Circumcision – Position Statements by National Pediatric Bodies
In 1971 the American Academy of Paediatrics (AAP) Committee for the Newborn came out with a statement that said there are "no valid medical indications for circumcision" [124], although this statement had only a slight effect on the rate of newborn circumcision in the USA.
In 1975 the statement was modified to "no absolute valid ..." [570], which remained in the 1983 statement, but in 1989 it changed significantly to "New evidence has suggested possible medical benefits" [16].
However, in its 1999 Statement [325] the AAP went backwards. Although the literature review it conducted was academically weak, it did, nevertheless, mention the vast array of benefits. The major flaw of this document was that it fell short of stating the obvious, if it had used a more balanced literature survey, in recommending circumcision. This may have been quite understandable, given medico-legal worries in the face of very hostile, politically active anti-circ groups.
In a joint response the Chair of the 1989 AAP Taskforce on Circumcision, Edgar Schoen, and others more expert than those on the 1999 Taskforce, rebutted the 1999 statement [502, 503]. Others also leveled valid criticisms [58, 315].
Surprisingly, in 2005 the AAP reaffirmed its 1999 policy [18], in effect suppressing all of the very strong affirmative evidence published since its 1999 statement. Schoen strongly condemned the AAP for ignoring the 7 years of extensive research findings since 1998 [508]. Further to this, in 2007, when challenged by Schoen [513], a Section Editor of the top journal in the field, Pediatrics, called for the AAP to reassess its position in the light of new data [164].
The various statements by such real experts highlight the information that follows in the present much more comprehensive and better-balanced internet review.
It is clear that providing a scientifically accurate Statement by a pediatric body is difficult in the face of minority lobby groups whose agenda tends to be a political one rather than medical or scientific. This is not to detract from the clear scientific weaknesses in the 1999 AAP Statement and their pamphlet [58, 502].
Dr Edgar Schoen stated that the benefits of routine circumcision of newborns as a preventative health measure far exceed the risks of the procedure [498]. He has continued to this day to campaign for public education of the benefits of circumcision, publishing a very worthy book on the topic in 2005 [507].
During the period 1985-92 there was an increase in the frequency of post-newborn circumcision (to over 80% in one study [636]) and during that same time Schoen points out that the association of lack of circumcision and urinary tract infection (UTI) has moved from "suggestive" to "conclusive" [498]. Moreover, this period heralded the finding of associations with other infectious agents, including HIV. In fact he goes on to say that "Current newborn circumcision may be considered a preventative health measure analogous to immunization in that side effects and complications are immediate and usually minor, but benefits accrue for a lifetime" [498].
Through the 1990s and into the new millenium the rate of circumcision has continued to rise. In the light of an increasing volume of medical scientific evidence pointing to the benefits of neonatal circumcision, the pediatric professional bodies of various countries have been forced to review the evidence and formulate more up-to-date policy statements. These documents MUST be read in their ENTIRETY to be fully comprehended. (Isolated quotes have been taken from these by anti-circ groups to fuel their propaganda.)
What is stated in the details of the various Statements is much like what is presented in the present review of the medical literature. However, it is important to note that vital facts have been distorted, watered down or omitted from the various Statements of pediatric bodies, whereas the present review is very much more comprehensive and balanced. Moreover, no medical body has advocated prohibition of circumcision and arguments by opponents are weak and specious [592].
Statements of the American Association of Pediatrics in 1999 [325], the Canadian Paediatric Society in 1996 [179] and the Royal Australasian College of Physicians, Division of Paediatrics and Child Health in 2004 [66] provide information on the benefits and possibility of rare or minor risks. These suffer, however, from falling short of drawing the obvious conclusion from the evidence they present, i.e., that circumcision is the best choice for lifetime health and sexual well-being.
The hesitancy is undoubtedly a consequence of the sensitivity of this issue, as well as medico-legal caution and the recognition of the hysteria that this subject can provoke because of the diversity of opinion in the community, where anti-circ groups tend to bombard such professional bodies in an attempt to "win" their “political” cause. More on this can be found in the section "Anti-circumcision lobby groups".
The British Medical Association has not even attempted to review the medical literature, producing instead a pompous paternalistic and legalistic statement in 2003 [79, 80]. In 2006 it produced a document that recognized the ‘spectrum of views within BMA’s membership’, stating that the ‘BMA has no policy’, and ‘the BMA believes that parents should be entitled to make choices about how best to promote their children’s interests’ subject to limitations imposed by society [81].
In 2007, however, the British Medical Journal (the official journal of the BMA) published two short ‘head-to-head’ opposing commentaries, one consisting typical anti-circ emotive, legalistic nonsense that was opposed [245a], and the other, by an Editorial staffer, that was a quite sensible, balanced overview of the many benefits and why ‘it is far better to help parents to find a competent operator’ than make it difficult for them as the BMA guidelines advise [429a]. These were followed by an article on medical indications for circumcision, which distorted and downplayed the benefits by selectively citing publications that supported the authors’ negative agenda [346a]. It is nevertheless a good sign that at long last the BMA via the BMJ have begun to address the issues.
By and large, the statements of most of these professional bodies tend to recommend that medical practitioners fully inform parents of the benefits and minor, rare risks of having their male children circumcised. Thus publicly most give the impression that the benefits and harms are very evenly balanced [179]. Indeed, professional bodies have carefully avoided taking sides in the polarized debate, by making noncommittal guidelines and leaving it to the medical practitioner to discuss the matter with the parents [187].
While such bland tolerance has accommodated a broad range of strong and conflicting opinions, the medical profession is now faced with a growing knowledge-base that indicates a wide range of health benefits of circumcision and that these exceed any risks, meaning that the time is fast approaching when affirmative statements cannot be avoided [187]. Indeed, Prof Roger Short states “If we believe in evidence-based medicine, then there can be no debate about male circumcision; it has become a desirable option for the whole world” [528].
Of course, well-informed medical practitioners only have to read the present Statements of pediatric bodies in full to be able to draw their own conclusion.
In a deplorable ploy, the Royal Australasian College of Physicians’ (RACP) 2002 and 2004 Policy Statement sidestepped making a conclusion by instead substituting the words there ‘is no medical indication for routine infant male circumcision’, i.e., that the foreskin as it presents at birth lacks any medical condition that would mandate its removal. This tactic is to be condemned as inexcusably irresponsible, especially in the current era of preventative medicine and medical knowledge of the benefits of circumcision. Indeed the RACP’s 2004 Policy lacks scholarship and is not evidence-based.
It has been resoundingly criticized in a large peer-reviewed journal article by the author of the present internet review and other international experts [371]. The RACP subsequently phoned the present author and acknowledged the flaws in its 2004 policy statement. It then initiated a proper review and revision of its policy, no longer basing the RACP statement on the views of ‘selected’ pediatricians, but involving public health expertise as well.
The American Urological Association has a statement on circumcision that, albeit brief, is very much in keeping with the medical evidence of its wide-ranging benefits. This was updated in 2007 to include the latest evidence on protection from HIV/AIDS [20].
On 28 March 2007 the World Health Organization and UNAIDS endorsed circumcision for HIV/AIDS prevention [621]. Later in 2007 a further statement was produced that listed the vast array of benefits as well as issues concerning the ‘roll-out’ of circumcision, particularly to places and people at high risk of HIV infection [646]. This noted that most cultures that do not circumcise are neutral on this issue and would readily embrace it when the benefits are explained.
In the light of these facts and other mounting evidence of the benefits many are now calling for endorsement of routine circumcision by pediatric bodies. To quote one 9 author commentary in Pediatrics: ‘Therefore, if parents choose circumcision for their newborn male child, or if an adolescent decides that circumcision might be appropriate to reduce risk of STD acquisition, it is a medically rational choice that should be included in government health or private insurance benefits’ [184].
Edgar Schoen, Chairman of the 1989 AAP Task Force on Circumcision has stated ‘It is time for the AAP to acknowledge the evidence and to catch up to the American public’ [508].
Another author, in Pediatrics, concludes ‘I firmly believe that there is now sufficient new information to prompt a revised AAP policy statement regarding neonatal circumcision, considering the very significant beneficial effects ad the very minor risks associated with this procedure’ [146]. Other US experts stated in 2007 ‘Given recent studies suggesting the public health benefits of male circumcision, a reconsideration of national male circumcision policy is needed to respond to current trends’ [369]. Recognized authoritative figures in the USA in particular strongly advocate circumcision of all newborn boys. More details of what they have said in the medical literature appear later.
