“Cutting off a functional, protective, and sensitive body part is a far-reaching decision that the vast majority of Europeans believe should be left to its owner when he becomes old enough to understand the consequences. Despite the recent, backward-looking statements by U.S. medical organizations, more and more Americans are beginning to agree.”
Morten Frisch, M.D., Danish epidemiologist

Non-U.S. statements | U.S. statements | Critiques of AAP statement | Critiques of CDC draft guidelinesReferences

Medical Organization Statements on Circumcision


Medical organizations outside the U.S. have taken official positions on medical circumcision, despite the rarity of this practice in most non-English-speaking countries. European pronouncements, for instance, are noteworthy for scientific caution, reliance on evidence-based medicine, rejection of mere tradition or parental preference, and a thoughtful concern for the human rights of the child.

By contrast, U.S. medical associations – especially the American Academy of Pediatrics, the lead broker of this cultural practice for decades – have been strategically deferential to parental choice and tradition. The AAP has been equivocal on the medical evidence since declaring circumcision “unnecessary” in 1971 – then walking that disavowal back ever since. The AAP has consistently dangled the specter of unpleasant, even dangerous (but highly unlikely) outcomes for intact boys, while disingenuously leaving it up to frightened young parents to make an immediate ‘decision.’ The rare mention by the AAP of the human rights of the child to an intact body has been, at best, parenthetical, and at worst, disdainful and dismissive.
The AAP’s 2012 statement – its most pro-circumcision statement to date – is drastically out of line with numerous ethical, legal, and medical authorities in Europe and Australasia that have looked at the exact same evidence and come to opposite conclusions.

While the AAP has persistently focused on justifications for genital cutting of boys, the International Coalition for Genital Integrity has produced a position statement that focuses on genital wholeness and children’s rights, which D.O.C. endorses.

Non-U.S. medical organization statements on circumcision

Canadian Paediatric Society (CPS) (2015)
The CPS does not recommend the routine circumcision of every newborn male. It further states that when “medical necessity is not established, …interventions should be deferred until the individual concerned is able to make their own choices.”

Royal Dutch Medical Association (KNMG) (2010)
The KNMG states “there is no convincing evidence that circumcision is useful or necessary in terms of prevention or hygiene.” It regards the non-therapeutic circumcision of male minors as a violation of physical integrity, and argues that boys should be able to make their own decisions about circumcision.

The Royal Australasian College of Physicians (RACP) (2010)
The RACP states that routine infant circumcision is not warranted in Australia and New Zealand. It argues that, since cutting children involves physical risks which are undertaken for the sake of merely psychosocial benefits or debatable medical benefits, it is ethically questionable whether parents ought to be able to make such a decision for a child.

British Medical Association (BMA) (2006)
The BMA considers that the evidence concerning health benefits from non-therapeutic circumcision is insufficient as a justification for doing it. It suggests that it is “unethical and inappropriate” to circumcise for therapeutic reasons when effective and less invasive alternatives exist.

Expert statement from the German Association of Pediatricians (BVKJ) (2012)
In testimony to the German legislature, the President of the BVKJ has stated, “there is no reason from a medical point of view to remove an intact foreskin from …boys unable to give their consent.” It asserts that boys have the same right to physical integrity as girls in German law, and, regarding non-therapeutic circumcision, that parents’ right to freedom of religion ends at the point where the child’s right to physical integrity is infringed upon.

In addition, medical organizations and children’s ombudsmen from a number of other countries, including Finland, Norway, Slovenia, South Africa, Denmark, and Sweden, have gone on record in opposition to non-therapeutic circumcision of boys.

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U.S. medical organization statements on circumcision (AAP, CDC)

The 2012 Statement of the American Academy of Pediatrics’ Task Force on Circumcision

The American Academy of Pediatrics’ (AAP) Policy Statement and Technical Report on male circumcision, released in August 2012, are culturally biased and seriously flawed.

Doctors Opposing Circumcision calls on the AAP to withdraw its policy, and to replace it with an evidence-based statement guided by respect for genital wholeness and the human rights of the child.

The following commentary highlights some of the many problems with the AAP’s statement, with hyperlinks to further discussion on the evidence. See below for other critiques of the AAP’s statement.

Anatomy

  • The AAP fails to consider the structure or functions of the foreskin, a normal, healthy body part, focusing only on its amputation. It does not even define the foreskin, let alone describe its anatomy. The statement ignores the protective functions of the foreskin, and categorically dismisses its sexual functionality. p. e769
  • It treats normal intact penile features as pathological.
    • For example, natural, unforced separation of the prepuce from the glans might take as long as 17 or more years, with 10 years the average,[1,2] but the AAP claims, without citation, that it should separate within 2 to 4 months. p. e763
    • It associates “preputial wetness” with disease, when it is actually normal, just like wetness of the mouth or eye.
  • It bases its conclusions about sexuality on two satisfaction surveys of African adult volunteers for circumcision, in the context of HIV prevention (and therefore subject to bias [3]), while ignoring anatomical evidence and a variety of studies demonstrating detriment to sexual function.

Benefit vs. Risk

    • The AAP makes the key claim, repeated numerous times, that “the benefits of newborn male circumcision outweigh the risks,” without ever quantitatively comparing them. Indeed, it admits multiple times that the true rate and impact of circumcision complications is unknown, but still illogically makes this claim.
      • “The true incidence of complications after newborn circumcision is unknown.” p. e772
      • “It is unknown how often these late complications require surgical repair; this area requires further study.” p. e772
      • “Based on the data reviewed, it is difficult, if not impossible to adequately assess the total impact of complications.” p. e775
      • “Financial costs of care [after complications], emotional tolls, or the need for future corrective surgery are unknown.” p. e775

A guiding principle of medicine, however, suggests that a procedure should not be recommended until its complications, losses, and harms are fully understood.

Costs

  • The AAP’s report calls repeatedly for “access” and “third-party reimbursement” for circumcision, based on its flawed risk:benefit analysis, ignoring its own acknowledgment of insufficient information on the costs of circumcision. The report fully ignores the costs of follow-up care for complications and repeat procedures. p. e775
  • It repeats the common claim that it is safer to circumcise babies than adults, but offers no evidence for that claim. It compares the costs of circumcising at birth versus later in life, but fails to compare these with the option of doing nothing at all.
  • The only cost-effectiveness study cited did not consider circumcision complication rates. The report ignores a recent comprehensive cost:utility analysis that concluded, “Neonatal circumcision is not good health policy and support for it as a medical procedure cannot be justified either financially or medically.”

Ethics

  • The AAP’s discussion of the ethical questions relating to removing healthy genital tissue from a non-consenting person – versus leaving it for him to decide himself – assigns no value to the child’s future autonomy or his human rights to bodily integrity.
  • It explicitly argues against deferring circumcision until the child can make his own decisions (p. e760), without providing information on the disadvantages of immediate circumcision. Informational manipulation of this kind – particularly for a procedure that is medically unnecessary and elective – violates medical ethics. Furthermore, it contravenes the AAP’s own statement on pediatric proxy consent.
  • The AAP’s ethical consultant has said elsewhere that “circumcision is not medically essential and poses a risk of harm,” and that a parental request is not sufficient to justify doing any surgery, and the statement ignores these.

The CDC’s draft guidelines on male circumcision

Following the AAP’s lead, in December 2014, the Centers for Disease Control and Prevention (CDC) released draft guidelines on circumcision, which were similarly biased and flawed.

Many of the same problems, omissions, and biases found in the AAP policy are also found in the CDC’s draft guidelines. The guidelines seek to promote universal circumcision by recommending that all parents of intact boys – and, indeed, all intact males of any age – be specifically counseled that “the benefits of circumcision outweigh the risks.” During the public commentary following the release, the CDC logged more than 3200 comments on the draft, 97% of them opposed. To date, the draft has not been approved.

For other critiques of the CDC’s draft guidelines, see the links below.

Conclusion

Doctors Opposing Circumcision calls on the AAP to withdraw its circumcision policy, in the same way it withdrew its 2010 female genital cutting policy, in which it had recommended allowing a token – and illegal – ritual nick to baby girls. D.O.C further calls on the CDC to reject its draft guidelines.

The 2012 AAP’s male circumcision policy and the CDC’s draft guidelines seem bent on ignoring the healthy intact penis, while promoting an obsolete cultural practice that is outside evidence-based medicine. In doing so, it is out of step with numerous medical, legal, and ethical bodies in Europe and Australasia that have looked at the exact same evidence and concluded that there is no medical value to neonatal circumcision, that it violates the principles of medical ethics and human rights, and indeed, that it should probably be banned.[5,6,7] The AAP and the CDC, with their flawed policies, do a disservice to the growing number of boy babies being left intact, and to their parents. They do an even greater disservice to those boys who will be circumcised as a result of this ill-informed and misplaced advocacy – and to the men those boys will become.

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Selected Critiques of the AAP’s Position Statement

Frisch M, Aigrain Y, Barauskas V, Bjarnason R, Boddy S, Czauderna P, et al. Cultural bias in the AAP’s 2012 Technical Report and Policy Statement on male circumcision. Pediatrics. 2012;131(4):796-800.

Svoboda JS, Van Howe RS. Out of Step: fatal flaws in the latest AAP policy report on neonatal circumcision. J Med Ethics. 2013;39(7):434-441.

Darby R. Risks, benefits, complications and harms: neglected factors in the current debate on non-therapeutic circumcision. Kennedy Inst Ethics J. 2015;25(1):1-34. [Editor’s pick]

Van Howe RS. Statement by statement analysis of the 2012 report from the American Academy of Pediatrics Task Force on Circumcision: when national organizations are guided by personal agendas II. Academia website. n.d.

Commentary on American Academy of Pediatrics 2012 Circumcision Policy Statement. Doctors Opposing Circumcision website. Revised 2013 May 24.

Chapin G. Intact America’s official response to the American Academy of Pediatrics’ 2012 report on circumcision. Intact America: Say no! to circumcision website. 2012 Aug 27.

Chapin G. My letter to the American Academy of Pediatrics: “What were you thinking?” Intact America: Say no! to circumcision website. 2012 Aug 31.

Svoboda JS. Neonatal circumcision violates children’s rights, needlessly amputating functional tissue. Attorneys for the Rights of the Child website. 2012 Sep 6.

Goldman R. Response to the American Academy of Pediatrics (AAP) Circumcision Policy Statement. Circumcision Resource Center website. n.d.

Na AF, Tanny SPT, Hutson JM. Circumcision: Is it worth it for 21st century Australian boys? J Paed Child Health. 2015;51:580-583.

Earp BD. The AAP report on circumcision: bad science + bad ethics = bad medicine. Practical Ethics, University of Oxford. Academia website. Updated 2013 May 27.

AAP Circumcision Technical Report with annotations. The Intactivism Pages website. Edited 2012 Oct 7.

Longley G. Critique of the 2012 AAP Circumcision Position Statement. Circumcision Information Resource Center of Colorado website. 2013.

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Selected Critiques of the CDC’s Draft Guidelines

Public comment on the CDC male circumcision recommendations of 2014. Doctors Opposing Circumcision website. 2015 January 7.

Earp BD. Do the benefits of male circumcision outweigh the risks? A critique of the proposed CDC guidelines. Front Pediatr. 2015;3:18.

Van Howe RS. A CDC-requested, evidence-based critique of the Centers for Disease Control and Prevention 2014 draft on male circumcision: how ideology and selective science lead to superficial, culturally-biased recommendations by the CDC. Academia website. January 2015.

Adler P. The draft CDC circumcision recommendations: Medical, ethical, legal, and procedural concerns. Int J Child Rights. 2016. [Forthcoming.]

Frisch M, Earp BD. Circumcision of male infants and children as a public health measure in developed countries: a critical assessment of recent evidence. Glob Public Health. 2016 May 19:1-16. [Epub ahead of print] PMID: 27194404

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References

1. Øster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish Schoolboys. Arch Dis Child. 1968;43:200-3.
2. Thorvaldsen MA, Meyhoff H. Patologisk eller fysiologisk fimose? Ugeskr Læger. 2005;167(17):1858-62. Norwegian.
3. Earp BD. The need to control for socially desirable responding in studies on the sexual effects of male circumcision. PLoS ONE. 2015;10(9):1-12.
4. Paediatric Death Review Committee: Office of the Chief Coroner of Ontario. Circumcision: a minor procedure? Paediatr Child Health. 2007;12(4):311-2.
5. Royal Dutch Medical Association (KNMG). Non-therapeutic circumcision of male minors. Utrecht (Netherlands): Royal Dutch Medical Association; 2010 May.
6. Swedish docs in circumcision protest. The Local – Sweden’s News in English (Stockholm) website. 2012 Feb 19. Available at: www.thelocal.se/20120219/39200
7. Marshal W. Non-therapeutic male circumcision. Hobart (Australia): Tasmania Law Reform Institute; 2012 Aug.

Published March 2016

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