Critical Reporting of the 1999 AAP Circumcision Statement

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1999 American Academy of Pediatrics Task Force Committee Statement on Circumcision

Suggested Guidelines for
Evaluation and Critical Reporting

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The 1999 American Academy of Pediatrics Task Force Statement on Circumcision is noteworthy for what it does say, but also for what it does not say. Here are some critical questions to verify, as well as potential biases to look for in the statement. Links access relevant support documentation.

View 1999 American Academy of Pediatrics (AAP) Circumcision Policy.

View NOHARMM's official response. Read NOHARMM's Critical Analysis of the 1999 AAP Statement

Does the 1999 AAP statement acknowledge...?

Alternatives to Circumcision	Anatomy/Function	Ethical Issues	Health Concerns
Human Rights/Legal Concerns	Long-Term Outcomes	Opposing Opinions/Policies	Pain

Alternatives:

existence of non-surgical prophylaxis/treatment alternatives for the problems that circumcision is alleged to address?

Anatomy, Function, Development and Care:

the unique histology of the penis, which clearly shows the existence of erogenous nerves in the foreskin?
the specialized functions, normal development and proper care of the intact penis?
that infant circumcision amputates that which, in the adult male, constitutes 50% or more of the penile shaft skin (approximately 12-15 square inches of tissue)?

Ethical Issues:

the concerns of prominent medical ethicists who consider non-therapeutic circumcision of healthy children for reasons of social custom a violation of modern medical ethics, and perhaps the law?
equal application of ethical standards to both genders? (Example: Removing the female foreskin/clitoral hood can improve hygiene by reducing smegma buildup, but is termed "mutilation," while removing the male foreskin is termed a "hygienic procedure.")
that circumcision in the U.S. began as a form of physician-assisted sexual oppression of children; that the social demand for circumcision was created by the medical profession; and that today's medical community bears an ethical responsibility to actively discourage the practice?
the ethical dilemma of physicians performing non-therapeutic surgery, thereby acting as the agents of social custom?
the full range and severity of potential outcomes (reduction of penile sensory ability, gangrene, death, surgical accidents, gender reassignment, etc.), or does it dismiss these from inclusion in the informed consent process?
the inherent conflict of interest physicians face when attempting to discourage parents who demand a non-therapeutic, yet financially profitable, intervention on a vulnerable child?
the ethical question of normal tissue (the foreskin) being removed from infants and either sold or donated to biotissue corporations, which convert the foreskin into profitable artificial skin products? Foreskins for Sale

Health Concerns:

that there is reliable scientific evidence demonstrating that the risk of urinary tract infection is not caused by the foreskin but by underlying congenital urinary tract anomalies, a risk that can be effectively reduced by breastfeeding?
that penile and cervical cancer, as well as sexually transmitted diseases (including HIV/AIDS), are behavior-based diseases that are more effectively addressed by sexual health education programs, proper hygiene and condom usage, than by circumcision?
the advice of the American Cancer Society, which discouraged the AAP from promoting circumcision as prevention for genital cancers?
the need for continuing education programs for practicing physicians to update themselves about the development of the foreskin, so that they discontinue the obsolete advice to retract a child's foreskin (which can damage the penis and require circumcision)?
the need for improved education of medical students concerning the unique anatomy, specialized functions, normal development and proper care of the intact penis, as well as the ethics of non-therapeutic surgery on unconsenting children?

Human Rights and Legal Concerns:

the existence of human rights concerns, as non-therapeutic circumcision of a healthy child violates basic human rights to physical integrity and self-determination? See articles on this site by Baer, Chessler and Svoboda.
that recent legislation protecting the genital integrity of female minors leaves male children unprotected from violations of their genital integrity and is being challenged? Details: Zenas Baer, Attorney (Tel. 218-483-3372)
that physicians should be advised of the current legal challenges to male newborn circumcision under International Law and Constitutional principles of equal rights and non-discrimination?
the inherent conflict in the AAP's claim to be a child advocacy organization when its statement asserts an alleged "parental right" to amputate and destroy a functional part of a child's body?
that the alleged "parental right" to choose circumcision of a healthy child, as well as parental "informed consent," are either non-existent or invalid? (Parents cannot give proxy consent for non-therapeutic surgery on a healthy child).

Long-Term Outcomes:

the anatomic loss of the entire erogenous penile mucosa, with abnormal keratinization of the residual glans penis mucosa, and the loss of almost all of the penile dartos muscle? Details: Christopher J. Cold, M.D. (Tel. 800-782-8581, ext. 79806)
that a significant percentage of males circumcised as infants wish they had a complete penis, or have experienced long-term adverse physical, sexual or psychological consequences from this surgery they did not choose?
that in the Spring of 1997 the AAP invited letters from men circumcised as infants (and received several hundred letters) detailing the harm they suffered as a result of circumcision? NOHARMM has copies of many of these letters. Details: Tim Hammond (Tel. 415-826-9351)
that increasing numbers of men see themselves as damaged by circumcision and are engaged in foreskin restoration methods? See: Circumcision Reversal Gains Popularity The New Mexican and The Case Against Circumcision Brit. J. Sex. Med. Details: R. Wayne Griffiths (Tel. 510-827-4077) National Organization of Restoring Men

Opposing Opinions & Policies

the circumcision position statements of Australia, Britain and Canada, all of which advise against infant circumcision?
the existence of, reasons for, and need for support of doctors and nurses who conscientiously oppose participation in non-therapeutic circumcisions?
the objections to circumcision by genital integrity and children's rights advocates as being based on the fundamental human right to bodily integrity, or does it mischaracterize the objections as being based only on pain?

Pain:

that on those occasions when pain relief is used on infants undergoing circumcision: 1) EMLA topical anesthetic is contraindicated for newborns and on genital tissue, and 2) Dorsal Penile Nerve Block uses needles to inject narcotics into the penis, and the potential for nerve damage manifesting in adolescence or adulthood has not been adequately assessed on a prospective basis?
that there is no pain-relief system that totally eliminates the pain of infant circumcision and that circumcised boys will still suffer pain during and after the surgery?
that the least expensive, most ethical, and only effective way to eliminate infant circumcision pain is to refuse parental requests/demands for non-therapeutic circumcision?

Look for hidden bias, undisclosed information, or disinformation (20 questions)

The AAP's candor about the injury that circumcision inflicts will likely be limited by its need to protect from legal liability its members who still perform circumcisions or who have performed them in the past.

Does the statement...?

express concern that imposing a non-therapeutic genital alteration on a child exploits the child's vulnerability?
provide a valid explanation for why circumcision cannot be delayed until the child is of an age to determine for himself whether or not to be circumcised?
expand upon which parts of a normal, healthy infant's anatomy can be removed with parental consent? (Example: If parents are counseled about the risks and benefits, can healthy tonsils be removed with parental consent? Can healthy breast tissue be removed from male infants, since twice as many U.S. men die from breast cancer (400 annually) as from penile cancer (220 annually?)
recognize that the primary motivation for infant circumcision in the U.S. is not medical, but social and cultural, and if so, does the AAP propose a public education program to acquaint parents and others with the value of intact genitals and the rights of the child? Why or why not?
explain how hospital solicitation for elective, non-therapeutic infant circumcision is permissible, when solicitation for other elective, non-therapeutic surgeries violates medical ethics and may constitute medical fraud/malpractice?
minimize the dangers of circumcision by terming it a "simple" or "the most common" procedure?
obscure the prognosis that the overwhelming majority of intact babies will become, as they do in the rest of the world, happy functional intact men?
dismiss as "anecdotal," information that could only be obtained anecdotally, such as male dissatisfaction with an incomplete penis?
suggest negative psychological ramifications of remaining intact, without recognizing similar psychological consequences from amputating part of the primary male sexual organ?
adequately warn doctors and parents of the significant resentment rate among non-intact (circumcised) males?
ignore the loss of functional erogenous tissue, which would otherwise be unacceptable in a female, and presume that damage from male circumcision must be extreme before recognizing it as "harmful"?
demonstrate "selective quantification," using unbalanced statistical arguments for circumcision? (Example: Is a ten-fold increase in urinary tract infections [UTI] alleged among intact male newborns, without clarifying that less than 1% of intact male newborns will ever get a UTI, and that infection rates are higher in female newborns?). See Urinary Tract Infection and Circumcision. Excellent analysis by a doctor, with easy-to-read graphs.
urge application of equal standards for medical care? (Example: Female children, who get urinary tract infections at a higher rate than males, receive no preventive intervention, while males are subjected to surgery. When females get a UTI, they are treated with antibiotics, to which circumcised and intact males would respond equally well, but more often than not, intact males are treated surgically with circumcision.)
evidence gender and cultural bias by discounting comparisons with female circumcision? (Example: Primitive forms of female circumcision are contrasted with "modern" forms of male circumcision, without recognizing that the vast majority of male circumcisions in the world occur under the same rudimentary and unsanitary conditions as female circumcision, while in some parts of the world less severe forms of female circumcision are medicalized alongside male circumcision.)
make vague recommendations ( e.g., that parents should be counseled, without defining what parents should be told)?
use only the biased term "uncircumcised," instead of positive terminology such as normal, natural, whole, complete, or intact? (Example: Do we call someone "untonsillectomized" or women "unmastecomized?")
use the euphemism "circumcision," instead of clearer and more accurate terms such as "amputation of the foreskin," "penile surgery," "wound," "scar," etc.
employ misleading terms such as "prevent" disease, when circumcision cannot "prevent" any disease? Does it use trivializing terms such as "discomfort" to describe "excruciating pain."
employ "apples and oranges" comparisons, such as comparing inherent short-term risks to potential long-term benefits, while omitting inherent long-term disadvantages?
discuss only the statistical risks and benefits of circumcision, or does it include the guaranteed disadvantages, such as: financial cost, permanent disfigurement, keratinization (leading to sensitivity loss), as well as the loss of erogenous tissue, natural lubrication, penile bulk, and protection from injury?