ILLINOIS: AAP's selective letter policy

Salon des Refusés

 September 13, 2012

The AAP gets letters - but so far, doesn't publish them

By Hugh Young
The American Academy of Pediatrics' publication, Pediatrics has been treating e-letters in reaction to its policy on circumcision very oddly.

The policy came out at midnight (ET) on August 27, 2012. In the following weeks, several letters have appeared, mainly critical of the policy (previously here, previously here and still here as of September 13, 0510 ET).

But more hard-hitting letters, despite being fully referenced, have not appeared, and others have been added and removed in capricious ways.

These letters were up for several days, but have since been removed:

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AAP Circumcision Policy Statement and Technical Report

James W. Prescott, Ph.D., Developmental Neuropsychologist BioBehavioral Systems

...

... strong objections to its principle findings and recommendations must be made.
It is not true that Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it.

The unresolved injuries and risks of inflicted pain have yet to be resolved ... . The analytic legal and judicial issues of inflicting pain upon an unconsenting person were not addressed ...

The forceable shredding of the foreskin from the glans--a fused biological organ in newborns and young children--is an act of torture, as is the stripping of the skin from the body is universally recognized as an act of torture that is prohibited by the Universal Declaration of Human Rights and the U.N. Convention on the Rights of the Child. a) No child shall be subjected to torture or other cruel, inhuman or degrading treatment or punishment

...

Judith Palfrey, M.D., Past President, American Academy of Pediatrics was compelled to renounce the AAP Bioethics Committee's policy statement on Ritual Cutting of Female Minors with the following statement: "The AAP does not endorse the practice of offering a "clitoral nick". This minimal pinprick is forbidden under federal law..." (17 May 2010).

...

The equal protection clause of the 14th Amendment to the US, Constitution extends the protection of PL 104-208 to male children ... To affirm that FGM and not MGM is an act of torture defies reality and judicial rulings.

The American Academy of Pediatrics has misused its authority by not addressing the analytic legal, judicial, cultural and religious history of genital mutilation that has so influenced medical opinion and practices throughout human history and has corrupted its current and wrongful recommendations on circumcision.

There are no religious rights or freedoms to inflict harm or injury upon another person contrary to the history of religious traditions and medical history.

There are no parental or medical rights to the sexual abuse of newborns/children, which genital mutilation entails. FIRST, DO NO HARM  

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Re:AAP Circumcision Policy Statement and Technical Report

Christopher R Lawson, Deputy Head
Sunshine Coast Clinical School, University of Queensland

Among many basic errors of epidemiology, the authors do not even understand how to calculate Number Needed to Treat. (From p. e767: "Given that the risk of UTI among this population is approximately 1%, the number needed to circumcise to prevent UTI is approximately 100.")

Two of the referenced papers from which this figure was derived, written by investigators who do understand how to calculate NNT, found respectively that 111 and 195 circumcisions were needed to prevent one UTI. These data were reported in the abstracts.

Finally, for the authors to say "Most available data were published before 1995 and consistently show an association between the lack of circumcision and increased risk of UTI" and then arbitrarily exclude all data prior to 1995 is an unforgiveable design flaw.

This paper is epidemiologically incompetent and an embarrassment to the AAP.

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EHR SIIS & Informed Consent Document Needed

Eileen M. Wayne, Director
InformedConsent.org, Inc. 501 C3

I am an informed consent expert witness. I represent the patient, not the patient's parents, surgeon, pediatrician, or religious representative.

Surgery requires a chief complaint, abnormal physical findings, and a pathological diagnosis. It requires signed, legal, informed consent. ...

Surgery in general, & amputative surgery in particular, must follow the rule of "Severity of Illness, Intensity of Service." Starting with local therapy, progressing to oral, then intravenous therapy, all must be documented to have failed before contemplating amputative surgery. ...

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These have been sent, but have not so far appeared:

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Neonatal Circumcision Violates Children's Rights, Needlessly Amputating Functional Tissue

J. Steven Svoboda,
Attorneys for the Rights of the Child

The long awaited circumcision policy statement from the American Academy of Pediatrics (AAP) may be most notable for what it does not address. The statement steadfastly omits any analysis of the foreskin, its erogenous, protective, and immunological functions, or crucially, the impact its removal has on normal sexual functioning and on the health and quality of life.

The AAP's Task Force on Circumcision ignores a child's well-established human and legal rights to decide for himself at an age of understanding whether he wants to part with his foreskin. Instead, the Committee says-with more honesty than ethics--that the common reluctance of an older child or adult to be circumcised justifies parents forcing a partial penile amputation upon him at an age when he is too small to effectively resist.

Male circumcision violates a child's right to bodily integrity, not to mention numerous civil and criminal laws. Malpractice awards are mounting up, including a recent $700,000 settlement reported in the Massachusetts Lawyers Weekly. The AAP's repeated suggestion that, "In most situations, parents are granted wide latitude in terms of the decisions they make on behalf of their children" badly misstates the law. In fact, starting in 1944 with Prince v. Massachusetts, courts have repeatedly affirmed that: "Parents may be free to become martyrs themselves. But it does not follow they are free, in identical circumstances, to make martyrs of their children before they have reached the age of full and legal discretion when they can make that choice for themselves."

Additionally, and perhaps even more egregiously, the AAP's policy statement contradicts its own bioethics policy statement, which affirms that parental wishes cannot justify unnecessary surgery and that "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." Moreover, according to this same bioethics policy statement, a "pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent."

One puzzling aspect of the AAP policy statement is a contradictory dance performed on the question of how strong the alleged benefits of the procedure are. On the one hand, there is no recommendation for universal neonatal circumcision, and it is admitted-as it previously stated in its 1999 policy statement--that the "health benefits are not great enough to recommend routine circumcision of all male newborns." Moreover, nowhere are the benefits and risks numerically compared, and the AAP repeatedly states that complication data is unknown. How then can it rationally conclude that, "Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks…?" And how can pediatricians be tasked by the AAP to "assist parents by explaining in a nonbiased manner, the potential benefits and risks…" despite the fact that the AAP says the risks are unknown?

The US has both the highest rate of circumcision and the highest rates of HIV and AIDS in the industrialized world, so a claim that the first can prevent the other two doesn't pass the smell test. The AAP admits as much by saying that "key studies to date have been performed in African populations with HIV burdens that are epidemiologically different from HIV in the United States." Moreover, the African studies were closer to a lowest common denominator than a "gold standard," suffering from numerous critical flaws including selection bias, randomization bias, experimenter bias, inadequate blinding, supportive bias, participant expectation bias, lack of placebo control, inadequate equipoise, attrition of subjects, failure to investigate non-sexual HIV transmission, lead time bias, and time-out discrepancy.  Additionally, the "60%" figure refers to the relative risk and seems calculated to deliberately mislead; the absolute risk reduction is only a measly 1.3%. As the AAP itself concedes, given vast differences in health conditions and modes of transmission between the US and Africa, the results can hardly justify infant male circumcision in the United States. Babies don't get HIV and AIDS from sexual contact.

In fact, not a single study has ever proven that circumcision has actually decreased any disease in the United States. Over a hundred boys die each year from this needless procedure, yet the AAP fails to attach much significance to the deaths stemming from the practice. Rather than objectively evaluating all available evidence, the AAP selectively quotes and references highly contested and controversial studies to attempt to justify an entrenched yet outmoded cultural-not medical-practice.

We were surprised to witness the reappearance of disproven justifications for circumcision such as urinary tract infections (UTIs), penile cancer, and even syphilis. The AAP also ignores the showing by Chessare that even if claims about UTIs are valid, the complications from the procedure exceed the benefits in preventing UTIs.

From there, matters become even more interesting and even less defensible. The AAP fancifully claims at several points, using slightly different language, "It is reasonable to take these non medical benefits and harms for an individual into consideration when making a decision about circumcision." In fact, few things are less reasonable and more unprecedented than physicians making medical decisions based on non-medical factors and vagaries of their infant patients' parents' culture and religion as central to whether to do a procedure. It is ironic that harms are improperly mentioned here but not properly discussed elsewhere. The other procedures that get cultural validation when medical basis is lacking can be counted on the fingers of zero hands.

Moreover, a huge logical hole appears when the policy statement suggests that, "Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families." One cannot coherently argue that circumcision is elective and of variable value at the individual level yet terribly important in a larger public health context.

The AAP selects, sometimes out of context, bits of language that seems to lend its position support, and completely ignores contradictory data. Thus the policy statement cites a study that proves that male circumcision removes the most sensitive part of the penis, then proceeds to ignore that inconvenient truth. The policy statement cites a study suggesting that circumcising men actually increases the HIV risk to heterosexual women and similarly ignores that uncongenial finding. Another study is introduced as evidence for circumcision helping prevent HIV, yet the AAP omits to mention that it also demonstrates that intact males who wait at least ten minutes after intercourse before wiping have a much lower rate of contracting HIV than do circumcised men. The policy statement cites a study showing that smoking and a narrow foreskin, not a normal one, contribute to penile cancer, yet the AAP ignores those findings as not supporting the circumcision juggernaut.

We question why the AAP is effectively recommending an unnecessary surgery at a time when the US faces a crisis in not being able to provide even necessary care for all our children. As was just demonstrated in a report by the Institute for Medicine, an astonishing $750 billion is wasted on health care each year in this country. Recently it was estimated that close to $2 billion of that amount may arise from this unnecessary and harmful procedure. In these days of rising medical costs and scarce resources, we simply cannot afford to continue to carry out such a harmful and outmoded practice.

Given the many virtues claimed for male circumcision by the AAP, one may be forgiven for wondering why European men are not falling down dead in the street and are even enjoying better health indicators than American men including in the areas the statement cites as improved after circumcision? Neonatal circumcision is a gross violation of children's rights. It inevitably causes pain when performed on infants, amputating tissue having erogenous, protective, and immunological functions. The AAP should immediately retract its policy statement and replace it with a document reflecting such critical concerns as the functions of the lost tissue and the importance of respecting non-consenting children's rights.

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The Flawed AAP Circumcision Statement Should be Rescinded

Petrina Fadel,
Catholics Opposed to Circumcision

The new 2012 AAP Circumcision Policy Statement should be rescinded immediately. Below are enumerated some of the serious problems with this new statement.

The Abstract states on page 585 that "health benefits are not great enough to recommend routine circumcision for all male newborns", but this is not repeated even once in the long text on pages 758-785.

Other long columns favoring circumcision, however, are repeated over and over again, on pages 761-762, 770, 775-776, and 778. The 1999 AAP Statement was 8 pages long (pages 686-693), but this diatribe against living with a foreskin goes on for 28 pages. There is almost the feeling that the AAP hopes that if it keeps repeating something over and over again, eventually it might become true.

The AAP on page 772 admits that "the true incidence of complications after newborn circumcision is unknown". "(T)here are no adequate studies of late complications in boys undergoing circumcision in the post-newborn period; this area requires more study." (page 773) "There are not adequate analytic studies of late complications in boys undergoing circumcision in the post-newborn period." (page 774) Under "Stratification of Risks" the AAP says, "Based on the data reviewed, it is difficult, if not impossible, to adequately assess the total impact of complications, because the data are scant and inconsistent regarding the severity of complications."

After all these admissions, the AAP then has the audacity to conclude that "the health benefits of newborn male circumcision outweigh the risks". (page 756). If one doesn't know how often complications occur, then one can't make the judgment that the benefits outweigh the risks! The AAP lacks the evidence it needs to make such a claim, and the claim is bogus.

Under "Task Force Recommendations" (page 775), the AAP says, "Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks ..." The AAP doesn't know the incidence of risks, but it expects physicians to know the unknown.

The 1999 Statement studied 40 years' worth of research, and the 2012 studied only selective research since 1999. Only 1031 of 1388 studies were accepted to look at. Balance might have been found in the 357 studies that were omitted, but the AAP was not seeking balance. The AAP statement goes on ad nauseum about alleged "benefits", to the point of fear-mongering that something will go wrong if an infant isn't circumcised. It's a high pressure sales pitch to try to get the American public to buy the circumcisions that AAP and ACOG doctors are selling. This is in direct contrast to Europe, where circumcision is uncommon and the health of European children equals or surpasses that of American children.

No studies on ethics were included in this statement, and it is clear that the rights of the child and how a grown man might feel about having had HIS foreskin stolen from him as a defenseless child were never given any consideration at all by the AAP. These are major issues, and even more important than many of the other issues the AAP discusses. Material was provided to the AAP to study this aspect of circumcision, but it was ignored. With one bioethicist on the panel, the AAP might at least have given the ethics of circumcision a cursory examination, considering that they were provided with many sources showing the emotional distress many men feel. Ethics, however, did not enter the picture for the AAP. Respect for the bodily integrity of another person was not included, and medical ethics were thrown out the window as infants were thrown under the bus.

The AAP now pushes for third-party reimbursement of non-therapeutic circumcision, at the expense of taxpayers during budget crises and deficits. Other countries don't waste money on unnecessary circumcisions, but the AAP wants Medicaid and private insurance to subsidize unnecessary circumcisions. Wasteful spending drives up medical costs for everyone. The cost for circumcision on page 777 ranges from $216 to $601 per circumcision in the U.S. In 2010, the in-hospital U.S. circumcision rate was 54.7%. Thus, 45.3% of newborn males left the hospital genitally intact. If the AAP were to convince parents of these 45.3% to circumcise (as they are attempting to do in this 2012 statement), then there would be 45.3% of roughly 2.1 million baby boys that could be an additional income source for physicians. This would be an additional 951,300 male infants to profit from. At prices the AAP quotes, this could mean an additional $205,480,800 to $571,731,300 for doctors who circumcise. There is a clear financial conflict of interest among AAP Task Force members who circumcise.

Between $205 and $571 million is no small sum for physicians, and as Thomas Wiswell, M.D. (who appears several times in the References) stated on June 22, 1987 in the "Boston Globe", "I have some good friends who are obstetricians outside the military, and they look at a foreskin and almost see a $125 price tag on it. Each one is that much money. Heck, if you do 10 a week, that's over $1,000 a week, and they don't take that much time. "(Lehman 1987) Money like that would certainly help doctors make their mortgage payments, car payments, pay for vacations, etc. - a financial "benefit" the AAP failed to mention. Under Literature Search Overview, it is understandable why AAP physicians might consider it important to investigate "What are the trends in financing and payment for elective circumcision?"

No studies on the anatomy and functions of the foreskin were included. It is common sense to consider what the functions of a healthy body part are before amputating it. Probably because the male AAP Task Force members are all circumcised, this idea was difficult for them to grasp. Only one study on the sexual impact of circumcision was included, and this from Africa. Other studies were ignored or discounted.

"The effect of male circumcision on the sexual enjoyment of the female partner", which appeared in BJU INTERNATIONAL, Volume 83, Supplement 1, Pages 79-84, January 1, 1999, is not mentioned. Nor is the newest Danish study that was publicized on November 14, 2011 - "Male circumcision leads to a bad sex life" - "Circumcised men have more difficulties reaching orgasm, and their female partners experience more vaginal pains and an inferior sex life, a new study shows." See: http://sciencenordic.com/male-circumcision-leads-bad-sex-life The AAP had time to include this study, but it was ignored. "Sexual Satisfaction and Sensitivity" (page 769) never once mentions or considers how circumcision impacts the sexual experience for females. The AAP gets it totally wrong about males, and then totally ignores females!

People sent material to the AAP about CIRCUMserum, Senslip, and foreskin restoration for men trying to undo some of the damages of circumcision and improve their sexual experience and that of their female partners. It didn't fit the Task Force's pro-circumcision agenda, so it was ignored. The Policy Statement is totally lacking in ethics and information about the anatomy and functions of the foreskin. Instead, the Task Force is more interested in training more doctors to circumcise and in how to do so with different devices and various forms of anesthesia.

The physical and sexual harms from circumcision are minimized or dismissed outright. Deaths from circumcision and botched circumcisions are considered "case studies", and children horribly damaged from circumcision aren't very important to the AAP, despite its claim that it is "Dedicated to the Health of All Children". When cribs are faulty or car seats aren't safe, the AAP becomes concerned and warns parents. When physicians botch circumcisions and are at fault, children don't matter.

After one botched circumcision lawsuit in 2010 and a $10.8 million award, the company that manufactured the Mogen clamp went out of business. The AAP report should have advised physicians to NOT use the Mogen clamp because of the botched circumcisions that have resulted with this device. If still in use, no doubt there will be future tragedies with the Mogen clamp, but parents will only be able to sue the doctor and hospital and not the manufacturer. See: http://www.ajc.com/news/nation-world/atlanta-lawyer-wins-11-573890.html

There is so much reliance on studies from Africa in this statement that it seems like the AAP should change its name to the African Academy of Pediatrics. In contrast to the AAP, the American Association of Family Physicians (AAFP) has stated: "...the association between having a sexually transmitted disease (STD) - excluding human immunodeficiency virus (HIV) and being circumcised are inconclusive... most of the studies ...have been conducted in developing countries, particularly those in Africa. Because of the challenges with maintaining good hygiene and access to condoms, these results are probably not generalizable to the U.S. population". But generalize the AAP did! In addition, the AAP listed page after page of STDs that allegedly circumcision would prevent. A recent study in Puerto Rico found that circumcised men have HIGHER rates of STDs and HIV, but this wasn't included. See: http://www.ncbi.nlm.nih.gov/pubmed/22897699

The 60% reduced risk of HIV following circumcision is a relative risk reduction, not the absolute risk reduction. "Across all three female-to- male trials, of the 5,411 men subjected to male circumcision, 64 (1.18%) became HIV-positive. Among the 5,497 controls, 137 (2.49%) became HIV- positive", so the absolute decrease in HIV infection was only 1.31%, which is not statistically significant." (Boyle GJ, Hill G. Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. J Law Med 2011; 19:316-34.)

Infants are not at risk of STDs or HIV through sexual contact, so this speculation about their future risk is foolhardy. Infants might also be at risk for many other diseases, but surgical amputation of healthy body parts is a foolhardy approach for the prevention of disease. That is not good medicine. If an infant is at risk of an STD, then it is probably safe to say that an adult is perpetrating a crime against the child and needs to be arrested and charged.

Judaism and Islam are mentioned as religions that practice religious circumcisions. Once again, the new AAP statement ignores Christianity, which teaches that circumcision is unnecessary. Christianity is the largest religion in the U.S., but its teachings don't even get a mention by the AAP. With an over-representation of members on the Task Force who have a religious bias favoring circumcision, they don't seem concerned that their endorsement of circumcision goes against the religious beliefs of others.

The AAP promotes parents choosing medically unnecessary circumcisions for their male children, completely contradicting what it said in PEDIATRICS, Volume 95 Number 2, Pages 314-317, February 1995. It said then, "Thus "proxy consent" poses serious problems for pediatric health care providers. Such 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. . . the pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent."

Parents deserve factual information about circumcision, but they won't find it in the new AAP Statement. In fact, the AAP wrongly advises parents of intact boys to retract the foreskin and wash under it with soap and water. (page 763) Soap can alter the good bacteria under the foreskin, potentially causing infections that should then be treated with liquid acidophilus to restore the good bacteria. Water is sufficient for cleansing. Circumcised doctors with circumcised sons probably don't know this, just as they know nothing about the value of the foreskin.

On page 764, the AAP speculates that the foreskin contains a high density of Langerhans cells, "which facilitates HIV infection of host cells." Actually, the exact opposite is true. "Langerin is a natural barrier to HIV-1 transmission by Langerhans cells" (Nature Medicine- 4 March 2007). This study states, "Langerhans cells (LCs) specifically express Langerin . . . LCs reside in the epidermis of the skin and in most mucosal epithelia, such as the ectocervix, vagina and foreskin."

The incidence of UTIs can be reduced through breastfeeding, which the AAP says it supports. This is nowhere mentioned under "Male Circumcision and UTIs" on page 767. HPV can be prevented with a vaccine for both boys and girls, but it is not mentioned on that page. A recent study reporting on the large number of re-circumcisions done following infant circumcisions is also not mentioned (another costly risk ignored by the AAP). On page 770, EMLA is mentioned as a possible anesthetic, but EMLA is not supposed to be used on infants. Unnecessary surgery performed with anesthesia still remains unnecessary surgery.

Under "Ethical Issues" (pages 758-759), two of the references for this opinion come from Douglas Diekema, M.D. who signed his name to this statement as well as to the 2010 AAP statement endorsing ritual genital nicks of females. The rights of the child are totally ignored in this section, and religious and cultural beliefs for circumcision are touted. This is Diekema's personal opinion that the Task Force bought into, based upon what he wrote before. It is at odds with what the AAP's own Committee on Bioethics wrote in January 1988- "The constitutional guarantees of freedom of religion do not sanction harming another person in the practice of one's religion." Circumcision does and has harmed children.

Under Ethics, references are taken from M. Benatar and D. Benatar (both Jewish circumcision defenders), as well as from AR Fleishman (who probably has a religious bias favoring circumcision). Under "Ethical Issues" (page 759), there's an interesting choice of words by the AAP. "In cases, such as the decision to perform a circumcision in the newborn period ... and where the procedure is not essential to the child's immediate well-being", the AAP admits here that circumcision "is not essential". It even calls circumcision "elective" in several places, but it then proceeds to do a massive sales pitch for unnecessary circumcisions.

Under Ethics, Reference #14 comes from the British Medical Association- "The law and ethics of male circumcision: guidance for doctors: J. Med Ethics 2004. The BMA did not print a favorable piece on circumcision, but the AAP cherry-picked something from it on page 760. Medical associations in other countries, like the British Medical Association, do not endorse circumcision as the AAP has so foolishly chosen to do.

On page 760, the AAP states, "The Task Force's evidence review was supplemented by an independent, AAP-contracted physician and doctoral- level epidemiologist who was also part of the entire evidence review process." Why is this doctor's name not even mentioned or listed alongside the Task Force members? The AAP should be open and reveal the name of this person they paid to play such a significant role.

Several times in the report, the AAP states (page 762), "For parents to receive nonbiased information about male circumcision in time to inform their decisions...clinicians need to provide this information at least before conception, and/or early in the pregnancy, probably as a curriculum item in childbirth classes." There is absolutely no way doctors can do this before conception. "Inform their decisions" sounds like code words for brainwashing parents, a form of mind control sanctioned by the AAP!

The AAP on page 763 uses the term "Uncircumcised" under "Care of the Circumcised Versus Uncircumcised Penis", and later the term "non- circumcised". The correct terminology is intact penis, or normal or natural penis. We don't say "uncircumcised" female or "non-circumcised" female.

The APP on page 764 states, "Mathematical modeling by the CDC shows that, taking an average efficacy of 60% from the African trials, [Note: the relative risk versus the much lower absolute risk] and assuming that protective effect of circumcision applies only to heterosexually acquired HIV", etc." The AAP states here that they are "assuming", which means to "suppose to be the case, without proof." There's a saying that goes if you "assume" anything, it makes an "ass" out of "u" and "me". Assumptions are not evidence, but the AAP relies upon assumptions.

"Analgesia and Anesthesia for a Circumcision After the Newborn Period" (page 771) states, "Additional concerns associated with surgical circumcision in older infants include time lost by parents and patients from work and/or school." The AAP is promoting newborn circumcision so parents don't have to miss work? Parents miss work all the time when their children get sick as toddlers and later on. Now, with its misplaced priorities, the AAP is concerned about parents missing work, but not concerned about the rights of the child.

Under "Complications and Adverse Events" (page 772), the AAP twice mentions how circumcision risks are lower in hospitals with trained personnel than with those performed by untrained practitioners in developing countries. U.S. parents don't live in a developing country, so this doesn't belong in the AAP statement!

The AAP sings its own praises under "Medical Versus Traditional Providers". "Physicians in a hospital setting generally have fewer complications than traditional providers in the community setting." Was this the AAP saying that doctors are safer than mohels? I don't think they'll like that!

In 2009, ten years after the AAP did not recommend circumcision (and still doesn't apparently, if one reads the words on page 585 that are almost hidden), their own survey of AAP members found that "18% responded recommending to all or most of their patients' parents that circumcision be performed." (page 776) It's not surprising that AAP doctors would recommend a surgery that means more money for them. On pages 777-778 the AAP wants to know about the effectiveness of their new 2012 statement. "The Task Force recommends additional studies to better understand ... The impact of the AAP Male Circumcision policy on newborn male circumcision practices in the United States and elsewhere." In other words, how effective can the AAP be in deceiving and misleading American parents about circumcision, and people in other countries as well? The AAP may discover that educated parents are on to them.

The AAP wants to work with the ACOG, AAFP, American Society of Anesthesiologists, and American College of Nurse Midwives to develop a plan about which groups are best suited to perform newborn male circumcisions. (page 777) In other words, how is the AAP going to secure its share of the money it wants from amongst all these groups?

The AAP targets blacks and Hispanics in the U.S. for unnecessary circumcisions. "African-American and Hispanic males in the United States are disproportionately affected by HIV and other STIs, and thus would derive the greatest benefit from circumcision." (page 777) But then, under Areas for Future Research, the AAP says, "The Task Force recommends additional studies to better understand ... The impact of male circumcision on transmission of HIV and other STDS in the United States because key studies to date have been performed in African populations with HIV burdens that are epidemiologically different from HIV in the United States." The AAP just spent several pages before this promoting newborn circumcision to allegedly prevent STDs and HIV based on African studies, but now it's admitting that more studies are needed because the results could be different in the U.S. Was this put in to help with the solicitation for more funding for pro-circumcision researchers at Johns Hopkins and elsewhere, to keep them going?

When asked if the RCTs would be repeated in the U.S. at the 2009 National HIV Prevention Conference in Atlanta, Dr. Katrina Kretsinger of the CDC replied that they would not, because it would be unethical to do so! If these studies would be unethical to do in the U.S., then how were they ethical to do on black men in Africa?

The AAP does say one good thing. On page 760 the AAP says, "The Task Force advises against the practice of mouth-to-penis contact during circumcision, which is part of some religious practices, because it poses serious infectious risk to the child." While working at the New York City Health Department, Task Force Chair Susan Blank, M.D. has not banned metzitzah b'peh among fellow Jews who are Orthodox, and under her watch babies have died of herpes as a result. There is so much wrong with this new statement that it should immediately be rescinded. The 1999 circumcision statement certainly had its flaws by ignoring ethics and the anatomy and functions of the foreskin, but it wasn't as atrocious as this new statement is.

American parents should take advice from foreign medical associations that recognize that circumcision is medically unnecessary and has serious ethical problems underlying the practice. Until the AAP uses better judgment and rescinds this statement, parents should not look to the AAP for advice on circumcision.

Petrina Fadel, Director Catholics Against Circumcision
http://www.catholicsagainstcircumcision.org/

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George Hill, John Geiskeker
Doctors Opposing Circumcision

The recent statement of the AAP Task Force on Circumcision rendered a disservice to the thousands of honest and hard-working pediatricians across the US, while benefiting mostly obstetricians.¹² It did nothing to enhance the reputation of pediatricians as advocates for their child patients.

Circumcision is in such deep decline -- near single digits -- in other Anglophone countries that this obsolete 19^th century intervention will entirely disappear there in the next generation, if not earlier. Those countries -- the UK, Canada, Australia and New Zealand, have healthy children who enjoy universal health care without circumcision, and more to the point, lower STD and HIV infection rates than the USA.

The incidence of non-therapeutic male circumcision in America has been declining for years and now stands at about 54 percent, the lowest incidence since the early 1930's. Genital integrity has become the norm in twelv e states and stands poised to become the norm in America.

Unfortunately, the members of the Task Force, whose personal, religious, cultural, and institutional ties suggest obvious pro-circumcision bias, merely represented the commercial wishes of the three medical groups that profit the most from circumcision. The AAP statement can be read as a transparent, last-ditch, self-serving effort to reverse the trend toward genital integrity for America's boys and merely shore-up the revenue stream from a declining cultural practice.

Normal Anatomy. The task force declined to provide crucial information on the structure, composition, and physiological function of the human foreskin -- the healthy and highly nerve-supplied tissue amputated by circumcision -- although the information is readily available in excellent reviews.^3-4 This discussion is wholly material to a decision regarding male circumcision. Even had the Task Force wished to denigr ate normal, healthy, human anatomy, it was incumbent on them to do so on the record.

HIV in Africa. The centerpiece of this action was to be the three early-terminated trials that were carried out on adult males in sub-Saharan Africa, published in 2005 and 2007.  Unfortunately for this scheme, these three RCTs have now been thoroughly vetted and debunked,^5-10 although the authors of the Circumcision Policy Statement chose to ignore these findings.² Furthermore, a new large-scale study from Puerto Rico finds more STDs and HIV infection in circumcised men.¹¹ The new evidence indicates that HIV infection in America will increase if the recommendations contained in this new statement are implemented.
Urinary Tract Infection. In addition to the specious HIV claim, the task force resurrected ancient claims about urinary tract infection, which are based on methodologically flawed, retro spective studies conducted nearly 30 years ago. Chessare demonstrated twenty years ago that the risks exceed the benefits; however the task force ignored his findings.¹²

Furthermore, the task force misrepresented the meta-analysis by Singh-Grewal et al., which found that "the benefit of circumcision on UTI only outweighs the risk in boys who have had UTI previously and have a predisposition to repeated UTI."¹³ More pointedly, a Canadian physician writing in the Canadian Medical Association Journal stated '"Circumcision prevents UTI the way garlic prevents vampires." ¹⁴

HPV. The task force tried to show that circumcision reduces HPV infection while ignoring the increasing use of a very successful HPV vaccine.¹⁵

Errors of Bioethics/Limits of surrogate consent. The authors assert that parents have a right to consent to circumcision. This originated with an erroneous applicat ion of the law of surrogate consent for therapeutic operations to non-therapeutic operations that was made by the ad hoc committee of four physicians in 1975 (apparently without benefit of legal counsel) and has been repeated ever since.¹⁶ The task force also improperly relies on a guidance for the treatment of dying children,¹⁷ which is inapplicable to the treatment of healthy boys.

U. S. courts do not recognize that parents have an unfettered right to consent to the intentional injury of children by non-therapeutic operations.^18-21

Conclusion. This new circumcision policy statement promises to bring even more embarrassment and discredit upon the AAP than the infamous 1989 statement, which recommended withholding pain relief for boys undergoing circumcision.²²

The board of directors of the American Academy of Pediatrics has an ethical duty to vacate this statement immediately be fore it can be implemented.²³ Failure to do so is likely to increase HIV infection in the United States ^9-11 when circumcised boys become sexually active without the immunological protection of their missing foreskins,³ -- or worse, feel over-confident that they cannot contract STD's based on the statement.

Our international educational organization recommends that the American public reject this statement as biased, unethical, and unwarranted by evidence-based medicine.²⁴

George C. Denniston, M.D., M.P.H., President
George Hill, Vice-President
John V. Geisheker, J.D., LL.M.
Executive Director,
Doctors Opposing Circumcision
Seattle, Washington

References

1. Task force on circumcision. Circumcision policy statement. Pediatrics 2012;130(3): 585-6.
2. Task force on circumcision. Male circumcision. Pediatrics  2012;130(3):e756-85.
3. Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Inf  1998;74(5):364-7.
4. Cold CJ, Taylor JR. The prepuce. BJU Int  1999; 83, Suppl. 1: 34-44.
5. 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.
6. 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.
7. Sidler D, Smith J, Rode H. Neonatal circumcision does not reduce HIV/AIDS infection rates. S Afr Med J  2008;98(10):762-6.
8. Myers A, Myers J. Rolling out male circumcision as a mass HIV/AIDS i ntervention seems neither justified nor practicable. South Afr Med J 2008;98(10):781-2.
9. 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
10. 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.
11. Rodriguez-Diaz CE, Clatts MC, Jovet-Toledo GG, et al. More than foreskin: Circumcision status, history of HIV/STI, and sexual risk in a clinic-based sample of men in Puerto Rico. J Sex Med 2012 [Epub ahead of print] DOI: 10.1111/j.1743-6109.2012.02871.x
12. Chessare JB. Circumcision: Is the risk of urinary tract infection really the pivotal issue? Clin Pediatr 1992;31(2):100-4.
13. Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention o f urinary tract infection in boys: A systematic review of randomized trials and observational studies. Arch Dis Child 2005;90(8):853-8.
14. Guest CL. Visibility of the urethral meatus and risk of urinary tract infections in uncircumcised boys. CMAJ published online July 19, 2012. http://www.cmaj.ca/content/early/2012/07/09/cmaj.111372.abstract/reply#cmaj_el_712552. Accessed September 9, 2012.
15. Centers for Disease Control and Prevention. National and state vaccination coverage among adolescents aged 13-17 years - United States, 2011. MMWR Morb Mortal Wkly Rep  2012;61:671-7.
16. Thompson HC, King LR, Knox E, Korones SB. Report of the ad hoc task force on circumcision. Pediatrics  1975;56(4):610-1.
17. Fleischman AL, Nolan K, Dubler NN, et al. Caring for gravely ill children. Pediatrics  1994;94:433-9.
18. Prince v. Massachusetts. 321 U.S. 158 (1944).
19. Little v. Little. 576 SW2d 493 (1979).
20. State v. Baxter. Washington Court of Appeal No. 32766-0-II (2006).
21. Boldt v. Boldt. Oregon Supreme Court S054714 (2008); cert. denied Oct. 6. 2008.
22. Schoen EJ, Anderson G, Bohon C, et al. Report of the task force on circumcision. Pediatrics  1989;84;388-91.
23. Council on Ethical and Judicial Affairs. Opinion 8.02 - Ethical Guidelines for Physicians in Administrative or Other Non-clinical Roles. Chicago: American Medical Association, 2007. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion802.page? Accessed September 9, 2012.
24. Anonymous. Commentary on the American Academy of Pediatrics 2012 Circumcision Policy Statement.  Seattle: Doctors Opposing Circumcision, 2012. http://www.doctorsopposingcircumcision.org/pdf/2012-08-26A_Commentary.pdf Accessed September 9, 2012.

Conflict of Interest:

None declared

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Mark Reiss
Doctors Opposing Circumcision

To The Editor:
"Benefits of Circumcision Are Said to Outweigh Risks" (page A2, August 27) presents a balanced review of the recent report of The American Academy of Pediatrics. This report leans heavily on "evidence" of H.I.V. transmission in Africa. While the HIV/AIDS crisis in Africa is of epidemic proportion, this bears little relationship to newborn foreskins. A decision by American parents to circumcise their sons based on African studies is senseless.

With the exception of ritual circumcision in Judaism and Islam, the incidence of newborn circumcision in Europe is negligible. Europeans have long understood the overwhelming trauma that circumcision brings to infant boys and the men they are to be. The United States needs to join the majority of the civilized world and stop circumcising their newborns.

Mark D. Reiss, M.D.
Executive Vice President, Doctors Opposing Circumcision

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Culturally biased and badly flawed

Hugh Young
Independent researcher, unaffiliated

The American Academy of Pediatrics policy on male genital cutting is culturally biased and seriously flawed. It should be withdrawn.

   
• It fails to consider the structure or functions of the foreskin, a normal healthy body part, only the cutting of it off. It does not, for example cite Taylor's groundbreaking 1996 paper¹. The erogenous value of the foreskin has been known for millennia, even to its enemies.² Recent denial of that value is confined to those who have no experience of it.    
• It bases its conclusions about sexuality on two physiological studies that did not consider the foreskin and on surveys of African adult volunteers for circumcision in the context of HIV prevention.    
• It pathologizes normal intact penile concomitants, separation of the prepuce from the glans after two months (it can take as long as 17 years) and preputial wetness.    
• It is filled with confirmation bias - finding the results the authors want.    
• It claims benefits of circumcising outweigh the risks without ever numerically comparing them.    
• It exaggerates benefits and minimizes risks and harm: For example -        
  • It cites a study showing that "circumcision ablates the most sensitive part of the penis" and ignores that finding.³        
  • It admits the African HIV findings may not be applicable to the USA, but goes ahead and applies them.        
  • It cites a study suggesting circumcising men increases the HIV risk to women, and ignores that finding.4 (That study was called off "for futility" - an increased risk of HIV transmission apparently of no interest to the researchers - before it could reach statistical significance.)        
  • It cites a study showing that a narrow foreskin (phimosis), not a normal one, is the issue in penile cancer, and ignores that finding.       
  • It dismisses major complications and death from circumcision because it did not find any statistical studies of them.        
  • It discusses the action of the Mogen circumcision clamp without mentioning that the clamp has caused too much of several boys' penises to be cut off; lawsuits have driven the company out of business.⁷
     
• It repeats the common claim that it is safer to circumcise babies than adults, but offers no evidence for that claim.    
• Its discussion of the ethical question of removing genital tissue from a non-consenting person versus leaving it for him to decide assigns no value to his autonomy or his human right to bodily integrity.⁸It compares the costs of doing it early vs late, but not the benefits of not doing it at all.    
• Its ethical consultant has said elsewhere that circumcision is not necessary and has a risk of harm, and that (quoting the AAP's own bioethics policy) a parental wish is not sufficient to justify doing any surgery, and it ignores that.^9,10

The AAP withdrew its female genital cutting policy after a storm of outrage two years ago, when it proposed allowing a token ritual nick to baby girls, "much less extensive than neonatal male genital cutting" (my emphasis). Since that was unacceptable, how can this be acceptable?

The public mood is turning against infant circumcision. The Intactivism movement has found a receptive audience, especially among young people through social media. The AAP's policy seems bent, not on considering the healthy intact penis at all, but on restoring insurance and public funding to circumcision in order to find a new market among the poor. It does a disservice to the growing number of boy babies being left intact, and their parents - and an even greater disservice to the boys who will be circumcised as a result of its strident advocacy, and to the men they become.

I am annotating the policy further here: http://www.circumstitions.com/Docs/aap-12-anno.pdf
Hugh Young, BSc

References:
1. Taylor, J.P., A.P. Lockwood and A.J.Taylor The prepuce: Specialized mucosa of the penis and its loss to circumcision Journal of Urology (1996), 77, 291-295
2. Young, H. (ed) Pleasures of the Foreskin http://www.circumstitions.com/Pleasure.html accessed August 31, 2012
3. Sorrells ML, Snyder JL, Reiss MD, et al. Fine-touch pressure thresholds in the adult penis. BJU Int. 2007;99(4):864-869
4. Wawer MJ, Makumbi F, Kigozi G, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet. 2009;374(9685): 229-237
5. Daling JR, Madeleine MM, Johnson LG, et al. Penile cancer: importance of circumcision, human papillomavirus and smoking in in situ and invasive disease. Int J Cancer. 2005;116(4):606-616
6. Tsen HF, Morgenstern H, Mack T, Peters RK. Risk factors for penile cancer: results of a population-based case-control study in Los Angeles County (United States). Cancer Causes Control. 2001;12(3):267-277
7. Tagami, T, Atlanta lawyer wins $11 million lawsuit for family in botched circumcision, The Atlanta Journal-Constitution, July 19, 2010 http://www.ajc.com/news/nation-world/atlanta-lawyer-wins-11-573890.html accessed August 31, 2012
8. For example, Sir William Blackstone: "Besides those limbs and members that may be necessary to man ... the rest of his person or body is also entitled by the same natural right to security from the corporal insults of menaces, assaults, beating, and wounding; though such insults amount not to destruction of life or member...." - Commentaries on the Laws of England. 1765
9. Diekema DS. Boldt v. Boldt: a pediatric ethics perspective. J Clin Ethics. 2009;20 (3):251-257
10. Diekema DS. affidavit No. 03-2-00329-7 in the case of CM (a minor child) vs Biedel in the Superior Court of Washington (available at http://www.circumstitions.com/ethics-diekema.html accessed August 31, 2012)
Conflict of Interest:
I maintain the Intactivism Pages, http://www.circumstitions.com
(30 August 2012) 

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 Georganne Chapin of Intact America has sent the the AAP a hard copy of her open letter of August 31, 2012.