Why is the AAP promoting public funding for an unnecessary and harmful surgery when we struggle even to provide basic care for all our children? In these days of rising medical costs and scarce resources, we simply cannot afford male circumcision.

Human rights attorney J. Steven Svoboda and pediatrician Robert S. Van Howe, M.D. have published a new article in one of the world’s leading journals on medical ethics arguing that the American Academy of Pediatrics’ (AAP’s) position regarding male circumcision lacks credible support. The article, titled, “Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision,” http://jme.bmj.com/content/early/recent, is being published online today, leading off the latest issue of the Journal of Medical Ethics (JME). The US’ premier organization of pediatricians has already arranged for the JME to publish its response in what Svoboda and Van Howe view as an ill-fated attempt to justify the medically and ethically flawed arguments in its policy statement and technical report.

Svoboda and Van Howe criticize the AAP’s apparent cultural bias in favor of circumcision, which they note puts the AAP firmly out of step with world medical opinion on this issue. They argue that the AAP documents suffer from troubling deficiencies, ultimately undermining their credibility. According to the authors, these deficiencies include the omission of critical issues, biased use of the medical literature, and conclusions that are not supported by the evidence given.

Svoboda commented, “The AAP ignores so many important topics that it is hard to know where to begin. For example, the anatomy and function of the foreskin are not mentioned in their documents, even though they propose to cut it off without first considering the harm and pain that result from its removal. The AAP’s circumcision recommendations contradict its own bioethics policy statement, which requires pediatric care to be based only on the needs of the patient. Non-therapeutic circumcision is incompatible with widely accepted ground rules for surgical intervention in minors.”

Dr. Van Howe, a Clinical Professor at Michigan State University College of Human Medicine, said, “When physicians decide whether to do a procedure, they must, and normally do, exclude from their medical decisions non-medical factors regarding the parents’ culture. Contrary to what the AAP suggests, doctors are not cultural brokers. Their duty is promoting and protecting the health of their patients, not following practices lacking a solid ethical and medical foundation.”

Svoboda and Van Howe write that the AAP report suffers from being two-and-a-half years out of date at the time of its publication. They note that the last literature search was performed in April 2010 for a report published in August 2012. Svoboda and Van Howe write that studies that suggest benefits for circumcision appear in the technical report while at least one hundred studies that fail to support a benefit or that find detrimental effects of circumcision are left out. The authors add that the AAP also cherry-picks information from within the articles it cites, selecting bits of language out of context that lend support to its position while often ignoring contradictory data.

Svoboda commented, “The response to our article by the AAP Task Force calls for avoiding an ideological agenda. When European authorities agree that cultural bias rather than scientific fact is driving the AAP’s position, I would suggest that our only agenda is ethical and medically sound care for infants and young children. The AAP fails to raise any substantive argument pointing to either evidence or reasoning about which we are mistaken.”

The AAP itself concedes, Svoboda and Van Howe write, that the there are vast differences between HIV transmission to adults in Africa and to children in the US. In Africa, the authors observe, one of the most likely places to contract HIV is in a health clinic. Svoboda observed, “The US has the highest rates of circumcision, of HIV, and of other sexually transmitted infections in the industrialized world, so the chance that the first can prevent the other two seems extremely remote.”

Svoboda asked, “Why is the AAP promoting public funding for an unnecessary and harmful surgery when we find ourselves struggling even to provide basic care for all our children? In these days of rising medical costs and scarce resources, we simply cannot afford to continue to carry out such a harmful and outmoded practice.”

While the AAP attempts to paint itself in its reply in the JME as being in line with world medical opinion, in fact, as noted by Svoboda and Van Howe, the AAP has put itself in a shrinking minority in attempting to justify an outmoded cultural practice that results in the death of more than one hundred boys each year. Circumcision also leads to frequent legal judgments and settlements in favor of plaintiffs, as documented by a list ARC released today of more than fifty such cases totaling over $80 million (http://www.arclaw.org/resources/settlements). Even the American Medical Association agrees that there is insufficient justification for performing the procedure on newborns absent specific medical indications. Unlike the AAP, its peer organizations in Europe and also in Australia, the United Kingdom, and Canada recognize that medical considerations must be considered in conjunction with ethical and legal considerations and therefore, male circumcision should be neither recommended to parents nor funded by government insurance systems.

A few months ago, the German Pediatric Association favorably cited an earlier version of Svoboda’s and Van Howe’s article, noting that even if benefits do exist the procedure can safely be delayed until the boy himself can make the decision.

The JME considers the issue of male circumcision important enough to have devoted an entire special issue to the topic, including a second article by Mr. Svoboda on male circumcision and human rights, and a second article by Dr. Van Howe about male circumcision and parental rights.

Svoboda and Van Howe’s article appears at a similar publication date with a commentary to appear in the AAP’s own Pediatrics by thirty-eight leading European medical authorities, who have independently reached a conclusion consistent with Svoboda and Van Howe’s in criticizing the cultural bias in the AAP’s two documents.

After graduating from Harvard Law School, Svoboda founded the human rights organization Attorneys for the Rights of the Child (http://www.arclaw.org) in 1997 to safeguard children’s right to bodily integrity. In Geneva in 2001, Svoboda and ARC first placed male circumcision on the official United Nations record as a human rights issue.

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