On Monday, August 27, 2012, at 12:01am ET the AAP is scheduled to release their newest policy statement on circumcision. While the rest of the world moves in a direction far away from the forced genital cutting of healthy babies and minor children, with many nations implementing bans on the practice, this new AAP statement takes an awkward, pro-cutting slant, and one that it not grounded in sound medical evidence. What follows is the critique of one scholar, Petrina Fadel, who serves as the Director of Catholics Against Circumcision. For a full pdf copy of the AAP's statement (31 pages) write to DrMomma.org(at)gmail.com to request.
PART ONE
Dear AAP Board Members:
I am writing to you to request that you withdraw or rescind the newest 2012 AAP Circumcision Policy Statement. Below I have critiqued for you some of the serious problems with this new statement.
The Abstract states on page 585 that “health benefits are not great enough to recommend routine circumcision for all male newborns,” but this is not repeated even once in the long text on pages 758-785. Other long columns favoring circumcision are repeated over and over again, on pages 761-762, 770, 775-776, and 778. The 1999 AAP Statement was 8 pages long (pages 686-693), but this diatribe against living with a foreskin goes on for 28 pages. There is almost the feeling that AAP physicians hope that if they repeat something over and over again, eventually it might become the truth.
The AAP concludes on page 778 that “the health benefits of newborn male circumcision outweigh the risks”, and yet on page 772 the AAP admits that “the true incidence of complications after newborn circumcision is unknown”. If one doesn’t know how often complications occur, then one can’t make the judgment that the benefits outweigh the risks! The AAP lacks the evidence it needs to make such a claim.
The 1999 Statement studied 40 years’ worth of research, and the 2012 studied only selective research since 1999. Only 1031 of 1388 studies were accepted to look at. Balance might have been found in the 357 studies that were omitted, but the AAP was not seeking balance. The AAP statement goes on ad nauseum about alleged “benefits”, to the point of fear-mongering that something will go wrong if an infant isn’t circumcised. It’s a high pressure sales pitch to try to get the American public to buy the circumcisions that AAP and ACOG doctors are selling. This is in direct contrast to Europe, where circumcision is uncommon and the health of European children equals or surpasses that of American children.
No studies on ethics were included in this statement, and it is clear that the rights of the child and how a grown man might feel about HIS foreskin being stripped from him were never given any consideration at all by the AAP. These are major issues, and even more important than many of the other minor issues the AAP discusses. Material was provided to the AAP to study this aspect of circumcision, but it was ignored. With one bioethicist on the panel, you would have thought that the AAP might at least have given the ethics of circumcision a cursory examination, considering that they were provided with many sources showing the emotional distress many men feel. Ethics and mental health, however, nowhere enter the picture for the AAP. Respect for the bodily integrity of another person were not included, and medical ethics were thrown out the window as infants were thrown under the bus.
Financing studies weren’t included in the studies, but the AAP did its best to push financing repeatedly for third-party reimbursement of non-therapeutic circumcision, at the expense of taxpayers during a time of budget crises. Those with private insurance would see premiums and medical costs rise. The cost for circumcision on page 777 ranges from $216 to $601 per circumcision in the U.S. In 2010, the in-hospital U.S. circumcision rate was 54.7%. Thus, 45.3% of newborn males left the hospital genitally intact. If the AAP were to convince parents of these 45.3% to circumcise (as they are attempting to do in this 2012 statement), then there would be 45.3% of roughly 2.1 million baby boys that could be an additional income source for physicians. (Remember, don’t consider the ethics!) This would be an additional 951,300 male infants to profit from. At prices the AAP quotes, this could mean an additional $205,480,800 to $571,731,300 for doctors who circumcise. This is no small sum, and as Thomas Wiswell, M.D. stated on June 22, 1987 in the Boston Globe, “I have some good friends who are obstetricians outside the military, and they look at a foreskin and almost see a $125 price tag on it. Each one is that much money. Heck, if you do 10 a week, that's over $1,000 a week, and they don't take that much time. “(Lehman 1987) Money like that would certainly help doctors make their mortgage payments and their car payments, pay for vacations, etc. - a “benefit” that the AAP failed to mention. Under Literature Search Overview, it is understandable why AAP physicians might consider it important to investigate “What are the trends in financing and payment for elective circumcision?”
No studies on the anatomy and functions of the foreskin were included. This is surprising, since it would seem like common sense to consider what the functions of any healthy body part are before amputating it. Probably since the male AAP Task Force members are all circumcised, this idea was difficult for them to grasp. Only one study on the sexual impact of circumcision was included, and this from Africa. Other studies were ignored or discounted. “The effect of male circumcision on the sexual enjoyment of the female partner”, which appeared in BJU INTERNATIONAL, Volume 83, Supplement 1, Pages 79-84, January 1, 1999, is not mentioned. Nor is the newest Danish study that was publicized on November 14, 2011 – “Male circumcision leads to a bad sex life” - "Circumcised men have more difficulties reaching orgasm, and their female partners experience more vaginal pains and an inferior sex life, a new study shows." See: http://sciencenordic.com/male-circumcision-leads-bad-sex-life The AAP had time to include this study, but it was ignored. Others sent material to the AAP about CIRCUMserum, Senslip, foreskin restoration that men are undergoing to undo some of the damages of circumcision and how this improves the sexual experience for both men and women. It didn’t fit the AAP’s pro-circumcision agenda, so it was ignored. The Policy Statement is totally lacking in ethics, anatomy, and foreskin functions. Instead, the Task Force is more concerned with how to train more doctors to circumcise, and how to do so with different devices and various forms of anesthesia.
The physical and sexual harms from circumcision are minimized or dismissed outright. Deaths from circumcision and botched circumcisions are considered “case studies”, and the children horribly damaged from circumcision don’t merit the AAP’s consideration, even though the AAP’s alleged mission is that it is “Dedicated to the Health of All Children”. When cribs are faulty or car seats aren’t safe, the AAP becomes concerned and warns the public. When physicians botch circumcisions and are at fault, children don’t matter. After one botched circumcision lawsuit and a large settlement, the company that manufactured the Mogen clamp went out of business. The AAP report should have advised physicians to NOT use the Mogen clamp because of the botched circumcisions that have resulted with this device. If still in use, no doubt there will be future tragedies with the Mogen clamp, but parents will only be able to sue the doctor and hospital and not the manufacturer.
There was so much reliance on studies from Africa in this statement , that it seemed like the AAP should change its name to the African Academy of Pediatrics. In contrast to the AAP, the American Association of Family Physicians (AAFP) has stated: "...the association between having a sexually transmitted disease (STD) - excluding human immunodeficiency virus (HIV) and being circumcised are inconclusive... most of the studies [of the effect of circumcision on HIV] ...have been conducted in developing countries, particularly those in Africa. Because of the challenges with maintaining good hygiene and access to condoms, these results are probably not generalizable to the U.S. population". But generalize the AAP did! In addition, the AAP listed page after page of STDs that allegedly circumcision would prevent, and wrote conflicting statements about syphilis. A recent study in Puerto Rico found that circumcised men have HIGHER rates of STDs and HIV. The 60% reduced risk of HIV following circumcision is the relative risk reduction, not the absolute risk reduction. There’s a huge difference. Across all three female-to-male trials, of the 5,411 men subjected to male circumcision, 64 (1.18%) became HIV-positive. Among the 5,497 controls, 137 (2.49%) became HIV-positive”, so the absolute decrease in HIV infection was only 1.31%, which is not statistically significant.” (Boyle GJ, Hill G. Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. J Law Med 2011; 19:316-34.)
Infants are not at risk of STDs or HIV through sexual contact, so this speculation about their future risk is foolhardy. Infants can also be at risk for many other diseases, but surgical amputation of healthy body parts is a foolhardy approach for prevention and treatment of disease. If an infant is at risk of an STD, then it is probably safe to say that an adult is perpetrating a crime against the child and needs to be arrested and charged.
Judaism and Islam are mentioned as religions that practice religious circumcisions. Once again, the statement ignores Christianity, which teaches that circumcision is unnecessary. Christianity is the largest religion in the U.S., but its teachings don’t even get a mention by the AAP, which is rather insulting! With an over-representation of members on the Task Force who have a religious bias favoring circumcision, this is not surprising.
The AAP promotes parents choosing medically unnecessary circumcision for their male children, completely contradicting what it said in PEDIATRICS, Volume 95 Number 2, Pages 314-317, February 1995. It said then, “Thus "proxy consent" poses serious problems for pediatric health care providers. Such providers 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 pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent.”
Parents deserve factual information about circumcision, but they won’t find it in the new AAP Statement. In fact, the AAP wrongly advises parents of intact baby boys to retract the foreskin and wash it with soap and water. (page 763) Soap can alter the good bacteria under the foreskin, potentially causing infections that should then be treated with liquid acidophilus to restore the good bacteria. Water is sufficient for cleansing. Circumcised doctors with circumcised sons probably don’t know this.
On page 764, the AAP speculates that the foreskin contains a high density of Langerhans cells, “which facilitates HIV infection of host cells." Actually, the exact opposite is true. "Langerin is a natural barrier to HIV-1 transmission by Langerhans cells" (Nature Medicine- 4 March 2007). This study states, "Langerhans cells (LCs) specifically express Langerin . . . LCs reside in the epidermis of the skin and in most mucosal epithelia, such as the ectocervix, vagina and foreskin.”
UTIs can be prevented through breastfeeding, which the AAP allegedly supports. This is nowhere mentioned under “Male Circumcision and UTIs” on page 767. HPV can be prevented with a vaccine for both boys and girls, but it is not mentioned on that same page. A recent study reporting on the large number of re-circumcisions done following infant circumcisions is also not even mentioned. On page 770, EMLA is mentioned as a possible anesthetic, but EMLA is not supposed to be used on infants. The fact remains that unnecessary surgery performed with anesthesia is still unnecessary surgery.
There is so much wrong with this new statement that it should immediately be withdrawn before it is presented on Monday. The AAP should either start all over again (with new, unbiased Task Force members), or renew its 1999 statement which attempted to at least give a more balanced view of circumcision. The 1999 circumcision statement certainly had its flaws by ignoring ethics and the anatomy and functions of the foreskin, but it wasn’t as atrocious as this new statement is.
If the AAP wants to be regarded as a credible organization, it will look to the judgment of other foreign medical associations who recognize that circumcision is medically unnecessary and has serious ethical problems underlying its practice. American parents should look to these foreign medical associations for good advice, since the AAP is not providing it in its new statement.
After rereading the AAP's new Circumcision Statement, several more problems have emerged with this statement. This statement needs to be rescinded and withdrawn immediately! Others are becoming aware of this matter as well.
Under "Ethical Issues" (pages 758-759), two of the references for this opinion come from Dr. Douglas Diekema (AAP's bioethicist), who signed his name to this statement. The rights of the child are totally ignored in this section, from an organization that claims to be concerned with the welfare of children but in this case isn't. This is Diekema's own personal opinion that the Task Force has bought into, based on what he wrote before. References are also taken from M. Benatar and D. Benatar (both Jewish circumcision supporters), as well as from AR Fleishman (whom I suspect has a religious bias favoring circumcision). Under "Ethical Issues" (page 759), there's an interesting choice of words by the AAP. "In cases, such as the decision to perform a circumcision in the newborn period, ... and where the procedure is not essential to the child's immediate well-being ..." , the AAP admits here that circumcision "is not essential". It even calls circumcision "elective" in several other places, but it then proceeds to do a massive sales pitch for this unnecessary surgery.
Under Ethics, Reference #14 comes from the British Medical Association- "The law and ethics of male circumcision: guidance for doctors: J. Med Ethics 2004. The BMA did not print a favorable piece on circumcision, but the AAP cherry-picked something from it on page 760. Medical associations in other countries, like the British Medical Association, do not promote circumcision as the AAP has so foolishly chosen to do.
On page 760, the AAP states, "The Task Force's evidence review was supplemented by an independent, AAP-contracted physician and doctoral-level epidemiologist who was also part of the entire evidence review process." Who was this? The AAP should reveal the name of this physician.
Several times in the report, the AAP states (page 762), "For parents to receive nonbiased information about male circumcision in time to inform their decisions...clinicians need to provide this information at least before conception, and/or early in the pregnancy, probably as a curriculum item in childbirth classes." There is absolutely no way doctors can do this before conception, and "Inform their decisions" is code for brainwashing parents as early as possible. This is mind control at its worst, supported by the AAP!
The AAP on page 763 uses the term "Uncircumcised" under "Care of the Circumcised Versus Uncircumcised Penis", and later the term "non-circumcised" when saying, "The non-circumcised penis should be washed with soap and water." The correct terminology is intact penis, or normal or natural penis. We don't say "uncircumcised" female or "non-circumcised" female.
The APP on page 764 states, "Mathematical modeling by the CDC shows that, taking an average efficacy of 60% from the African trials, [Note: This is the relative risk, not absolute risk, which is 1.31%.) and assuming that protective effect of circumcision applies only to heterosexually acquired HIV" ..." The AAP states here that they are assuming, which means to "suppose to be the case, without proof." There's a saying that if you "assume" anything, it makes an ass out of u and me. Assumptions are not evidence, and since when should the AAP be relying upon or making assumptions? "Sexual Satisfaction and Sensitivity" (page 769) never once mentions or considers how circumcision impacts the sexual experience for females. The AAP gets it totally wrong about males, while then totally ignoring females! A Danish study by Morten Frisch (whom the AAP uses as a reference in #118) revealed late last year that circumcised men have more difficulties reaching orgasm, and their female partners experience more vaginal pains and an inferior sex life.
"Analgesia and Anesthesia for a Circumcision After the Newborn Period" (page 771) states, "Additional concerns associated with surgical circumcision in older infants include time lost by parents and patients from work and/or school." The AAP is promoting newborn circumcision so parents don't have to miss work? Parents miss work all the time when their kids get sick as toddlers or later on as young children. Now, all of a sudden, the AAP is concerned about parents missing work, but not concerned about the rights of the child.
Under "Complications and Adverse Events" (page 772), the AAP twice mentions how circumcision risks are lower in hospitals with trained personnel than those performed by untrained practitioners in developing countries. U.S. parents don't live in a developing country, and this doesn't even belong in an AAP statement!
"The true incidence of complications after newborn circumcision is unknown ..." (page 772) "Two large US hospital-based studies with good evidence estimate the risk of significant acute circumcision complications ... " "(T)here are no adequate studies of late complications in boys undergoing circumcision in the post-newborn period; this area requires more study." (page 773) "There are not adequate analytic studies of late complications in boys undergoing circumcision in the post-newborn period." (page 774) Under "Stratification of Risks" the AAP says, "Based on the data reviewed, it is difficult, if not impossible, to adequately assess the total impact of complications, because the data are scant and inconsistent regarding the severity of complications." After admitting that the true incidence of complications is unknown (i.e. the risks), the AAP then has the audacity to state that "the health benefits of newborn male circumcision outweigh the risks". (page 756). Under "Task Force Recommendations" (page 775), the AAP says, "Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks ..." The AAP doesn't know the incidence of risks, so how do they expect physicians to know that?
The AAP sings its own praises under "Medical Versus Traditional Providers". "Physicians in a hospital setting generally have fewer complications than traditional providers in the community setting." Was this the AAP saying that doctors are safer than mohels? I don't think they'll like that!
In 2009, ten years after the AAP did not recommend circumcision (and still doesn't apparently, doesn't on its words on page 585, but which one would never know after wading through this rubbish), their own survey of AAP members found that "18% responded recommending to all or most of their patients' parents that circumcision be performed." (page 776) I don't find that surprising that AAP doctors would recommend a surgery that means more money for them. On pages 777-778 the AAP wants to know about the effectiveness of their new 2012 statement to mislead parents. "The Task Force recommends additional studies to better understand ... The impact of the AAP Male Circumcision policy on newborn male circumcision practices in the United States and elsewhere." In other words, how effective are we in deceiving American parents and people in other countries?
The AAP wants to work with the ACOG, AAFP, American Society of Anesthesiologists, and American College of Nurse Midwives to develop a plan about which groups are best suited to perform newborn male circumcisions. (page 777) In other words, how is the AAP going to divvy up the money it so eagerly wants?
The AAP targets blacks and Hispanics in the U.S. for unnecessary circumcisions. "African-American and Hispanic males in the United States are disproportionately affected by HIV and other STIs, and thus would derive the greatest benefit from circumcision." (page 777) But then, under Areas for Future Research, the AAP says, "The Task Force recommends additional studies to better understand ... The impact of male circumcision on transmission of HIV and other STDS in the United States because key studies to date have been performed in African populations with HIV burdens that are epidemiologically different from HIV in the United States." The AAP just spent several pages before this promoting newborn circumcision to allegedly prevent STDs and HIV based on African studies, but now it's admitting that more studies are needed because the results could be different in the U.S. Was this put in to help with the solicitation for more funding for pro-circumcision researchers at Johns Hopkins and elsewhere, to keep them going? Maybe these researchers are tired of Africa and want to come home?
The AAP did actually say ONE good thing, but only ONE good thing in this whole statement. On page 760 the AAP says, "The Task Force advises against the practice of mouth-to-penis contact during circumcision, which is part of some religious practices, because it poses serious infectious risk to the child." If I were to guess, I'd say that perhaps Dr. Susan Blank put that in. While working for the New York City Health Department, Dr. Blank has done nothing to ban metzitah b'peh, so as not to offend the Orthodox Jews who practice it. Babies have died of herpes from metzitzah b'peh under her watch.
This atrocious AAP Statement needs to be rescinded immediately. I suggest that the AAP use good judgment and do precisely that.
Sincerely,
Petrina Fadel,
Director Catholics Against Circumcision
National Headquarters:
The American Academy of Pediatrics
141 Northwest Point Boulevard
Elk Grove Village, IL 60007-1098
USA 847/434-4000
(tel) 800/433-9016
(toll-free tel) 847/434-8000 (fax)
Washington, DC Office:
The American Academy of Pediatrics
Department of Federal Affairs
601 13th Street, NW Suite 400 North
Washington, DC 20005 USA
202/347-8600 (tel)
202/393-6137 (fax)
Upon request, this is an easy copy/paste of the 2012 AAP Task Force on Circumcision and AAP Board of Directors' email addresses:
sblank@health.nyc.gov, michael.brady@nationwidechildrens.org, ebuerk@aap.org, wcarlo@peds.uab.edu, diek@u.washington.edu, andrew.freedman@cshs.org, maxwell@email.chop.edu, swegner@ncaccesscare.org, clebaron@cdc.gov, lesley.atwood@allina.com, scraigo@tuftsmedicalcenter.org, Susan@susanflinn.com, esther_janowsky@unc.edu, ezimmerman@aap.org, robert-block@ouhsc.edu, Thomas_McInerny@urmc.rochester.edu, marion.burton@uscmed.sc.edu, CAllen@aap.org, dlaraque@maimonidesmed.org, shassink@aap.net, ferushton@embarqmail.com, mbull@iupui.edu, mseverson@aap.org, KMatthews@aap.org, kyasuda@uw.edu, mabbottmd@aol.com, sgoza@aap.net
AAP Circumcision Policy Statement Reading and Responses:
Sign the INAAPT petition to the AAP: http://www.inaapt.com
AAP 2012 Policy Statement Excerpt: http://www.facebook.com/notes/saving-our-sons/aap-policy-statement-on-infant-circumcision-sept-1-2012/476789462340180
AAP Circumcision Policy Statement: A Critique: http://www.drmomma.org/2012/08/aap-circumcision-policy-statement.html
The Bias of the AAP: http://www.udonet.com/circumcision/vincent/bias_of_the_aap.html
University of Oxford: The AAP Report on Circumcision: Bad Science + Bad Ethics = Bad Medicine
http://blog.practicalethics.ox.ac.uk/2012/08/the-aap-report-on-circumcision-bad-science-bad-ethics-bad-medicine/
Pediatrics "Cultural Bias in the AAP's 2012 Technical Report and Policy Statement on Male Circumcision": http://pediatrics.aappublications.org/content/early/2013/03/12/peds.2012-2896.full.pdf
Children's Health & Human Rights Partnership Condemns New AAP Policy Statement: http://chhrp.org/index.php/news/childrens-health-human-rights-partnership-condemns-new-aap-policy-statement/Pediatrics "Cultural Bias in the AAP's 2012 Technical Report and Policy Statement on Male Circumcision": http://pediatrics.aappublications.org/content/early/2013/03/12/peds.2012-2896.full.pdf
Medical Organization Statements from around the world on RIC: http://www.drmomma.org/2013/05/the-medical-benefits-of-infant.html
Circumcision Resource Center Response to AAP Policy Statement:
http://www.circumcision.org/aap.htm
Circumstition's Annotated AAP Policy Statement: http://www.circumstitions.com/Docs/aap-12-anno.pdf
ARC Law Response: http://arclaw.org/resources/press-releases/attorneys-rights-child-condemns-american-academy-pediatrics-hiding-truth-pu
Doctors Opposing Circumcision Commentary on AAP Policy Statement: http://www.doctorsopposingcircumcision.org/pdf/2012-08-26A_Commentary.pdf
Doctors Opposing Circumcision Response: http://www.doctorsopposingcircumcision.org/pdf/2012-08-22_PublicNotice.pdf
Circumcisions R Us: Try Again AAP: http://pippaabston.wordpress.com/2012/09/01/circumcisions-r-us-try-again-aap/
My thoughts on the AAP Circumcision Policy Statement and What I've Learned from a Decade of Intactivism: http://www.drmomma.org/2012/08/the-aap-2012-circumcision-policy.html
Intact America Response: http://www.intactamerica.org/pr_082212
AAP: Breastfeeding Advocates or Pro-Circumcision Profiteers? http://lifesasaladbar.blogspot.com/2012/08/aap-breastfeeding-advocates-or-pro.html
I don't need the AAP to know: http://www.attachedparentsatwork.com/EffYouAAP.html
Where logic and ethics go to die: http://mamaraw.com/2012/08/24/where-logic-ethics-go-to-die/
To the AAP Task Force on Circumcision: http://intacthouston.wordpress.com/2012/08/27/to-the-aap-task-force-on-circumcision/
AAP / Circumcision Graphics: http://www.facebook.com/media/set/?set=a.476778032341323.112615.166998263319303&type=1
AAP Demonstration: http://www.facebook.com/events/339781256109134/permalink/340627516024508/
Join in the conversation: www.Facebook.com/SavingOurSons
At least they never cited Brian Morris!
ReplyDeleteBut a few of Morris' buddies were on the Task Force... have to sneak in some circumfetish agendas somewhere.
DeleteNo, but after the AAP summarise the Sorrells finding on page e769 as
Delete"There is fair evidence that men circumcised as adults demonstrate a higher threshold for light touch sensitivity with a static monofilament compared with uncircumcised men;"
- leaving out its key finding that "Circumcision ablates [removes] the most sensitive part of the penis"
it was Morris and Waskett who found
"these findings failed to attain statistical significance for most locations on the
penis,"
- with "most locations" being their way of ignoring the foreskin.
See the whole policy annotated at http://tinyurl.com/aapanno
How tragic.....even a pediatric medical organization fails to protect children from non therapeutic genital alterations....in favor of financial gains.
ReplyDeleteThe AAP is clearly thinking about $$$ and not about human rights.
ReplyDeleteWhen I read the AAP statement my chest really constricted. it aches me to know that so many baby boys will suffer as a result of what is obviously a money and ignorance driven statement. The whole idea that the 'benefits' are not outweighed by the very real risks of circumcision... I mean, seriously, what baby boy has faced hemorrhage, infection or death from being left intact!?
ReplyDeleteWhere can we find the link to the full report you are quoting from ?
ReplyDeleteMaria, the publication referenced will be available in print Sept 1st in 'Pediatrics' (the AAP's publication). It will also be available at the AAP's website as of 12:01am ET Monday morning. You may be able to obtain a copy of the policy by writing to DrMomma.org@gmail.com as well.
DeleteThanks for the information. It seems like the AAP is trying to shift its policy statement from previously being neutral to being pro-circ. Last time it said the benefits and risks were equal and so circ was basically a wash. Now it is saying that the benefits outweigh the risks. So while they say they are not recommending it for all boys, I suspect the American media and many American parents will view it as an endorsement of circumcision once they see it on Monday.
DeleteHere is a copy of the letter I have emailed to the AAP, through various petition sites, as well as to the individual AAP board members.
ReplyDeleteHello. I am writing to you as the mother of two young, genitally intact (uncircumcised) sons, as a student nurse, and as an active participant in some large online parenting forums, with particular involvement in issues concerning circumcision and intactness.
Firstly I want to say that I am very happy with my decision to keep my sons intact. I also want to say that I owe the AAP a great debt of gratitude for its publication entitled "Care of the Uncircumcised Penis". I have been scrupulous in following the care recommendations of this document (which is to say that I have never attempted to retract or manipulate my sons' foreskins in any way). I have given copies of that document to my children's daycare provider, and I have chosen for them a physician (family practice) who seems familiar with those guidelines and has followed them in his practice (which is to say that he has never even tried to touch their penises). I credit this document, and my adherence to it, with the fact that my two sons at ages 3 1/2, have never had even a hint of a problem with their penises.
I now want to express some of my concerns to you about the upcoming revision of your recommendations concerning newborn circumcision. From what I've been able to gather, it sounds as if you will be coming out with statement that the benefits unequivocally outweigh the risks, and stopping just short of a recommendation in favor of it (while paying lip service to parent's rights to choose not to). I understand that your ultimate conclusion is to be that all third party payers should be mandated to cover this elective surgery on newborns.
I want to suggest to you that you risk doing an enormous amount of damage to the credibility of your institution, and even bringing global discredit to the American medical profession in general. I want to suggest that you consider that this could ultimately harm the professional interests of your members, and the health interests of the children your organization claims to be committed to protecting.
I have seen enough leaks concerning this document to know that its conclusions are completely out of step with the medical consensus of the rest of the industrialized world. I've seen enough that I believe the evidence you will present is heavily biased in favor of some methodologically flawed studies done in Sub-Saharan Africa, while ignoring mountains of contrary evidence from studies and health statistics in the developed world including the United States. This, coupled with the focus on money and guaranteed third party payment, will suggest to many people that your organization is subordinating both science and ethics for the narrow financial interests of its members and associated medical professionals (stakeholders).
I don't know if you are aware of just how much the trust in doctors has declined in this country in recent years, but these new recommendations are likely only to accelerate this process. This decline in trust is coming at a real cost. Parents are increasingly rejecting recommended vaccination schedules. On the parenting boards that I frequent, I see more and more people stating their intent to have home births and to reject well baby visits rather than deal with a profession they have so thoroughly lost faith in.
Please do not think that the perceived prestige of your organization will cover any shoddy work that you may be presenting in these recommendations. The internet and social networking have created a whole new world of information access and exchange, and any weaknesses, shoddy work, and flimsy evidence will be readily recognized and pointed out, globally, and on a massive scale. You will not be able to hide behind the cover of your organization's reputation.
My letter continued:
ReplyDeleteNow I wish to move on to some of my more specific concerns. In your 1999 statement, you included the recommendation that "If circumcision is performed in the newborn period, it should only be done on infants who are stable and healthy." I believe that this statement needs clarification and strengthening. I don't know whether you are familiar with the case, but in 2010 a 7 week old NICU baby in Indiana who was critically ill with a major heart defect, was circumcised and subsequently hemorrhaged for over 6 hours before a urologist was called in to repair the nicked artery in his penis. The baby in question died a few hours later. This case would never have come to the attention of the public except that the mother blogged the details of the circumcision and its immediate aftermath including the death. The hospital never even admitted to any connection between the circumcision and hemorrhage, and the subsequent fatality.
I believe that there are several important issues brought up by this case. First, we have no way of knowing how many similar cases may be happening in this country, as this one became public knowledge only through a fluke. Clearly there is a need for greater clarification of the contraindications to newborn circumcision. This case also points up the fact that there is currently no system in place for tracking complications or adverse events that occur following circumcision (such as for vaccines through the VAERS system). I understand that you are to state definitively that benefits outweigh risks for circumcision. But I ask you, how can it even be possible to make such an assertion when there is no system in place to even track complications? As a participant on parenting forums, I see literally hundreds of posts concerning circumcision complications, but for the most part it seems that they are brushed under the rug by doctors, and do not appear to enter into any of the cost/benefit calculations for the procedure.
Another recent case involved a Florida baby who was who was circumcised two days prior to his discharge from the NICU (another baby who was not medically stable). While this baby was fortunate not to suffer any immediate complications, the case was notable in that the surgery was done with no signed consent, and after the parents had been solicited for circumcision and refused it on multiple occasions. I believe that this case points up some of the major problems with the consent process that often accompanies this surgery.
According to many mothers posting on the parenting boards, the consent process consisted of little more than a piece of paper, in a pile of papers, hastily signed during labor or following childbirth, often while in a heavily medicated state. Many report never having had a consultation with the surgeon (and sometimes not even knowing who the surgeon was). Many of them report being given no real information about what the surgery actually entailed, and many of them went through the entire consent process without even being made aware that it is an elective procedure and that they had the option to refuse it.
Because all of this information is now freely available on the internet, when these mothers learn more, they often end up feeling distraught and ridden with guilt and remorse for not doing more research. But what kind of a responsibility do you, the doctors, have to make sure that this most basic of information is transmitted during what is allegedly supposed to be an "informed" consent process?
Another issue highlighted by the case in Florida is the way in which this surgery is often aggressively solicited to parents in the hospital following delivery. The mother in this case was asked repeatedly about circumcision, and repeatedly refused it. She never signed a consent, but the operation was still done, reportedly during a brief period in which she left her baby's side to quickly take a shower and change clothes.
My letter part 3:
ReplyDeleteAccording to posts on the parenting forums, it is not uncommon for parents to be asked over and over and over again about circumcision, even when they have made their refusal adamantly clear. In many instances, this solicitation approaches the level of harassment or even bullying. I think it would be a very good idea for your organization to clarify some improved standards for obtaining informed consent, and for demonstrating respect for parental choice in the clinical setting.
The final major area of concern that I have is further related to the issue of respect for parental choice. The most fundamental way in which the medical profession can demonstrate respect for the parental choice to keep a son genitally intact is to ensure that its members are in possession of the most basic information about the anatomy, normal development, and proper care of the intact penis. In a particular forum for parents of intact sons, there are over 100 posts (out of a total number of around 1200) concerning cases of doctors or nurses forcefully and often aggressively retracting the foreskins of infants and toddlers, attempting such retractions (and being fought off by parents), advising of the necessity of forcibly retracting to clean, or suggesting to parents that the foreskin is "tight" and that the baby will need to be circumcised unless the parents embark on a program of aggressive manual stretching and pulling of the foreskin during bathtime.
As I am sure you are aware, all of these actions and suggestions run completely counter to the recommendations of your own excellent document "Care of the Uncircumcised Penis". It seems to me that any doctor accredited by your organization should at least be familiar with the information contained in that brief document. The truth is that many of us are all too aware that there is, in most medical education programs in this country, no training at all in the basic anatomy, development, functions, or proper care of the intact penis. I would strongly suggest that your organization take some basic steps to ensure that your membership becomes more familiar with this sort of information; maybe even promoting some sort of standard curriculum to be included in all medical training programs.
Parents of intact sons should at least be able to trust that they can take their children to the doctor without the risk of their receiving a serious genital injury. And please believe me that there is immense injury done to the reputations of all of your esteemed colleagues, and of the medical profession in general, every time one of these types of incidents occurs.
Thank you very much for hearing me out on my concerns.
Sincerely,
Has a petition been created or will that wait until Monday when this is actually released? Due to pressure, they rescinded their ritual nick for girls. Maybe we can do the same thing with this circumcision policy.
ReplyDeleteGreat letter, whoever you are! So thorough and well written--hope it receives the attention it warrants.
ReplyDelete--Kari in Ventura
I give a standing ovation to Petrina Fadel for having read the Task Force's report very closely and for having written up her conclusions in such detail.
ReplyDelete30 years ago, I met at a party a woman who worked in the cancer statistics registry of a USA inner city hospital. She told me bluntly that "cervical cancer is a venereal disease that mostly affects young black women from the wrong side of the tracks." We now know that this is in good part true, and that certain strains of HPV are to blame. Tobian-Gray-Bailey-Halperin et al believe that black people from the slums cannot be trusted to use condoms or remain faithful. Therefore they conclude black baby boys should be cut at birth, for prophylactic reasons.
Problem: in 18 states, Medicaid won't pay for RIC. Also, many private health insurers no longer pay for it. The real goal of Tobian et al is to convince the Federal government to overrule these coverage exclusions. Once that is accomplished, maternity ward staff will lean hard on underclass mothers, to convince them to permit the circumcisions of their infant sons. Tobian et al would be content if only underclass boys were circumcised. But there is no way to be open about this without seeming racist and classist. So the "evidence" is couched in language that makes it seem that circumcision is healthier for every one, a contention refuted, of course, by data from Europe and Japan.
Intactivism has made deep inroads among white middle class families, and the Task Force surely knew this. They silently accepted this fact because they knew that circumcision has no prophylactic benefits for middle class boys and men. The AAP also knows that it cannot win a war of words with the intactivist movement, which couches its arguments primarily in terms of human rights and sexual benefits, a language that is apparently alien to the Task Force.
I think a couple more points could be added to Patrina's every well written report:
ReplyDeleteI have been told that every nerve in the body has a dedicated brain cell. If this is true then what happens to the portion of the brain that is assigned to the severed genital parts following mutilation?
No one seems to pay attention to the difficulty some mutilated men have in performing sex with a condom. If we agree that removing the foreskin reduces sensitivity and leads to some level of erectile dysfunction AND if we agree that wearing a condom also reduces sensitivity THEN it seems that we need to focus on the fact that a lot of men will engage in sex without a condom b/c he can't maintain an erection while wearing one.
The AAP needs to be sent to read the testimonies of the several hundred men who have filled out the harm survey http://www.circumcisionharm.org/
The AAP needs to add a statement that says "Not all babies who have been circumcised will grow up to appreciate the partial amputation of his penis. Parents need to consider the impact of relationship this can cause in such cases, since this is an irreversible cosmetic surgery."
Tomorrow, after calling the AAP, please also call the ACOG to demand that they rescind their endorsement of the AAP statement. If anyone lives near Washington, DC and wants to picket them too, that would be wonderful.
ReplyDeleteObstetricians commit the highest number of infant circumcision and profit from them the most. They are just as guilty as the AAP is in misleading parents. Send letters to them at: exbd@acog.org
"The American College of Obstetricians and Gynecologists has endorsed this statement." (page 586 and page 757 of the AAP's Circumcision Statement)
http://www.acog.org/About_ACOG/Contact_Us
Executive Board Affairs: exbd@acog.org Email for: Executive Board members; Board meetings, national officers, ACOG Officers & Committees Directory
American Congress of Obstetricians and Gynecologists
409 12th Street SW
Washington, DC 20024-2188
Mailing Address:
PO Box 70620
Washington, DC 20024-9998
Phone:
(800) 673-8444
(202) 638-5577
From Petrina:
ReplyDeletePlease write to the people below, and call the AAP and ACOG headquarters tomorrow to ask them to rescind their new male circumcision statement. Remind them that their support of male genital cutting is no more acceptable than their 2012 statement in favor of female genital cutting, which they were forced to rescind.
National Headquarters:
The American Academy of Pediatrics
141 Northwest Point Boulevard
Elk Grove Village, IL 60007-1098
USA
847/434-4000 (tel)
800/433-9016 (toll-free tel)
847/434-8000 (fax)
•Washington, DC Office:
The American Academy of Pediatrics
Department of Federal Affairs
601 13th Street, NW
Suite 400 North
Washington, DC 20005 USA
202/347-8600 (tel)
202/393-6137 (fax)
2012 AAP TASK FORCE ON CIRCUMCISION
Susan Blank, MD, MPH, Chairperson sblank@health.nyc.gov
Michael Brady, MD, Representing the AAP
Committee on Pediatrics AIDS
michael.brady@nationwidechildrens.org
Ellen Buerk, MD, Representing the AAP Board of
Directors
ebuerk@aap.org
Waldemar Carlo, MD, Representing the AAP
Committee on Fetus and Newborn
wcarlo@peds.uab.edu
Douglas Diekema, MD, MPH, Representing the
AAP Committee on Bioethics
diek@u.washington.edu
Andrew Freedman, MD, Representing the AAP
Section on Urology
andrew.freedman@cshs.org
Lynne Maxwell, MD, Representing the AAP Section
on Anesthesiology maxwell@email.chop.edu
Steven Wegner, MD, JD, Representing the AAP
Committee on Child Health Financing
swegner@ncaccesscare.org
LIAISONS
Charles LeBaron, MD – Centers for Disease
Control and Prevention clebaron@cdc.gov
Lesley Atwood, MD – American Academy of
Family Physicians lesley.atwood@allina.com
Sabrina Craigo, MD – American College of
Obstetricians and Gynecologists scraigo@tuftsmedicalcenter.org
CONSULTANTS
Susan K. Flinn, MA – Medical Writer
Susan@susanflinn.com
Esther C. Janowsky, MD, PhD
esther_janowsky@unc.edu
STAFF
Edward P. Zimmerman, MS
ezimmerman@aap.org
______________________________________________________________________
AAP Board of Directors – Executive Committee
1. Robert W. Block, MD, FAAP robert-block@ouhsc.edu
2. Thomas K. McInerny, MD, FAAP Thomas_McInerny@urmc.rochester.edu
3. O. Marion Burton, MD, FAAP marion.burton@uscmed.sc.edu
4. Carole E. Allen, MD, FAAP CAllen@aap.org
5. Danielle Laraque, M.D., FAAP dlaraque@maimonidesmed.org
6. Sandra Gibson Hassink, MD, FAAP shassink@aap.net
7. Francis E. Rushton, Jr, MD, FAAP ferushton@embarqmail.com
8. Marilyn J. Bull, MD, FAAP mbull@iupui.edu
9. Michael V. Severson, MD, FAAP mseverson@aap.org
10. Kenneth E. Matthews, MD, FAAP KMatthews@aap.org
11. Kyle Yasuda, MD, FAAP kyasuda@uw.edu
12. Myles B. Abbott, MD, FAAP mabbottmd@aol.com
13. Sara H. Goza, MD, FAAP sgoza@aap.net
Thank you for sharing this easy to use list of the AAP Board and Circumcision Task force.
DeleteWhat is the ACOG contact info that is recommended for writing/calling?
DeleteI see their circumcision pamphlet here (atrocious): http://www.acog.org/~/media/For%20Patients/faq039.pdf?dmc=1&ts=20120826T1957536638
Well done! I have written, I have emailed, and I will be calling first thing in the morning.
ReplyDeleteI think a change.org petition could garner lots of attention for changing the AAP's statement. If a more eloquent person wrote one up I would certainly sign it and pass it on.
ReplyDeleteThis is the letter I wrote, that you are welcome to use as well if you like.
ReplyDelete-------
To whom it may concern:
I have read a lot concerning the newest AAP policy set to come out tomorrow, that will (most likely) conclude that the benefits of circumcision outweigh the risks.
It is clear that the material used to reach this conclusion is cherry-picked and biased. The ethical implications of removing a healthy body part from someone who cannot consent, in order to possibly reduce their risk of diseases that could very well be avoided or treated in other less drastic ways is not even addressed by the statement drafts that I have read. The effects of male circumcision on females (disease transmission, sexual effects, etc.) are not fully addressed either. The rest of the world is moving in the opposite direction and the AAP would be an embarrassment to our country if they release a statement that in any way favors circumcision.
Please halt the release of this pro-circumcision material and spend some time developing and presenting more accurate information. Parents deserve accurate information, and boys deserve the same choices and rights as girls.
Sincerely,
(name)
This is what I sent to my Idaho AAP chapter and the AAP headquarters. It's short and to the point. You're welcome to use it, if you want to.
ReplyDelete---------------------------------
Dear (whomever you're addressing):
I am writing to you to insist that you withdraw or rescind the newest 2012 AAP Circumcision Policy Statement.
There is no medical justification for routine infant circumcision. Genital surgery does not prevent HPV and HIV, condoms do. UTIs are no more common in intact boys than they are in cut boys, and both can easily be treated with antibiotics, just like for girls. Circumcision can have complications and there is even the risk of death. Try telling parents who have to deal with these issues that the benefits outweigh the risks. As I'm sure you know, 80% of the world's male population is intact and have no issues. They benefit from their foreskins, like all males should be allowed to. Male circumcision affects women, too. Without the gliding action of a foreskin, many women endure discomfort and even pain due to the friction and dryness of circumcised sex.
It's our pediatricians who need current, accurate intact care information, and circumcision needs to end. Please update your policy to discourage unnecessary, cosmetic, painful, risky genital surgery of non consenting infant males. Please protect girls AND boys.
Sincerely,
(Your name)
Dear AAP Board Members:
ReplyDeleteI am writing because I am very concerned; your new policy statement regarding RIC is full of misinformation. This is an injustice to the parents who look to you for guidance in keeping their children healthy and well, and it is especially an injustice to the infants who will be mutilated and suffer needlessly because their parents were influenced by your new statement.
Please withdraw your statement and in place of that, release some accurate, unbiased information regarding the risks of RIC, the benefits of leaving babies intact, and information regarding proper intact care.
The reason why I ask that you withdraw your statement is this: there is no medical justification for RIC. It is an elective surgery. Claiming that the benefits of RIC outweigh the risks is incredibly inaccurate. Your entire new policy statement is full of contradictions and the data you utilized to support your decision was cherry-picked to support your conflict of interest. The AAP is not cut off from the knowledge that the rest of the world possesses in regards to RIC. I am certain that you are well aware that the risks of RIC by far exceed any supposed “benefits” that this dreadful procedure may offer. I am also sure that you are already well aware of the fact that approximately 80% of the males in the world are intact and generally have no issues resulting from having been left intact.
What other body parts shall we routinely remove from newborns for the miniscule possibility of preventing something later in life? If a urinary tract infection occurs, should it not be treated with antibiotics, if needed? And do condoms not suffice to protect against STD’s? These are just a few examples of why I believe your logic pertaining to RIC to be illogical.
In addition to these concerns, there is also the blatant disregard for basic human rights. I see it as unethical to remove a perfectly healthy, normal part of the anatomy without an individual’s consent and without justification.
Our nation’s pediatricians need accurate intact care information. And parents nationwide need true, unbiased information regarding the many risks of RIC and the benefits of keeping their babies whole. I insist that you withdraw your new 2012 AAP Policy Statement regarding routine infant circumcision.
It's hideous, I have written to them as well. I do so hope we can put pressure on them to stop this barbaric procedure.
ReplyDeleteARE YOU KIDDING? 2 years ago, the AAP issued a formal statement respecting the religious and traditional rights of parents to practice female genital mutilation. For freaking real! Only after massive protests and a huge public outcry did they rescind the statement. They are not exactly a beacon of wisdom, and will never be the ones to take a stand and take action until the entire herd is in agreement. Pathetic. Good thing we don't need them.
ReplyDeleteOh, how you've done a SICKENING about face, AAP.
ReplyDeleteIn October of 2011, you posted on your public Facebook page:
"American Academy of Pediatrics: The AAP does not recommend routine infant circumcision. To learn more, visit aap.org"
October 18, 2011 at 11:54am
A new statement from the Children's Health & Human Rights Partnership has just been released and added to the links above. We'd encourage those of you who've already read through the links to visit this site as well:
ReplyDeletehttp://chhrp.org/index.php/news/childrens-health-human-rights-partnership-condemns-new-aap-policy-statement/
This is the letter I sent, plus contact info for others to write:
ReplyDeletehttp://intacthouston.wordpress.com/2012/08/27/to-the-aap-task-force-on-circumcision/
Circumstition's Annotated Version of the AAP Policy (all 31 pages!):
ReplyDeletehttp://www.circumstitions.com/Docs/aap-12-anno.pdf
Let's unleash the power of social media to make them rescind the statement as they did for females. Let's use the publicity roaring about this to advance our cause to protect baby boys.
ReplyDeleteWhile this is a terrible move by the AAP and I agree all concerned human rights advocates should mobilize to address it, a lot of people are missing a very fundamental point, by using language like, "my choice to keep my son(s) intact." We need to be very clear: if there's no medical issue with the prepuce, there's no "choice" to be made. Doctors have no business offering elective amputation, much less deluding parents into thinking any kind of "important decision" needs to be made.
ReplyDeleteHIS body. HIS choice.
Dear 2012 AAP TASK FORCE ON CIRCUMCISION:
ReplyDeleteI am writing to you to insist that you withdraw or rescind the newest 2012 AAP Circumcision Policy Statement.
There is no medical justification for routine infant circumcision. Genital surgery does not prevent HPV and HIV, condoms do. UTIs are no more common in intact boys than they are in cut boys, and both can easily be treated with antibiotics, just like for girls. Circumcision can have complications and there is even the risk of death. Try telling parents who have to deal with these issues that the benefits outweigh the risks. As I'm sure you know, 80% of the world's male population is intact and have no issues. They benefit from their foreskins, like all males should be allowed to. Male circumcision affects women, too. Without the gliding action of a foreskin, many women endure discomfort and even pain due to the friction and dryness of circumcised sex.
It's our pediatricians who need current, accurate intact care information, and circumcision needs to end. Please update your policy to discourage unnecessary, cosmetic, painful, risky genital surgery of non consenting infant males. Please protect girls AND boys.
Sincerely,
Rina Joye Bly.
Nature has decided to provide us something for some benefit. I'm not sure why is it that in the US alone most of the doctors / scientists suddenly think they are god ....
ReplyDeleteThe link below is to another very powerful counterattack to the Task Force Report, this one by Doctors Opposing Circumcision.
ReplyDeletehttp://www.doctorsopposingcircumcision.org/pdf/2012-08-26A_Commentary.pdf
I am personally deeply offended that the Task Force report was silent about the possibility that circumcision may adversely affect a woman's experience of sex. This is smug and patriarchal in the extreme. The American medical profession is oblivious to the rise of sex positive feminism, and the decline of traditional feminine demureness. The typical married 30 year old knows more about sex than the typical male medical school prof or obgyn.
More and more women are taking responsibility for their own orgasms, and part of that social change entails a growing appreciation for the male equipment having all its natural moving parts.
My comment to the NBC article:
ReplyDeleteAs an RN, I advocate for men to keep all their sexual parts. The foreskin has a purpose, just like the clitoral hood on women. Without it and it's 20,000 nerve endings, normal and natural sex is not possible. Since the physicians who recommend circumcision are themselves circumcised, come from a circumcising culture or are the partners of circumcised men, they have a bias against the natural body. No one ever died from leaving the foreskin intact, so if a man wants to be cut as an adult, that should be his decision and only his. When you change the form, you change the function. Research what is lost with circumcision, the more you know, the more you're against it.
The AAP statement (and the accompanying "Technical Bulletin" is jaw dropping. Thank you for reviewing it. I haven't read all of it yet, but I did notice something that you missed in your review...the AAP Bulletin states that a moist glans in an intact male is a sign of poor hygeine!
ReplyDeleteHead...desk. Is a moist vagina also a sign of poor hygeine? Moist nostrils?
I am amazed a high ranking medical organisation is using its credibility to recommend child mutilation practices to the general population who would be inclined to listen to such a august body when making decisions about their baby boys if they were ill informed.
ReplyDeleteMedial people should be about protecting babies not cutting them up with knives. The statement shows lack of knowledge of the latest studies, mens anatomyy and benefits of being intact. We protect our girls from FMG why not our boys. Why are we want to leave our Mark on innocent children. Facts on botched circumcision are many..check out Intactivism.com.....the pictures are horrific.
AAP please rescind your stance as it has a very strong religious overtone!!
So sad. Misguided. Thank you for this thorough and thoughtful response to an reality that makes my stomach hurt and my heart drop. Breathing.
ReplyDeleteYou can submit a letter online to American Medical Association at their amednews.com website: http://www.ama-assn.org/amednews/2012/09/03/hlsa0903.htm re: today's article there, "Will male circumcision guidance reverse trends in the procedure?"
ReplyDeleteThank you for providing this information to mothers and fathers. I think it is important for people to fully understand that this type of surgery is unnecessary. I am a 36 year old male with an intact penis and have never had any problems. I've heard of people state they would circumcise their son just because the didn't want to deal cleaning it, yet these same people won't dock their dogs tails or crop their ears because it is cruel, inhumane and unnecessary surgery. The same holds true for humans, both sexes. Please continue to get the word out - I am trying on my end getting into arguments with people and writing on blogs when I come across them. Thank you thank you thank you!
ReplyDeleteI am actually a circumcised American doing research before I make that decision. This was of great help and I think I'll let my child make that decision when he is older. Being circumcised, I am unaware of what I don't have or what I should be feeling.
ReplyDeleteI must admit when I first heard of people who don't circumcised their children, I was surprised and a little bias. With caucasian Americans it's not really a discussion, its a norm. My parents (his Grandparents) won't like it, but will have to deal with it.