumcised and uncircumcised boys) are indeed comparable. Variables that relate to circumcision, such as ethnic preferences, socioeconomic status (or military rank), race, prematurity, or hypospadias, may also relate to the risk of infection.
A retrospective population-based case-control study of sexually transmitted urethritis was conducted at a large military base over a 21-month period. During the study, 9,514 patients were seen for sexually transmitted disease. The analysis was restricted to active duty males and showed that Blacks had 14.8 times the incidence rate of gonococcal urethritis (GCU) and 4.7 times the rate of nongonococcal urethritis (NGU) compared to Whites. There were slightly fewer cases of NGU than GCU. A case-control study of active duty soldiers showed that both Black and White circumcised subjects were 1.65 times as likely to have NGU as uncircumcised subjects (95% CI: 1.37-2.00). However, circumcision was not associated with an increased incidence of GCU.
This study was undertaken to investigate the relation of cancer of the cervix to circumcision status as determined by actual examination of the marital partner. A total of 1,148 histologically confirmed cases from 5 New York City hospitals were included in the study: 454 of invasive carcinoma, 411 of carcinoma in situ, and 283 of cervical dysplasia. Controls were matched by age and ethnic group. The examination of marital partners for circumcision status was limited to patients and matched controls who were married to first husband. Five degrees of circumcision status, i.e. coverage of the glans by the foreskin, were recorded. Patients married to first husband included 91 with invasive carcinoma, 140 with carcinoma in situ, and 98 with cervical dysplasia. Successful completion of examination of the marital partner was obtained for 64 of the invasive carcinoma case control pairs, 108 of the carcinoma in situ pairs, and 74 of the cervical dysplasia pairs. Nosignificant differences were found in the circumcision status of marital partners of cases and controls. This held true even when the invasive and in situ pairs were combined to provide a series of 172 pairs.
For almost two decades, there has been an ongoing dispute among physicians, particularly pediatricians, as to the justification for neonatal circumcision, especially on a "routine" basis. Neonatologists have regarded the operation as without merit.1 Physicians in all fields agree on the necessity for careful explanation to the parents, preferably before the infant is born. They deplore the occasional grave complications that are largely produced by poor technique and inexperienced operators. One major reason formerly used to justify neonatal circumcision—correction or prevention of phimosis—has been shown to be untenable by serial studies from birth to adulthood.
The major indications now proposed as justifying the procedure are prevention of penile cancer and balanitis and a reduction in herpes genitalis and, possibly, cancer of the uterine cervix. These diseases are decades removed from the neonatal period, and opponents of circumcision regard them as lacking incontrovertible proof or as inconsequential. They say that
The purpose of this study was to investigate the current incidence of circumcision, the reasons governing parental decisions regarding circumcision, the immediate and later complications from the procedure, as well as genital problems occurring in uncircumcised boys. The incidence of circumcision was found not to have changed over the past five years despite the recommendations of the American Academy of Pediatrics Task Force on Circumcision. The reasons given for circumcision reflected mostly the strength of tradition, rather than a medical approach. Four per cent of newborns experienced early complications from the procedure, whereas 13 per cent experienced later, minor complications. Problems reported in uncircumcised infants were probably variants of normal. While the results of this study and evidence for discontinuing neonatal circumcision, we strongly recommend that, if physicians dissuade parents from having their infants circumcised, they must give adequate information concerning hygiene and the slow, natural separation of the foreskin from the glans.
The effects of circumcision upon mother-infant interaction were examined in an observational study of 59 mother-infant pairs during hospital feedings on days 2 and 3 of life. Each pair was observed during 4 hospital feedings using a specifically designed mother-infant interaction observation system that examined 43 discreet behaviours relating to feeding, gaze, facial expression, vocalizations and touch. The experimental group was circumcised after the second feeding and the control group after the fourth feeding. Analysis revealed no major behavioral differences between the experimental and control groups. Yet, different trends between the two groups were observed regarding two variables shortly after surgery. These differences disappeared by 24 h post-operatively. Differences related to the frequency of feeding intervals and infant availability scores. The study also revealed a surprisingly limited repertoire of behavior exhibited by both the mother and infant during feeding sessions. Our data suggest that circumcision has brief and transitory effects on mother-infant interactions observed during hospital feeding sessions, the only time mothers who are not rooming-in have an opportunity to be with their infants.