ILLINOIS: American Academy of Pediatrics backs down, a bit, sort of.

Pediatrics
May 2016

The Circumcision Debate: Beyond Benefits and Risks

by Andrew L. Freedman and M.D. Faap

In 2007, following a flurry of reports describing a benefit of circumcision in the fight against HIV, the American Academy of Pediatrics reconvened the task force on circumcision to update its policy statement of 1999.[1] Rather than simply incorporating this new information, the committee chose to start from scratch and rereview the medical literature. The task force’s work culminated in a policy statement published in 2012, the centerpiece of which was the statement that “the health benefits of newborn male circumcision outweigh the risks.”[2] This formulation of the debate, “benefits versus risks” rather than “medical necessity,” [or "benefits and harms", or "functions of the foreskin" or "ethics"]  resulted in wide-ranging ramifications.

To many, especially in the lay press, this was interpreted as moving the needle from a neutral stance, as the 1999 guidelines were viewed, to being pro circumcision. It was vigorously criticized by anticircumcision activists, as well as many, primarily European, physicians and medical societies. Difficulties with this approach included the lack of a universally accepted metric to accurately measure or balance the risks and benefits.  [In fact, the AAP made no effort to balance them at all] In particular, there was insufficient information about the actual incidence and burden of nonacute [or acute] complications [or death].[3] In this issue, Sneppen and Thorup[4] use meticulous epidemiologic technique to assess the likelihood of needing a circumcision in a society in which the cultural norm is to preserve the prepuce. [And they find that likelihood to be less than one in 200] Work such as this, along with the subsequent avalanche of reports evaluating the risks and benefits [What "avalanche" apart from a flurry of advocacy articles by wild-eyed Brian Morris?], has helped to inform and animate the dialogue among physicians with a stake in the circumcision debate. But has this really helped to inform the public? Or are we just arguing among ourselves?

What is often lost in the reporting on the American Academy of Pediatrics guidelines was the second half of the benefits/risk sentence, “the procedure’s benefits justify access to this procedure for families who choose it, ” and later “health benefits are not great enough to recommend routine circumcision.” [This line was missing from most summaries.] What was the task force really saying?

To understand the recommendations, one has to acknowledge that when parents decide on circumcision, the health issues are only one small piece of the puzzle. In much of the world, newborn circumcision is not primarily a medical decision. [In most of the world it is not a decision at all.] Most circumcisions are done due to religious and cultural tradition. In the West, although parents may use the conflicting medical literature to buttress their own beliefs and desires, for the most part parents choose what they want for a wide variety of nonmedical reasons.

There can be no doubt that religion, culture, aesthetic preference, familial identity, and personal experience all factor into their decision. Few parents when really questioned are doing it solely to lower the risk of urinary tract infections or ulcerative sexually transmitted infections. Given the role of the phallus in our culture, it is not illegitimate to consider these realms of a person’s life in making this nontherapeutic, only partially medical decision. [The owner of a phallus, unlike a mere penis, is an adult man. He is the only one with any right to make this nontherapeutic, only partially medical decision.] The task force was sensitive to the fact that as physicians, although we claim authority in the medical realm, we have no standing to judge on these other elements.

The ethical standard used was “the best interest of the child,” and in this setting the well-informed parent was felt to be the best proxy to pass this judgment. [But there is no need for a judgement, and hence no need for a proxy.] Protecting this option was not an idle concern [Who said this option has to be protected, or that paediatricians have any role in protecting it?] at a time when there are serious efforts in both the United States and Europe to ban the procedure outright. [No, only to agre-restrict it until the owner is of an age to decide for himself whether  he wants less penis. ]

...

In circumcision, what we have is a messy immeasurable choice that we leave to parents to process and decide for themselves rather than dictate to them. [False dichotomy. The real choice is between leaving the baby alone and anyone being allowed to cut healthy parts off her or him or them.]  This may seem odd in a society in which circumcision is rarely sought, but makes perfect sense in the multicultural world in which many of us live. [The elephant in the room here is the ethics of performing unnecessary, nontherapeutic, only partially medical reductive genital surgery on a non-consenting person.]

To the medical community, your efforts to improve our ability to accurately educate parents are needed. [Physician, educate thyself. Learn about the complex structure and many functions of the foreskin before you claim any right to educate others about it.] But we have to accept that there likely will never be a knockout punch that will end the debate.

...

To the anticircumcision activists, I would suggest that rather than directing an angry focus on the negative and the courts, your efforts would be better spent to educate and promote the prepuce positively [which is why we call ourselves "intactivists"] , to win in the court of public opinion, and to change the culture, so as to make having a foreskin be the “popular thing to do.” {He still doesn't get it. Having a foreskin is not something you do, because it is "popular". A foreskin is something you have as of right because you were born with it, unless someone steals it from you.]

I know it sounds naïve, but my challenge to all of us is to imagine a day we can peacefully live in a world in which not all penises have to look the same. ['Why can't we just get along?' They don't have to look the same, but how they look should be up to their owners, nobody else. And it's not all about looks.]


REFERENCES

 1. American Academy of Pediatrics. Circumcision Policy Statement. Task Force on Circumcision. Pediatrics. 1999;103(3);686-693. Reaffirmation published on 116(3);796

 2. American Academy of Pediatrics Task Force on Circumcision. Circumcision policy statement. Pediatrics. 2012;130(3):585–586

 3. Blank S, Brady M, Buerk E, et al; American Academy of Pediatrics Task Force on Circumcision. Male circumcision. Pediatrics. 2012;130(3).
Available at: www. pediatrics. org/ cgi/content/ full/ 130/ 3/ e756

4. Sneppen I, Thorup J. Foreskin morbidity in uncircumcised males. Pediatrics. 2016;137(5):e20154340
-----
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential confl icts of interest to disclose. [Except being paid to cut babies' genitals, and cutting his own son on his parents' kitchen table, contrary to all surgical protocols.]
 
To cite: Freedman AL and FAAP M. The Circumcision Debate: Beyond Benefi ts and Risks. Pediatrics. 2016;137(5):e20160594

ILLINOIS: AAP exhibits cultural bias in its denial of it

March 21, 2013

AAP Task Force reveals cultural bias while denying it

by Hugh Young

Last August, the American Academy of Pediatrics released its new circumcision policy in a flurry of publicity. The policy claimed that "the benefits outweigh the risks" (without actually comparing them). It fell short of recommending universal infant circumcision, though it was widely reported as having done so, and it recommended that insurance pay for this "non-recommended " procedure.

This week, Pediatrics published a rebuttal from 38 heads or spokespeople for the paediatric associations of Austria, Britain, Denmark, England, Estonia, Finland, Germany, Iceland, Latvia, Lithuania, Norway, Sweden and the Netherlands, and senior paediatricians in Canada, the Czech Republic, France and Poland, accusing the AAP of cultural bias, and finding fault with its methodology, its conclusions, and its ethics.

The AAP has published their letter with a reply from its "Task Force on Circumcision" that just underlines the same cultural bias for which it was criticised. It basically says "You're another!" without noticing that leaving a child's genitals alone, doing nothing to them, is medically and ethically a different kind of thing from cutting part off.

They reveal their bias even while denying it: they refer to the whole penis as "uncircumcised" and discount the sexual value of the foreskin found by some studies because "the relevance to individuals undergoing circumcision during infancy was questionable." but with no consideration of their relevance to individuals not undergoing circumcision during infancy.

They falsely claim that "approximately half of US males are circumcised, and half are not." In fact, a chart in their own policy indicates the rate is more like 80%. This is in order that they can say "Although that [50:50 ratio] may lead to a more tolerant view toward circumcision in the United States than in Europe, the cultural “bias” in the United States is much more likely to be a neutral one than that found in Europe, where there is a clear bias against circumcision."

In fact, in Europe, the default position is to do nothing, simply to leave the child's body alone. No need for any "cultural bias" or any Task Forces on Leaving Children's Genitals Alone.

They go on "... a culture that is comfortable with both the circumcised penis and the uncircumcised penis would seem predisposed to a more dispassionate analysis of the scientific literature than a culture with a bias that is either strongly opposed to circumcision or strongly in favor of it."
In what mad world is the United States "a culture that is comfortable with" the whole penis when the Task Force won't even call it that? When a TV show can include nine negative references to foreskins and the men with them without exciting comment? (Positive references are virtually unknown.) To rebut the claim of the 38 that the foreskin has a sexual function, the Task Force says:

Members of the task force appreciate that the foreskin has nerve fibers: the task force clearly recommends adequate pain control for infants undergoing circumcision. However, the task force did not move beyond what these studies actually reveal (the foreskin has nerve bundles and pain fibers, the foreskin contains Meissner corpuscles, the inner surface of the foreskin resembles a mucous membrane) to speculate about the effect that circumcision might have on sexual function or pleasure.
The 38 European critics do not need to "speculate": its male members or their male partners will have foreskins. Of course the inner foreskin resembles a mucus membrane, because it is one - like the lips. The lips also "have nerve fibres". Whose first thought about those would be about how to minimise the pain of lip-removal? Who either doubts, or can find a study to prove, that the nerves of the lips are intimately involved in the pleasure of kissing? Who needs one?

The Task Force, both in its policy and this response to its critics, criticises the only study that actually attempted to measure the sensitivity of the foreskin itself by ignoring its main finding - that "male circumcision [removes] the most sensitive part of the penis."

They now admit that the critics' "argument about the basic right to physical integrity is an important one, ..." yet they ignored this important argument in their 2012 policy, and now they contrast it with a new, unmeasured and undocumented claim that "...it is also true that some males will be harmed by not being circumcised." By that reasoning, the man who had to cut his own arm off after it was trapped under a boulder in the desert was "harmed by not having had it previously amputated" but nobody would ever think that meant infant amputation should be given even a moment's consideration - yet this is just "to prevent zipper injury" writ large.

The Task Force says nothing about the critics' case, based on the AAP's own policy, that the diseases circumcision reduces are so rare, or of such late onset, or so readily prevented or treated, that circumcising infants to prevent them is a bad option compared to letting the child grow up to decide the fate of his own genitals.

Its claim that "the benefits outweigh the risks" is now nowhere to be seen, and goes undefended.

Earlier story

EUROPE: Thirty-eight top pediatricians slam AAP circumcision policy

Pediatrics
March 18, 2013

The following article is due to appear in the next issue of Pediatrics, the journal of the American Academy of Pediatrics.

It is signed by the heads or spokespeople for the paediatric associations of Austria, Britain, Denmark, England, Estonia, Finland, Germany, Iceland, Latvia, Lithuania, Norway, Sweden, and the Netherlands, and by senior paediatricians in Canada, the Czech Republic, France and Poland.

It comprehensively dismantles the AAP's 2012 circumcision policy statement.

Cultural Bias in AAP's 2012 Technical Report and Policy Statement on Male Circumcision Abstract 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. Authors and Affiliations (38 people) Morten Frisch, MD, PhD: Consultant, Statens Serum Institut, Copenhagen, and Adjunct Professor of Sexual Health Epidemiology, Faculty of Medicine, Aalborg University, Aalborg, Denmark Yves Aigrain, MD, PhD: Professor of Pediatric Surgery, Hôpital Necker Enfants Malades, Université Paris Descartes, Paris, France Vidmantas Barauskas, MD, PhD: Professor and President of the Lithuanian Society of Paediatric Surgeons, Lithuania Ragnar Bjarnason, MD, PhD: Professor of Pediatrics, Landspitali University Hospital, Reykjavik, Iceland Su-Anna Boddy, MD: Consultant in Pediatric Surgery and Chairman of the Children’s Surgical Forum of the Royal College of Surgeons of England, UK Piotr Czauderna, MD, PhD: Professor of Pediatric Surgery, Medical University of Gdansk, Gdansk, Poland Robert P. E. de Gier, MD: Consultant in Pediatric Urology and Chairman of Working Group for Pediatric Urology, Dutch Urological Association, The Netherlands Tom P. V. M. de Jong, MD, PhD: Professor of Pediatric Urology, University Children's Hospitals UMC Utrecht and AMC Amsterdam, The Netherlands Günter Fasching, MD: Professor and President of the Austrian Society of Pediatric and Adolescent Surgery, Austria Willem Fetter, MD, PhD: Professor and President of the Paediatric Association of the Netherlands, The Netherlands Manfred Gahr, MD: Professor and General Secretary of the German Academy of Paediatrics and Adolescent Medicine, Germany Christian Graugaard, MD, PhD: Professor of Sexology, Aalborg University, Faculty of Medicine, Denmark Gorm Greisen, MD, PhD: Professor of Pediatrics, Rigshospitalet, Copenhagen, Denmark Anna Gunnarsdottir, MD, PhD: Consultant in Pediatric Surgery, Landspitali University Hospital, Reykjavik, Iceland, and Karolinska University Hospital, Stockholm, Sweden Wolfram Hartmann, MD: President of the German Association of Pediatricians, Germany Petr Havranek, MD, PhD: Professor of Pediatric Surgery, Thomayer Hospital, Charles University, Prague, Czech Republic Rowena Hitchcock, MD: Professor and President of the British Association of Paediatric Urologists, UK Simon Huddart, MD: Professor and Honorary Secretary of the British Association of Paediatric Surgeons, UK Staffan Janson, MD, PhD: Professor and Chairman of Committee on Ethics and Children’s Rights, Swedish Paediatric Society, Sweden Poul Jaszczak, MD, PhD: Vice President and Chairman of the Ethics Committee of the Danish Medical Association, Denmark Christoph Kupferschmid, MD: Practicing Pediatrician and Member of Ethics Committee of the German Academy of Pediatrics, Germany Tuija Lahdes-Vasama MD: Consultant in Pediatric Surgery and President of The Finnish Association of Pediatric Surgeons, Finland Harry Lindahl, MD, PhD: Associate Professor of Pediatric Surgery, Helsinki University Children's Hospital, Helsinki, Finland Noni MacDonald, MD: Professor of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Canada Trond Markestad, MD: Professor of Pediatrics, Chairman of the Ethics Committee of the Norwegian Medical Association, Oslo, Norway Matis Märtson, MD, PhD: Consultant in Pediatric Surgery and President of the Estonian Society of Paediatric Surgeons, Tallinn, Estonia Solveig Marianne Nordhov, MD, PhD: Consultant in Pediatrics and President of The Norwegian Paediatric Association, Norway Heikki Pälve, MD, PhD: Chief Executive Officer of the Finnish Medical Association, Finland Aigars Petersons, MD, PhD: Professor and President of the Latvian Association of Pediatric Surgeons, Latvia Feargal Quinn, MD: Consultant in Pediatric Surgery, Our Lady's Children's Hospital, Dublin, Ireland Niels Qvist, MD, PhD: Professor of Pediatric Surgery, Odense University Hospital, Odense, Denmark Thrainn Rosmundsson, MD: Chief of Pediatric Surgery, Landspitali University Hospital, Reykjavik, Iceland Harri Saxen, MD, PhD: Associate Professor of Pediatrics, Helsinki University Children’s Hospital, Helsinki, Finland Olle Söder, MD, PhD: Professor and President of the Swedish Pediatric Society, Stockholm, Sweden Maximilian Stehr, MD, PhD: Professor of Pediatric Surgery, Dr. v. Haunersches Kinderspital, Ludwig-Maximilians Universität, Munich, Germany Volker C.H. von Loewenich, MD: Professor and Chairman of the Commission for Ethical Questions, German Academy of Pediatrics, Frankfurt, Germany Johan Wallander, MD, PhD: Professor and Chairman of the Swedish Society of Pediatric Surgery, Sweden Rene Wijnen, MD, PhD: Professor and Chairman of the Dutch Society of Pediatric Surgery, The Netherlands

Earlier story

HELSINKI: AAP Policy; "routine circumcision is insane" - Paediatrics Professor

Pediatrics
January 22, 2013

Routine circumcision is insane

by Harry G Lindahl, Associate Professor of Paediatric Surgery
Helsinki University Children's Hospital

Re: "Circumcision Policy Statement" 130:3 585-586doi:10.1542/peds.2012-1989

The evolution of mammals gained speed about 65 million years ago, when a meteorite fell on Yucatan and killed the dinosaurs. For all that we know, at that time, the mammals had a foreskin. If the mammal foreskin would be such a harmful piece of tissue as the pro circumcision lobbyists claim, it certainly would have fallen off during the 65 million years of evolution. However, mammals, including the human species, still have a foreskin. Rat is the most successful mammal on this planet. It has a foreskin. Evolution is merciless, and whatever mistakes it makes about the less important organs, such as the brain or stomach, it certainly knows best about the reproductive organs.

Therefore, the claim, that there are health benefits in excising a piece of healthy tissue from the penis of a healthy neonate, is as absurd as would be the claim that amputating the left little finger of a neonate has health benefits. However, if you would make such an absurd claim, either of the prepuce or of the left little finger, you would have to provide the highest level of proof according to the principles of evidence based medicine. This means several randomized controlled studies performed by independent researchers, all having the same result. There is no such evidence, neither of the prepuce nor of the left little finger.

The AAP is having a "Circumcision task force". This is as absurd as having a task force for "The Routine Amputating of the Left Little Finger of a Neonate". Is the AAP insane? To an European Paediatric Surgeon it seems so.

Earlier story