Statement by Statement Analysis of the 2012 Report from the American Academy of Pediatrics Task Force on Circumcision: When National Organizations are Guided by Personal Agendas II
by Robert S. Van Howe, MD, MS, FAAP Professor and Interim Chair of Pediatrics Central Michigan University College of Medicine
In September of 2012, the American Academy of Pediatrics Task Force on Circumcision released its report, which concluded that the benefits of the procedure outweighed the risks. A close analysis of the report reveals the Task Force used a selective, subjective and biased bibliography to support their predetermined conclusions. The Task Force neglected to discuss the anatomy, function, and normal development of the foreskin, nor did they discuss the harm or ethical consequences associated with circumcision. The Task Force deviated from standard practices in its analysis of the medical literature thereby producing a report that falls far below the quality standards set by other AAP policy statements. The report promoted expansion of the procedure as well as the revenue streams for those who perform it. Since release of the report, other national medical organizations have rejected infant circumcision as unwarranted medically and as ethically unacceptable. No organizations outside of the United States have adopted their conclusions. The report is poorly written, poorly researched, makes unsubstantiated claims, and reaches an illogical conclusion. Introduction In the weeks following the release of the report from the American Academy of Pediatrics (AAP) Task Force on Circumcision in September of 2012, I went through the report statement and compiled my critique of their statement. I shared this critique with a handful of people at that time. In December 2014, the Centers for Disease Control and Prevention (CDC) subjected their “draft recommendation” to public comment. As a peer-reviewer selected by the CDC, I wrote and submitted a detailed commentary, which can be found at Academia.edu. Given the effort I had previously put into providing a critique of the AAP’s 2012 report, it is time to update my analysis of the AAP’s misguided statement and distribute it more widely.
1. Recommendations are predetermined and supported by a selective bibliography.
2. There is a failure to adequately research the topics and medical evidence.
3. There is a failure to assign the appropriate weight to the evidence with a tendency to give more weight to evidence that supports circumcision and less weight to evidence that does not support circumcision, even between studies of similar design.
4. There is a failure to evaluate the quality of individual publications using standard methods.
5. There is a failure to recognize or discuss the value and function of the foreskin.
6. There is a failure to recognize the value and human rights of the infant.
7. Conclusions are reached despite no evidence to support them.
8. The report is more reflective of the make-up of the committee rather than medical evidence.
9. A key element of this report is to assure that parents can continue to request infant male circumcision, so that physicians can continue to be paid for performing this procedure.
10. Consistent disdain is expressed toward males who have an intact penis: the term “uncircumcised” is pejorative, inflammatory, and a form of bias consistent with hate speech.
11. There is an underlying racist/anti-immigrant theme.
12. Pieces of information are extracted from citations and used to support their agenda, but other pieces of information from the same citation that do not support their agenda are ignored.
13. There is a failure to acknowledge studies that do not support the benefits of circumcision.
14. The work of scientists who question the validity of the medical benefits of circumcision is routinely attacked.
15. The report was two years out of date at the time it was released.
1. Human rights and bioethics, including the right to an open future.
2. The most common complication of circumcision, meatal stenosis, as well as the myriad of other complications.
3. The anatomy of the normal, complete, intact penis.
4. The histology, anatomy, and function of the foreskin.
5. The psychological sequelae of circumcision.
6. The harms and risks associated with circumcision.
7. Cost utility analysis. 8. Contrary evidence and opinions.
9. Incidence of phimosis and balanitis in intact boys.
10. Non-specific urethritis and the overall risk of sexually transmitted infections.
11. The impact of risk compensation.
12. Positions taken by other national medical organizations throughout the world.
Statement 1: “Male circumcision consists of the surgical removal of some, or all, of the foreskin (or prepuce) from the penis.”
Comment: Accurate, but incomplete, and below academic standards. It does not adequately describe the foreskin as functional, erogenous tissue. The Task Force fails to mention the anatomy, histology, physiology, or sexual functions of the foreskin. This is unacceptable since most medical reviews and discussions begin with a complete scientific discussion of the basic anatomy, histology, and physiology in regards to the organ, or disease, being discussed before moving on to other topics of pathophysiology, disease, epidemiology, and treatment. In the 1984 AAP pamphlet “Care of the Uncircumcised Penis” the functions of the foreskin are discussed. In subsequent versions of the same pamphlet dropped the discussion of the subsequent versions of the same pamphlet dropped the discussion of the functions of the foreskin as though they never existed. When contacted, officials from the AAP are unable identify why this information was removed from the pamphlet.
The weaknesses and biases of the AAP policy are bad enough, but a more fundamental question is why and whether we need a policy on circumcision in the first place. No other AAP policy document focuses so obsessively on a particular procedure or on a particular element of a bodily organ – for make no mistake, any circumcision policy is really a report card on the foreskin itself. We don’t see policy statements on the liver, the nose or the heart, but rather on the diseases and other problems that affect those organs; we don’t find suspicious and hostile criticisms of those organs, but advice on how to manage such problems with a view to protecting and preserving them. The AAP has policies on sinusitis, the management of liver cancer and heart disease – and a policy on the foreskin, as though it was some sort of cancerous growth or disease that needed to be “dealt with”. Clearly, something very strange is going on here.
The odd thing is that the original purpose of circumcision policy statements issued by paediatric bodies in the early 1970s was to stop circumcision. Routine circumcision had become entrenched in Anglophone medical practice during the first half of the twentieth century, but by the 1960s paediatricians (child health specialists) had become aware that the operation was causing much harm and not doing any obvious good. The harms were not merely a high incidence of complications, but a flood of damaged penises, so scarred and distorted that one Australian doctor reported that he was “appalled at the phallic mutilations exhibited by many of these children, some of whom have even been subjected to a subsequent “tidying up” procedure after being badly mauled in infancy” (A. Clements, Medical Journal of Australia, 29 April 1972, 946). Circumcision policy statements issued by paediatric bodies in Australia, Canada and the United States were intended to halt this butchery by reassuring parents and doctors that the foreskin was not pathogenic or any kind of problem, but a normal element of the male genitals that could safely be left to its own devices.
These statements had a substantial impact in Australia, where circumcision incidence plummeted from more than 80% in the 1950s to less than 12% by the mid-1990s. There was a moderate decline in Canada, but only a slight fall in the USA, where incidence actually rose after the AAP’s first policy statement in 1971. It did not begin to decline until the mid-1980s, and even then only after agitation by community-based anti-circumcision groups.
Why is the United States different?
One of the reasons for this exceptionalism is that in the USA routine circumcision is not the province of paediatricians (who are left with the sad job of repairing the botches), but of obstetricians and gynecologists. They had taken over the operation in the 1930s, assisted by the invention of the Gomco circumcision clamp by obstetrician Hiram Yellen, and had incorporated it as a routine step in the childbirth process – a procedure no more optional or problematic than tying off the umbilical cord. As Miller and Snyder wrote rapturously in 1953, “the obstetrician finishes his episiotomy, walks across the hall and circumcises the infant, and is finished with the whole business. The time saved for both the physician and nursing staff is considerable”; even better, “no babies are forgotten and left uncircumcised.” For reasons of professional pride, emotional commitment and financial advantage, the obgyns have not been keen to give the practice up.
Another reason was pressure from religious minorities, worried that if circumcision generally was abandoned it would become difficult to maintain traditional circumcision practices within their own communities. (Translated: if Jewish boys saw that other boys their age had their foreskin, they would want one too.) The fear became more intense after the passage of the United Nations Convention on the Rights of the Child in 1989, with its threatening provision in Article 24 (3): “States Parties shall take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children”. Even worse, this was followed by the passage of legislation in many countries to prohibit and criminalise any form of female genital cutting. Jewish and Muslim religious leaders were afraid that such legislation would lead to demands that similar protection be given to boys – a fear that has proved well-founded.
In response to this threat, the conservatives took advantage of the obvious loophole in the CRC – the reference to “prejudicial to health”. If it could be shown that circumcision was not prejudicial to health (i.e. harmful) or, even better, that it was beneficial, the situation would be saved: genital cutting of girls could be banned as harmful (and condemned as FGM), while circumcision of boys was preserved, and even promoted as a boost to male reproductive health. The most masterly exponent of this strategy was Edgar Schoen, an MD employed by Kaiser Health (a leading supplier of circumcision equipment and services), a fervent believer in circumcision, and a prolific contributor to medical journals, among whose editors he had many friends. His presence on the AAP taskforce that produced the 1989 policy statement ensured that the document adopted a more positive stance towards circumcision, asserting that it had definite health advantages, while not going so far as to recommend it. The tone of the policy was, however, more hostile than previously towards the foreskin, tending to picture it as a source of disease and a difficult problem for parents.
The battle intensified during the 1990s, as the grass-roots anti-circumcision forces grew more confident, and the conservative believers in circumcision scratched around for additional medical benefits. Urinary tract infections were suddenly found to be more common in uncircumcised boys, and the arrival of HIV-AIDS offered hope that a foreskin-HIV link could be found if the researchers were given enough money and worked hard enough.
The AAP’s 1999 policy statement was less pro-circumcision, reflecting the waning influence of Schoen (by then retired), and the rising importance of bioethical and human rights issues, the growing presence of the anti-circumcision movement, and an increasing body of circumcision-critical material in the professional literature. It was this Cold War stand-off that probably accounted for the long delay in the production of the next statement, not finalised and released until 2012. By then there had been two contradictory developments.
On the anti-circumcision front, both the Royal Dutch Medical Association and the Royal Australasian College of Physicians released statements critical of circumcision. The Dutch policy was stronger, finding nothing positive to say about circumcision, and forcefully rejecting it as medically harmful and ethically impermissible. The RACP was more cautious, but nonetheless agreed with Dutch concerns about bioethical and human rights issues, and concluded that routine circumcision was not warranted and should not be recommended. On the pro-circumcision front, the researchers finally managed to find evidence that circumcision of adults in some regions of sub-Saharan Africa could reduce the risk of female to male transmission of HIV during unprotected intercourse, a discovery that rapidly led to the funding of massive circumcision programs in the epidemic areas. The discovery and programs were not short of publicity, especially not after a naïve geek called Bill Gates was persuaded to provide a few hundred million dollars from his charitable foundation. (Though some cynics wondered whether Microsoft was really quite the most appropriate source for an anti-virus program.)
Out of Africa
The question then became whether the African revelations were relevant to infants and boys in developed countries, where HIV was not a heterosexual epidemic but a relatively rare disease largely confined to homosexual men and injecting drug users. Considering that the African Random Clinical Trial results were released in 2007 and the policies of the Dutch and the RACP in 2010, it is evident that Dutch and Australian health authorities judged the answer to be NO, and this attitude was soon shared by health authorities in other developed countries, with one exception: yes, the United States (as usual). A series of softening-up articles on the benefits of circumcision published in the Journal of the American Medical Association and other forums prepared the way for the AAP’s 2012 statement. This claimed that the results of the African RCTs, and a few related studies, constituted enough “new evidence” to justify a more positive stance towards circumcision: while the AAP could not go so far as to actually recommend it, the Task Force asserted that “the benefits exceeded the risks”, and left the impression (by insinuation and omission, rather than by explicit statement) that any parent who failed to take the hint and get his boys circumcised was really pretty irresponsible.
AAP strategy backfires
It did not take long for the flaws and gaps in the policy’s reasoning and evidence to attract numerous critiques, a reaction that rather surprised (and hurt) the Task Force, which seems to have thought that the authority of the AAP (as a powerful American institution) would crush opposition in the Unites States and impress medical organisations in other countries. On the contrary, as Professor Van Howe points out in his latest critique, the most striking result of the AAP’s efforts has been to reanimate the anti-circumcision forces:
“One of the unintended consequences of the release of the 2012 Report of the AAP Task Force on Circumcision is that it helped rally European physicians, ethicists, and legal scholars to protest the human rights abuses associated with the practice. In the wake of the report’s release, the Council of Europe and a number of national medical organizations in a variety of European countries have condemned the practice of newborn circumcision as a human rights violation. They have found the “benefits” of circumcision to be inconsequential. When responding to a letter written by 38 leading European medical experts that characterized the Task Force as “culturally biased,” instead of addressing the substantive issues raised, the Task Force responded with righteous indignation and issued a thinly-veiled accusation that the writers were anti-Semitic. …
“The irony is that their reactionary approach backfired. When the Task Force led the charge to preserve infant circumcision, they were hoping to attract the attention of Americans and bring the Europeans, who had to that point remained silent on the issue, in line behind them. Instead, it woke up the sensibilities of the Europeans, which has now been noticed by many Americans, leading them to question the practice of infant circumcision in increasing numbers. By overreacting and putting out a statement based on cultural beliefs and personal preference rather than on science, the Task Force members have embarrassed themselves, the members of the American Academy of Pediatrics, and American physicians generally. What is interesting is the pro-circumcision physicians who have infiltrated the Centers for Disease Control and Prevention tried the same tactic in late 2014 by issuing a “draft recommendation,” which took seven years to develop, was short on science and execution, and it was based primarily on cultural factors. Unlike the Task Force report, a public commentary period was required for their “draft recommendations.” Of the thousands of comments submitted, over 95% exposed the scholarly dishonesty of their draft.”
And not only European physicians: papers published by Australian child health experts have tacitly rejected the AAP position, and the cruelest blow was delivered by the Canadians: far from endorsing or following the US position, as was widely expected, the updated policy of the Canadian Paediatric Society maintained its recommendation against routine circumcision. Et tu, Brute?
Now that the AAP is completely isolated in its (admittedly equivocal) support for circumcision, the question is how long the 2012 policy can survive. If its flaws are as great as Professor Van Howe contends, our conclusion must be that it should never have been issued, and that the AAP ought to get to work on a new one as soon as they can muster a competent team.
Why have a policy on circumcision at all?
But why have a policy on circumcision in the first place – remembering that it is really a policy on the foreskin: should it be allowed to survive, or should it be condemned as a menace to society (as Dr Peter Charles Remondino insisted in the 1890s)? Health authorities do not prepare policies on other bodily organs – liver, spleen, scrotum, breast etc – but rather on how to manage disorders that affect them. The only comparable policies are those condemning any form of female genital cutting, but these do not single out the clitoris, labia or female prepuce as objects of suspicion. What makes the genitals so special? Could it be, as Professor Van Howe suggests, their cultural, religious and social significance, rather than their role in the physiology and anatomy of the body, that makes the difference?
Had circumcision not been introduced by anti-sex doctors in the nineteenth century it would not, of course, be necessary to have a policy on circumcision at all. Countries outside the Anglophone world, where circumcision did not become established, have never felt the need for a such a policy – at least, not until the increasing Muslim presence and the recent provocation from the AAP made them wonder. But in the Anglophone world doctors did introduce circumcision, and it is only right and proper that they should take responsibility for putting a stop to it. If we take Jonathan Hutchinson’s claim about the value of circumcision as a preventive of masturbation and syphilis, aired in the mid-1850s, as the starting-point of circumcision advocacy, we can see that it took about a century of medical propaganda for circumcision to become routine and ubiquitous, reaching its zenith of popularity in the 1950s and 60s. With that example in mind, we may reasonably infer that it will take another century for the practice to die out, along with the Old Guard generation that believes in it. If we take Douglas Gairdner’s celebrated paper of 1949 as the beginning of the end, we may reasonably expect circumcision to have been pretty much eradicated by the middle of this century. That may seem like the distant future, but there are only 34 years separating us from 2050, almost exactly a single generation. It took well over 100 years to abolish slavery, and I think we can be confident that we will be able to eliminate circumcision without the need for a civil war.