The Womanly Art of Breastfeeding: Circumcision

Genital cutting ('circumcision') can have a dramatic impact on successful breastfeeding, as can other forms of trauma in the first days, weeks and months of human life. An especially crucial time for mother/baby bonding and secure attachment development (instinctual and important for normal health, and contributing to mother's milk production and baby's suckling/feeding habits) is the first month of life. During this time it is paramount to protect baby from any and all unnecessary pain, stress and traumatic events. There are, of course, times when medical necessity wins out over baby's need for security, protection and avoidance of pain; circumcision, however, is not one of those times.

We receive a significantly large volume of mail from mothers who notice that their baby feeds differently (or no longer wants to nurse at all) post-circumcision. Those who note the most significant change are often mothers who dearly wish to breastfeed, but find they are returned with a baby who is "completely different - not himself" after genital cutting. Too often mothers ponder with tear-filled eyes, "Why didn't anyone tell me this could happen?"

And this is a justifiable question to ask. After all, we have mountains of literature and research on the science of human lactation and on intact care and circumcision. We know what factors lead to the most probable successful outcome of breastfeeding (and secure attachment), and we know which factors present a risk to successful breastfeeding, or increase failure to thrive potential. Genital cutting (on female or male babies) is one significant risk factor.

So powerful is the detrimental effect of circumcision on breastfeeding that many state hospitals (especially in the Western and some Southern U.S. states) have made the move to not allow circumcision to take place in the first week(s) post-birth. Instead, if a parent elects to surgically amputate the prepuce organ from their baby's body, they must schedule the surgery for a later date. Lactation consultants working within these hospitals have stated that failure to thrive rates decrease when genital cutting decreases. We've seen in other hospital records that the number of babies who suffer from failure to thrive and feeding complications (as well as parent-reported cases of 'colic' and overall agitation/fussiness) are positively correlated with two things: (1) male sex and (2) being circumcised.

If parental and professional observation exposes the realities of the circumcision / breastfeeding troubles connection; if research supports such notations; if hospital records and lactation consultants' cases reinforce the realities of it all; and if we have the resources to provide expecting mothers with all available information on the topic, why are we not doing so?

This was not always the case. Genital cutting began in the United States in an effort to curtail masturbation among boys and reduce sexual 'promiscuity' among men who were serving overseas. It was a failed attempt (promoted and pushed by Drs. Kellogg and Graham) but one that was so flooded within media at the time, that it seeped into our every day lives in birthing units around the nation by the 1950s/60s. Many baby boys born at the time were cut before their mothers even held them as perfect, whole babies, or had a chance to say, "No" to circumcision. However, thanks in part to the feminist movement of the 1960s/70s, women started to wake up to the realities of birth and what was happening to them - to their bodies - and to the bodies of their babies. Nurses and other medical professionals began speaking up to expose the old lie that "babies don't feel pain" and as the natural birth movement took hold, women who were awake and conscious for their births and first breastfeeding days began to question circumcision and see first hand how it changed their babies.

Newspaper and magazine articles, as well as books began to be published on the subject of circumcision, and in 1985 The National Organization of Circumcision Resource Centers (NOCIRC) was founded by Marilyn Milos, R.N., in California.

La Leche League International (LLLI) started its efforts in the latter half of the 1950s, and quickly became a trusted resource and refuge for nursing mothers and their babies. Several early authors seem to have been in-the-know on the harmful effect that genital cutting can have on breastfeeding, because cautions were in place in the early editions of La Leche League International's first book, The Womanly Art of Breastfeeding.

Prior to any national organizations gathering information on circumcision, LLLI had 'Circumcision' indexed in the text of its early editions:

When reading the books, expecting mothers learned that (1) circumcision is painful and unnecessary, (2) circumcision is an optional surgery that need never happen, (3) circumcision, even if chosen, can be done at a later date so as not to impair breastfeeding, (4) circumcision can harm bonding between mother and baby, and (5) additional academic resources are available to learn more about the realities of circumcision.

Although factually flawed in some information presented at the time (eg. there is zero medical evidence that supports the myth that a baby is less likely to hemorrhage at 8 days old versus any other time in the newborn's life as coagulation and clotting factors develop slowly over the first 6-12 months of a baby's life and prothrombin levels are at <80% throughout childhood), the following is an excerpt from the 1981 edition of The Womanly Art of Breastfeeding. (1) 

ELECTIVE SURGERY FOR YOU OR BABY 

If you are going to be in the hospital anyway for the birth of your baby, you or you doctor may suggest that you have some other medical matter attended to. Examples of elective surgery for the mother include stripping the legs of varicose veins or tying the fallopian tubes (tubal ligation). As for the baby, it may be considered almost routine to circumcise boy babies when they are only a few hours or days old. But circumcision is an elective surgery and you have a choice of whether or not to have your baby circumcised. You can also choose to wait a while before having this done. We bring these subjects up because, physically and emotionally, these procedures all take their toll on mother and child. Since they represent elective surgery, their appropriateness at this critical time must be questioned.  

Circumcision is as painful a procedure to a newborn as it is to an adult. As a religious rite, circumcision is not performed until the baby is eight days old, when he is less apt to hemorrhage. The reasons given in the past for non-religious, almost routine circumcision of the newborn were generally hygienic and are no longer accepted by many physicians and parents. If you're interested in learning more about this subject, see the Book List at the end of this book.* 

The most important reason for siding against elective surgery following childbirth is that it interferes with a mother and her new baby being together and getting to know each other. While a mother may feel very good following the birth of her baby, her body nevertheless has some recovering to do. Adding the strain of recovering from a surgical procedure might lessen her enjoyment of these early days with her baby. 

In regard to tubal ligation, there can often be an unexpected emotional reaction in the mother. When it dawns on her that the baby in her arms is her last, there may be feelings of deep sadness. It might become difficult for her to keep a normal perspective on her mothering of this baby. She may become exceedingly anxious about doing everything just right.
Whatever the inconvenience you may experience by postponing such operations for you or your baby, it is slight compared to the upheaval such surgery can cause in your life at this time.

*At the end of the 1981 edition of The Womanly Art of Breastfeeding, Edward Wallerstein's scholarly text, Circumcision: An American Health Fallacy (1980) was listed in the Book List as a recommended resource. Today, there are many more well referenced books available on the study of circumcision and its detriments, and the intact body and healthy purposes of the prepuce organ ('foreskin' or 'clitoral hood'). Research on the subject is far from lacking, which would indicate the availability to provide The Womanly Art of Breastfeeding readers with more, rather than less, resources for further research.

Unfortunately, with the subsequent edition of The Womanly Art of Breastfeeding (1987), any mention of circumcision was omitted from the text. It was dropped from the index, and this section on elective surgery was removed. However, sections before and after this portion of the text remain somewhat similar, even into the 5th Edition (1991) suggesting the removal was deliberate.

The Womanly Art of Breastfeeding is now in its 8th edition (2010). Despite the fact that we now know more than ever about infant pain experience, neurological wellbeing, development and feeding as they pertain to the newborn period, over 30 years later information on circumcision's powerful potential detriment to successful breastfeeding has yet to be re-included in the LLLI text.

The Womanly Art of Breastfeeding (2010) 8th Edition

In response to this absence of information that breastfeeding women deserve to have before their babies are born, a petition was started by one Canadian mother and breastfeeding advocate (not affiliated with DrMomma.org in any manner) urging La Leche League International to once again include said information. You can view and sign the petition here. 

Replying to this petition, Diana West, IBCLC, La Leche League Leader and co-author of The Womanly Art of Breastfeeding 8th Edition, writes via Mothering.com, "I want to address the breastfeeding community directly about this petition." She continues: 

First, those supporting the petition are absolutely right that there are medical and psychological consequences to circumcision that clearly have the potential to negatively affect breastfeeding simply because most circumcisions are performed in the first week when breastfeeding is particularly vulnerable and research has clearly shown that pain negatively affects breastfeeding.  

I haven't yet dug into the research -- is there any particular to this issue? If so send to me at dwest@bfar.org -- But pain from circumcision is documented as an impediment to effective breastfeeding in Nancy Mohrbacher's excellent textbook, Breastfeeding Answers Made Simple (2010, Hale Publishing, page 114t, 116). So for this reason, I and my co-authors Diane Wiessinger and Teresa Pitman, absolutely agree that it should have been included in the 8th edition of The Womanly Art of Breastfeeding.  

So why wasn't it? 

No conspiracy here. We simply (to our shame) did not think of it. As you can see from the size of the book, we tried to include every single thing we possibly could think of, but that one honestly just slipped by us. We are really very, very human authors (just ask our families!). Also, Nancy's book was published at the exact same time as ours, so we didn't have it as a reference when we were in the writing stage.  

We, of course, completely understand that mentioning circumcision in The Womanly Art of Breastfeeding could be construed as mixing causes, but in light of the new documented information we now have about the negative effects of circumcision on breastfeeding, we absolutely will include it in the next edition if we are the authors, framing the discussion in terms of the documented medical and psychology contraindications in the context of breastfeeding FOR THOSE WHO CHOOSE TO CIRCUMCISE FOR NON-RELIGIOUS REASONS so as to avoid mixing causes.  

It would not be our intention to comment on religious circumcision, but only on the objective effect of the procedure relative to breastfeeding when it is done for reasons OTHER than religious. So please forgive us for not mentioning this important issue in the 8th edition. It was really just a human error and we are very sorry for it.  

Thankfully, there will always be future editions of The Womanly Art of Breastfeeding, because it is a uniquely "living" and ever-evolving book, so we'll absolutely have an opportunity to fix this oversight. In the meantime, if there are other changes that you'd like to see, feel free to send them to me at dwest@bfar.org. We can't promise all issues will be so easy to fix, or that we'll agree with every suggestion, but we absolutely want to hear your thoughts and ideas.  

Finally, we want you to know that we appreciate the support of the breastfeeding community more than we can express. Your warm reception of our complete re-write of this revered breastfeeding icon has been so touching to each of the three of us. We thank you all for your passion and dedication to helping breastfeeding mothers and babies. Together, we'll build even better resources for future mothers. 

Diana West, IBCLC 

La Leche League Leader  

DWest@bfar.org

We appreciate West's response to the present absence of information in LLLI's primary text, and hope to see it re-included in future editions. However, we do also wish to note that all babies, female and male, regardless of their parent's chosen faith, are born into this world equally deserving of genital autonomy and fully informed mothers. The implications of circumcision upon a newborn and his breastfeeding success do not only apply to those cutting for one reason versus another. My right to practice my religion ends where another human being's body/rights/wellbeing start -- and this applies to the stranger down the street as well as to the baby in my home. My success in breastfeeding, and the detriments that circumcision may have upon this success, are not nullified as a result of my faith.

Because religion has surfaced (and has been suggested by some to be the reason that circumcision 'disappeared' from LLLI's texts in the first place), and because it seems to be the pivotal point upon which people become uncomfortable in their ability to educate openly and honestly about circumcision and breastfeeding, it is important to highlight the fact that Jewish mothers are just as deserving of information as are mothers of any other faith. What we do with this information is up to each of us. And in fact, there is an ever growing population of Jewish parents and professionals speaking up in favor of genital autonomy for their own sons, and making powerful, compelling points along the way. See:

Judaism and Circumcision Resources
Questioning Circumcision: A Jewish Perspective
Circumcision: Identity, Gender and Power
Jewish Circumcision Resource Center
Jews Against Circumcision
Beyond The Bris
The Intactivist Movement Within Judaism
Faith Considerations on Circumcision (Judaism, Christianity, Islam)

Why shouldn't a new, young, Jewish mother know that circumcision may be detrimental to her breastfeeding relationship, and that she has the option of a Brit Shalom instead of a Brit Milah? Is there any danger that comes in offering up a whole host of options (and research based, medical truths) as they pertain to breastfeeding?

If this is going to be the one area that causes an overall silencing of circumcision / breastfeeding discourse, then let's at least allow for the discussion and voices from within Judaism. There are many to be heard and listened to today. We would, of course, encourage the inclusion of medical and research-based information on genital cutting's impact on breastfeeding in future editions of The Womanly Art of Breastfeeding. But we'd also suggest that authors dive into some of the cultural happenings in related areas as well -- don't assume that all Jewish mothers do not also want (and deserve) this information. There are some of us who are thankful to have had it in our decision making and early mothering days.

Nancy Mohrbacher's comprehensive texts Breastfeeding Answers Made Simple and Breastfeeding Answers Made Simple (Pocket Guide), as mentioned by West in her response, contain information on circumcision's detrimental impact on the breastfeeding relationship. Mohrbacher is also co-author of the excellent book, Breastfeeding Made Simple -- a book that we highly recommend new nursing moms read before their baby's birth day. It is a superb text to use in understanding breastfeeding and baby basics, as well as to proactively ward off problems and to work through issues and concerns that sometimes surface.

Another book that discusses the implications of circumcision on breastfeeding, specific to multiples, is Having Twins and More by Elizabeth Noble, OB/GYN.

Reference: 

1) Lake, C. & Booker, P. (2004). Pediatric Cardiac Anesthesia. Lippincott, Williams & Wilkins: Baltimore, MD. pp. 304-316. [Discussion about the myth of clotting happening on/by the 8th day of life and the reality that clotting factors emerge over the course of many months and years in a baby/child's development. If genital cutting is to take place, the best time to do so is when a child has reached adulthood and is healthy and strong enough to undergo the surgery by his/her own choosing.]

Related Reading: 

The Effect of Circumcision on Breastfeeding http://www.drmomma.org/2009/12/effects-of-circumcision-on.html 

Breastfeeding and Circumcision [DrMomma] http://www.drmomma.org/2009/11/breastfeeding-circumcision.html 

Circumcision Increases Breastfeeding Complications http://www.drmomma.org/2009/11/circumcision-leads-to-breastfeeding.html

Circumcision and Breastfeeding [Circumstitions] http://www.circumstitions.com/Nursing.html 

Circumcision, Breastfeeding and Bonding [CIRP] http://www.cirp.org/library/birth

Circumcision and Breastfeeding [The Milk Mama] http://themilkmama.com/2011/05/03/circumcision-and-breastfeeding

The Big Breastfeeding Coverup: Circumcision Censorship http://lifesasaladbar.blogspot.com/2011/06/big-breastfeeding-cover-up-circumcision.html

Books, Boobies and Big Business http://lifesasaladbar.blogspot.com/2012/03/llli-books-boobies-and-big-business.html

LLLI Breastfeeding / Circumcision Information Petition http://www.petitiononline.com/170211FM/petition.html

Circumcision Harms Breastfeeding advocacy shirt https://www.facebook.com/photo.php?fbid=427229633958631&set=a.196873073660956.55556.196862966995300

Breastfeeding/Circumcision Meme: http://www.facebook.com/photo.php?fbid=403941822958278&set=a.324857987533329.82696.166998263319303

Breastfeeding Resource Page http://www.drmomma.org/2009/08/books-for-breastfeeding-mother.html

Circumcision Resource Page http://www.drmomma.org/2010/01/are-you-fully-informed.html

Anna Lahr, CLC, Director of PPN Oahu and Co-Director of Intact Hawaii, shares a moment with her little one while wearing a 'Circumcision Harms Breastfeeding' shirt from Made By Momma. Lahr recently presented information on circumcision at Hawaii's large New Baby Expo event, which garnered the encouragement of Dr. William Sears, M.D. 

Info cards available at Etsy: