Letter 88-89 Response

American Academy of Pediatrics Releases – Neutral Statement on Infant Circumcision

Peaceful Beginnings’ Response:
by Rosemary Romberg

In the summer of 1988 in concern over the American Academy s pending re-evaluation of their position on routine infant circumcision I sent a detailed letter to each AAP member outlining many important concerns surrounding the issue. With this letter each member was also sent a xeroxed copy of the chapter on complications from my book Circumcision: The Painful Dilemma, a copy of my information sheet on the care of the infant foreskin and a short medical article which noted higher rates of urinary tract infections among circumcised newborns. This material was also sent to each member of Peaceful beginnings Medical and Professional Advisory Board and to a large number of other concerned individuals. One hardcover copy of my book Circumcision: The Painful Dilemma was also sent to the AAP.

Peaceful Beginnings received no response from any of the AAP members. Apparently they have also refused communication with all other groups and individuals who share our concern. When Peaceful Beginnings’ Fall 1988 newsletter was sent out shortly thereafter one AAP member requested removal from our mailing list. Whether or not any of my or anyone else’s likeminded material was read or heeded by any AAP member is unknown.

We contend that all members of the medical profession should work openly directly and intelligently with all concerned members of the lay public on this and all health related matters. Possession of a medical degree does not confer exclusive ability to study and evaluate scientific data. Medical snobbery and elitism serve no one.

While Peaceful beginnings considers the AAP’s conclusions disappointingly neutral and omissive in many respects, we do applaud their honesty in defining the inherent risks of infant circumcision and in reporting the inconclusive documentation in defense of the procedure.

We note that the Canadian Paediatric Society remained in firm opposition to infant circumcision after reviewing the same research data.

We are appalled by grotesque distortion and irresponsibility on the part of some members of the press who have injected ideas of their own which were not accurately representative of the AAP’s report, have falsely proclaimed in headlines that the AAP has “reversed its position” on circumcision and in other ways have untruthfully made the AAP’s verdict appear more pro-circumcision than it is.

While we recognize that the decision for or against circumcision must be made by parents in consultation with their physician, we are also concerned that circumcision oriented doctors may distort parents perception of what actually will be done to their infant if circumcised. Marilyn Milos RN of NOCIRC notes that doctors who are biased towards circumcision are influenced by four factors: (1) The doctor is circumcised. (2) The doctor has sons who are circumcised. (3) The doctor has performed circumcisions. (4) The doctor has colleagues who perform circumcisions.

Urinary Tract Infections

Reports suggesting higher incidence of urinary tract infections among intact infants was a major impetus for the AAP’s re-evaluation of its position on routine infant circumcision. Comments in their report include: “…studies in Army hospitals are retrospective in design and may have methodological flaws. For example they do not include all boys born in any single cohort or those treated as outpatients, so the study population may have been influenced by selection bias. … in the absence of well-designed prospective studies conclusions regarding the relationship of urinary tract infection to circumcision are tentative.”

To this we recommend for consideration: ( 1. ) The incidence of reported rates of urinary tract infections among intact infants was low (rates ranged between 1/1,000 to 1/25,000 in various reports.) ( 2.) Questionableness in methodology in collection of urine samples from infants. (3.) The apparent absence of reports of significant outbreaks of urinary tract infections among infants in other countries where circumcision is not practiced (4.) The relationship of urinary tract infections to other congenital problems unrelated to circumcision status. (5.) Ready treatability of urinary tract infections with antibiotics. (6.) Questionableness of destroying at least hundreds if not thousands of normal foreskins of healthy infants to possibly prevent one infection. (7.) The possibility of total or near total preventability of urinary tract infections among infants by leaving the foreskin entirely alone during the diaper wearing period.

(8.) A recent medical report published in The Lancet based on observations made in Sweden suggests that urinary tract infections in infants may be caused by infants being exposed to the “wrong germs” in centralized newborn nurseries in hospitals. In their words    “… it is suggested that the effects of one unphysiological intervention (i.e. circumcision) are counterbalancing those of another —i.e. colonization of the baby’s gastrointestinal tract and genitals in maternity units by Escherichia coli strains of non-maternal origin to which the baby has no passive immunity.” *

Their hypothesis, of course, will need further investigation, but those of us who support home birth and birth alternatives have for years contended that especially vigorous, resistant strains of bacteria which abound in hospital environments presented a strong argument against routine hospital birth and separation of mothers and babies.

The writers of this article propose that in lieu of circumcision to prevent uti’s, newborns should be routinely, intentionally colonized with their own mothers’ intestinal flora. Obviously, if birth takes place at home or in a “birthing center”, or if a practice of “total rooming in” is supported within hospitals, this too would eliminate any danger from alien germs in a central nursery environment.

*Winberg, Jan; Bollgren, Ingela; Gothefors, Leif; Herthelius, Maria; & Tuleus, Kjel
“The Prepuce A Mistake of Nature?”
The Lancet, March 18. 1989, p. 598.

(Ed. note: The Altschul studies which revealed extremely low rates of uti’s among infants came from Kaiser hospitals which are known to offer rooming in. The Wiswell studies which revealed much higher rates of uti’s among infants came from U.S. Army hospitals. Although the maternity arrangement of the Army hospitals is not described, it is known that some military hospitals do not offer rooming in.)

Cancer of the Penis

In the words of the AAP: “Circumcision has been shown, to decrease the incidence of cancer of the penis (a rare condition among U.S. males.) This condition occurs almost exclusively in uncircumcised men. Poor hygiene, lack of circumcision, and certain sexually transmitted diseases also correlate with the incidence of penile carcinoma.

    The decision not to circumcise a male infant must be accompanied by a lifetime commitment to genital hygiene to minimize the risk of developing penile cancer.”

Their conclusion on penile cancer remains virtually unchanged from their previous verdict reached in 1971 and 1974.

Omitted from the AAP report was mention of the extremely low rates of cancer of the penis (roughly 1/100,000 adult males in “developed” countries, between 1/10,000 and 1/30,000 adult males in “underdeveloped” countries. [The significant variable appears to be plumbing fixtures and living standards rather than circumcision status.]) Also omitted was mention of similarly low rates of penile cancer among non circumcising populations such as Canada, Russia, and most parts of Europe, to those in the U.S. with a largely circumcised male population. We also emphasize the questionableness of destroying thousands of healthy foreskins to possibly prevent one case of penile cancer in old age. (This data is listed in detail in my book Circumcision The Painful Dilemma.)

Cancer of the penis is preventable by normal bathing practices. This means reasonable standards of cleanliness which most parents expect of their offspring, regardless of circumcision. We are concerned that the AAP’s wording “lifetime commitment to genital hygiene” may sound unnecessarily complicated to the uninformed parent.

Sexually Transmitted Diseases

According to the AAP, “… evidence regarding the relationship of circumcision to sexually transmitted diseases is conflicting, although published reports suggest that chancroid, syphilis, human papillomavirus and herpes simplex virus type 2 infection are more frequent in uncircumcised men, methodologic problems render these reports inconclusive.”

We wish to point out that in previous decades circumcision was less frequent among the lower socioeconomic classes, which may in turn have been associated with less attention to personal cleanliness and higher rates of sexual promiscuity. Today’s continually rising rates of all types of sexually transmitted diseases in the US, despite our largely circumcised male population strongly suggest that lack of foreskin offers little or no deterrent to acquiring sexually transmitted disease. Of additional concern is that unwarranted speculations promoting circumcision as a preventative for STD may mislead some circumcised males into a false sense of security, thereby failing to take other precautions or alter their lifestyles. (Hence indirectly contributing to an increase in the rates of STD.)

Cervical Cancer

According to the AAP: “Evidence linking uncircumcised men to cervical carcinoma is also inconclusive. … The strongest predisposing factors in cervical cancer are a history of intercourse at an early age and multiple sex partners.”

They also mention a study linking higher rates of cancer of the cervix among women who are sexual partners of intact men infected with human papillomavirus. As of this writing Peaceful Beginnings is not familiar with the study in question.

Again we would point out the relationship between sexually transmitted diseases and other variables such as personal hygiene and multiple sex partners, which may be of greater significance than lack of circumcision.

The AAP s verdict on cervical cancer appears to be unchanged from that of previous years when infant circumcision was more succinctly pronounced “not an essential component of total health care.” Low rates of cervical cancer among Jewish women were at one time believed to be associated with the circumcised state of virtually all Jewish men. However, other studies have revealed no differences between rates of cervical cancer among non-Jewish women married to intact husbands and those married to circumcised husbands. The studies which strong1y suggest that presence or absence of a foreskin among male sexual partners is not a significant contributory factor to cervical cancer are also thoroughly documented in my book Circumcision: The Painful Dilemma.

Pain and Behavioral Changes

The AAP notes: “Infants undergoing circumcision without anesthesia demonstrate physiologic responses suggesting that they are experiencing pain. Behavioral changes include a cry pattern indicating distress during the circumcision procedure and changes in activity (irritability, varying sleep patterns) and in infant-maternal interaction for the first few hours after circumcision. These behavioral changes are transient and disappear within hours after surgery.”

We commend the AAP for at least acknowledging the baby s reaction to circumcision, a consideration apparently omitted from their previous reports.

Whether the pain of circumcision lasts minutes, hours, days, or a lifetime is irrelevant to the ethical question hereby presented. Infants are exquisitely sensitive, defenseless, and aware of their surroundings. Therefore, they should be treated only with gentleness, respect, and love. Deliberately inflicting pain upon an infant or small child in any way, outside of instances of absolute medical necessity, should be declared unethical and therefore should cease to exist.

From the pediatric branch of the medical profession, which the public expects to be particularly compassionate and concerned for the overall well-being of infants, we would have expected more.

Local Anesthesia

According to the AAP: “Dorsal penile nerve block in appropriate doses may reduce the pain and stress of newborn circumcision. However, reported experience with local anesthesia in newborn circumcision is limited, and the procedure is not without risk. Complications due to local anesthesia are rare and consist mainly of hematomas and local skin necrosis (death of tissue). It would be prudent to obtain more data from large controlled series before advocating local anesthesia as an integral part of newborn circumcision.”

In a separate statement the AAP has recommended that infants always be properly anesthetized for all surgical procedures. Therefore we are curious about the apparent lapse in reasoning here.

However, we also agree that local anesthesia does have attendant risks. Proponents of local anesthesia for newborn circumcision agree that its use does not eliminate the baby’s stress from circumcision, but perhaps helps to minimize it. Upset over being forcibly restrained and worked on, pain from the injections themselves (two administered directly into the penis}, and post-operative pain are still very much present. Some doctors who have attempted using local anesthesia for infant circumcision have claimed that the infant appears to be just as traumatized when this method is used.

Apart from circumcision, we also strongly question the ethics of using unconsenting minors as “Guinea pigs” in studies which involve the performance of any unnecessary operation, with or without anesthesia.

Peaceful Beginnings neither supports, nor opposes use of local anesthesia for infant circumcision. (This would be similar to asking a breastfeeding support group to endorse a specific baby bottle or infant formula.) However, we are strongly concerned that the use of local anesthesia will give parents a misguided concept of infant circumcision being “totally painless” and “perfectly okay.”

Complications

The AAP’s statement reads: “The exact incidence of postoperative complications is unknown, but large series indicate that the rate is low, approximately 0.2 to 0.6 percent. The most common complications are local infection and bleeding.”

The figures of 0.2 to 0.5 translate to 1/500 to 1/163. In other words, between one out of 500 and one out of 153 newborn infants undergoing circumcision will experience a significant complication from the operation. This generally concurs with our findings. Percentages of urinary tract infections among intact male infants have ranged from as high as 1/100 to as infrequent as 1/25,000 in various recent reports. Penile cancer among intact males occurs at rates between 1/10,000 to 1/100,000 throughout the world.

The condition of meatal ulceration – localized ammonia burns on the sensitive glans of the circumcised infant caused by urine-soaked diapers – was not mentioned in the AAP report. Meatal ulceration does not occur in the intact infant because of the protective role of the less sensitive foreskin. This condition is described in extensive detail in the chapter on complications from Circumcision: The Painful Dilemma which I sent to each AAP member prior to their convening. If meatal ulceration is recognized as a result of circumcision, then the complication rate is much higher.

Incidentally, the AAP report included no data concerning complication rates from circumcision during adulthood or later childhood. Comments in the press suggesting that adult circumcision is riskier than infant circumcision were merely interjected opinions of the writers – hence irresponsible journalism. Our findings, which have uncovered an abundance of medical documentation of complications of infant circumcision, but hardly any for adult circumcision, plus the commonsense knowledge that a full grown, mature body is better equipped to cope with a hemorrhage or infection than a tiny, newborn body, all suggest that the operation is indeed riskier during infancy.

Several important facets of the concern over infant circumcision were omitted from the AAP report:

Care of the Intact Child

Misinformation and ignorance as to the correct care of the penis of the intact child abounds. Unqualified phrases such as “careful penile cleansing” or “lifetime commitment to genital hygiene” can lead parents and health care providers to believe that the matter   (missing section)  resentment and emotional difficulties over their lack of a normal body part. This is too important of a concern for the AAP to ignore.

The Protective Function of the Foreskin

A circumcision oriented society tends to regard foreskins as only problematic, much as a bottle-feeding oriented society may view breastfeeding only in terms of “inconvenience”, nipple soreness, or breast infections. Just as bottle-feeding oriented doctors may be unaware of the benefits of breastfeeding, the AAP has omitted important information as to the function of the foreskin in protecting the more delicate glans of the penis from urine and abrasions.

The troublesome problem of meatal ulceration, (described above under “complications”) is totally preventable if the foreskin is left in place to protect the more delicate glans (much as eyelids protect the more delicate eyes, )

Additionally, some men, circumcised in adulthood, who have been able to compare their “before and after” sexual experiences, have claimed that much sensitivity in the glans is indeed lost without the protective foreskin in place, that the foreskin affords greater ease in sexual penetration and a wider range of options during masturbation and foreplay, and that the foreskin, with its sensitive nerve ending is an erogenous zone in itself. Unfortunately, these facts are extremely difficult for circumcised males to accept.

We surmise that the AAP, under pressure from many sides, has attempted to produce a statement that would somehow “please everybody.” Unfortunately, they may instead succeed in pleasing nobody. Their statement is vague, and upon release immediately underwent considerable misunderstanding and distortion leading to much public confusion.

We anticipate, however, that rates of newborn circumcision will continue to decline in the U.S. as they have over the past several years, in part due to public awareness efforts by private sector groups such as Peaceful Beginnings and NOCIRC, and in part due to a growing public disenchantment with many facets of established medical health care along with increasing respect for the body in it’s naturally occurring state.

We also anticipate that the AAP, and other similar medical specialty organizations will again reevaluate their position on routine infant circumcision in future years, probably in the light of future research and observations, it is our hope that in the future such reevaluations can take place within an atmosphere of open communication and understanding between medical professionals and informed, concerned lay people.

Written by Rosemary Romberg.

Original draft was written in March 1989.
Revised: November 1989.
Second Revision for Website: May 2000.

UPDATE: In 1999, the AAP task force on circumcision (comprised of a completely different group of doctors) re-convened, and issued a similarly non-committal statement: “… these data (in support of circumcision) are not sufficient to recommend routine neonatal circumcision….the procedure is not essential to the child’s current well-being.” They conclude by urging parental decision and recommend procedural analgesia. (PEDIATRICS, vol. 103, #3, p. 686-693, March 1, 1999.)


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