Circumcision and COVID-19:
Which surgeries are “essential” during a pandemic?
On a failure of ethics at the American Academy of Pediatrics
On April 2, 2020, in response to the COVID-19 pandemic, the American Academy of Pediatrics’ Committee on Fetus and Newborn issued “Initial Guidance: Management of Infants Born to Mothers with COVID-19.”[1]
The AAP’s 18-page document details the extra cautions and procedures necessary to attend an infected mother in order to protect providers, the mother herself, and her infant. Childbirth is, of course, time-sensitive, cannot be postponed, and so must be considered an essential rather than an elective procedure during the pandemic.
But one detail of the April 2, 2020 AAP guidance struck our international physicians’ organization as a jarring lapse of both bioethics and basic principles of epidemiology. At one point the authors declare, “Well newborns should receive all indicated care, including circumcision if requested.” No explanation followed to suggest why circumcision—the partial or total removal of the penile foreskin from presumptively healthy newborns—should be considered ‘essential’ rather than elective (“requested”), or even why the procedure would be offered to a potentially COVID-infected mother.
The updated version of the April 2 advice, issued July 22, 2020,[2] does not contain the explicit circumcision reference. But when contacted, the lead author claims, “The AAP continues to recommend that birth centers utilize their usual processes for circumcision.” (Karen Puopolo, MD, PhD, email communication, July 24, 2020) And a second author notes that “this [policy] has not changed.” (Mark Hudak, MD, email communication, July 23, 2020)
It is not yet known whether the virus can be transmitted transplacentally or by ambient, superficial virus present on the mother’s derma or expelled as an aerosol.[3] And neonates, with their immature immune systems, are unusually vulnerable to known viruses, let alone novel corona viruses.
Meanwhile, state medical authorities forbade elective procedures during this period of the pandemic. Because newborn circumcision is medically unnecessary and concerns a child who has no relevant penile disease or deformity, it is, by any view, an elective procedure. Elective procedures consume scarce PPE (Personal Protective Equipment), pull clinicians away from attending COVID-19 victims, and create an unnecessary vector for further infection.
According to a recent consensus statement by the Brussels Collaboration on Bodily Integrity, “an intervention to alter a bodily state is medically necessary when (1) the bodily state poses a serious, time-sensitive threat to the person’s well-being, typically due to a functional impairment in an associated somatic process, and (2) the intervention, as performed without delay, is the least harmful feasible means of changing the bodily state to one that alleviates the threat.”[4]
We propose that medically necessary interventions, as so defined, should be considered ‘essential’ during a pandemic situation, while those that are not medically necessary should be ethically forbidden.
The AAP, a trade association, has for decades functioned as the main ‘cultural broker’ of male circumcision in the United States, scrupulously careful to transfer the responsibility for this medicalized custom to the parents (“if requested”), rather than clearly stating that there is no medical indication for penile reduction surgery in healthy infants.
There have been anecdotal reports communicated to our organization of circumcisions performed without PPE, or performed immediately after birth using the same set of PPE, well before the child is stable thus adding to his ‘allostatic load.’[5]
That the AAP should endorse performance of a medically unnecessary cultural procedure during a pandemic is worrisome enough, even when the birth mother tests negative for COVID-19. But in addition, the circumcision procedure itself is a potential vector for community transmission. It should not be carried out in a setting already precarious for providers, not to mention the vulnerable child himself.
We call on the AAP to publicly retract its troubling endorsement, and remind their 67,000 Fellows, that—like many other medically unnecessary, elective surgical procedures that can safely be deferred—non-therapeutic circumcision should not be performed during a pandemic.
John V. Geisheker, JD, LL.M.
Executive Director,
General Counsel,
Doctors Opposing Circumcision
References
1. Wyckoff AS. AAP issues guidance on infants born to mothers with suspected or confirmed COVID-19. AAP News (American Academy of Pediatrics). 2 Apr 2020.
2. Wyckoff AS. Rooming-in, with precautions, now OK in revised AAP newborn guidance. AAP News (American Academy of Pediatrics). 22 Jul 2020.
3. Vivanti AJ, Vauloup-Fellous C, Prevot S, et al.Transplacental transmission of SARS-CoV-2 infection.Nat Commun. 2020:11(3572).
4. The Brussels Collaboration on Bodily Integrity.Medically unnecessary genital cutting and the rights of the child: moving toward consensus. Am J Bioeth.2019;19(10):17-28.
5. Elhaik E. Neonatal circumcision and prematurity are associated with sudden infant death syndrome (SIDS).J Clin Transl Res. 2019;4(2):136-151.