BERKELEY: AAP circumcision policy rebutted in Journal of Medical Ethics

the Journal of Medical Ethics
March, 2013

Lawyer and pediatrician dismantle the AAP policy

An article in the Journal of Medical Ethics comprehensively takes down the American Academy of Pediatrics' 2012 circumcision policy.

Written by Michigan State University Clinical Professor Robert Van Howe and Berkeley lawyer J Steven Svoboda, it focuses on the ethical issues rather than the medical issues that concern the European pediatricians whose rebuttal is released today.

“The AAP ignores so many important topics that it is hard to know where to begin," 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.

A few months ago, the Royal Dutch Medical Association favorably cited an earlier version of Svoboda’s and Van Howe’s article, noting that even if benefits do exist, the procedure can safely be delayed until the boy himself can make the decision.

Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision by J Steven Svoboda, Attorneys for the Rights of the Child, Berkeley, California, USA Robert S Van Howe, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, Marquette, Michigan 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.

OAKLAND: More than $80 million paid out for botched circumcisions

Attorneys for the Rights of the Child
March 16, 2013

More than $80,000,000 paid out for botched circumcisions

by Hugh Young

More than 80 million dollars have been paid out in settlements for botched and wrongful circumcisions since 1985, according to Attorneys for the Rights of the Child.

It has been compiling a list of cases since 1997 and first published it today.

They range from $22.8 million to a boy in Atlanta, Georgia who was severely burnt, down to $30,000 to a Palm Beach, California, boy who lost more than his foreskin to a mohel.

Two of the cases, totalling $18.3 million, were won against Mogen Circumcision Instruments Ltd, makers of the Mogen clamp. The company has gone out of business, but the Mogen clamp is still being used.

The number of botched circumcision cases that were settled out of court is unknown. The number that were successfully blamed on something else, such as an undiagnosed pre-condition or poor aftercare, is also, of course, unknown.

In its 2012 circumcision policy, the American Academy of Pediatrics said, "The majority of severe or even catastrophic injuries are so infrequent as to be reported as case reports (and were therefore excluded from this literature review)" before concluding (without actually weighing them) that "the benefits outweigh the risks".

BERLIN: Paediatric Association condemns circumcision law

Gesetzentwurf der Bundesregierung
November 27, 2012

German Pediatric Society roundly condemns infant circumcision.

Dr.Wolfram Hartmann, President of the Professional Association of Child and Youth Doctors in Germany, spoke on November 26, 2012 to the Bundestag committee considering the Government's "Draft law on the scope of child's care regulations at a circumcision of the male child" and the draft law of MPs Marlene Rupprecht, Katja Dörner, Diana Golze, Caren Marks, Rolf Schwanitz, other MPs: "Draft law on the scope of the child's care and the rights of the male child at a circumcision "

The Association opposes the first, which sets conditions for the performance of child circumcision, but no limit on who may do it, and supports the second, which sets a minimum age of 14, with informed consent.

Dr Hartmann told the committee

This statement is coordinated with the German Academy for Child and Youth Medicine (DAKJ), the umbrella organization of all pediatric associations in Germany (German Society for Child and youth medicine DGKJ, Professional Association of the Child and Youth doctors, German Society for social pediatrics and youth medicine DGSPJ), to which other organizations are co-opted (see also . I also refer to the statement of the Germany Society for Child Surgery) on that subject.

From a medical point of view, there is no reason to remove the intact foreskin of under-aged boys not capable of giving consent. In pre-school age, it is also very rare to have a true medical indication to remove (circumcise) the foreskin. At this age, the foreskin (prepuce) is physiologically more or less strongly fastened to the glans. Attempts to pull back the immature and adhered foreskin often cause inflammations and painful fissures.

"The male foreskin is part of the dermal organ and fulfills an important role in protecting the very delicate glans. ...

The repeatedly-quoted statement of the AAP contradicts earlier statements by the same organization, without being able to refer to new scientific evidence. The AAP statement has meanwhile been considered scientifically untenable by almost all pediatric societies and associations worldwide.

... The American lawyers association for children's rights, Attorneys for the Rights of the Child also criticized the AAP statement in a letter to the Pediatrics magazine [Which was not published there, but was published here]. It [says the AAP policy] contains errors and inconsistencies and violates both the AAP's own statements regarding bioethics, and several civil and criminal law regulations in the USA.

The WHO recommendations for prophylactic circumcisions only refers to mature, sexually active men in countries with low hygienic standards and is not suitable to justify the prophylactic circumcision of under-aged boys not capable to give consent. ...

.... The government's current draft law on the scope of child's care regulations at a circumcision of the male child unwillingly opens the door for demands to legalize the circumcision of girls.

BERKELEY: Attorneys for the Rights of the Child

Attorneys for the Rights of the Child
August 22, 2012

Attorneys for the Rights of the Child Condemns American Academy of Pediatrics for Hiding the Truth, Putting Doctors Ahead of Patients in its Circumcision Statement

Berkeley, CA – The human rights group Attorneys for the Rights of the Child (ARC) has condemned the American Academy of Pediatrics (AAP) for its upcoming “Circumcision Policy Statement,” due out on August 27, 2012, which ignores and minimizes the truth about male circumcision and places doctors’ interests ahead of patients’ needs.  J. Steven Svoboda, ARC’s Executive Director, commented today, “Based on comments that have appeared in the media attributed to members of the task force preparing the statement, the AAP appears to endorse a disproven procedure that violates the infant patient’s rights and removes functional tissue without providing any proven benefit.”
The AAP position statement ignores the wealth of medical evidence that painfully amputating functional tissue from newborns is a dangerous and outmoded practice.”

Not a single study has ever proven that circumcision has actually decreased any disease in the United States. Svoboda observed, “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.  Over a hundred boys die each year from this needless procedure, yet the AAP quotes an absurdly low overall complication rate overall and fails to mention the deaths stemming from the practice.”

The AAP released a policy statement in 2010 in Pediatrics defending certain forms of female circumcision if performed for “cultural” reasons.  Physicians who had followed the AAP’s suggestion at that time would have thereby violated federal law protecting females from such procedures.  After ARC and other organizations opposing genital cutting pointed out the errors, the AAP quickly retracted its statement and replaced it with a new statement calling for the elimination of all forms of female genital cutting.  Svoboda commented, “Boys deserve no less protection from the AAP than girls received. If circumcision is so great, why have no European countries adopted it, and why do their males enjoy better average health than Americans?”

The AAP statement demonstrates its ignorance of the fact that European men don’t circumcise and yet enjoy better health outcomes including the areas the statement cites as improved after circumcision.   Moreover, medical organizations and politicians in Finland, Sweden, Norway, the Netherlands, Germany, Switzerland, Austria, and other countries are calling for the practice to stop.  Even in the US, the American Medical Association (AMA) agrees that there is insufficient justification for performing the procedure on newborns absent specific medical indications.

Svoboda noted that studies of adult males in Africa have numerous methodological flaws and that even if valid, given vast differences in health conditions and modes of transmission between the US and Africa, the results can hardly be applied to justify infant male circumcision in the United States.  “Babies don’t get HIV and AIDS from sexual contact,” Svoboda added.

“Male circumcision,” Svoboda said, “is a disfigurement that carries risks without providing benefits.  It 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.  Svoboda noted, “Although the AAP’s statement regarding male circumcision is presumably influenced by its desire to protect its members who perform the outmoded procedure, the AAP has no business promoting a harmful and discredited cultural relic masquerading as a medical 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.”

Americans are getting the message, as according to the Centers for Disease Control and Prevention (CDC), rates have dropped substantially in recent years.

Attorneys for the Rights of the Child is a non-profit organization founded in 1997 to protect children from unnecessary medical procedures to which they do not consent.