Scene 1: Two fathers encounter each other at a Boy Scout meeting. After a little conversation, one reveals that his son won’t be playing football because of concerns about head injuries. The other father reveals that he and his son love football, that they spoke with their pediatrician about it, and that their son will continue with football at least into middle school. There’s a bit of wary nodding, and then, back to the Pinewood Derby.
Scene 2: Two mothers meet on a playground. After a little conversation about their toddlers, one mother mentions that she still breastfeeds and practices “attachment parenting,” which is why she has a sling sitting next to her. The other mother mentions that she practiced “cry it out” with her children but that they seem to be doing well and are good sleepers. Then one of the toddlers begins to cry, obviously hurt in some way, and both mothers rush over together to offer assistance.
Scene 3: In the evening, one of these parents might say to a partner, “Can you believe that they’re going to let him play football?” or “I can’t believe they’re still breastfeeding when she’s three!” Sure. They might “judge” or think that’s something that they, as parents, would never do.
But which ones are actually involved in a war?
War. What is it good for?
I can’t answer that question, but I can tell you the definition of ‘war’: “a state of armed conflict between different nations or states or different groups within a nation or state.” Based on this definition and persistent headlines about “Mommy Wars,” you might conclude that a visit to your local playground or a mom’s group outing might require decking yourself out cap-á-pie in Kevlar. But the reality on the ground is different. There is no war. Calling disputes and criticisms and judgments about how other people live “war” is like calling a rowboat on a pond the Titanic. One involves lots of energy release just to navigate relatively placid waters while the other involved a tremendous loss of life in a rough and frigid sea. Big difference.
I’m sure many mothers can attest to the following: You have friends who also are mothers. I bet that for most of us, those friends represent a spectrum of attitudes about parenting, education, religion, Fifty Shades of Grey, recycling, diet, discipline, Oprah, and more. They also probably don’t all dress just like you, talk just like you, have the same level of education as you, same employment, same ambitions, same hair, or same toothpaste. And I bet that for many of us, in our interactions with our friends, we have found ourselves judging everything from why she insists on wearing those shoes to why she lets little Timmy eat Pop Tarts. Yet, despite all of this mental observation and, yes, judging, we still manage to get along, go out to dinner together, meet at one another’s homes, and gab our heads off during play dates.
That’s not a war. That’s life. It’s using our brains as shaped by our cultural understanding and education and rejection or acceptance of things from our own upbringing and talks with medical practitioners and books we’ve read and television shows we’ve watched and, for some of us, Oprah. Not one single friend I have is a cookie cutter representation of me or how I parent. Yet, we are not at war. We are friends. Just because people go online and lay out in black and white the critiques that are in their heads doesn’t mean “war” is afoot. It means expressing the natural human instinct to criticize others in a way that we think argues for Our Way of Doing Things. Online fighting is keeping up with the virtual Joneses. In real life, we are friends with the Joneses, and everyone tacitly understands what’s off limits within the boundaries of that friendship. That’s not war. It’s friendly détente.
The reality doesn’t stop the news media from trying to foment wars, rebellions, and full-on revolutions with provocative online “debates” and, lately, magazine covers. The most recent, from Time, features a slender mother, hand on cocked hip, challenging you with her eyes as she nurses her almost-four-year-old son while he stands on a chair. As Time likely intended, the cover caused an uproar. We’ve lampooned it ourselves (see above).
But the question the cover asks in all caps, “Are you mom enough?” is even more manipulative than the cover because it strikes at the heart of all those unspoken criticisms we think–we know–other women have in their heads about our parenting. What we may not consider is that we, too, are doing the same, and still… we are not actually at war. We’re just women, judging ourselves and other women, just like we’ve done since the dawn of time. It’s called “using your brain.” Inflating our interactions and fairly easily achieved parental philosophy détentes to “war” caricatures us all as shrieking harpies, incapable of backing off and being reasonable.
The real question to ask isn’t “Are you mom enough?” In fact, it’s an empty question because there is no answer. Your parenting may be the most perfect replica of motherhood since the Madonna (the first one), yet you have no idea how that will manifest down the road in terms of who your child is or what your child does. Whether you’re a Grizzly or a Tiger or a Kangaroo or a Panda mother, there is no “enough.”
So, instead of asking you “Are you mom enough?”, in keeping with our goal of bringing women evidence-based science, we’ve looked at some of the research describing what might make a successful parent–child relationship. Yes, the answer is about attachment, but not necessarily of the physical kind. So drop your guilt. Read this when you have time. Meanwhile, do your best to connect with your child, understand your child, and respond appropriately to your child.
Why? Because that is what attachment is–the basic biological response to a child’s needs. If you’re not a nomad or someone constantly on the move, research suggests that the whole “physically attached to me” thing isn’t really a necessary manifestation of attachment. If you harken to it and your child enjoys it (mine did not) and it works for you without seeming like, well, an albatross around your neck, go for it.
What is attachment?
While attachment as a biological norm among primates has been around as long as primates themselves, humans are more complicated than most primates. We have theories. Attachment theory arose from the observations of a couple of human behaviorists or psychologists (depending on whom you ask), John Bowlby and Mary Ainsworth. Bowlby derived the concept of attachment theory, in which an infant homes in on an attachment figure as a “safe place.” The attachment figure, usually a parent, is the person who responds and is sensitive to the infant’s needs and social overtures. That parent is typically the mother, and disruption of this relationship can have, as most of us probably instinctively know, negative effects.
Bowlby’s early approach involved the mother’s having an understanding of the formational experiences of her own childhood and then translating that to an understanding of her child. He even found that when he talked with parents about their own childhoods in front of their children, the result would be clinical breakthroughs for his patients. As he wrote,
Having once been helped to recognize and recapture the feelings which she herself had as a child and to find that they are accepted tolerantly and understandingly, a mother will become increasingly sympathetic and tolerant toward the same things in her child.
Later studies seem to bear out this observation of a connection to one’s childhood experiences and more connected parenting. For example, mothers who are “insightful” about their children, who seek to understand the motivations of their children’s behavior, positively influence both their own sensitivity and the security of their infant’s attachment to them.
While Bowlby’s research focused initially on the effects of absolute separation between mother and child, Mary Ainsworth, an eventual colleague of Bowlby, took these ideas of the need for maternal input a step further. Her work suggested to her that young children live in a world of dual and competing urges: to feel safe and to be independent. An attachment figure, a safe person, is for children an anchor that keeps them from become unmoored even as they explore the unknown waters of life. Without that security backing them up, a child can feel always unmoored and directionless, with no one to trust for security.
Although he was considered an anti-Freudian rebel, Bowlby had a penchant for Freudian language like “superego” and referred to the mother as the “psychic organizer.” Yet his conclusions about the mother–child bond resonate with their plain language:
The infant and young child should experience a warm, intimate, and continuous relationship with his mother (or permanent mother substitute) in which both find satisfaction and enjoyment.
You know, normal biological stuff. As a side note, he was intrigued by the fact that social bonds between mother and offspring in some species weren’t necessarily tied to feeding, an observation worth keeping in mind if you have concerns about not being able to breastfeed.
The big shift here in talking about the mother–child relationship was that Bowlby was proposing that this connection wasn’t some Freudian libidinous communion between mother and child but instead a healthy foundation of a trust relationship that could healthily continue into the child’s adulthood.
Ainsworth carried these ideas to specifics, noting in the course of her observations of various groups how valuable a mother’s sensitivity to her child’s behaviors were in establishing attachment. In her most famous study, the “Baltimore study” [PDF], she monitored 26 families with new babies. She found that “maternal responsiveness” in the context of crying, feeding, playing, and reciprocating seemed to have a powerful influence on how much a baby cried in later months, although some later studies dispute specific influences on crying frequencies.
Ainsworth also introduced the “Strange Situation” lab test, which seems to have freaked people out when it first entered the research scene. In this test, over the course of 20 minutes, a one-year-old baby is in a room full toys, first with its mother, then with mother and a strange woman, then with the stranger only (briefly), then with the mother, and then alone before the stranger and then the mother return. The most interesting findings of the study came from when the mother returned after her first absence, having left the baby alone in the room with a stranger. Some babies seemed quite angry, wanting to be with their mothers but expressing unhappiness with her at the same time and physically rejecting her.
From her observations during the Strange Situation, Ainsworth identified three types of attachment. The first was “Secure,” which, as its name implies, suggested an infant secure and comfortable with an attachment figure, a person with whom the infant actively seeks to interact. Then there’s the insecure–avoidant attachment type, in which an infant clearly is not interested in being near or interacting with the attachment figure. Most complex seems to be the insecure–resistant type, and the ambivalence of the term reflects the disconnected behavior the infant shows, seeming to want to be near the attachment figure but also resisting, as some of the unhappy infants described above behaved in the Strange Situation.
Within these types are now embedded various subtypes, including a disorganized–disoriented type in which the infant shows “odd” and chaotic behavior that seems to have no distinct pattern related to the attachment figure.
As you read this, you may be wondering, “What kind of attachment do my child and I have?” If you’re sciencey, you may fleetingly even have pondered conducting your own Strange Situation en famille to see what your child does. I understand the impulse. But let’s read on.
What are the benefits of attachment?
Mothers who are sensitive to their children’s cues and respond in ways that are mutually satisfactory to both parties may be doing their children a lifetime of favors, in addition to the parental benefit of a possibly less-likely-to-cry child. For example, a study of almost 1300 families looked at levels of cortisol, the “stress” hormone, in six-month-old infants and its association with maternal sensitivity to cues and found lower levels in infants who had “more sensitive” mothers.
Our understanding of attachment and its importance to infant development can help in other contexts. We can apply this understanding to, for example, help adolescent mothers establish the “secure” level of attachment with their infants. It’s also possibly useful in helping women who are battling substance abuse to still establish a secure attachment with their children.
On a more individual level, it might help in other ways. For example, if you want your child to show less resistance during “clean-up” activities, establishing “secure attachment” may be your ticket to a better-looking playroom.
More seriously, another study has found that even the way a mother applies sensitivity can be relevant. Using the beautiful-if-technical term ‘dyads’ to refer to the mother–child pair, this study included maternal reports of infant temperament and observations of maternal sensitivity to both infant distress and “non-distress.” Further, the authors assessed the children behaviorally at ages 24 and 36 months for social competence, behavioral problems, and typicality of emotional expression. They found that a mother’s sensitivity to an infant’s distress behaviors was linked to fewer behavioral problems and greater social competence in toddlerhood. Even more intriguing, the child’s temperament played a role: for “temperamentally reactive” infants, a mother’s sensitivity to distress was linked to less dysregulation of the child’s emotional expression in toddlerhood.
And that takes me to the child, the partner in the “dyad”
You’re not the only person involved in attachment. As these studies frequently note, you are involved in a “dyad.” The other member of that dyad is the child. As much as we’d like to think that we can lock down various aspects of temperament or expression simply by forcing it with our totally excellent attachment skills, the child in your dyad is a person, too, who arrived with a bit of baggage of her own.
And like the study described above, the child’s temperament is a key player in the outcome of the attachment tango. Another study noted that multiple factors influence “attachment quality.” Yes, maternal sensitivity is one, but a child’s native coping behaviors and temperament also seem to be involved. So, there you have it. If you’re feeling like a parental failure, science suggests you can quietly lay at least some of the blame on the Other in your dyad–your child. Or, you could acknowledge that we’re all human and this is just part of our learning experience together.
What does attachment look like, anyway?
Dr. William Sears took the concept of attachment and its association with maternal sensitivity to a child’s cues and security and… wrote a book that literally translated attachment as a physical as well as emotional connection. This extension of attachment–which Sears appends to every aspect of parenting, from pregnancy to feeding to sleeping–has become in the minds of some parents a prescriptive way of doing things with benefits that exclude all other parenting approaches or “philosophies.” It also involves the concept of “baby wearing,” which always brings up strange images in my mind and certainly takes outré fashion to a whole new level. In reality, it’s just a way people have carried babies for a long time in the absence of other easy modes of transport.
When I was pregnant with our first child and still blissfully ignorant about how little control parents have over anything, I read Sears’ book about attachment parenting. Some of it is common-sense, broadly applicable parenting advice: respond to your child’s needs. Some of it is simply downright impossible for some parent–child dyads, and much of it is based on the presumption that human infants in general will benefit from a one-size-fits-all sling of attachment parenting, although interpretations of the starry-eyed faithful emphasize that more than Sears does.
Because much of what Sears wrote resonated with me, we did some chimeric version of attachment parenting–or, we tried. The thing is, as I noted above, the infant has some say in these things as well. Our oldest child, who is autistic, was highly resistant to being physically attached much of the time. He didn’t want to sleep with us past age four months, and he showed little interest in aspects of attachment parenting like “nurturing touch,” which to him was seemingly more akin to “taser touch.” We ultimately had three sons, and in the end, they all preferred to sleep alone, each at an earlier and earlier age. The first two self-weaned before age one because apparently, the distractions of the sensory world around them were far more interesting than the same boring old boob they kept seeing immediately in front of their faces. Our third was unable to breastfeed at all.
So, like all parents do, we punted, in spite of our best laid plans and intentions. Our hybrid of “attachment parenting” could better be translated into “sensitivity parenting,” because our primary focus, as we punted and punted and punted our way through the years, was shifting our responses based on what our children seemed to need and what motivated their behaviors. Thus, while our oldest declined to sleep with us according to the attachment parenting commandment, he got to sleep with a boiled egg because that’s what he wanted. Try to beat that, folks, and sure, bring on the judging.
The Double X Science Sensitivity Parenting (TM) cheat sheet.
What does “sensitive” mean?
And finally, the nitty-gritty bullet list you’ve been waiting for. If attachment doesn’t mean slinging your child to your body until you’re lumbar gives out or the child receives a high-school diploma, and parenting is, indeed, one compromise after another based on the exigencies of the moment, what consistent tenets can you practice that meet the now 60-year-old concept of “secure” attachment between mother and child, father and child, or mother or father figure and child? We are Double X Science, here to bring you evidence-based information, and that means lists. The below list is an aggregate of various research findings we’ve identified that seem reasonable and reasonably supported. We’ve also provided our usual handy quick guide for parents in a hurry.
Plan ahead. We know that life is what happens while you’re planning things, but… life does happen, and plans can at least serve as a loose guide to navigation. So, plan that you will be a parent who is sensitive to your child’s needs and will work to recognize them.
Practice emotion detection. Work on that. It doesn’t come easily to everyone because the past is prologue to what we’re capable of in the present. Ask yourself deliberately what your child’s emotion is communicating because behavior is communication. Be the grownup, even if sometimes, the wailing makes you want your mommy. As one study I found notes, “Crying is an aversive behavior.” Yes, maybe it makes you want to cover your ears and run away screaming. But you’re the grownup with the analytical tools at hand to ask “Why” and seek the answer.
Have infant-oriented goals. If you tend to orient your goals in your parent–child dyad toward a child-related benefit (relieve distress) rather than toward a parent-oriented goal (fitting your schedule in some way), research suggests that your dyad will be a much calmer and better mutually adapted dyad.
Trust yourself and keep trying. If your efforts to read your child’s feelings or respond to your child’s needs don’t work right away, don’t give up, don’t read Time magazine covers, and don’t listen to that little voice in your head saying you’re a bad parent or the voice in other people’s heads screaming that at you. Just keep trying. It’s all any of us can do, and we’re all going to screw this up here and there.
Practice behaviors that are supportive of an infant’s sensory needs. For example, positive inputs like a warm voice and smiling are considered more effective than a harsh voice or being physically intrusive. Put yourself in your child’s place and ask, How would that feel? That’s called empathy.
Engage in reciprocation. Imitating back your infant’s voice or faces, or showing joint attention–all forms of joint engagement–are ways of telling an infant or young child that yes, you are the anchor here, the one to trust, and really good time, to boot. Allowing this type of attention to persist as long as the infant chooses rather than shifting away from it quickly is associated with making the child comfortable with independence and learning to regulate behaviors.
Talk to your child. We are generally a chatty species, but we also need to learn to chat. “Rich language input” is important in early child development beginning with that early imitation of your infant’s vocalizations.
Lather, rinse, repeat, adjusting dosage as necessary based on age, weight, developmental status, nanosecond-rate changes in family dynamics and emotional conditions, the teen years, and whether or not you have access to chocolate. See? This stuff is easy.
As you read these lists and about research on attachment, you’ll see words like “secure” and “warm” and “intimate” and “safe.” Are you doing this for your child or doing your best to do it? Then you are, indeed, mom enough, whether you wear your baby or those shoes or both. That doesn’t mean that when you tell other women the specifics of your parenting tactics, they won’t secretly be criticizing you. Sure, we’ll all do that. And then a toddler will cry, we’ll drop it, and move on to mutually compatible things.
Yes, if we’re being honest, it makes most of us feel better to think that somehow, in some way, we’re kicking someone else’s ass in the parenting department. Unfortunately for that lowly human instinct, we’re all parenting unique individuals, and while we may indeed kick ass uniquely for them, our techniques simply won’t extend to all other children. It’s not a war. It’s human… humans raising other humans. Not one thing we do, one philosophy we follow, will guarantee the outcome we intend. We don’t even need science, for once, to tell us that.
A few days ago, I received an email from my friend HelenJonsen about a fundraising effort that is very near and dear to her heart. Helen and her family are volunteering for the 3rdAnnual Hope & Heroes Walk to show their support for the clinic that helped her own daughter, in her journey with cancer. Taking place on April 29th, 2012 in Manhattan’s Clinton Cove Park, this fundraiser is to help ensure that the unique clinical care programs and cutting edge research funded by Hope & Heroes will continue.
Specifically associated with Columbia University’s Herbert Irving Child & Adolescent Oncology Center, Hope & Heroes boasts the ultimate NY start. In 1997, Beth, a teenage Hodgkin’s Disease patient, decided to write the then NY Yankees first baseman, Tino Martinez. Tino responded to Beth’s letter and invited her watch the Yankees during their spring training. Tino and Beth “hit” it off, and their friendship inspired Tino to become more proactive in the lives of other young cancer patients by pledging a donation for every RBI he made. The NY sports scene quickly caught wind of this, and a local sportswriter, Mike Lupica, dubbed this effort “Hope and Heroes.”
While the cancer center had been accepting donations for the purpose of supporting the innovative programs started by its director, Dr. Michael Weiner, the effort had finally been given a name. But, it wasn’t until 2002 when Hope & Heroes filed for a 501(c)(3), giving this charity an official stamp.
According to Jeremy Shatan, the acting Executive Director of Hope & Heroes, the clinic sees about 100-150 new patients each year and about 5,000 – 7,000 total patient visits. This number includes patients who are currently receiving treatment as well as those who have recovered but are still being monitored.
The money donated to Hope & Heroes Children’s Cancer Fund is used, in part, to finance many special programsthat would otherwise be impossible. Benefitting both the young patients and their families, these programs include the use of complementary medicine folded in to an often harsh regimen of surgery, chemotherapy, and/or radiation. In addition, Hope & Heroes also helps to provide emotional counseling to those in need, as well as allow these young cancer patients to participate in translational research studies, which opens the possibility for novel treatments.
The Hope & Heroes Children’s Cancer Fund has forged a permanent place in the hearts of many, including Helen and her family. We at Double X Science find this effort to beyond a “good deed.” Please show support for this organization by donating. Because you never know when a kid will need it.
To donate to the 3rd Annual Hope & Heroes Walk, go here.
How can chili powder kill a child? Dr. Rubidium explains. by Dr. Rubidium, Ph.D., DXS contributor
On the evening of Sunday, January 6th, 2-year-old Joileen G. was pronounced dead at a San Bernardino hospital. A few hours into Monday, Joileen’s caregiver for that Sunday — Amanda Sorensen — was arrested. On Wednesday, Ms. Sorensen, who is also the girlfriend of Joileen’s father, was charged with “…malice aforethought murder…” and “…assault… by means of force that to a reasonable person would be likely to produce bodily injury, resulting in the child’s death.” The alleged “means of force” wasn’t a belt or a fist, but chili powder.
Though it will likely take weeks before the exact cause and manner of death are known from an autopsy and toxicology tests, various media outlets are reporting that Joileen died of “chili powder poisoning.”
Millions to billions of people enjoy chili peppers world-wide each day, from eating handfuls of whole chili peppers to a few shakes of hot sauce on their eggs. Chili peppers and their products aren’t considered a poison, but that’s because most of us have far too narrow a view of poisons. The field of poisons is actually very broad, as are its definitions.
For example, for toxicologists, a poison is any substance that is harmful when administered to a living organism. But quantity (dose) and species (you versus, say, a turtle) and route (mouth? skin?) and what it’s combined with count, too. Other factors influencing whether or not something will poison you include age, sex, health, and genetics
An infant girl suffering from pertussis, a vaccine-preventable disease, struggles to breathe. Those indentations in her ribs are one of the signs of her extreme difficulty drawing breath. Via CDC.
What’s not to fear directly about vaccines? There’s a needle that someone pokes into your child. Your child screams. You tense up. What’s in there? you wonder. Viral or bacterial bits that, in ways that are mysterious to a non-immunologist, will keep your child well when intuition seems to say they ought to make your child sick.
Needles, screaming, microbial bits…these naturally would make any parent blanch. The number of vaccines has added to the fear for at least a decade, leading to non–evidence-based calls to “spread out” the schedule or reduce the number of vaccinations.
In fact, the evidence supports the schedule as it’s recommended.
The fear of vaccination is not new. Since Edward Jenner and his cowpox inoculation at the turn of the 19th century, people have latched onto the fear of the known—those needles!—and unknown—what’s in those things?
What might be considered the first anti-vaccine cartoon appeared in response to Jenner’s proposed inoculation of cowpox to combat smallpox.
The vision of cows growing out of arms is comical, but the reality of possible side effects from today’s vaccines can lead some parents to keep their children away from the doctor’s office. Indeed, this anxiety has done so since the days of the 19th century anti-vaccination leagues, aligned against the widespread use of Jenner’s smallpox vaccine.
The vaccine wars in those days were just as bitter and divisive as they are today, including an 1885 march in England in which anti-vaccination forces carried a child’s coffin and an effigy of Jenner himself. Today’s most fanatical crusaders against vaccines may not carry coffins or effigies, but death threats against those who promote vaccines for public health are not unknown.
The fact that the vast majority of parents overcame those fears and had their children vaccinated has led to some of the greatest public health successes of the 20th century. Thanks to the willingness of people to participate in vaccination programs, smallpox disappeared and polio became a thing of the past in much of the world. Indeed, people in those eras knew, often from personal experience, what these diseases could do—maim and kill—and the fear of those very real outcomes outweighed fears of the vaccinations.
But today, we’re different. In the United States, most of us under a certain age have never witnessed a death from diphtheria or tetanus or smallpox or measles. We haven’t seen a child drained of life as a rotavirus rapidly depletes the molecules she needs to live. Many of us have not witnessed the sounds of pertussis, the vomiting, the exploding lungs in an agony of infant death. Why? Because of vaccines.
This very success has, ironically, led to the resurgence of fear and misgiving about vaccines. No longer weighed against anxiety of death or disability from disease, the fear of vaccines now aligns against the bright picture of a nation of children largely free of life-threatening illness.
Without the collective memory of days when children played on the playground one day and died the next of vaccine-preventable disease, the calculus of parental fear pits only the side effects of vaccines against the healthy child. Vaccination requires intentional agency—parental agreement—to impose on that healthy child the very small risk that vaccines carry. Some parents simply are not comfortable either with that intentionality or that risk.
Feeding this reluctance is the explosion of Internet sites that warn against vaccines or disseminate incorrect information about them. The Centers for Disease Control and Prevention (CDC) has provided abundant information about vaccines, including a page devoted to countering erroneous information with facts.
This information will not move the fiercest anti-vaccine groups that lump the CDC in with pharmaceutical companies and others in an alleged conspiracy to harm millions via a money-making vaccine industry. However, it certainly helps concerned parents who simply seek to calm fears, weigh evidence, and make an informed decision about choosing vaccines over the life-threatening illness and compromised public health that result when people don’t vaccinate.
Indeed, these threats to public health have grown considerably with recent large outbreaks of measles and pertussis, including a growing measles outbreak in Europe involving more than 26,000 cases of measles, more than 7000 hospitalizations, and nine deaths as of this writing. The growing threat has led to calls for more stringent requirements for childhood vaccines, including dropping exemptions and requiring that all children be vaccinated over parental objections. This tactic likely would increase vaccination rates among children attending school.
But instead of strong-arming parents into having their children vaccinated, what we really need is a two-fold approach to education. First, we need sober, non-sensationalist reporting from the news media about vaccine-related stories, including stories about side effects, research, and court cases. These articles—and their sensational headlines—are in all likelihood among the prime drivers of the rumor mill against vaccines.
Second, when parents read these stories and turn to a medical professional for input, that input must come as part of a two-way communication between the health professional and the parent, not in lecture format or as patronizing. A little, “I understand your concerns because I’ve had them, too, but here’s what I know that gives me confidence in vaccines,” is considerably better than, “Your child has to be vaccinated, or you can get out of my office.” The onus is on parents to ask with open minds and an understanding that the medical professional in front of them has likely devoted considerable time to gaining the education and expertise necessary to address their questions. Health care isn’t a competition about who knows more. It’s about evidence-based health practices.
As centuries of history attest, no efforts will completely eradicate vaccine fears. Motivations fueling anti-vaccine sentiment that go beyond information gaps range from personal economic benefit to a desire to out-expert the experts to the inertia of fear.
But a careful and persistent information campaign and outreach efforts from medical professionals in the trenches may help keep vaccination rates sufficiently high. Parental investment in gaining information from trained professionals and making decisions based on facts rather than fear is also an indispensable component. To ensure adequate rates requires either these efforts or a resurgence of the deadly diseases that have graphically demonstrated the real balance of the threats at issue here.
Which one would we rather have?
Emily Willingham, Double X Science Editor Twitter, @ejwillingham ———————————————————————— A version of this post originally appeared on the blog of PKIDs, Parents of Kids with Infectious Diseases. The mission of PKIDs includes educating the public about infectious diseases and methods of prevention and transmission. Follow PKIDs on Twitter @PKIDs.
“You wanna do WHAT?!” Photo courtesy of Justyna Furmanczyk at sxc.hu.
By Tara Haelle, DXS contributor
[Tara Haelle (www.tarahaelle.com) is a health and science writer and a photojournalist based in Peoria, IL after years as a Texan, where she earned her undergraduate degrees and MA in journalism at UT-Austin. She’s the mental health editor for dailyRx.com in addition to reporting on pediatrics, vaccines, sleep, parenting, prenatal care and obesity. This post first appeared on her blog, Red Wine & Apple Sauce focuses on health and science news for moms (www.redwineandapplesauce.com), and you can follow her on Twitter at @health_reporter and @tarasue. She’s also swum with 9 different species of sharks, climbed Kilimanjaro and backpacked in over 40 countries, but that was in the years of B.C. (Before Children). She finds that two-year-olds are tougher to tussle with than tiger sharks.]
I am grateful that their statement was issued with the sensitivity and caution needed for such a controversial practice and decision. Some of the headlines have been frustrating, implying that the AAP said “Circumcision is better.” Um, no. That’s not what they said. They said that the “preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure.” (To be fair, most headlines basically ran with “benefits trump risks” or some variation thereof.)
In other words, if you choose to do this procedure, the benefits you will gain are greater than the risks involved in the procedure. This is very different from saying “It’s better to be circumcised.” In fact, their policy explicitly points out that they do not officially “recommend” the procedure routinely: “Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns.” (That last part just means yes, insurance companies, you should pay for it.)
An analogy: A child with obstructive sleep apnea can have a tonsillectomy/adenoidectomy (called an adenotonsillectomy) to remove their tonsils and adenoids for treatment. The tonsils and adenoids (lumps of issue behind the nose) generally cause the blockage that interferes with a child’s breathing while asleep, so removing them can usually cure the sleep apnea (in 75 to 100 percent of the cases).
There are risks to adenotonsillectomy, namely infection and excessive bleeding. There are risks to sleep apnea, including obesity, heart disease, diabetes, depression and death. For a child with obstructive sleep apnea, the benefits generally outweigh the risks of the procedure. A parent can still elect not to give their child the surgery.
Is it better for the child with sleep apnea to have the surgery? Probably. But perhaps not. It depends on the situation and the child. Is it better for a child without obstructive sleep apnea to have the surgery? Of course not. Why take any risk when there’s no benefit?
Now consider the two primary benefits conferred by circumcision: lower risk of urinary tract infections during the first year and reduced risk of HIV and a several other sexually transmitted infections during heterosexual sex. The risks of circumcision are most commonly bleeding, infection or the wrong amount of tissue snipped off, and this happens in about 1 of every 500 newborn boys (0.2 percent). Other studies found the rates higher, up to 2 to 3 percent, but these complications were still just minor bleeding. They even offered a comparison of a similar surgery as the one I discussed above: complications involving severe bleeding from tonsillectomies occur about 1.9 percent of the time in kids age 4 and under.
For parents with wild imaginations about horror stories, fear not: “The majority of severe or even catastrophic injuries are so infrequent as to be reported as case reports (and were therefore excluded from this literature review). These rare complications include glans or penile amputation, transmission of herpes simplex after mouth-to-penis contact by a mohel (Jewish ritual circumcisers) after circumcision, methicillin-resistant Staphylococcus aureus infection, urethral cutaneous fistula, glans ischemia and death.” Basically, yea, there’s a bunch of really bad stuff that can happen, but it’s really, really, really, really rare. Probably rarer than being struck by lightning. Twice. But that happens too.
So, the risks are pretty low. How beneficial are the benefits? Here’s a condensed run-down from the AAP’s technical report:
Circumcision reduces the odds of contracting HIV during male-female sex by 40 to 60 percent… in Africa. When the CDC calculated that figure with the rate of contracting HIV by heterosexual sex in the U.S., they came up with a 15.7 percent reduction here. It’s something, but nowhere near as good as a condom. Plus, if your kids turns out to be gay, there’s not much evidence that circumcision helps him avoid contracting HIV. (And on the other side of the coin, circumcision can make it a little easier for women to contract HIV from a man, per one study cited in the AAP review.)
Circumcised men are about 30 to 40 percent less likely to get any type of human papillomavirus (HPV), including both the relatively harmless strains and the ones that can lead to cervical cancer or raise your risk of cancer of the mouth, throat, penis and anus. Now, the CDC has recommended that boys get the HPV vaccine, but the vaccines available do not cover all the strains. Gardasil takes care of four of them, including the two responsible for about 70 percent of cervical cancer (HPV-16 and HPV-18) and the two responsible for 90 percent of genital warts. Cervarix only takes care of HPV-16 and HPV-18. So, circumcision would offer some protection against getting the HPV strains that the vaccines don’t cover, most of which — but not all — are not linked to cancer or warts.
There’s some evidence that circumcision reduces risk of herpes (HSV-2) by about 28 to 34 percent, based on two studies in Africa.
Evidence for protection against syphilis is weak. There’s no evidence that circumcision decreases the risk of contracting gonorrhea or chlamydia.
There’s good evidence that uncircumcised boys get more urinary tract infections that circumcised boys, in part because bacteria can hang out in that moist area under the hood. The AAP estimates that 7 to 14 of every 1,000 uncircumcised boys will get a UTI before their first birthday, compared to 1 to 2 out of 1,000 circumcised boys. With such a low rate overall, in either population, the AAP notes that “the benefits of male circumcision are, therefore, likely to be greater in boys at higher risk of UTI, such as male infants with underlying anatomic defects such as reflux or recurrent UTIs.” (These are mostly the boys that get UTIs anyway.)
So, those are definitely some benefits to circumcision, especially if your little guy will have sex one day (which, presumably, you want him to do at some point in the far off, I-don’t-want-to-think-about-it future). It’s also fair to say that good sex education and condom use would make those benefits almost moot (not the UTIs, which are pretty low risk, and not all HPV strains, which sometimes infect even with condom use).
In any case, these two benefits, a lower risk for UTIs and some STIs, then become the risks of not being circumcised. The former is — usually — not very serious. There are some very serious urinary tract infections, and untreated ones can damage the kidneys. And they’re certainly not fun. They aren’t, however, usually life or death situations. HIV (somewhat still) is. Of course, boys are still at a pretty high risk for getting HIV if they sleep with someone who has it and don’t use a condom, circumcised or not. But every bit of protection helps, right?
Unless it requires lopping off part of a little boy’s penis. There. I said it. Because that’s what many parents are simply uneasy about, regardless of the health benefits, which are great or marginal, depending on your perspective. And that’s why the AAP stopped short of recommending circumcision as a routine procedure.
They did include in their review several studies related to sexual satisfaction and sensitivity, one of the complaints that “intactivists” bring up. The AAP summarizes it pretty nicely: “The literature review does not support the belief that male circumcision adversely affects penile sexual function or sensitivity, or sexual satisfaction, regardless of how these factors are defined.”
But it’s not possible to take into consideration, in scientific, mathematical terms, the primary complaint of those who oppose circumcision, which is that the man these little boys become may have wanted that little flap over the tip. And this is one of those gray areas that give parents pause. Once you cut that hood, you can’t put it back. How many circumcised men regret what their parents did? Well, probably not vast numbers, or circumcision rates would have plummeted.
So, this is where we end up. There are some decent benefits. There are very few and mostly minor risks to the procedure. And there’s big, giant, gray unknown area of “what if’s” and “could have been’s” for the boys who get snipped. It’s disingenuous to compare the practice to female circumcision, as some do, since neither its intent nor its effect is to influence sexual satisfaction. But whether it’s the right thing to do…? The AAP says it’s up to mom and dad. (Which, in many households, like mine, probably means mostly dad.)
“Parents ultimately should decide whether circumcision is in the best interests of their male child,” they wrote. “They will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices. The medical benefits alone may not outweigh these other considerations for individual families.”
What are those other considerations? Well, whether you want your little guy to have a foreskin. Or, whether you don’t know if he does or doesn’t want it and figure he should decide that in 18 years. Maybe daddy’s not circumcised and you both want him to look like daddy. (I know many people who circumcised for this reason alone.)
About the only certain thing that can be said about circumcision, based on the AAP’s policy statement and research and what we know about opposition to the practice, is that this controversy will be with us for years to come.
The opinions in this post do not necessarily reflect or disagree with the opinion of the DXS editorial team.