DOC Letter to American Academy of Pediatrics Officials

Doctors Opposing Circumcision (DOC) is concerned about compromises of sound medical practice, bioethics, and medical law that are found in the 1999 Circumcision Policy Statement of the American Academy of Pediatrics (AAP). DOC has expressed some of its concerns in similar letters signed by George C. Denniston, M.D., President, mailed on October 15, 2002 to five top officials of the AAP. Those officials are Louis Z. Cooper, MD, FAAP, President; Donald E. Cook, MD, FAAP, Past President; E. Stephen Edwards, MD, FAAP, Vice President; Joe M. Sanders, Jr., Executive Director; and Edward Zimmerman, Co-director, Department of Practice and Research.

The text of the letter is provided below. Links to supporting documents online are also provided.





October 15, 2002.

Re: Non-therapeutic circumcision of male children

Dear Doctor Cooper:

The AAP Circumcision Policy Statement (1999)1 corrected numerous egregious misstatements in the 1989 report2 prepared by the Task Force led by Edgar J. Schoen and contained many important advances. It is, however, only a half-measure that does not fully reflect the AAP's commitment to protect the human rights of minor children. There are still numerous errors and misstatements that need to be addressed. The world has moved on since 1999 and, since the Circumcision Policy Statement did not fully address the issues in 1999, it now is time to revisit neonatal circumcision once again."

I would like to cover some of the problems in this letter.

Conflict with other AAP Positions

The 1999 Circumcision Policy statement is inconsistent with numerous other AAP statements and, therefore, is inconsistent with sound medical practice. These inconsistencies were apparently allowed so as to permit the continued practice of neonatal circumcision.

  1. The Circumcision Policy Statement says that anesthesia should be used for the pain of circumcision. The recent joint statement on pain however, emphasizes that painful procedures should be avoided.3 There should be no problem with avoiding neonatal circumcision because the Council on Scientific Affairs recognizes that neonatal circumcision is a non-therapeutic procedure.4
  2. The Circumcision Policy Statement recognizes that neonatal circumcision is a painful and traumatic procedure. The previously issued statement of the Workgroup on Breastfeeding, however, states "Procedures that may interfere with breastfeeding or traumatize the infant should be avoided or minimized."5 The Circumcision Policy Statement takes no recognition of the need to avoid traumatic procedures to ensure the successful initiation of breastfeeding6 and therefore is deficient in this respect.
  3. The Committee on Bioethics states, "Every child should have the opportunity to grow and develop free of preventable illness or injury," and cites the UN Convention on the Rights of the Child.7 Circumcision is a radical procedure that excises a generous amount of healthy functional tissue from the penis8 with various protective, immunological, mechanical, and erogenous functions,9 10 and so is a substantial injury. The injury of circumcision easily may be prevented simply by avoiding circumcision. The Circumcision Policy Statement, however, takes no notice of the right of the child to grow and develop free from preventable injury.
  4. The Committee on Bioethics states that doctors 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," and proxy consent does not absolve him from this duty.11 The Circumcision Policy Statement is in direct conflict with this principle because it states, "it should be the parents who determine what is in the best interest of the child." This is also in conflict with the Committee on Bioethics position that parent may only grant permission for diagnosis and treatment of disease.12 Neonatal circumcision is neither diagnosis nor treatment so according to the Committee on Bioethics no parental rights exist to grant permission for non-therapeutic non-diagnostic circumcision.
  5. The Section on Urology advises that there are two time windows in which genital surgery is best performed from the viewpoint of emotional development.13 The first window is from six weeks of age until approximately 15 months of age if parental separation is limited. The second window is from 24 months of age until 36 months of age. The Section of Urology cites the need to avoid interference with bonding as a reason to avoid genital surgery in the first weeks of life. Neonatal circumcision as contemplated by the 1999 Circumcision Policy Statement is usually performed within the first week after birth and, therefore, is in direct conflict with the recommendations of the Section on Urology.

The lack of harmony with other AAP positions provides strong indication that the AAP has compromised sound medical practice in the interest of promoting male neonatal circumcision.

Conflict with Policy Statements of Other Medical Societies

The American Academy of Family Physicians (AAFP) has developed its own position statement on neonatal circumcision. That statement recognizes ethical problems with the circumcision of minor children for "other than medical reasons."14 The AAFP likens male neonatal circumcision to a "cosmetic procedure" because of its lack of medical value. The AAP Circumcision Policy Statement, however, fails to recognize the ethical problems inherent in non-therapeutic child circumcision, cites "potential" benefits as an excuse to carry out a circumcision and, therefore, is in substantial conflict with the new position of the AAFP.

The Canadian Paediatric Society recommends "Circumcision of newborns should not be routinely performed," meaning that circumcision should not be performed in the absence of medical indication. And of course there are no medical indications for circumcision in the newborn.15 The Circumcision Policy Statement has no such recommendation, and improperly condones circumcision for social reasons.

Six medical societies in Australia and New Zealand issued a joint policy statement in September on the circumcision of male children.16 That statement reaffirms, "there is no medical indication for routine male circumcision." It then adopts the view of the Canadian Paediatric Society that "Circumcision of newborns should not be routinely performed." They found the potential benefits cited by the AAP statement, such as prevention of UTI, STDs, and penile cancer, are NOT grounds for circumcising a child. The 1999 Circumcision Policy Statement now stands in conflict with the recently adopted position of six medical societies in Australasia.

The College of Physicians and Surgeons of Saskatchewan (CPSS) recently issued a strongly worded memorandum to doctors in that province about the practice of child circumcision.17 It told doctors to tell parents that child circumcision is not a recommended procedure, and that they should refuse to perform the circumcision. The CPSS expressed great concern about possible litigation. In Canada, the colleges of physicians and surgeons have the legal duty to regulate medical practice. The recent death of a child two days after a circumcision has made clear that the risks of circumcision far outweigh any conceivable benefit.18 It now appears likely that colleges in other provinces will adopt similar positions.

AMA Principles of Medical Ethics (2001)

The Council on Ethical and Judicial Affairs of the American Medical Association updated its Principles of Medical Ethics in 2001.19 There are significant changes relative to the ethics of non-therapeutic circumcision of children at parental request.

Principle I has been amended to require a doctor to respect the human rights of the patient. This is extremely significant because the Netherlands Institute of Human Rights reports that the circumcision of male children violates numerous human rights,20 including the right to physical integrity, the right to self-determination, and even the right to life because sometimes a circumcision causes death of an infant. The Circumcision Policy Statement makes no mention of the need to respect the human rights of the patient and is deficient in this respect.

Principle VIII is new. It provides, "A physician shall, while caring for a patient, regard responsibility to the patient as paramount." Male circumcision, in the absence of medical indication and performed at the request of the parent, violates this rule because it makes parental desires paramount over the physician’s responsibility to the child-patient. This new principle is consistent with the statement of the AAP Committee on Bioethics that doctors 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." Thus, the guidance of the Circumcision Policy Statement that "it should be the parents who determine what is in the best interest of the child" is in conflict with both the AMA principles of medical ethics and the AAP’s own bioethics statement.

Adverse Sexual Effects

The Circumcision Policy Statement properly acknowledges the landmark foreskin anatomy and histology research of Taylor and others.21 Additional reports now document the adverse sexual effects of male circumcision.22 23 24 25 The discussion in the Circumcision Policy Statement is inadequate and misleading. The new evidence dictates that an update be provided.

Adverse Emotional Effects

There is new evidence concerning adverse emotional effects of male circumcision. Rhinehart reports from his clinical practice PTSD secondary to neonatal circumcision in adult males.26 Boyle et al. report various psychological problems secondary to neonatal circumcision and altered sexual behaviors.27

Some emotional effects such as the tendency to repeat the trauma and the adamant father syndrome may contribute to the perpetuation of an outmoded medical practice. This calls into question the competence of many circumcised fathers to make a rational objective decision about permission for neonatal circumcision.

Ethics and Law

The conflict between the present Circumcision Policy Statement and the Committee on Bioethics statement and the AMA Principles of Medical Ethics has been discussed above.

Assuming for the moment that parents have lawful authority to consent to neonatal circumcision, full provision of all relevant and material information is necessary or the doctor may be found negligent.28 The Committee on Bioethics describes the requirements:

1. Provision of information: patients should have explanations, in understandable language, of the nature of the ailment or condition; the nature of proposed diagnostic steps and/or treatment(s) and the probability of their success; the existence and nature of the risks involved; and the existence, potential benefits, and risks of recommended alternative treatments (including the choice of no treatment).29

Non-circumcision is a viable alternative to circumcision. Parents must have all relevant and material information about non-circumcision or no treatment in addition to all relevant and material information about circumcision.30 The 1999 Circumcision Policy Statement is entirely deficient on the potential risks and proven benefits of non-circumcision and so does not provide necessary information.

There is reason to believe that parents lack the power to consent to invasive non-therapeutic surgical operations that are not for the benefit of the child. Parents are expected to act in the best interests of their children in making decisions about medical care.31 A British court has ruled, however, that circumcision was not in the best interest of a boy and that decision was upheld on appeal.32

Lawyers from several countries, including the United States, argue that parents do not have the right to grant proxy consent for a non-therapeutic invasive operation on a minor child.33 34 35 36

The view that parents do not have the right to consent to this type of surgery is based on numerous court decisions, including the United States Supreme Court opinion, “Parents may be free to become martyrs themselves. But it does not follow that they are free to, 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.”37

If parental permission for circumcision is not valid due to lack of informed consent, not acting in the best interests of the child, or that parents lack legal authority to grant permission for non-therapeutic alteration of a child’s genitals, the circumcision would become a battery, with applicable civil and perhaps criminal penalties.

The ethical guidance of the 1999 Circumcision Policy Statement selectively cited two authorities while ignoring limitations on parental powers and rights cited by those very same statements.38 39 This has created an unfortunate pro-circumcision bias in the statement that is entirely improper.

Circumcision usually is performed on minor children shortly after birth. Circumcision is a defined, documented, and quantified injury to the penis.40 Infants and children are legally incompetent to consent to surgery or to sue. However, upon reaching the age of majority persons may institute litigation to recover damages for injuries suffered in childhood. This causes an exceptionally long period of risk for doctors who perform circumcisions. An Australian man recently sued the doctor who circumcised him as a child and collected substantial amounts of money in damages.

Conclusion

The 1999 Circumcision Policy Statement was inadequate and wrong in many instances when it was published. It has not improved with time. Giannetti strongly argues that the AAP may be liable for trade association liability due to the poor science in the Circumcision Policy Statement.42 This reflects poorly on the reputation of the Academy, whether true or not. The AAP should act promptly to remove any support for Giannetti’s arguments.

Other medical societies have adopted policies that are substantially more child friendly and child protective than that of the AAP. The AAP once again stands alone in condoning this outmoded medical procedure, perhaps to cater to parental desires and physician practices.

The 1999 Circumcision Policy Statement places parental wishes above children's legal rights to bodily integrity, security of the person, life, autonomy, privacy, and other rights. This is in opposition to expressed AAP policy to promote children’s rights.43 44 It is time for a new statement that truly puts the child’s needs and the child’s rights first. DOC recommends that the Committee on Bioethics be charged with the responsibility for developing a new statement since the problems are primarily in the ethical and legal arena.

We enclose a copy of the Saskatchewan College of Physicians and Surgeons warning memorandum to doctors in that province. The Journal of Urology, the official journal of the American Urological Association has also issued a warning to its readers in this month’s issue regarding the legal risks incurred in the non-therapeutic circumcision of children.45 We also urge you to issue a cautionary memorandum to your members/fellows similar to that issued by the Saskatchewan College of Physicians and Surgeons.

DOC will place this letter on its website because the public and the medical community need to know about the contradictions and errors in the present Circumcision Policy Statement.

Very truly yours,

      /s/

George C. Denniston, MD, MPH
President

Enclosure: The enclosure is found below the citations.


1 American Academy of Pediatrics Task Force on Circumcision. Circumcision Policy Statement (RE9850), Pediatrics 1999;103(3):686-693.
2 Task Force on Circumcision. Report of the Task Force of Circumcision (RE9148). Pediatrics 1989;84(4):388-391.
3 American Academy of Pediatrics. Committee on Fetus and Newborn, Committee on Drugs, Section on Anesthesiology, Section on Surgery Prevention and Management of Pain and Stress in the Neonate (RE9945). Pediatrics 2000;105(2):454-461.
4 Council on Scientific Affairs, American Medical Association. Report 10: Neonatal circumcision. Chicago: American Medical Association, 1999.
5 Work Group on Breastfeeding. Breastfeeding and the use of human milk (RE9729). Pediatrics 1997;100(6):1035-39.
6 Anonymous. The Effects of Circumcision on Breastfeeding. San Anselmo, CA: National Organization of Circumcision Information Resource Centers, 2002. Available at: http://199.88.87.143/statements/breastfeeding_statement2002.html.
7 Committee on Bioethics, American Academy of Pediatrics. Religious objections to medical care (RE9707). Pediatrics 1997; 99(2):279-281.
8 Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-295.
9 Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Inf 1998;74:364-367.
10Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 Suppl. 1:34-44.
11 American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995;95(2):314-317.
12 Ibid.
13 Section on Urology, American Academy of Pediatrics. Timing of Elective Surgery on the Genitalia of Male Children With Particular Reference to the Risks, Benefits, and Psychological Effects of Surgery and Anesthesia (RE9610) Pediatrics 1996;97(4):590-4.
14 Commission on Clinical Policies and Research. Position Paper on Neonatal Circumcision. Leawood, Kansas: American Academy of Family Physicians, 2002. Available at: http://www.aafp.org/policy/camp/4.html
15 American Academy of Pediatrics, Committee on Fetus and Newborn. Standards and Recommendation for Hospital Care of Newborn infants. 5th ed. Evanston, IL: American Academy of Pediatrics, 1971:110; Foetus and Newborn Committee. FN 75-01 Circumcision in the Newborn Period. CPS News Bull Suppl 1975; 8(2):1-2; Beasley S, Darlow B, Craig J, et al. Policy Statement on Circumcision. Sydney: Royal Australasian College of Physicians, 2002.
16 Beasley S, Darlow B, Craig J, et al. Policy Statement on Circumcision. Sydney: Royal Australasian College of Physicians, 2002. Available at: http://www.racp.edu.au/hpu/paed/circumcision/
17 Ehman AJ. Cut circumcision from list of routine services, Saskatchewan MDs advised. CMAJ 2002; 167 (5):532.
18 Jackie Smith. The growing consensus against circumcision. National Post, Toronto, 30 August 2002.
19 Council on Ethical and Judicial Affairs. Principles of Medical Ethics (2001). Chicago: American Medical Association. Available at: http://www.ama-assn.org/ama/pub/category/2512.html
20 Jacqueline Smith. Male Circumcision and the Rights of the Child. In: Mielle Bulterman, Aart Hendriks and Jacqueline Smith (Eds.), To Baehr in Our Minds: Essays in Human Rights from the Heart of the Netherlands (SIM Special No. 21). Netherlands Institute of Human Rights (SIM), University of Utrecht, Utrecht, Netherlands, 1998: pp. 465-498.
21 Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-295.
22 Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 Suppl. 1:34-44.
23 Coursey JW, Morey AF, McAninch JW, et al. Erectile function after anterior urethroplasty. J Urol 2001;166(6):2273-6.
24 Pang MG, Kim DS. Extraordinarily high rates of male circumcision in South Korea: history and underlying causes. BJU Int 2002;89:48-54.
25 Fink KS, Carson CC, DeVellis RF. Adult Circumcision Outcomes Study: Effect on Erectile Function, Penile Sensitivity, Sexual Activity and Satisfaction. J Urol 2002;167(5):2113-2116.
26 Rhinehart J. Neonatal circumcision reconsidered. Transactional Analysis Journal 1999; 29(3):215-221.
27 Boyle GJ, Goldman R, Svoboda JS, Fernandez E. Male circumcision: pain, trauma and psychosexual sequelae. J Health Psychology 2002;7(3):329-43.
28 Svoboda JS, Van Howe RS, Dwyer JG. Informed Consent for Neonatal Circumcision: An Ethical and Legal Conundrum. J Contemporary Health Law Policy 2000;17:61-133.
29 American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice (RE9510). Pediatrics 1995;95(2):314-317.
30 Hill G. Informed consent for circumcision. South Med J 2002;95(8):946.
31 Svoboda JS, Van Howe RS, Dwyer JG Informed Consent for Neonatal Circumcision: An Ethical and Legal Conundrum. J Contemporary Health Law Policy 2000;17;61-133.
32Re J [2000] 1 FCR 307.
33 Richards D. Male Circumcision: Medical or Ritual? J Law Med 1996;3: 371-6.
34 Povenmire R. Do Parents Have the Legal Authority to Consent to the Surgical Amputation of Normal, Healthy Tissue From Their Infant Children?: The Practice of Circumcision in the United States. Journal of Gender, Social Policy & the Law 1998-99;7:87-123.
35 Boyle GJ, Svoboda JS, Price CP, Turner JN. Circumcision of Healthy Boys: Criminal Assault? J Law Med 2000:7:301-10.
36 Svoboda JS, Van Howe RS, Dwyer JG. Informed Consent for Neonatal Circumcision: An Ethical and Legal Conundrum. J Contemporary Health Law Policy 2000;17:61-133.
37 Prince v. Massachusetts, 321 U.S. 158, 159-60 (1944).
38 American Academy of Pediatrics, Committee on Bioethics. Informed consent, parental permission and assent in pediatric practice (RE9510). Pediatrics 1995;95:314-319.
39 Fleischman AL, Nolan K, Dubler NN, et al. Caring for gravely ill children. Pediatrics 1994;94:433-439.
40 Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-295.
41 Butler B. The cruel cut that ruined a man’s life. Sunday Times, Perth, WA, 26 December 1999: 2.
42 Giannetti MR. Circumcision and the American Academy of Pediatrics: Should Scientific Misconduct Result in Trade Association Liability. Iowa Law Rev 2000;85: 1507 (2000).
43 Haggerty RJ. Convention on the Rights of the Child: It's Time for the United States to Ratify. Pediatrics 1994;94(5):746-747.
44 Committee on Bioethics, American Academy of Pediatrics. Religious objections to medical care (RE9707). Pediatrics 1997; 99(2):279-281.
45 Canning DA. Informed consent for neonatal circumcision: an ethical and legal conundrum. J Urol 2002;168 (4 Pt 1): 1650-1.



Enclosure: Kendel, D. A. Caution Against Routine Circumcision of Newborn Male Infants (Memorandum to physicians and surgeons of Saskatchewan). Saskatoon: College of Physicians and Surgeons of Saskatchewan, February 20, 2002. Photocopy.