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.

SHEFFIELD, UK: Hospitals plan to charge for circumcision

National Secular Society
January 10, 2013

Sheffield hospitals plan to charge for non-medical circumcision

Hospitals in Sheffield carry out about 200 non-medical male circumcisions a year, costing the Health Authority in the region of £170,000. Now, in an attempt to save money, the NHS Sheffield's Clinical Commissioning Group has proposed to make families who want their sons circumcised pay for the procedure. Each operation costs about £1,000.

But Coun Shaffaq Mohammed, who is a director at the Pakistan Muslim Centre in Sheffield, is worried about the potential knock-on effects.

He told Postcode Gazette: "I'm very concerned. Whilst it may seem like an easy saving, this could lead to a serious increase in backstreet operations. This is a dangerous path to tread and as a result may actually lead to parents seeking emergency treatment and actually increase burden on the NHS."
[This argument is never used to justify state funding of female genital cutting.]

Dr Margaret Ainger, a GP from Page Hall medical practice on Owler Lane and lead for children's services in the NHS Sheffield Clinical Commissioning Group, said: "We understand that for some, circumcisions are an important part of their religion and therefore our doctors are working with our key community groups on how best we could make advice and guidance available to those who need it. Conversations with these groups are planned and we are keen to get people involved in tailoring this advice."

The cut is set to come into force in the 2013/14 financial year. The commissioning group has been in discussions with Sheffield Children's Hospital about the possibility of instead providing a private service at the hospital.

A report to be presented at a council meeting next week states: "(The team is) exploring the potential to develop a service which will provide care under local anaesthetic on a private basis and paid for by the children's parents."

Dr Ainger added: "No decision has been made as of yet but we are exploring what options would be available to the Sheffield public by working in partnership with both the Children's Hospital and local authority to make sure that any family wishing to circumcise their sons have the best possible advice and guidance available."

Male circumcision, which is the surgical removal of the foreskin, is often carried out for non-medical reasons such as religious beliefs or personal preferences. It is common in both the Muslim and Jewish communities.

According to national guidelines from the Department of Health, circumcisions should not be funded when they are requested for non-medical reasons. The proposals bring Sheffield into line with this national guidance.

Dr Ainger said: "Non-therapeutic circumcisions are not clinical interventions and as a group, we would not want anybody to undergo a medical procedure if there was no specific clinical need."

Terry Sanderson, President of the National Secular Society, commented: "This is yet another example of public money being used for religious purposes. There is absolutely no need for children to be subjected to such a procedure – in fact there are plenty of arguments why they shouldn't be. The idea that scarce NHS funding is being used for something that has only religious and no medical significance is scandalous.

"There is however a real danger that those seeking circumcisions will turn to practitioners without medical qualifications. We call on the Government to amend Child protection legislation to make it unlawful for anyone other than qualified medical staff to circumcise minors for any reason. This is just a first step, though. We believe that non-therapeutic circumcision should not be permitted until the boy is old enough to give informed consent.

"Non-therapeutic infant circumcision is a breach of children's rights and it's time legislators reconsidered the current carte blanche afforded to infant circumcision on the basis that the parents' freedom of religion is the only consideration. This approach has already been taken by a Cologne Court and is backed by reputable medical bodies including the Royal Dutch Medical Association."

UNITED NATIONS: Humanists put circumcision on Human Rights Agenda

September 17, 2012

Humanists put circumcision ethics on UN agenda

The International Humanist and Ethical Union has presented papers to the United Nations Human Righs Council naming non-therapeutic circumcision as a human rights issue that requires the council's attention.

At the session of September 17, IHEU representative Josephine Mackintosh told the Council:
The recent German [Cologne district] court ruling outlawing non-therapeutic infant male circumcision correctly places the welfare, and the "fundamental rights and freedoms" of vulnerable children above the unrestrained expression of adult beliefs.

The court correctly determined that: non-therapeutic cutting of a child's body is an assault; that children are unable to give informed consent; that surrogate parental consent is not valid for an operation with no clinical indication and with the potential to cause serious harm; and that children have a right to be protected from bodily harm.

Such determinations cannot legitimately be overridden by adults convinced that children might be harmed by denying them this forced, irreversible surgery to their most intimate body parts. When the children become adult they can freely decide whether or not to undergo the procedure.

We understand, and have some sympathy with the sensitivities of certain religious groups which may feel threatened or even attacked by the judgment, particularly in the light of recent history. But it would be wrong to describe this judgment as religious persecution, or anti-Semitic; some Jewish voices are calling for an end to the practice and there is even an association called Jews Against Circumcision. Powerful groups must not be permitted to impose their views on the vulnerable on ideological or theological grounds in contravention of international law.

The Royal Dutch Medical Association and seven other Dutch scientific associations concluded in 2010 that the procedure can be harmful and that it violates the boy's human rights to autonomy and physical integrity.

The German judgment is therefore both laudable and overdue. Reflecting as it does States' obligations under the ICCPR, it should be followed by all member states.

Statement to the General Assembly

ILLINOIS: New AAP male circumcision policy expected next month

August 13, 2012	.

The Intactivism Pages
August 13, 2012

AAP male circumcision policy due in September

By Hugh Young

The American Academy of Pediatrics plans to issue a new policy on male circumcision at the end of the month. The policy is forshadowed in the Contents of the September issue of Pediatrics.

The new policy has been delayed several times since it was announced that a task force had been convened to examine the issue. The previous AAP male circumcision policy was issued in 1999.[This site rebuts it here.]

The AAP has never recommended male circumcision, but since the 1970s it has issued policies that leave the decision up to parents. The policies have always closely reflected US - but not world - cultural biases toward circumcision, omitting the structure and functions of the foreskin, passing over the lack of ethics in practising unnecessary reductive surgery on healthy newborns, and emphasising minor benefits while minimizing its risks and inevitable harms.

The AAP's treatment of the issue is in sharp contrast to that of other countries, such as the Royal Dutch Medical Association (KNMG), which roundly condems the practice. In May, a court in Cologne, Germany, ruled that circumcision of a healthy boy was bodily harm under the Basic Law.

One member of the task force on male circumcision, Dr Douglas Diekema, has hinted that the policy would lean further towards recommending genital cutting of healthy babies in the USA, in the light of studies of male volunteers for the adult operation in high-HIV-prevalance areas of Africa that seemed to show a reduction in their - but not women's - acquistion of HIV by heterosexual intercourse. (To the contrary, one study suggested male circumcision might increasethe risk to women. USAID surveys of HIV rates show higher rates among circumcised than non-circumcised men, in a majority of the countries for which it has figures.)

Dr Diekema was the chair of the AAP's Bioethics Committee in 2010 when it issued a policy that would allow a token, ritual nick to girls' genitals "much less extensive than neonatal male genital cutting". An outcry by anti-FGC organisations, led by Intact America, caused the policy to be "retired" within a month.

Speaking in more general terms, Dr Diekema has said under oath "I fully agree with the Bioethics Committee of the American Academy of Pediatrics when they state:

"...[P]roviders 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."

- but he has never applied this to male infant circumcision.

VANCOUVER: Foreskin Pride parade wants stronger stand from doctors

Metro News (Vancouver)
August 3, 2012

Foreskin Pride March rallies for ban on child circumcisions

By Kate Webb

A group of foreskin-loving activists plans to rally outside the downtown offices of the College of Physicians and Surgeons of B.C. Saturday calling on the federal government to ban circumcisions on minors.

Glen Callender, founder of the first ever Foreskin Pride March, wants to see the Criminal Code amended to include foreskins in the list of specified sexual organs that can not be mutilated or removed before the age of 18.

The College’s official stance is that routine infant circumcision is a cosmetic, medically unnecessary procedure, with risks that outweigh the benefits.

“The bottom line here is that here in Canada we protect the genitalia of girls from any kind of unnecessary surgery until they’re 18 years old, and then they have the right to modify their vulva as they see fit,” he told Metro.

“If girls have that right, then boys and intersex kids should have the same right. The Charter guarantees equal protection under the law.”

Circumcision rates have been falling in Western countries for decades, according to the Royal Dutch Medical Association, which condemns the practice.

In the U.K., the number of circumcisions on newborns fell from 35 per cent in the 1930s to 3.8 per cent by 2000. In the U.S. the incidence fell from 85 per cent in 1965 to 56 per cent in 2006.

In Canada, the prevalence fell from 47 per cent in 1973 to 32 per cent in 2007.

Dr. Neil Pollock, one of Vancouver’s most prominent circumcision surgeons who has performed the procedure more than 30,000 times, did not return Metro’s call requesting comment Thursday, and when reached Friday said he was too busy to do a phone interview on such short notice.

The Foreskin Pride marchers will rally at 3 p.m. at the Vancouver Art Gallery after protesting at noon on Saturday at the College. An adults-only education session on foreskin at the Qmunity queer resource centre at Bute and Davie Streets starts at 7 p.m.

On Sunday, for the third year, Callender will host adults-only demonstrations at his “foreskin awareness booth” from 11 a.m. to 6 p.m. at the Sunset Beach Pride Festival.

ROTTERDAM: Amicable exchange of views

July 5, 2012

Amicable exchange of views in Rotterdam

A day-long seminar in Rotterdam last week generated an amicable exchange of views.

The seminar, "The Doctor and the Foreskin" was organised by the Royal Dutch Medical Association (KNMG) parallel to the conference of the International Association of Bioethics. It came hard on the heels of the decision of the District Court of Cologne that non-therapeutic infant circumcision was contrary to the German Basic Law.

The first presentation of the day was by Gabriela Gomez, from Venezuela, about "scale up" of "voluntary medical male circumcision" and saw no problem with this. She thought talk of "mutilation" was unhelpful.

Michel Garrene's presentation was provided a measured response to the African HIV research. He acknowledged that the authors had proved efficacy at the individual level but demonstrated that that they had failed to prove effectiveness at a population level.

Anton van Niekerk, a moral philosopher from South Africa, pointed out that if someone produced a vaccine that was only 60% effective they would be laughed out of the arena.

Tom de Jong, a Danish Paediatric Urologist, gave a synopsis of how foreskin problems should be tackled, as opposed to circumcision.

Morten Frisch gave details of his research on the sexual effects of circumcision. He also mentioned his experience with Brian Morris as a reviewer of his paper.

Trond Markestad gave a synopsis of the situation in Norway. The religious communities, including the Church of Norway, had concluded it should be permitted, whereas the human rights organisations had concluded it should not.

Three different proposals have emerged:

1. Prohibit circumcision under age of 16, supported by the Centre Party, Humanists and the Children’s Ombudsman.
2. Permit circumcision of children by anyone, supported by Jews, Moslems and the Church of Norway.
3. Permit circumcision of children, but only by a doctor, supported by Norwegian Medical Association, who are concerned that a ban would drive the practice underground, thus resulting in more harm to children.

One Jewish man observed that not being circumcised had no bearing on whether or not someone was a Jew. An Israeli woman said that an increasing number of Israeli parents were opting against circumcision and that change would take place from the bottom up.

Arie C Nieuwenhuuijzen Kruseman, President of KNMG, concluded with a conciliatory tone.