Critical Analysis of the 1999 AAP Statement on Infant Circumcision

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Critical Analysis of the
1999 American Academy of Pediatrics
Policy Statement on Infant Circumcision

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

Positive Points:

It takes a position of not recommending circumcision.
It puts the claims of medical benefits in context to show that they are insignificant.
By calling for pain medication, it recognizes that the extreme pain and trauma of circumcision cannot be ignored. However, it acknowledges that analgesia only reduces the pain and does not eliminate it. Also, anesthesia cannot mask the lifelong mutilation with which a male must live.
It cleary states that the final step in circumcision is "amputation of the foreskin." Therefore, circumcised males have been subjected to partial genital amputation.
It acknowledges reports that "penile sensation and sexual satisfaction are decreased for circumcised males."
It identifies 20 complications of circumcision.
It suggests that some medical professionals have coerced parents to choose circumcision.

Shortcomings:

Embryologic and Anatomic Considerations

The AAP Task Force on Circumcision did not discuss the functions of the foreskin. How can a parent make an informed decision about circumcision if they do not know these functions?

Epidemiology

It appears that the AAP attempts to inflate circumcision rates. It used a 1970 reference to report a Canadian newborn circumcision rate of 48%. Health & Welfare Canada statistics report that the national newborn circumcision rate in Canada today is less than approximately 25%.

The AAP also reported the national newborn circumcision rate in the U.S. to be 64.1%, based on National Center for Health Statistics (NCHS) data from 1995, rather than reporting the lower 1996 figure of 60.2%, which was readily available at the time that the Task Force met. The AAP faults the NCHS data as being "based on voluntary collection of data from participating hospitals", which provide "an inadequate sample." The NCHS states that its sample is larger than that mentioned by the AAP and the data are collected from a national probability sample with a 95% participation rate. Also, hospitals often increase their income by billing insurers for circumcisions that were not performed. This too creates the impression that circumcisions are more common than they actually are.

Sexual Practice, Sensation and Circumcision Status

The adverse physical, sexual and psychological effects of infant circumcision on men's health and well-being are dismissed as "anecdotal." This, despite the fact that over 300 men wrote to the AAP in 1997 to describe the harm they've suffered from this surgery they did not choose, as well as the harm findings from over 500 respondents to NOHARMM's survey, which were published in the January 1999 British Journal of Urology.

The AAP cites a seriously flawed 1966 survey by Masters & Johnson to defend the notion that there is no difference in sensation or sexual satisfaction between the circumcised and intact penis.

Urinary Tract Infections

The AAP did not mention an 8-year prospective study by Mueller that found little difference in UTI among between circumcised and intact boys and that the common cause in both was abnormalities in the genitourinary tract, not the presence or absence of a foreskin. See also Urinary Tract Infection and Circumcision. Excellent analysis by a doctor, with easy-to-read graphs.

Ethical Issues

The 1999 AAP Task Force on Circumcision does not recommend circumcision on medical grounds yet appears to condone doctors acting on parental requests for circumcision for non-medical reasons (i.e., culture, religion, ethnicity). This completely contradicts a key passage of the 1995 Committee on Bioethics report which states: "(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 AAP indicates that the process of informed consent obligates the physician to "enumerate the risks, benefits and alternatives " for the patient to make an informed choice. Most physicians are not aware of the nonsurgical alternatives to circumcision. How can they explain these to parents?

The AAP failed to answer the question of whether it is ethical for physicians to act as the agents of social custom by performing non-therapeutic, culturally-motivated surgeries on unconsenting children.

The AAP failed to indicate that the current U.S. custom of male circumcision was started by the medical community (see: A Short History of Circumcision in the Physicians' Own Words) and therefore the medical community bears a responsibility to actively work for the elimination of physician involvement in non-therapeutic circumcision.

Complications

In both 1989 and 1999 the AAP admitted that the exact incidence of complications was unknown. The AAP, like the rest of the medical community, bears a responsibility to parents to investigate what the exact incidence of complications is. An intolerable situation exists where hospitals and doctors do not adequately record these incidents (or they record the cause as something other than circumcision). How can parents be fully informed of these risks if even the AAP does not know and makes no attempt to know?

The AAP seriously underestimates the complication rate at 1%. A more realistic figure estimated by Williams and Kapila is 2%-10%, an important study that was never cited by the 1999 AAP Task Force on Circumcision.

The AAP failed to offer guidance on how much of the penis is to be removed during neonatal circumcision:

Should all specialized sensory receptors of the ridged band be removed?

Should most of the penile dartos muscle be removed?

Should all of the penile mucosa be ablated?

What is the desired penile alteration of neonatal circumcision?

What anatomic landmarks describe the desired effect?

Should the tip of the glans penis, the corona, or the coronal sulcus be visible after neonatal circumcision?

If there are no medical indications for circumcision, what are the indications for a re-circumcision if the parents don't like the looks of the original circumcision?

[Questions originated by Dr. Christopher Cold Tel: 715-387-9806 E-mail: coldc@dgabby.mfldclin.edu ]

In general, the AAP has not shown any leadership on this issue for the past 25 years. It has failed to make continuing education programs mandatory for pediatricians on the development, functions and care of the foreskin. The AAP calls for parents to be fully informed, yet fails to sponsor any coherent, consistent, or widespread educational programs for parents to insure that they are fully informed before making this decision.

Circumcision Resource Center analysis of the AAP Policy Statement

1999 AAP Policy Statement on Circumcision

More Pages Related to Male & Female Circumcision