Letters To AAP 2011 –
Letters to Members of the American Academy of Pediatrics’ Task Force on Circumcision
This letter was written by Petrina Fadel in August of 2012 after AAP’s new statement. Followed by informational links and an open letter to the AAP by Rosemary, June of 2010 after the AAP rescinded their approval of a “ceremonial nick” for female infants (of Muslim families.).
Dear AAP Board Members:
I am writing to you to request that you withdraw or rescind the newest 2012 AAP Circumcision Policy Statement. Below I have critiqued for you some of the serious problems with this new statement.
The Abstract states on page 585 that “health benefits are not great enough to recommend routine circumcision for all male newborns”, but this is not repeated even once in the long text on pages 758-785. Other long columns favoring circumcision are repeated over and over again, on pages 761-762, 770, 775-776, and 778. The 1999 AAP Statement was 8 pages long (pages 686-693), but this diatribe against living with a foreskin goes on for 28 pages. There is almost the feeling that AAP physicians hope that if they repeat something over and over again, eventually it might become the truth.
The AAP concludes on page 778 that “the health benefits of newborn male circumcision outweigh the risks”, and yet on page 772 the AAP admits that “the true incidence of complications after newborn circumcision is unknown”. If one doesn’t know how often complications occur, then one can’t make the judgment that the benefits outweigh the risks! The AAP lacks the evidence it needs to make such a claim.
The 1999 Statement studied 40 years’ worth of research, and the 2012 studied only selective research since 1999. Only 1031 of 1388 studies were accepted to look at. Balance might have been found in the 357 studies that were omitted, but the AAP was not seeking balance. The AAP statement goes on ad nauseum about alleged “benefits”, to the point of fear-mongering that something will go wrong if an infant isn’t circumcised. It’s a high pressure sales pitch to try to get the American public to buy the circumcisions that AAP and ACOG doctors are selling. This is in direct contrast to Europe, where circumcision is uncommon and the health of European children equals or surpasses that of American children.
No studies on ethics were included in this statement, and it is clear that the rights of the child and how a grown man might feel about HIS foreskin being stripped from him were never given any consideration at all by the AAP. These are major issues, and are even more important than many of the other minor issues the AAP discusses. Material was provided to the AAP to study this aspect of circumcision, but it was ignored. With one bioethicist on the panel, you would have thought that the AAP might at least have given the ethics of circumcision a cursory examination, considering that they were provided with many sources showing the emotional distress many men feel. Ethics and mental health, however, nowhere enter the picture for the AAP. Respect for the bodily integrity of another person were not included, and medical ethics were thrown out the window as infants were thrown under the bus.
Financing studies weren’t included in the studies, but the AAP did its best to push financing repeatedly for third-party reimbursement of non-therapeutic circumcision, at the expense of taxpayers during a time of budget crises. Those with private insurance would see premiums and medical costs rise. The cost for circumcision on page 777 ranges from $216 to $601 per circumcision in the U.S. In 2010, the in-hospital U.S. circumcision rate was 54.7%. Thus, 45.3% of newborn males left the hospital genitally intact. If the AAP were to convince parents of these 45.3% to circumcise (as they are attempting to do in this 2012 statement), then there would be 45.3% of roughly 2.1 million baby boys that could be an additional income source for physicians. (Remember, don’t consider the ethics!) This would be an additional 951,300 male infants to profit from. At prices the AAP quotes, this could mean an additional $205,480,800 to $571,731,300 for doctors who circumcise. This is no small sum, and as Thomas Wiswell, M.D. stated on June 22, 1987 in the Boston Globe, “I have some good friends who are obstetricians outside the military, and they look at a foreskin and almost see a $125 price tag on it. Each one is that much money. Heck, if you do 10 a week, that’s over $1,000 a week, and they don’t take that much time. “(Lehman 1987) Money like that would certainly help doctors make their mortgage payments and their car payments, pay for vacations, etc. – a “benefit” that the AAP failed to mention. Under Literature Search Overview, it is understandable why AAP physicians might consider it important to investigate “What are the trends in financing and payment for elective circumcision?”
No studies on the anatomy and functions of the foreskin were included. This is surprising, since it would seem like common sense to consider what the functions of any healthy body part are before amputating it. Since the male AAP Task Force members are probably alll circumcised, this idea was difficult for them to grasp. Only one study on the sexual impact of circumcision was included, and this from Africa. Other studies were ignored or discounted. “The effect of male circumcision on the sexual enjoyment of the female partner”, which appeared in BJU INTERNATIONAL, Volume 83, Supplement 1, Pages 79-84, January 1, 1999, is not mentioned. Nor is the newest Danish study that was publicized on November 14, 2011 – “Male circumcision leads to a bad sex life” – “Circumcised men have more difficulties reaching orgasm, and their female partners experience more vaginal pains and an inferior sex life, a new study shows.” See: http://sciencenordic.com/male-circumcision-leads-bad-sex-life The AAP had time to include this study, but it was ignored. Others sent material to the AAP about CIRCUMserum, Senslip, foreskin restoration that men are undergoing to undo some of the damages of circumcision and how this improves the sexual experience for both men and women. It didn’t fit the AAP’s pro-circumcision agenda, so it was ignored. The Policy Statement is totally lacking in ethics, anatomy, and foreskin functions. Instead, the Task Force is more concerned with how to train more doctors to circumcise, and how to do so with different devices and various forms of anesthesia.
The physical and sexual harms from circumcision are minimized or dismissed outright. Deaths from circumcision and botched circumcisions are considered “case studies”, and the children horribly damaged from circumcision don’t merit the AAP’s consideration, even though the AAP’s alleged mission is that it is “Dedicated to the Health of All Children”. When cribs are faulty or car seats aren’t safe, the AAP becomes concerned and warns the public. When physicians botch circumcisions and are at fault, children don’t matter. After one botched circumcision lawsuit and a large settlement, the company that manufactured the Mogen clamp went out of business. The AAP report should have advised physicians to NOT use the Mogen clamp because of the botched circumcisions that have resulted with this device. If still in use, no doubt there will be future tragedies with the Mogen clamp, but parents will only be able to sue the doctor and hospital and not the manufacturer.
There was so much reliance on studies from Africa in this statement , that it seemed like the AAP should change its name to the African Academy of Pediatrics. In contrast to the AAP, the American Association of Family Physicians (AAFP) has stated: “…the association between having a sexually transmitted disease (STD) – excluding human immunodeficiency virus (HIV) and being circumcised are inconclusive… most of the studies [of the effect of circumcision on HIV] …have been conducted in developing countries, particularly those in Africa. Because of the challenges with maintaining good hygiene and access to condoms, these results are probably not generalizable to the U.S. population”. But generalize the AAP did! In addition, the AAP listed page after page of STDs that allegedly circumcision would prevent, and wrote conflicting statements about syphilis. A recent study in Puerto Rico found that circumcised men have HIGHER rates of STDs and HIV. The 60% reduced risk of HIV following circumcision is the relative risk reduction, not the absolute risk reduction. There’s a huge difference. Across all three female-to-male trials, of the 5,411 men subjected to male circumcision, 64 (1.18%) became HIV-positive. Among the 5,497 controls, 137 (2.49%) became HIV-positive”, so the absolute decrease in HIV infection was only 1.31%, which is not statistically significant.” (Boyle GJ, Hill G. Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. J Law Med 2011; 19:316-34.)
Infants are not at risk of STDs or HIV through sexual contact, so this speculation about their future risk is foolhardy. Infants can also be at risk for many other diseases, but surgical amputation of healthy body parts is a foolhardy approach for prevention and treatment of disease. If an infant is at risk of an STD, then it is probably safe to say that an adult is perpetrating a crime against the child and needs to be arrested and charged.
Judaism and Islam are mentioned as religions that practice religious circumcisions. Once again, the statement ignores Christianity, which teaches that circumcision is unnecessary. Christianity is the largest religion in the U.S., but its teachings don’t even get a mention by the AAP, which is rather insulting! With an over-representation of members on the Task Force who have a religious bias favoring circumcision, this is not surprising.
The AAP promotes parents choosing medically unnecessary circumcision for their male children, completely contradicting what it said in PEDIATRICS, Volume 95 Number 2, Pages 314-317, February 1995. It said then, “Thus “proxy consent” poses serious problems for pediatric health care providers. Such providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses… the pediatrician’s responsibilities to his or her patient exist independent of parental desires or proxy consent.”
Parents deserve factual information about circumcision, but they won’t find it in the new AAP Statement. In fact, the AAP wrongly advises parents of intact baby boys to retract the foreskin and wash it with soap and water. (page 763) Soap can alter the good bacteria under the foreskin, potentially causing infections that should then be treated with liquid acidophilus to restore the good bacteria. Water is sufficient for cleansing. Circumcised doctors with circumcised sons probably don’t know this.
On page 764, the AAP speculates that the foreskin contains a high density of Langerhans cells, “which facilitates HIV infection of host cells. Actually, the exact opposite is true. “Langerin is a natural barrier to HIV-1 transmission by Langerhans cells” (Nature Medicine- 4 March 2007). This study states, “Langerhans cells (LCs) specifically express Langerin . . . LCs reside in the epidermis of the skin and in most mucosal epithelia, such as the ectocervix, vagina and foreskin.”
UTIs can be prevented through breastfeeding, which the AAP allegedly supports. This is nowhere mentioned under “Male Circumcision and UTIs” on page 767. HPV can be prevented with a vaccine for both boys and girls, but it is not mentioned on that same page. A recent study reporting on the large number of re-circumcisions done following infant circumcisions is also not even mentioned. On page 770, EMLA is mentioned as a possible anesthetic, but EMLA is not supposed to be used on infants. The fact remains that unnecessary surgery performed with anesthesia is still unnecessary surgery.
There is so much wrong with this new statement that it should immediately be withdrawn before it is presented on Monday. The AAP should either start all over again (with new, unbiased Task Force members), or renew its 1999 statement which attempted to at least give a more balanced view of circumcision. The 1999 circumcision statement certainly had its flaws by ignoring ethics and the anatomy and functions of the foreskin, but it wasn’t as atrocious as this new statement is.
If the AAP wants to remain a credible organization, it will look to the judgment of other foreign medical associations, who recognize that circumcision is medically unnecessary and has serious ethical problems underlying its practice. American parents should look to these foreign medical associations for good advice, since the AAP is not providing it in its new statement.
Additional comments added by author.
I’ve reread the AAP’s new circumcision statement and have found additional things that I want to bring to everyone’s attention, to help you when speaking or writing about the AAP’s newest statement. These points are rather disjointed, but they paint a bigger picture of what the AAP has done. Use the information below when writing to or about the AAP’s Circumcision Statement. I think they’re hanging themselves with what they’ve said and what they’ve failed to say.
1. Under “Ethical Issues” (pages 758-759), two of the references for this rubbish come from Douglas Diekema (the alleged AAP “bioethicist”) who signed his name to this statement. There is no mention of the ethics underlying the rights of the child. This statement on parental opinion is Diekema’s personal opinion, based on what he wrote before. References are also taken from M. Benatar and D. Benatar (both Jewish circumcision supporters, to whom I wrote my response in the “American Journal of Bioethics” in 2003.) The other comes from AR Fleishman (religious bias?).
2. Under “Ethical Issues” (page 759), there’s an interesting choice of words by the AAP- “In cases, such as the decision to perform a circumcision in the newborn period, … and where the procedure is not essential to the child’s immediate well-being, the parents ” blah, blah, blah. They insert the word “immediate” because they are pushing circumcision to allegedly prevent diseases later. Nevertheless, there is an admission that circumcision “is not essential”. They even call circumcision “elective” in this statement. (page 757 and other places.)
3. Under Ethics, Reference #14 comes from the British Medical Association-“The law and ethics of male circumcision: guidance for doctors: J. Med Ethics 2004. As I recall, this was not a favorable piece on circumcision, but they’ve cherry-picked something from it on page 760. It’s more about physicians having training and performing circumcisions properly.
4. (pages 762-763) Several times in the report the AAP states, “For parents to receive nonbiased information about male circumcision in time to inform their decisions, (My note: “inform their decisions” really means so doctors can brainwash parents) clinicians need to provide this information at least before conception, and/or early in the pregnancy, probably as a curriculum item in childbirth classes.” There is absolutely no way doctors can do this before conception, but they want to brainwash parents as early as possible. I think efforts to get informative circumcision dvds into childbirth classes has been effective, because now the AAP wants information that is critical of circumcision in their own childbirth classes to not be presented. This is mind control at its worst, supported by the AAP!
5. (page 763) They use the term “uncircumcised” under “Care of the Circumcised Versus Uncircumcised Penis”, and later on the term “non-circumcised” when saying, “The non-circumcised penis should be washed with soap and water.” They refuse to use the word intact for intact penis.
6. (page 764) “Mathematical modeling by the CDC shows that, taking an average efficacy of 60% from the African trials, (My note: That is the relative risk, not the absolute risk which is 1.31%) and assuming that protective effect of circumcision applies only to heterosexually acquired HIV” … blah, blah, blah. There’s a saying that if you “assume” anything, it makes an ass out of u and me. Assumptions are not evidence, and since when should the AAP rely upon or be making assumptions? Assumptions can be wrong, and often are. Definition of assume- “Suppose to be the case, without proof.”
7. (page 769) “Sexual Satisfaction and Sensitivity” never once mentions or considers how circumcision impacts the sexual satisfaction of females. They get it totally wrong about males, and totally ignore females!
8. (page 771) Under “Analgesia and Anesthesia for a Circumcision After the Newborn Period”, they state, “Additional concerns associated with surgical circumcision in older infants include time lost by parents and patients from work and/or school.” They are promoting newborn circumcision so parents don’t have to miss work? Parents miss work all the time when their kids get sick as toddlers or as young children. The infant is the patient, and an infant isn’t going to miss work or school yet. This sentence makes no sense grammatically.
9. (page 772) Under “Complications and Adverse Events”, they twice mention how circumcision rates are lower in hospitals with trained personnel than in those by untrained practitioners in developing countries. U.S. parents don’t live in developing countries, and this doesn’t even belong in an AAP statement, I suspect they were strongly influenced by the African researchers.
10. (page 772)- “The true incidence of complications after newborn circumcision is unknown …”. “Two large US hospital-based studies with good evidence estimate the risk of significant acute circumcision complications … ” Here they are relying upon an “estimate.” (page 773) “(T)here are no adequate studies of late complications in boys undergoing circumcision in the post-newborn period; this area requires more study.” page 774- “There are not adequate analytic studies of late complications in boys undergoing circumcision in the post-newborn period.” “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).” [Joshua Haskins and all the other babies that died following circumcision are only “case studies”! Nice!) Under “Major Complications”, they only list MRSA and death, but these and other complications they call “rare.” Under “Medical Versus Traditional Providers”, this doctors’ group sings its own praises. “Physicians in a hospital setting generally have fewer complications than traditional providers in the community setting.” (Was this the AAP saying that doctors are safer than mohels? Hmmm.)
11. (page 775) Under “Stratification of Risks” they say, “Based on the data reviewed, it is difficult, if not impossible, to adequately assess the total impact of complications, because the data are scant and inconsistent regarding the severity of complications.” Then on page 777 they say the exact opposite. “Although it is clear that there is good evidence on the risks and benefits of male circumcision …” They are talking out of both sides of their mouths! THIS IS KEY- They really don’t know how great the risks are, but they conclude with in the Abstract (page 756) with this. “Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks …” So, they can’t adequately predict the incidence of risks, but then they conclude that the health benefits outweigh the risks! Then on page 775 they state under “Task Force Recommendations”- “Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks …” The AAP doesn’t know the incidence of risks, but they are expecting physicians to know the risks, and to do so in a nonbiased manner from a biased AAP statement? (Beam me up!)
12. (page 776) In 2009, ten years after the AAP did not recommend circumcision, their own survey of AAP members found that “18% responded recommending to all or most of their patients’ parents that circumcision be performed.” (It’s money for them!) Now, after this travesty of a statement, on pages 777-778 the AAP wants to know this about the effectiveness of their new 2012 statement when they say, “The Task Force recommends additional studies to better understand … The impact of the AAP Male Circumcision policy on newborn male circumcision practices in the United States and elsewhere.” In other words, how effective are we in fooling American parents and people in other countries?
13. (page 777) The AAP wants to work with the ACOG, AAFP, American Society of Anesthesiologists, and American College of Nurse Midwives (ACNM) to develop a plan on about which groups are best suited to perform newborn male circumcisions. In other words, how are we going to divide up the money we so eagerly want?
14. (page 777) The AAP targets blacks and Hispanics- “African-American and Hispanic males in the United States are disproportionately affected by HIV and other STIs, and thus would derive the greatest benefit from circumcision.” But then they say under “Areas for Future Research” [More funding for more circumcision research to keep the Johns Hopkins people going! Maybe these researchers want to come home. They sure want the money to keep flowing to them!]: “The Task Force recommends additional studies to better understand … The impact of male circumcision on transmission of HIV and other STIS in the United States because key studies to date have been performed in African populations with HIV burdens that are epidemiologically different from HIV in the United States.” They just spent several pages before this promoting newborn circumcision to prevent STDs and HIV later in life based on African studies, and now they are admitting here that need more studies because the results could be different in the U.S.? Hello!
15. The AAP did actually say ONE good thing, but only ONE good thing. On page 760 they said, “The Task Force advises against the practice of mouth-to-penis contact during circumcision, which is part of some religious practices, because it poses serious infectious risk to the child.” If I were to guess, I’d say Dr. Susan Blank made them put that in. In New York City, Blank has done nothing to ban metzitah b’peh while working for the NY City Health Department, because they don’t want to offend the Orthodox Jews who practice it. Babies have died of herpes from metzitzah b’peh under her watch.
16. Under References (pages 779-785) I recognize only three anti-circumcision people listed- RV Howe in #76 and #78, Frisch in #118, and Sorrells in #132. There are many pro-circumcision sources upon whom they rely heavily, many who have religious biases that cloud their thinking. With the approval of the AAP Task Force, I suspect that these individuals hijacked the circumcision deliberations with all their pro-circumcision nonsense.
Wawer – #32, #66
Auvert – #46, #54, #102
Gray – #47, #55, #56, #81
Tobian- #71, #103
Schoen- #110, #234
Wiswell- #114, #115, #123, #192, #230, #231, #232
Douglas Diekema and Lynne Maxwell are both on the AAP Task Force. They
are listed as references, Diekema in #10 and #13, and Maxwell in #159.
Today, the American Academy of Pediatrics (AAP) released a new statement on newborn circumcision which claims “the health benefits of newborn male circumcision outweigh the risks” and “the preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure.”
Post to the AAP Facebook page and send them a message: https://www.facebook.com/AmerAcadPeds
Here is the video the Whole Network created based on the Facebook pictures individuals submitted – look how many people all across America can together for this campaign in just one day! Truly amazing and inspiring:
Professional Responses to the AAP
Intact America: http://www.intactamerica.org/aap2012_response
Doctors Opposing Circumcision (PDF): http://www.doctorsopposingcircumcision.org/pdf/2012-08-26A_Commentary.pdf
The Circumcision Resource Center: http://www.circumcision.org/aap.htm
Childbirth activist Gloria Lemay has posted Petrina Fadel’s response: http://www.glorialemay.com/blog/?p=780
And 2 good articles are up:
Colorado: Circumcision opponents want new AAP recommendations retracted: http://www.healthpolicysolutions.org/2012/08/27/circumcision-opponents-want-new-aap-recommendations-retracted/
AAP Circumcision Policy ‘Seriously Flawed’, Condemned by Canadian Children’s Rights Group: http://finance.yahoo.com/news/aap-circumcision-policy-seriously-flawed-070100133.html
Join the “Wash Your Hands Clean of the AAP” event on Facebook!
A demonstration outside of the AAP’s upcoming October conference in New Orleans is being arranged:
Facebook Groups – keep up to date with the latest on the situation!
AAP Circumcision Task Force & Letter-Writing Campaign: https://www.facebook.com/groups/470229902998366/
The Whole Network: https://www.facebook.com/WholeNetwork
Intact America: https://www.facebook.com/intactamerica
News and information about circumcision and developments in Colorado: https://www.facebook.com/ColoradoNOCIRC
Private group for Colorado NOCIRC internal discussions and planning: https://www.facebook.com/groups/231513806960666/ If you’d like to join this group, please message Gillian Longley or Craig Garrett on Facebook.
The AAP omitted the fact that the foreskin is an important part of male anatomy with specific sexual, sensory, and protective functions. How can the AAP possibly recommend removing part of the body when they won’t even discuss its functions?
A previous letter written in June of 2010 by Rosemary Romberg
Open letter members of the American Academy of Pediatrics’ Task Force on Circumcision
You are to be commended for taking a stand against all types of female genital mutilation (even the “small ceremonial nick”) as practiced by some cultures. With the absence of any true medical need, all such practices should be outside the realm of any medical practitioner, regardless of any supposed cultural/ social/ religious contexts.
Respect for the integrity of the normal human body, the rights of all children, and the wholeness of the parent/child bonding experience is irrelevant unless it is equally afforded to both genders. Hence male genital mutilation (aka “circumcision”) of non-consenting infants and children must be equally condemned.
Curiously, cultures that routinely practice female circumcision offer spurious “health/cleanliness/social acceptability” justifications for the act which, however ludicrous to western minds, are uncomfortably similar to the common purported arguments for routine circumcision in the United States and other “civilized” countries.
The only true difference between female genital mutilation and its common male counterpart in the U.S. is that the former is foreign and therefore repugnant to western thinking, while the latter has become socially accepted and until recent decades, unquestioned. It is difficult to step out of ones own culture and question a widely accepted practice, but it is the responsibility of the medical profession to be objective about any given practice and not be swayed by “social acceptability.” One could just as easily construct an amputative philosophy around any other non life essential body part such as ears or toes, surround it in medical jargon and “studies” and make a case for routine extermination at birth.
Those of us who oppose infant circumcision believe that normal body parts, including foreskins, have the right to exist and that infants and children have the right to keep (or in adulthood decide the fate of) all normally occurring body structures. Medical services are limited and are gravely needed for healing and life preserving measures, NOT for routine destruction of normal body parts of unconsenting minors, girls and boys alike.
(author of Circumcision: The Painful Dilemma c. 1985, Bergin & Garvey, S. Hadley, MA.)
Founder and Executive
First, Do No Harm
Posted: 10/04/2012 1:20 pm Huffington Post
The American Academy of Pediatrics describes itself as “dedicated to the health and well-being of infants, children, adolescents and young adults.” Unfortunately, its new Circumcision Task Force report, published last month in the journal Pediatrics, reveals instead a trade association agenda that desperately seeks to justify and secure reimbursement for a medically-unnecessary surgery that harms children and violates their basic human rights. The self-interest and selective blindness of the AAP report is especially remarkable given the growing condemnation of child circumcision by physician groups and even courts in European and Commonwealth countries, which view the surgery as an outmoded American ritual that serves no therapeutic purpose and causes both short- and long-term harm.
In actuality, the AAP report stops short of recommending circumcision, even as it claims the surgery’s benefits outweigh the risks. Yet it states repeatedly that those risks are unknown and devotes not a word to the function and purpose of the foreskin, a normal and integral part of the penis and one that approximately 70 percent of all men worldwide have retained. The United States is virtually alone among developed countries in surgically altering the bodies of baby boys as a routine medical procedure. Rates of male circumcision in European countries are around 10 percent.
Not only does the Task Force report blatantly ignore the ethical obligation of physicians to respect their patients’ autonomy and do no harm, it repeatedly calls for doctors to be paid by private insurance or Medicaid for removing healthy, functioning tissue from an infant baby boy who cannot consent to this permanent alteration to his body.
Specifically, the report says:
“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.”
The Task Force says that it’s the parents’ responsibility to decide whether their particular newborn might benefit from being circumcised, though no guidance is given on how parents should make this decision.
In fact, 18 states do not cover circumcisions under Medicaid, and many insurance plans do not cover what the American Medical Association has referred to as a “non-therapeutic” procedure. The newborn circumcision rate is falling steadily in the United States, with current estimates placing it at about 50 percent — as compared with around 80 percent only a few decades ago.
The decline is attributable to a number of factors, among these, immigration from countries where intact boys and men are considered normal and healthy and a growing awareness among parents that the surgery is unnecessary and — indeed — painful, risky, and harmful. These parents are as loathe to circumcise their infant sons as they would be to assent to the genital cutting of their daughters, a practice popular in parts of Africa and the Muslim world but outlawed in most Western countries, including the United States.
Nonetheless, for 2012 alone, the toll of American baby boys tied down and surgically altered will number 1 million (no baby “consents” to circumcision, as a fleeting glance at an infant circumcision on video or in the flesh will make clear). This is a human rights violation on a massive scale.
In justifying the perpetuation of infant circumcision, the AAP Task Force cites studies conducted among sexually-active adults in parts of sub-Saharan Africa with very high HIV prevalence. These studies looked at the role circumcision might play in retarding transmission of the HIV virus. They claim to have found a reduction in transmission from females to males, though not from men to women. Circumcision has not been conclusively found to reduce transmission of HIV in men who have sex with men, which together with intravenous needle-sharing, account for most cases of HIV in the United States.
Whether or not circumcision actually plays a role in reducing HIV transmission among some adults in sub-Saharan Africa has no relevance to baby boys in the United States. Babies are not sexually active and are therefore at no risk of sexually-transmitted HIV or any other venereal disease. In my opinion, these African studies are being used as after-the-fact justification for a custom that is increasingly being rejected by those who see it as violating children’s rights to bodily autonomy and their own future freedom of religion.
As the AAP so comfortably supports infant and child circumcision, physicians abroad are stepping up to give baby boys the same kinds of human rights protection extended routinely to girls who might otherwise face the threat of female genital mutilation. The Royal Dutch Medical Association has recommended against routine male circumcision, the organization’s medical ethicist Gert Van Dijk calling it a medically-unnecessary form of surgery.
“The patient has to give consent, but children can’t give consent and we feel that is wrong and a violation of the child’s right,” Van Dijk said of circumcision. “In our code of medical ethics, it states that you must not do harm to the patient, but with this procedure this is exactly what you’re doing.”
In Denmark, the Prime Minister has commissioned an investigation into whether non-medical circumcision procedures violate its health code. In Germany, a court ruled in June that non-therapeutic male circumcision amounted to bodily injury and violated human rights provisions of the country’s laws. The judge explicitly ruled that the parents’ religious freedom cannot override the child’s right to physical integrity and self-determination.
“The body of the child is irreparably and permanently changed by a circumcision,” the judge wrote. “This change contravenes the interests of the child to decide later on his religious beliefs.”
Following the German court’s decision, hospitals in Austria and Switzerland suspended all medically-unnecessary infant circumcisions. Political discussion continues in Germany over whether religious circumcisions might be allowed, but no European physician organization is contending that there is any medical justification for routinely circumcising babies or children.
All of this — together with the insistence that parents bear the burden (and therefore the liability) of deciding whether or not to have their sons circumcised — makes it clear to me that the American Academy of Pediatrics Task Force report is all about justifying past practice, perpetuating it into the future, disclaiming responsibility for any adverse consequences, and ensuring a revenue stream for doctors.
Intactivists — those of us who argue for the human right of infant boys to remain whole until they can make their own informed decisions — plan to be in New Orleans this October when the AAP presents its Task Force report. We will be asking pediatricians to respect their first ethical obligation to their patients, which is to do no harm.
Circumcision Position Statements of Medical Societies Worldwide
NO national medical organization in the world recommends routine circumcision of male infants.
2010 Royal Australasian College of Physicians, Circumcision of Infant Males: “Ethical and human rights concerns have been raised regarding elective infant male circumcision because it is recognized that the foreskin has a functional role, the operation is non-therapeutic and the infant is unable to consent. After reviewing the currently available evidence, the RACP believes that the frequency of disease modifiable by circumcision, the level of protection offered by circumcision, and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.”
2010 Royal Dutch Medical Association, Non-therapeutic Circumcision of Male Minors: “There is no convincing evidence that circumcision is useful or necessary in terms of prevention or hygiene… Non-therapeutic circumcision of male minors is contrary to the rule that minors may only be exposed to medical treatments if illness or abnormalities are present, or if it can be convincingly demonstrated that the medical intervention is in the interest of the child… Non-therapeutic circumcision of male minors conflicts with the child’s right to autonomy and physical integrity.”
2009 College of Physicians and Surgeons of British Columbia, Circumcision (Infant Male): “Current understanding of the benefits, risks and potential harm of this procedure no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention.”
2006 British Medical Association, The Law and Ethics of Male Circumcision: Guidance for Doctors: “To circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate… The medical benefits previously claimed have not been convincingly proven… The BMA considers that the evidence concerning health benefits from non-therapeutic circumcision is insufficient for this alone to be a justification for doing it.”
2002 American Academy of Family Physicians, Position Paper on Neonatal Circumcision: “Evidence from the literature is often conflicting or inconclusive… A physician performing a procedure for other than medical reasons on a non-consenting patient raises ethical concerns.”
1999 (reaffirmed 2005) American Academy of Pediatrics, Circumcision Policy Statement: “Existing scientific evidence… [is] not sufficient to recommend routine neonatal circumcision.”
1996 Canadian Paediatric Society, Neonatal Circumcision Revisited: “Circumcision of newborns should not be routinely performed.”
1996 Australian Medical Association, Circumcision Deterred: “The Australian College of Paediatrics should continue to discourage the practice of circumcision in newborns.”
1996 Australasian Association of Paediatric Surgeons, Guidelines for Circumcision: “The Australasian Association of Paediatric Surgeons does not support the routine circumcision of male neonates, infants, or children in Australia. It is considered to be inappropriate and unnecessary as a routine to remove the prepuce [foreskin], based on the current evidence available… We do not support the removal of a normal part of the body, unless there are definite indications to justify the complications and risks which may arise. In particular, we are opposed to male children being subjected to a procedure which, had they been old enough to consider the advantages and disadvantages, may well have opted to reject the operation and retain their prepuce.”
American Academy of Pediatrics, Task Force on Circumcision. 1999. Circumcision policy statement. Pediatrics 102(3):686-693. http://www.cirp.org/library/statements/aap1999
Australian Medical Association. 1997. Circumcision Deterred. Australian Medicine. 6-20 January:5. http://www.cirp.org/library/statements/ama2
College of Physicians and Surgeons of British Columbia. Circumcision (Infant Male). In: Resource Manual for Physicians. Vancouver, BC: College of Physicians and Surgeons of British Columbia, 2009. https://www.cpsbc.ca/files/u6/Circumcision-Infant-Male.pdf
Commission on Clinical Policies and Research. 2002. Position Paper on Neonatal Circumcision. Leawood, Kansas: American Academy of Family Physicians. http://www.cirp.org/library/statements/aafp2002
Committee on Medical Ethics. 2006. The Law & Ethics of Male Circumcision: Guidance for Doctors. London: British Medical Association. http://www.bma.org.uk/ap.nsf/Content/malecircumcision2006
Fetus and Newborn Committee, Canadian Paediatric Society. 1996. Neonatal circumcision revisited. Canadian Medical Association Journal 154(6):769-780. http://www.cps.ca/english/statements/FN/fn96-01
Leditschke JF. 1996. Guidelines for Circumcision. Australasian Association of Paediatric Surgeons. Herston, QLD, Australia. http://www.cirp.org/library/statements/aaps
Royal Australasian College of Physicians. 2010. Circumcision of Male Infants. Paediatrics & Child Health Division. Sydney, Australia. http://www.racp.edu.au/page/policy-and-advocacy/paediatrics-and-child-health
Royal Dutch Medical Association (KNMG). 2010. Non-therapeutic Circumcision of Male Minors. http://www.circumstitions.com/Docs/KNMG-policy.pdf
Rev. March 2011
ON THE ETHICS OF CIRCUMCISION FOR POTENTIAL MEDICAL BENEFIT
From: “The Ethical Canary: Science, Society, and the Human Spirit”
by Margaret Sommerville, founding director of the Centre for Medicine, Ethics, and Law at McGill University, Montreal.
A common error made by those who want to justify infant male circumcision on the basis of medical benefits is that they believe that as long as some such benefits are present, circumcision can be justified as therapeutic, in the sense of preventive health care.
This is not correct.
A medical-benefits or ‘therapeutic’ justification requires that:
1) overall the medical benefits sought outweigh the risks and harms of the procedure required to obtain them,
2) that this procedure is the only reasonable way to obtain these benefits, and
3) that these benefits are necessary to the well-being of the child.
None of these conditions is fulfilled for routine infant male circumcision.
If we view a child’s foreskin as having a valid function, we are no more justified in amputating it than any other part of the child’s body unless the operation is medically required treatment and the least harmful way to provide that treatment.
FOR MORE INFORMATION, VISIT:
Attorneys for the Rights of the Child
2961 Ashby Ave. , Berkeley , CA 94705 Fax/Phone 510-827-5771
For Immediate Release: 03/16/2013
New Article Finds Fault With Pediatric Organization’s Support for Circumcision, Provoking a Formal Response
Summary: Human rights attorney J. Steven Svoboda and pediatrician Robert S. Van Howe, M.D. have published a new article in one of the world’s leading journals on medical ethics arguing that the American Academy of Pediatrics’ (AAP’s) position regarding male circumcision lacks credible support. The article leads off the latest issue of the Journal of Medical Ethics (JME) and has already led the AAP to arrange for the JME to publish its response in what Svoboda and Van Howe consider an ill-fated attempt to justify the medically and ethically flawed arguments in its policy statement and technical report.
Berkeley , CA – Human rights attorney J. Steven Svoboda and pediatrician Robert S. Van Howe, M.D. have published a new article in one of the world’s leading journals on medical ethics arguing that the American Academy of Pediatrics’ (AAP’s) position regarding male circumcision lacks credible support. The article, titled, “Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision,” is being published online today (http://jme.bmj.com/content/early/recent), leading off the latest issue of the Journal of Medical Ethics (JME). The US ’ premier organization of pediatricians has already arranged for the JME to publish its response in what Svoboda and Van Howe view as an ill-fated attempt to justify the medically and ethically flawed arguments in its policy statement and technical report.
Svoboda and Van Howe criticize the AAP’s apparent cultural bias in favor of circumcision, which they note puts the AAP firmly out of step with world medical opinion on this issue. They argue that the AAP documents suffer from troubling deficiencies, ultimately undermining their credibility. According to the authors, these deficiencies include the omission of critical issues, biased use of the medical literature, and conclusions that are not supported by the evidence given.
Svoboda commented, “The AAP ignores so many important topics that it is hard to know where to begin. For example, the anatomy and function of the foreskin are not mentioned in their documents, even though they propose to cut it off without first considering the harm and pain that result from its removal. The AAP’s circumcision recommendations contradict its own bioethics policy statement, which requires pediatric care to be based only on the needs of the patient. Non-therapeutic circumcision is incompatible with widely accepted ground rules for surgical intervention in minors.”
Dr. Van Howe, a Clinical Professor at Michigan State University College of Human Medicine, said, “When physicians decide whether to do a procedure, they must, and normally do, exclude from their medical decisions non-medical factors regarding the parents’ culture. Contrary to what the AAP suggests, doctors are not cultural brokers. Their duty is promoting and protecting the health of their patients, not following practices lacking a solid ethical and medical foundation.”
Svoboda and Van Howe write that the AAP report suffers from being two-and-a-half years out of date at the time of its publication. They note that the last literature search was performed in April 2010 for a report published in August 2012. Svoboda and Van Howe write that studies that suggest benefits for circumcision appear in the technical report while at least one hundred studies that fail to support a benefit or that find detrimental effects of circumcision are left out. The authors add that the AAP also cherry-picks information from within the articles it cites, selecting bits of language out of context that lend support to its position while often ignoring contradictory data.
Svoboda commented, “The response to our article by the AAP Task Force calls for avoiding an ideological agenda. When European authorities agree that cultural bias rather than scientific fact is driving the AAP’s position, I would suggest that our only agenda is ethical and medically sound care for infants and young children. The AAP fails to raise any substantive argument pointing to either evidence or reasoning about which we are mistaken.”
The AAP itself concedes, Svoboda and Van Howe write, that the there are vast differences between HIV transmission to adults in Africa and to children in the US. In Africa, the authors observe, one of the most likely places to contract HIV is in a health clinic. Svoboda observed, “The US has the highest rates of circumcision, of HIV, and of other sexually transmitted infections in the industrialized world, so the chance that the first can prevent the other two seems extremely remote.”
Svoboda asked, “Why is the AAP promoting public funding for an unnecessary and harmful surgery when we find ourselves struggling even to provide basic care for all our children? In these days of rising medical costs and scarce resources, we simply cannot afford to continue to carry out such a harmful and outmoded practice.”
While the AAP attempts to paint itself in its reply in the JME as being in line with world medical opinion, in fact, as noted by Svoboda and Van Howe, the AAP has put itself in a shrinking minority in attempting to justify an outmoded cultural practice that results in the death of more than one hundred boys each year. Circumcision also leads to frequent legal judgments and settlements in favor of plaintiffs, as documented by a list ARC released today of more than fifty such cases totaling over $80 million (www.arclaw.org/resources/settlements). Even the American Medical Association agrees that there is insufficient justification for performing the procedure on newborns absent specific medical indications. Unlike the AAP, its peer organizations in Europe and also in Australia, the United Kingdom, and Canada recognize that medical considerations must be considered in conjunction with ethical and legal considerations and therefore, male circumcision should be neither recommended to parents nor funded by government insurance systems.
A few months ago, the Royal Dutch Medical Association favorably cited an earlier version of Svoboda’s and Van Howe’s article, noting that even if benefits do exist the procedure can safely be delayed until the boy himself can make the decision.
The JME considers the issue of male circumcision important enough to have devoted an entire special issue to the topic, including a second article by Mr. Svoboda on male circumcision and human rights, and a second article by Dr. Van Howe about male circumcision and parental rights.
Svoboda and Van Howe’s article appears at a similar publication date with a commentary to appear in the AAP’s own Pediatrics by thirty-eight leading European medical authorities, who have independently reached a conclusion consistent with Svoboda and Van Howe’s in criticizing the cultural bias in the AAP’s two documents.
After graduating from Harvard Law School, Svoboda founded the human rights organization Attorneys for the Rights of the Child (www.arclaw.org) in 1997 to safeguard children’s right to bodily integrity. In Geneva in 2001, Svoboda and ARC first placed male circumcision on the official United Nations record as a human rights issue.