The American Academy of Pediatrics (AAP) revised statement on male infant circumcision claims “the benefits of circumcision may exceed the risk of complications” but the AAP fails to recognize the sensory and mechanical function of the human foreskin. The foreskin is richly innervated, erogenous tissue which enhances sexual pleasure and it also provides a unique, linear gliding mechanism during sexual intercourse. In 2009, the College of Physicians and Surgeons of British Columbia stated “the foreskin is rich in specialized sensory nerve endings.” In 2010, the Royal Australian College of Physicians stated “the foreskin is a primary sensory part of the penis, containing some of the most sensitive areas of the penis” and in the same year, the Royal Dutch Medical Association concluded “the foreskin is a complex erotogenic structure that plays an important role in the mechanical function of the penis during sexual acts.” The AAP statement fails to consider the obstinate relationship between structure and function as it pertains to the foreskin; circumcision alters the structure of the penis which inevitably alters function. The long term harm and sexual side effects of circumcision have not been adequately studied.
The revised statement also claims “circumcision may decrease the risk of heterosexual HIV transmission” and is supported with selective evidence from randomized control trials from Kenya, Uganda and South Africa. These trials reveal a number of methodological weaknesses and they contradict larger demographic trends in global HIV prevalence. For instance, the United States has a high prevalence of circumcision, yet has a significantly higher rate of HIV infection compared with countries like Sweden and Japan where the prevalence of circumcision is very low. Behavioural factors greatly overshadow any potential protective effect of circumcision and should be the focus of effective and ethical prevention strategies. Even if the African trials were scientifically valid, the evidence can not be applied to justify infant circumcision in North America where the incidence of heterosexual HIV transmission is low.
The revised statement also claims “circumcision may decrease the risk of urinary tract infections” yet the AAP ignores the wealth of international medical evidence to the contrary. Even if circumcision provided complete protection against urinary tract infections, this practice could never be justified based on the ethical principle of proportionality – there are effective and less destructive therapies available for preventing and treating urinary tract infections which do not involve the prophylactic removal of healthy genital tissue.
The AAP’s revised statement ignores the inherent conflict of circumcision with contemporary medical ethics. Infant circumcision violates the fundamental ethical principles of autonomy, beneficence and primum non nocere. Medical associations in the Netherlands, Finland, Sweden, Norway, Denmark, Germany and other countries have stated that there is no justification for performing the procedure without medical urgency. Medical associations in these countries are calling for the practice to stop due to ethical and human rights concerns. The AAP’s new position statement does a disservice to American parents and children.
Respectfully, Christopher L. Guest M.D., F.R.C.P.C.