Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision

Abstract

The American Academy of Pediatrics recently released its new Technical Report and Policy Statement on male circumcision, concluding that current evidence indicates that the health benefits of newborn male circumcision outweigh the risks. The technical report is based on the scrutiny of a large number of complex scientific articles. Therefore, while striving for objectivity, the conclusions drawn by the 8 task force members reflect what these individual physicians perceived as trustworthy evidence. Seen from the outside, cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious, and the report’s conclusions are different from those reached by physicians in other parts of the Western world, including Europe, Canada, and Australia. In this commentary, a different view is presented by non–US-based physicians and representatives of general medical associations and societies for pediatrics, pediatric surgery, and pediatric urology in Northern Europe. To these authors, only 1 of the arguments put forward by the American Academy of Pediatrics has some theoretical relevance in relation to infant male circumcision; namely, the possible protection against urinary tract infections in infant boys, which can easily be treated with antibiotics without tissue loss. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts, and penile cancer, are questionable, weak, and likely to have little public health relevance in a Western context, and they do not represent compelling reasons for surgery before boys are old enough to decide for themselves.

Nontherapeutic Circumcision of Minors as an Ethically Problematic Form of Iatrogenic Injury

“…Evidence suggests that circumcision can reduce the risk of urinary tract infections (UTIs) [16] and (when performed in adulthood) of female-to-male transmission of HIV in subSaharan Africa [27][28][29]. However, the first benefit has been questioned, and there is no evidence from controlled studies linking the second benefit to NTC in developed countries.…”

“…Frisch et al noted that the only relevant benefit of circumcision in infancy is a reduction in the risk of contracting a urinary tract infection (UTI) in early childhood [16]. According to the Cochrane Review, circumcision cannot be shown to meaningfully lessen the risk of contracting a UTI [30].…”

“…As noted, the balance of opinion among medical authorities in Northern Europe is that the risks and harms of NTC are not outweighed by tangible benefits [16]. Moreover, as discussed above, there are no valid medical indications for prophylactic circumcision [58,59].…”

“…If a man assigns value to the foreskin itself, as most noncircumcised men do, the loss of this tissue constitutes a harm, regardless of whether there are surgical complications [14]. The American Academy of Pediatrics' (AAP's) 2012 position statement, which asserts that the health benefits of NTC outweigh the risks [15], is in conflict with a consensus of Northern European medical authorities [16]. As the AAP acknowledges, men rarely volunteer to undergo a circumcision [15].…”

Circumcision of Privately Insured Males Aged 0 to 18 Years in the United States

“…Delaying circumcision past the neonatal period can increase the cost and risk of the procedure, and can decrease the time span that a boy is protected from UTIs and disorders of the foreskin during early childhood, and STIs and HIV once he becomes sexually active. Although some have suggested that that a boy should choose circumcision for himself as an older child or young man, rather than have his parents make the decision for him as a neonate, 27 pain, fear, cost, and misinformation discourage circumcision uptake by older boys and adults. 2,28,29 It can also be challenging to time the procedure to occur before sexual debut to achieve maximal protection from STIs.…”