Response to the American Academy of Pediatrics (AAP) Circumcision Policy Statement
Also available here. (full text below)
The endless search for a medical benefit of circumcision, from treating epilepsy, irritability, and masturbation in the late 1800s to preventing sexually transmitted diseases today, has always been suspect.
Close examination reveals that psychological factors affect every aspect of the practice, including who chooses to study circumcision, what questions are studied and what questions are ignored; which studies are approved for publication and which studies are rejected; what circumcision information is communicated to parents and what information is withheld from parents; what recommendations are made by policy committees and what recommendations are ignored; and what circumcision information is reported in the media and what information is withheld from the public.
The circumcision literature reflects the pro-circumcision bias of circumcised American researchers who seek to find benefits and avoid studying the harms of circumcision. The answer to the research question depends on what question is chosen as the focus of the research. The pro-circumcision bias in American medicine reflects the pro-circumcision bias in American culture. The United States is the only country in the world that circumcises many of its male infants for non-religious reasons.
Read what non-US physicians think about the AAP report on circumcision.
- The AAP report conflicts with positions in other countries that recommend against circumcision or are discussing restricting it. Other countries recognize the inherent physical, sexual, and psychological harm of circumcision and that it violates medical ethics to cut off a natural, healthy, functioning body part.
- The effects of circumcision pain and changes in infant behavior after circumcision are not mentioned in the AAP report. Studies show that circumcision is significantly painful, traumatic, and affects the brain as evidenced by large increases in heart rate, blood pressure, and stress hormone levels during circumcision. Some infants do not cry because they go into shock. After circumcision there are changes in infant behavior, sleep patterns, activity level, more irritability, and there are disruptions in mother-child bonding and feeding. Anesthetics, if used, consist of injections into the penis and do not eliminate circumcision pain.
- All circumcision risks and ethical objections to circumcision are not mentioned in the AAP report. Circumcision has about two dozen surgical risks including, in rare cases, death. Some doctors and nurses refuse to perform or assist with circumcisions because of ethical considerations.
- The AAP report does not mention the anatomy and functions of the foreskin. Based on medical studies, circumcision removes up to one-half of the erogenous tissue on the penile shaft. The adult foreskin is a double layer, a movable sleeve equivalent to approximately twelve square inches. Medical studies have shown that the foreskin protects the penile head, enhances sexual pleasure, and facilitates intercourse. (Common sense check: If the AAP used common sense, they would realize that missing twelve square inches of erogenous tissue would have an adverse effect on sexual function.)The AAP deleted information about the functions of the foreskin in a pamphlet for parents.
- The AAP report does not examine the connection between circumcision and erectile dysfunction though it is reported in the medical literature. Cutting off the foreskin removes several kinds of specialized nerves and results in the thickening and progressive desensitization of exposed erogenous tissue that would normally be protected by the foreskin. In a 2011 survey, circumcised men were 4.5 times more likely than those who were not circumcised to use an erectile dysfunction drug.
- The AAP report does not mention psychological harm. Some dissatisfied men report wide-ranging psychological consequences of circumcision including anger, a sense of loss and sadness, and sexual anxieties. Reduced emotional expression and the avoidance of intimacy may also be related to circumcision. Most circumcised men may seem satisfied because they accept cultural beliefs about circumcision and may not understand what circumcision is and the benefits of the foreskin. They may suppress certain feelings about circumcision because they are too painful. They also may not disclose these feelings due to fear of being dismissed or ridiculed.
- The AAP report is influenced by personal, cultural, financial, and professional conflicts of interest.These factors include committee members’ circumcision status, number of circumcisions performed, circumcision status of any male children, and religious or ethnic background.
- The AAP report inflates the potential benefits by stating in its summary, for example, that circumcision “prevents” penile cancer. A closer look at the report text shows that the incidence of penile cancer is 0.58 case in 100,000 in the United States, where circumcision is common, and 0.82 case in 100,000 in Denmark, where circumcision is rare. According to studies cited in the report, between 909 and 322,000 circumcisions would be required to prevent one case of penile cancer. (Common sense check: Do these numbers support circumcision to “prevent” penile cancer?)
- The AAP report inflates the potential benefits by stating in its summary, for example, that circumcision “prevents” urinary tract infection (UTI). The report text states, “Given that the risk of UTI among this population [boys under age 2] is approximately 1%, the number needed to circumcise to prevent UTI is approximately 100.” Therefore, 99 boys out of 100 receive no UTI “benefit” from circumcision. UTI is treatable with antibiotics. Good medical practice requires the least intrusive form of effective treatment. All the claimed “preventive health benefits” are debatable and insignificant.
- “Preventive [or potential] health benefits” are not actual health benefits. The overwhelming majority of males who are not circumcised will not get these infections or diseases. Therefore, circumcision does not give them any health benefit.
- Professionals have challenged many studies cited by the AAP report. For example, the AAP report mentions studies that claim reduced HIV transmission in Africa for circumcised men. However, (1) About 60 circumcisions were required to prevent one HIV infection. (2) The studies did not seek to determine the source of the HIV infections. Most HIV infections in Africa are transmitted by contaminated injections and surgical procedures. (3) The studies were not consistent with other evidence. (4) In Europe, where circumcision is rare, there is no increase in the incidence of HIV transmission. (5) Studies of African adults cannot be applicable to American infants.
- In its discussion of over three pages attempting to show that circumcision reduces STDs, the AAP report does not mention the word “condom.” Condoms are much more effective (99%) than circumcision, less invasive, much less costly, and they protect women from infection. (Common sense check: If a condom is better than circumcision, why circumcise?)
- The AAP report even attempts to make an issue of penile hygiene. In all previous AAP reports, hygiene is not an issue. For example, according to the 1999 report, “there is little evidence to affirm the association between circumcision status and optimal penile hygiene.”
- The AAP report ignores serious ethical questions connected with cutting off an important, healthy, and irreplaceable part of a child’s body without medical justification.
- The AAP Committee on Bioethics report states, “Pediatric health care 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… .[T]he pediatrician’s responsibilities to his or her patient exist independent of parental desires or proxy consent.” For these reasons, some physicians and nurses refuse to circumcise for ethical reasons. Yet the AAP report concluded that it is “legitimate” to circumcise if the parent requests it for nonmedical reasons. These two reports of the AAP are in conflict. This office wrote to a member of the AAP Committee on Bioethics requesting comment on this conflict. No response was received. (See bottom of page with letter to Susan Blank, Chair of the AAP Task Force on Circumcision.
- Circumcision violates the Golden Rule. Adults would not consent to having a healthy genital part cut off, with or without pain medication. Yet adults put a helpless, vulnerable, sensitive newborn child through this painful ordeal.
- According to an article in the medical literature, circumcision violates all seven principles of Medical Ethics. (Denniston, G., “Circumcision and the Code of Ethics,” Humane Health Care International 12 (1996): 72-74)
- The AAP report lacks balance. It uses much more space discussing potential benefits as compared to potential harms. This is consistent with their “Statement of the Issue” which only refers to “possible benefits” and ignores harms. The “Literature Search Overview” also ignores topics and questions related to harms, which are different from risks and complications.
- In its recommendations for future research, the AAP report calls for research into potential benefits. There is no mention of future research into the harm. Unexplored areas include testing male infants, older children, and adults for changes in feelings, attitudes, and behaviors (especially antisocial behavior); physiological, neurological, and neurochemical differences; and sexual and emotional functioning. For example, the effect of circumcision on male distrust, anxiety, and anger toward women is unrecognized and unexamined. Do the psychological and sexual consequences of circumcision affect America’s uniquely high divorce rate? We do not know. Circumcision is traumatic and changes the brain. Does circumcision affect the prevalence of autism and ADHD which both occur about four times more often in boys than in girls? We do not know. Sudden infant death syndrome occurs more often in boys than in girls. The rise and fall of male infant mortality correlates with the rise and fall of the circumcision rate. Is circumcision a contributing factor? We do not know.
- The AAP report does not mention physician coercion and unauthorized circumcisions. The previous 1999 AAP report warned physicians that parents should not be coerced by medical professionals to choose circumcision, suggesting that some medical professionals have coerced parents to choose circumcision. In fact, some infants have been circumcised even though parents explicitly requested no circumcision.
- The AAP report ignores difficulties with informed consent. The report notes that informed consent “obligates the clinician to explain any procedure or treatment and to enumerate the risks, benefits, and alternatives so the patient can make an informed choice.” (Of course, this cannot happen because the patient is the child.) A physician cannot do this if the physician is not aware of information omitted from the AAP report. Some physicians describe circumcision as not painful, just causing “discomfort.” Few physicians know the functions of the foreskin and are aware of the sexual and psychological effects of circumcision.
- The AAP report attempts to shift responsibility for circumcisions to the parents, but physicians are the ones doing the cutting. This is the only instance where laypeople make the decision about whether or not to operate.
- The underlying flawed assumption is that the way to evaluate circumcision is to perform medical studies. This assumption reflects the values and biases of medical doctors. Most medical studies are flawed. Most of the world rejects circumcision as a harmful genital surgery. They do not need medical studies. All they need are feelings and common sense. Watch a circumcision video and trust your feelings. Does it make sense to cut off a natural, healthy, functioning body part? Would you want anyone else to make that decision about your body? Medical doctors often ignore feelings and common sense.
Tell the AAP what you think of their report at http://www.facebook.com/AmerAcadPeds (under August 27, 2012) and http://pediatrics.aappublications.org/letters/submit/pediatrics;peds.2012-1989v1.
Read letters published by the journal Pediatrics that comment on the AAP circumcision policy.
Read what non-US physicians think about the AAP report on circumcision.