2012-08-26 Doctors Opposing Circumcision - Analysis of 2012 AAP policy on male infant circumcision
Commentary on American Academy of Pediatrics
2012 Circumcision Policy Statement
By the staff of
Doctors Opposing Circumcision
Doctors Opposing Circumcision has been provided with an advance copy of the two-page American Academy of Pediatrics (AAP) 2012 Circumcision Policy Statement1 and the accompanying thirty-page electronically-published “technical report” entitled Male Circumcision.2
The Circumcision Policy Statement was created by a “task force on circumcision”, which was appointed in 2007. The chair of the task force was given to Susan Blank, MD, MPD, an infectious disease specialist with no expertise in pediatrics and who was believed to have a religious/cultural bias in favor of male circumcision. Other prominent members included Andrew Freeman, MD, a pediatric urologist, who allegedly circumcised his own son for religious/cultural reasons; Douglas Diekema MD, a product of a circumcising culture in Michigan, who is supportive of a “ritual nick” in the genitals of female children;3 and Steven Wagner, MD, JD, a doctor-lawyer, who serves on the AAP Committee on Health Care Financing. It is clear that the members of the task force were chosen with a view to obtaining an outcome favorable for the continued practice of circumcision of male children and to provide for third-party payment to doctors.
The task force was augmented by representatives from the American College of Obstetricians and Gynecologists, and one the American Academy of Family Physicians, representing the two trade associations, other than the AAP, which profit most from performing medically unnecessary non-therapeutic circumcisions on children. Those trade associations are called “stakeholders”(p. 585 and p. e756). Stakeholders are people with a financial interest in an enterprise. When all charges are considered, medically unnecessary non-therapeutic circumcision produces more than $1.25 billion in income annually for the stakeholders.4
The task force asserts that current evidence that the health benefits of male circumcision outweigh the risks, but has failed to produce any sort of analysis to support that conclusion. Previously available cost-benefit studies do not support that conclusion.5 6 7 8
No information on nature and function of the foreskin
Male circumcision is a radical operation that irreversibly excises and amputates a healthy functional body part. The part removed is the foreskin or prepuce of the penis, which constitutes more than fifty percent of the skin and mucosa of the penis.9 The foreskin, which is a complex structure containing, smooth muscle, large vascular structures, is highly innervated, and has numerous protective, immunological, mechanical, sensory, and sexual2 physiological functions.10 11 The task force on circumcision, however, makes absolutely no mention of the nature or function of the foreskin, although this information is of great relevance to making a decision regarding circumcision.
Rights of the child
It is well established in both domestic law and international human rights law that a child is a person with rights of his own from the moment of birth. The task force on circumcision, however, treats the child-patient as a non-person with no legal rights of his own. There is no mention of the child’s right to bodily integrity12 or the child’s right to security of his person and special protection during childhood,13 which are violated by male circumcision. The child is seen as a chattel possession of the parents, with which they can do whatever they please. The AAP has failed to understand that domestic and international laws for the protection of individuals are written for the protection of the best interests of those individuals and that the violation of those laws cannot be in the best interests of those individuals.
Although the section on medical ethics is much expanded from the previous statement of 1999,14 it still suffers the same faults. Infants and children may not consent, so surrogate consent must be granted by parent or guardians, if child circumcision is to be performed. Although the statement quotes from the statement on consent, it omits the section that limit the power of the surrogate to consent:
Only patients who have appropriate decisional capacity and legal empowerment can give their informed consent to medical care. In all other situations, parents or other surrogates provide informed permission for diagnosis and treatment of children with the assent of the child whenever appropriate.15
Since the typical infant circumcision is a non-therapeutic surgical operation that is neither diagnosis nor treatment, this section would prohibit parental consent, so the task force ignored it. It appears that no one has the power to consent to non-therapeutic excision of healthy body tissue from a child’s body, which is the conclusion of appellate courts in Canada,16 Australia,17 and Germany.18
This task force relied, as did the previous task force, on a paper by Fleischman et al. (1994) on caring for gravely ill children.19 This paper is totally inappropriate and inapplicable to the care of healthy children who do not need treatment.
The Task Force consistently asserts parental rights while ignoring the rights of the child. It is clear from reading the task force’s distortion of medical ethics, that the protection and preservation of ritual circumcision is a major preoccupation of the AAP.3
Use and misuse of medical literature
Due to the emotional issues created by involuntary amputation of part of the male phallus,20 21 the medical literature is “voluminous, argumentative, polemical, confusing, chaotic, and contradictory.”22 For this reason, references can be found to support either side of an argument.
The task force examined medical literature published from 1995 to 2010. By doing this they excluded important articles unfavorable to male circumcision that were published before 1995 or after 2010. The task force then selectively cherry-picked the medical literature to support its predetermined position that male circumcision has health benefits. Much of their medical literature was produced by a team from the Bloomberg School of Public Health, which is funded by Michael Bloomberg, the well-known billionaire and current mayor of New York City.
Sexually transmitted disease
The task force claims that male circumcision reduces STD infection by forty to sixty percent. The task force frequently used unreliable studies from Africa that may not be applicable to the United States, of which many were produced by the pro-circumcision Bloomberg group.
American studies that do not confirm the task force hypothesis that the foreskin contributes to STD infection were ignored. Van Howe (1999) said in his systematic review, “In summary, the medical literature does not support the theory that circumcision prevents STDs.” 23
A longitudinal study of a birth cohort in Dunedin, New Zealand found little difference in STDs in circumcised and intact males.24
Human immunodeficiency virus
The decision to create a new task force was based on the publication in 2005 and 2007 of three randomized clinical trials (RCTs) that were carried out in Africa. The three studies purported to prove that male circumcision provided a 60 percent reduction in female to male heterosexual transmission of HIV.
Since 2007 a substantial number of papers have been published that debunk the claims of the three RCTs.25 26 27 28 29 30 The task force totally ignored these important papers.
Recent evidence shows higher rates of HIV infection among circumcised men as compared to non-circumcised men in numerous population groups, however the task force did not choose to report this information.
The three RCTs, even if they are correct, studied HIV transmission among adults in Africa. They are not applicable to children in North America. Nevertheless, the task force has 4 attempted to use these RCTs to promote the practice of male circumcision in North America.
Urinary tract infection
The 2012 task force, in its zeal to promote male circumcision, has resurrected the UTI myth, which was partially debunked by the 1999 task force.31 Furthermore, Chessare (1992) showed, even if the claims about UTI were correct, that the complications from circumcision exceed the benefits from prevention of UTI.32 (The task force would not have read this significant paper because it was written in 1992.)
The best way to prevent UTI is breastfeeding, which is well known to the AAP,33 but the task force chose not to divulge this information to the public, apparently preferring to promote male circumcision, instead of child health.
Bacterial Vaginosis (BV)
The task force on circumcision proposes that male infants should be circumcised to protect unrelated adult women from BV! This is an absurd, ludicrous suggestion at best.
The studies that suggest male circumcision prevents BV were carried out in Africa and may not be relevant to North America. One study was authored by known pro-circumcision doctors associated with the Bloomberg School of Public Health,34 so it is likely to suffer from researcher bias. The other study found that black race, cigarette smoking, lack of vaginal H2O2-producing lactobacilli, and anal intercourse before vaginal intercourse were confounding factors.35 The science that supports this claim is extremely dubious at best.
Even if the science was indisputable, it is not clear that amputation of a body part from a child to help an unknown adult non-related party is in the child’s best interest. The task force on circumcision has not provided any evidence that a surgical excision operation of a healthy functional body part from a child to help an unknown adult party is in any child’s best interest.
In a few cases, organ removal has been found to be in the best interest of the child, if the organ removal is to help a family member, however that is not the case here. Parents may not grant surrogate consent to surgery unless it is the best interest of the incompetent child-patient.36
Sexual function and sensation.
The task force used dubious studies carried out in Africa by pro-circumcision researchers,37 38 studies that did not study the foreskin,39 40 and a telephone survey of questionable quality from Australia.41
The task force ignored significant findings that did not meet their objective. Solinis and Yiannaki (2007) studied couples and reported:
There was a decrease in couple’s sexual life after circumcision indicating that adult circumcision adversely affects sexual function in many men or/and their partners, possibly because of complications of surgery and loss of nerve endings.42
Frisch et al. (2011) reported:
Circumcision was associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in women, notably orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment. Thorough examination of these matters in areas where male circumcision is more common is warranted.43
Taylor (2007) speculated that the ridged band of the foreskin regulated the bulbo-cavernosus reflex.44 Podnar (2012) found that it is difficult to elict the bulbo-cavernosus reflex (now called the penilo-caversosus reflex) in circumcised men.45
The task force, inadvertently or intentionally, has withheld significant information on the adverse effect of circumcision on sexual function from the American people.
Lack of knowledge of the foreskin
The task force has displayed an appalling lack of knowledge of the human foreskin. The task force falsely claimed (citing Camille et al. 2002) that “adhesions (actually fusion, not adhesions) present at birth spontaneous dissolve by age 2 to 4 months” (p. e763), however Camille et al. actually said no such thing.46 Øster (1968) proved that the fusions break down slowly over a widely variable period of years and can last to as late as 17 years of age.
The task force says that penile wetness (subpreputial moisture) is “considered a marker for poor hygiene and is more prevalent in uncircumcised men than in circumcised men.” In actuality, sub-preputial moisture is completely normal in the intact male,47 and contains lyzozyme and other protective substances.
As one trial lawyer exclaimed. “if they are wrong about this, what else are they wrong about!”
It’s all about the money.
The AAP and the other trade associations are concerned about state Medicaid agencies stopping payment for unnecessary circumcision because their doctors get less money. The protection of the source of the money is so important to the AAP that a section on financing newborn circumcision by third-party payers has been included in this so-called medical position statement.
A careful reading of this 2012 Circumcision Policy Statement shows that it was created five years ago with the clear intention of making infant circumcision nearly universal in the United States. If this happened, the medical industry’s income from circumcision would increase from about $1.25 billion to about $2.25 billion. The AAP, ACOG, and AAFP apparently saw HIV infection prevention as the way to make this happen. Unfortunately for their scheme, the three African RCTs have been debunked in the five years that have elapsed since the formation of the task force.
One apparent purpose for this statement is to cause taxpayer-funded Medicaid to start paying doctors to perform non-therapeutic, unnecessary circumcisions again.
To increase the income of their members (fellows), these trade associations are willing to put all American boys under the circumcision knife for amputative surgery.
The 2012 Circumcision Policy Statement was created by a team put together for the specific purpose of protecting the goose that lays golden eggs for the medical industry. None of the members had any specific expertise in circumcision. They collected a lot of literature but ignored older but useful studies. The advice given by this Circumcision Policy Statement is designed to support the continuation of an income stream for its stakeholders and also to protect ritual circumcision by mis-application of ethical and legal rules for therapeutic operations to a non-therapeutic operation.
The American Academy of Pediatrics – and more importantly the vulnerable children they claim to protect – would have been better served had the task force been fully neutral. Rather than choosing individuals with ethnic, religious, financial, professional, and even psychological motives to continue the practice of circumcision, a better choice would have been an unpaid group of volunteers, with no financial or cultural stake in the procedure
A group composed of Europeans, medically trained and some not, from historically non-circumcising cultures, would have much more scientifically honest and more credible.
This the AAP failed to do."
The Canadian Paediatric Society, the British Medical Association, the Royal Dutch Medical Association, and the Royal Australasian College of Physicians have issued statements that stand in opposition to this new position of the AAP.
Government and insurance company officials should be aware that the claims of this statement are designed to protect third-party payment and should not be considered genuine medical advice.
The American public should have none of this. The public should reject the 2012 AAP Circumcision Policy Statement.
The American Academy of Pediatrics has overplayed its hand and should repudiate this travesty of a medical article immediately, before it loses even more credibility.
1 Task force on circumcision. Circumcision policy statement. Pediatrics 2012;130(3):
2 Task force on circumcision. Technical report. Pediatrics 2012;130(3):e758-e785.
3 Diekema DS, et al. Ritual Genital Cutting of Female Minors. Pediatrics 2010; 125(5):1088-93. doi: 10.1542/peds.2010-0187.
4 Position Paper on Neonatal Circumcision and Genital Integrity. West Lafayette, Indiana: International Coalition for Genital Integrity, 2007.
5 Cadman D, Gafni A, McNamee J. Newborn circumcision: An economic perspective. Can Med Assoc J, 1984;131:1353-5.
6 Lawler FH, Bisonni RS, Holtgrave DR. Circumcision: a decision analysis of its medical value. Family Medicine. 1991; 23(8):587-93.
7 Ganiats TG. Humphrey JB. Taras HL. Kaplan RM. Routine neonatal circumcision: a cost-utility analysis. Med Decis Making. 1991; 11(4):282-93.
8 Van Howe RS. A cost-utility analysis of neonatal circumcision. Med Decis Making 2004;24:584-601.
9 Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-5.
10 Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Inf 1998;74(5):364-7.
11 Cold CJ, Taylor JR. The prepuce. BJU Int 1999; 83, Suppl. 1: 34-44.
12 Union Pacific Railway Company v. Botsford, 141 U.S. 250 (1891).
13 International Covenant on Civil and Political Rights, Article 9 and 24.
14 Task force on circumcision. Circumcision policy statement. Pediatrics 1999;103(3):686-93.
15 Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995;95(2):314-7.
16 E. (Mrs.) v. Eve. 2 S.C.R. 388 (1986).
17 Secretary, Department of Health and Community Services v. J.W.B. and S.M.B. (Marion's Case.) (1992) 175 CLR 218 F.C. 92/010.
18 Langericht Köln. (7 Mai 2012) Urteil 151 Ns 169/11.
19 Fleischman AL, Nolan K, Dubler NN, et al. Caring for gravely ill children. Pediatrics 1994;94:433-9.
20 Goldman R. The psychological impact of circumcision. BJU Int. 1999; 83 Suppl 1:93-103. doi:10.1046/j.1464-410x.1999.0830s1093.x.
21 Boyle GJ, Hill G. Circumcision-generated emotions bias medical literature. BJU Int 2012;109:e11. doi:10.1111/j.1464-410X.2012.10917.x
22 Wikipedia. q.v. Medical analysis of circumcision. Accessed August 25, 2012.
23 Van Howe RS. Does circumcision influence sexually transmitted diseases?: A literature review. BJU Int 1999; 83, Suppl 1:52-62.
24 Dickson NP, Van Rood T, Herbison P, Paul C. Circumcision and risk of sexually transmitted infections in a birth cohort. J Pediatr 2008;152:383-7. DOI: 10.1016/j.jpeds.2007.07.044
25 Dowsett GW, Couch M. Male circumcision and HIV prevention: is there really enough of the right kind of evidence? Reprod Health Matters 2007;15(29):33-44.
26 Green LW, McAllister RG, Peterson KW, Travis JW. Male circumcision is not the HIV ‘vaccine’ we have been waiting for! Future HIV Therapy 2008;2(3):193-9.
27 Sidler D, Smith J, Rode H. Neonatal circumcision does not reduce HIV/AIDS infection rates. S Afr Med J 2008;98(10):762-6.
28 Myers A, Myers J. Rolling out male circumcision as a mass HIV/AIDS intervention seems neither justified nor practicable. South Afr Med J 2008;98(10):781-2.
29 Van Howe, Storms MS. How the circumcision solution in Africa will increase HIV infections. Journal of Public Health in Africa 2011; 2:e4 doi:10.4081/jphia.2011.e4
30 Boyle GJ, Hill G. Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. J Law Med (Melbourne) 2011;19:316-34.
31 Task force on circumcision. Circumcision policy statement. Pediatrics 1999;103(3):686-93.
32 Chessare JB. Circumcision: Is the Risk of Urinary Tract Infection Really the Pivotal Issue? Clinical Pediatr 1992 31(2):100-4.
33 AAP Workgroup on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 1997;100(6)1035-9.
34 Gray RH, Kigozi G, Serwadda D, et al. The effects of male circumcision on female partners’ genital tract symptoms and vaginal infections in a randomized trial in Rakai, Uganda. Am J Obstet Gynecol. 2009;200(1):42.e1–e7.
35 Cherpes TL, Hillier SL, Meyn LA, et al. A delicate balance: risk factors for acquisition of bacterial vaginosis include sexual activity, absence of hydrogen peroxide-producing lactobacilli, black race, and positive herpes simplex virus type 2 serology. Sex Transm Dis. 2008;35(1):78–83.
36 J. Steven Svoboda, Robert S. Van Howe, James G. Dwyer, Informed Consent for Neonatal Circumcision: An Ethical and Legal Conundrum. 17 J Contemporary Health Law Policy 61 (2000).
37 Kigozi G, Watya S, Polis CB, et al. The effect of male circumcision on sexual satisfaction and function, results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakai, Uganda. BJU Int. 2008;101(1):65–70.
38 Krieger JN, Mehta SD, Bailey RC, et al. Adult male circumcision: effects on sexual function and sexual satisfaction in Kisumu, Kenya. J Sex Med. 2008;5(11):2610–22.
39 Bleustein CB, Fogarty JD, Eckholdt H, Arezzo JC, Melman A. Effect of circumcision on penile neurologic sensation. Urology. 2005;65(4):773–77.
40 Payne K, Thaler L, Kukkonen T, Carrier S, Binik Y. Sensation and sexual arousal in circumcised and uncircumcised men. J Sex Med. 2007;4(3):667–74.
41 Richters J, Smith AMA, de Visser RO, et al. Circumcision in Australia: prevalence and effects on sexual health. Int J STD AIDS 2006;17:547–54.
42 Solinis I, Yiannaki A. Does circumcision improve couple's sex life? J Mens Health Gend 2007;4(3):361.
43 Frisch M, Lindholm, Grønbæk M. Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. Int J Epidemiol 2011;40(5):1367-81. doi:10.1093/ije/dyr104.
44 Taylor JR. The forgotten foreskin and its ridged band. J Sex Med 2007;4(5):1516. doi:10.1111/j.1743-6109.2007.00588.x
45 Podnar S. Clinical elicitation of the penilo-cavernosus reflex in circumcised men. BJU Int 2011;209:582-5. doi:10.1111/j.1464-410X.2011.10364.x.
46 Camille CJ, Kuo RL, Wiener JS. Caring for the uncircumcised penis: What parents (and you) need to know. Contemp Pediatr 2002;11:61.
47 Parkash S, Raghuram R, Venkatesan, et al. Sub-preputial wetness - Its nature. Ann Nat Med Sci (India) 1982; 18(3): 109-12.
August 26, 2012.