The policy statement on circumcision (i.e. non-therapeutic circumcision of normal male infants and boys) released in September 2012 by the American (i.e. United States) Academy of Pediatrics is meeting a growing chorus of disapproval, rejection and ridicule. Child health experts in Europe and Canada; paediatricians and human rights lawyers in the United States; and a medical historian in Australia have all recently condemned the policy statement for failing to respect the bodies and advance the best interests of the very group that the AAP is (supposedly) dedicated to protecting - that is, children. If the AAP is not there to promote the best interests of children, what is it there for?
In an article published in the AAP house journal Pediatrics, child health experts from Austria, Britain, Denmark, Estonia, Finland, Germany, Iceland, Latvia, Lithuania, Norway, Sweden, the Netherlands, Canada, the Czech Republic, France and Poland have condemned the statement as unbalanced, tunnel-visioned, ignorant, wrong on many medical issues, and grossly inadequate in the all-important areas of medical ethics and human rights. The abstract of the article states:
The American Academy of Pediatrics (AAP) recently released its new technical report and policy statement on male circumcision, concluding that current evidence indicates that the health benefits of newborn male circumcision outweigh the risks. The technical report is based on the scrutiny of a large number of complex scientific articles. Therefore, while striving for objectivity, the conclusions drawn by the eight task force members reflect what these individual doctors perceived as trustworthy evidence. Seen from the outside, cultural bias reflecting the normality of non-therapeutic male circumcision in the US seems obvious, and the report’s conclusions are different from those reached by doctors in other parts of the Western world, including Europe, Canada, and Australia. In this commentary, a quite different view is presented by non-US-based doctors and representatives of general medical associations and societies for pediatrics, pediatric surgery and pediatric urology in Northern Europe. To these authors, there is but one of the arguments put forward by the AAP that has some theoretical relevance in relation to infant male circumcision, namely the possible protection against urinary tract infections in infant boys, which can be easily treated with antibiotics without tissue loss. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts and penile cancer, are questionable, weak and likely to have little public health relevance in a Western context, and do not represent compelling reasons for surgery before boys are old enough to decide for themselves.
Source: Morten Frisch et al, Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision. Pediatrics 131, April 2013
See also the analysis by High Young, AAP task force reveals cultural bias while denying it
In the United States itself, a clinical professor in pediatrics and a human rights lawyer have condemned the policy as culturally biased and invalidated by its neglect of such crucial issues as the anatomy, physiology and functions of the foreskin, the harm and complications of circumcision, and whether the removal of body parts from healthy children can be justified within accepted principles of medical ethics and human rights. Writing in the Journal of Medical Ethics, pediatrician Robert Van Howe and lawyer J. Steven Svoboda argue that the AAP ignores so many important topics that it is hard to know where to begin the critique. Svoboda says: “For example, the anatomy and function of the foreskin are not mentioned. 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. 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.”
Van Howe and Svoboda accuse the AAP of cherry-picking articles that support circumcision, and of taking passages out of context from within articles that do not support it. They conclude that male circumcision should be neither recommended to parents nor funded by government insurance systems.
Abstract: The American Academy of Pediatrics recently released a policy statement and technical report on circumcision, in both of which the organisation suggests that the health benefits conferred by the surgical removal of the foreskin in infancy definitively outweigh the risks and complications associated with the procedure. While these new documents do not positively recommend neonatal circumcision, they do paradoxically conclude that its purported benefits “justify access to this procedure for families who choose it,” claiming that whenever and for whatever reason it is performed, it should be covered by government health insurance. The policy statement and technical report suffer from several troubling deficiencies, ultimately undermining their credibility. These deficiencies include the exclusion of important topics and discussions, an incomplete and apparently partisan excursion through the medical literature, improper analysis of the available information, poorly documented and often inaccurate presentation of relevant findings, and conclusions that are not supported by the evidence given.
Source: J. Steven Svoboda and Robert Van Howe, Out of step: Fatal flaws in the latest AAP policy report on neonatal circumcision. Journal of Medical Ethics, online first, 18 March 2013
See also the analysis by Hugh Young, AAP Circumcision Task Force fails again, 24 March 2013
Viewing the controversy from Australia, medical historian Dr Robert Darby considers the flaws of the new AAP policy in a updated version of The Sorcerer’s Apprentice –– his analysis of the United States obsession with circumcision, published as an e-book on Amazon. Dr Darby notes that the AAP has never released a policy on guns or firearms, and wonders how many American boys are killed or injured each year in firearms accidents. Does the AAP think that foreskins are a greater risk to child health than firearms? If not, why have a policy on circumcision but nothing on gun control or firearm safety?
He writes in the preface:
This short book is a revised and much expanded version of an article originally published in Contexts, magazine of the American Sociological Association, invited to coincide with the publication of my history of the rise and fall of circumcision in Britain (A Surgical Temptation) in 2005. An expanded version was published on my website (www.historyofcircumcision.net). Apart from a few references, that book did not cover the rise of circumcision in the United States, though it was the persistence of the practice there and its rather slow decline in Australia that led me to study the British experience in the first place. For this version I have further revised the essay and expanded it to include an explanation for the efforts to revive claims as to the “health benefits” of routine circumcision that began to appear in the early 1990s, and an examination of the climax of this trend in the latest policy statement on circumcision issued by the American Academy of Pediatrics in September 2012.
Non-therapeutic (routine) circumcision of male infants and boys has always been an anomalous practice, defying all the normal rules of evidence-based medicine, biomedical ethics and surgery. Although evidence-based medicine requires that treatments be based on proof of the intervention having a direct net benefit (in the promise-of-benefit/risk-of-harm calculus) for the recipients, most of the evidence for the prophylactic (disease-preventing) effects of circumcision are applicable to adult men and even adult women, not to the male infants undergoing the surgery. Recognised authorities on biomedical ethics hold that no treatment is permissible without the informed consent of the subject; that treatments must always observe the principles of autonomy, non-maleficence, beneficence, proportionality and justice; and that surrogate consent (for incapable subjects, such as infants and the disabled) is valid only when clearly in the subject’s best interests or – when it involves amputation of body parts – in life-threatening situations. In the normal course of events, surgery is regarded as appropriate only when there is a pathological condition requiring surgical treatment; unnecessary surgery is rightly regarded as cosmetic (or even bad) surgery, and prophylactic removal of healthy tissue and body parts has never become part of the medical mainstream – except in relation to tonsils (briefly) and foreskins. Because tonsils have no psychological, sexual or cultural significance, it proved far easier to drop routine tonsillectomy than to abandon circumcision.
On a world scale, routine circumcision has never attracted widespread support; it has always been a controversial and contested operation, with a vast and inconclusive literature, as enthusiasts and advocates endeavoured to make a convincing case against the foreskin. As I write this preface, the polarisation of opinion has reached a new pitch, further demonstrating that there is no consensus on this issue. In the United States medical authorities have just overturned forty years of disapproval by announcing that although the “health benefits” of circumcision are not great enough to recommend it as a routine, they are sufficient to allow parents to decide for their children and for medical insurance schemes to pay for it. In the Netherlands, by contrast, the Royal Dutch Medical Association has issued a powerful statement rejecting circumcision, warning that it is not merely of no medical value to children, but that it infringes their right to bodily integrity. In Germany a court has found that non-therapeutic circumcision constitutes bodily harm and is thus unlawful. In Australia the Tasmania Law Reform Institute has recommended that it be legally prohibited in most cases, with limited exemptions for religious practice. In Helsinki an international conference heard many speakers defend the right of all children to bodily integrity, and criticize unnecessary genital surgeries of all types, whether performed for medical or cultural reasons, and whether on boys, girls or intersex children.
Never before have American health officials been so out of step with world opinion – and indeed, with informed opinion even in their own country. Within a few days of the publication of the latest circumcision statement, vigorous, well-argued critiques had appeared on numerous websites and blogs. Even the New York Times, usually the most rabidly pro-circumcision newspaper on earth, greeted the statement with the headline “Benefits of circumcision SAID to outweigh the risks”, suggesting that it was not entirely convinced. To give a flavour of the debate, I have included the commentary from the Seattle-based group, Doctors Opposing Circumcision, as an appendix.
European rejection of the practice reminds us that routine circumcision was a strictly Anglophone phenomenon, generated in the late Victorian period when understanding of disease processes was primitive, there were few effective treatments, medical ethics were non-existent, masturbation (i.e. any pleasurable touching of the genitals) was regarded as both a disease and a moral crime, and children were not considered to have any rights at all. Times have changed, but less so in the United States than elsewhere. While Britain gave up circumcision in the 1950s, New Zealand in the 1960s, Australia in the 1970s-80s and Canada in the 1990s, the practice remained entrenched in the United States and probably did not reach its peak until the 1960s. Statements against the practice regularly issued by the American Academy of Pediatrics as from 1971 had little impact. It was one of those sad situations, like the mess caused by the sorcerer’s apprentice, where it proved easier to start a habit than to give it up it, and surprising, when so many other pre-modern shibboleths have gone by the board, even the taboo against homosexual behaviour. Americans today seem more comfortable with the idea of gay men having sex together and even marrying each other than with the prospect of uncircumcised heterosexual men having sex with their wives and girlfriends. How has it come about that Americans are more afraid of foreskins than of homosexuals? Why does a nation that prides itself on its individualism and love of freedom remain so keen on this mark of uniformity and submission?
In this short essay I cannot provide a comprehensive answer to these question, but I hope at least to raise the principal headings under which an explanation may be found. We shall see that it has far more to do with culture, religion, tradition, power and economics – in short, the desires of adults – than with the health and happiness of American children.
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