Letter to the American Academy of Pediatrics

From Robert S. Van Howe, MD

About Circumcision: Pros and Cons --

Guidelines for Parents


"I cannot in good conscience distribute it to my
patients ... The brochure places both the pediatrician
and the Academy at risk for litigation."


November 17, 1995

Ms. Mary Claire Walsh
Project Manager
American Academy of Pediatrics
141 Northwest Point Blvd.
P. O. Box 927
Elk Grove Village, IL 60009-0927

Dear Ms. Walsh,

I have just received a copy of the AAP brochure, "Circumcision: Pros and Cons," and after reading through its contents I cannot in good conscience distribute it to my patients. The brochure is strongly biased in favor of the procedure and laden with factual errors. Because of these multiple misrepresentations of the current medical literature, I fear distribution of this brochure to my parents may place me at increased risk for litigation. As a fellow of the American Academy of Pediatrics, I am also concerned that the brochure may place the Academy at increased risk for successful litigation.

To help in the effort to provide accurate information to parents considering circumcision for their sons, I have the following observations:

1) There is no mention in brochure what is being removed by circumcision. Parents need to be informed that the foreskin constitutes 30-50% of the penile skin system and is, based on histologic studies, the most highly innervated portion of the penis.1 They need to know that the foreskin closely adheres to and protects the mucosal surface of the glans from outside irritation.

2) The statement "Circumcision is one of the oldest known surgical procedures in medicine" is inaccurate. While it may be the oldest ritual procedure of mankind, it was only rarely used as a medical procedure until the last hundred years.

3) The statement "During circumcision the foreskin is removed so that the tip of the penis and the opening through which the baby urinates are exposed" is incomplete. It needs to be stated that there is no medical reason for exposing the tip of the penis. The penis functions perfectly well with the tip unexposed. It also needs to be stated that exposure of the tip can result in topical infections of the glans.

4) Any mention of religious practices is inappropriate. It gives the impression that the AAP is proselytizing, which I am sure is not the intent of the Academy.

5) The statement, "After the circumcision, the tip of the penis may seem raw," is inaccurate. By stating that the penis may "seem" raw, the Academy is minimizing the trauma wrought from this procedure. Circumcision forcibly separates the mucosal surface of the foreskin that adheres to the mucosal surface of the glans. The tip of the penis is always raw after circumcision. To illustrate this in terms parents will understand, it may be best to equate it with having a fingernail ripped off the nail bed.

6) The section "Are there problems that can happen after circumcision?" is woefully incomplete and only addresses the more common, immediate complications of circumcision. Very common problems such as coronal adhesions (which occur in 25% of circumcised boys), the glans being covered by skin leading some parents to have the procedure redone (17%), entrapped epithelial debris (16%), and topical infections (7%) are not addressed.2 Parents need to be informed that infant boys who have their foreskins do not experience these problems.

To be more balanced, death as a complication to circumcision needs to be mentioned if cancer of the penis is mentioned. Both of these entities happen with approximately the same frequency.3

The psychological effects, which have been well documented, are not mentioned. It is important to point out that circumcision has been shown to adversely affect a newborns behavior for up to one week after the procedure,4 that boys who were circumcised at birth cry longer and louder when receiving their immunizations,5 and that genital trauma on children has been demonstrated leave a permanent mark on the brain.6-7

It also needs to be mentioned that the adverse physical, sexual and psychological impact of infant circumcision on adult males has not been studied.

7) The information given under the heading, "Circumcision pros and cons," is misleading and reflects a pro-circumcision bias. It needs to be mentioned that the circumcision rate in the United States is falling and at the current trend circumcised boys may soon be in the minority. Including the statement that "Many parents choose to have their sons circumcised because all the other men in the family were circumcised or because they don't want their son to feel different, " grants legitimacy to these vain considerations. As such, this statement encourages cosmetic surgery on non-consenting individuals. This is completely at odds with the Academy's most recent position on informed consent and violates most standards of medical ethics. Parents also need to be informed that half of circumcised infants will not look like the circumcised men in their family for the first several years of life.8

It is also prejudicial to suggest that parents would need to justify their decision to leave their son's foreskin in place while no suggestion is given that parents tell their circumcised son why the end of their penis is missing.

8) The statement, "Circumcision lowers your son's chances of getting a urinary tract infection (UTI) in the first year of life," is inaccurate. At best the retrospective studies that have been performed show a possible association. It would be more accurate to state that "Some studies have suggested that circumcision may lower your son's chances of getting a urinary tract infection (UTI) in the first year of life, but further study in this area is needed. Fortunately, UTIs are rare and easily treated with oral antibiotics."

9) A discussion of penile cancer should not be part of this brochure because it is so incredibly rare. Also new studies have cast doubt over whether circumcision plays a role in preventing penile cancer.9-10 If cancer is mentioned as a reason for circumcising, then death needs to be mentioned as a complication.

10) The statement, "Research shows that males who are circumcised have a slightly lower risk of getting sexually transmitted diseases (STDs)," is completely untrue. Several new studies have shown that circumcised males are at higher risk for developing genital warts,11-12 gonorrhea, syphilis,13 non-gonococcal urethritis,14-15 and HIV infections.16-18

11) The statement, "Circumcision eliminates foreskin infections that occur at the peak age of 3-5 years," is completely untrue and has never been documented in the medical literature. In an ongoing prospective study, which I am conducting, the opposite has been found.19 In addition, a retrospective study found more penile problems in circumcised boys at these younger ages than those left intact.20

12) The statement, "Circumcision prevents phimosis, a narrow opening that makes it impossible to retract the foreskin at a later age," is pure unsubstantiated speculation and has never been documented in the medical literature. From the accurate incidences published in the medical literature the percentage of intact boys developing "true" phimosis and those boys who are circumcised who develop phimosis are nearly identical.21-24

13) The statement, "Genital hygiene, which is particularly important in unsanitary conditions, may be easier after circumcision," is likewise pure speculation. My ongoing prospective study has shown the exact opposite to be the case. The reason for this is simple. The foreskin has smooth muscle near the tip that puckers it shut, thus preventing stool and feces from entering. The circumcised boy does not have such protection.

14) The statement, "Circumcision may be risky if done later in life," is inaccurate. The complication rates reported in the medical literature for neonatal and post-neonatal circumcision indicate the complication rate for neonatal circumcision may be higher.25-32

15) The statement, "parents should try to make a decision about circumcision," assumes that parent can ethically implement their decision about circumcision. This is contrary to most international statements on human rights and United States legal precedents.33 It is also contrary the AAP's position on informed consent.34 To date the AAP has not adequately addressed this issue and urgently needs to do so. To assume that parents have the right to make this decision when legally and ethically they may not, is a bias in favor of parental rights over a child's rights, which is out of character for the AAP and encourages unnecessary surgery.

16) The statement, "Infants who are circumcised without pain medication will feel some pain," is incredibly misleading. All of these infants experience excruciating pain. New evidence suggests that similar interventions on newborns are more painful for them than older infants and children.35 Sucking on a sugar solution has been shown to decrease the crying associated with circumcision36 but the humoral changes associated with the stress of the procedure are not ameliorated.37 Minimizing the pain related aspects of the procedure again reflects the pro-circumcision bias of this brochure. Parents should be encouraged to seek out a physician who uses anesthesia.

17) The statement, "The Academy is absolutely opposed to this practice [female genital mutilation] in all forms as it is disfiguring and has no medical benefit," is hypocritical because the same language applies to male circumcision.

18) The statement, "boys should be taught the importance of washing underneath the foreskin everyday to remove the smegma a white cheese-like substance that is found under the foreskin," is unbalanced. In my ongoing prospective study 17% of circumcised infants had a "white cheese-like substance" between their glans and remnant foreskin while none of the intact boys did.38 The statement incorrectly implies that only intact boys can develop can develop a "white cheese-like" substance.

19) The brochure closes by saying, "Circumcisions are often done for religious, social, and cultural reasons. The Academy suggests parents talk to their pediatrician about circumcision and make a decision after looking at the facts." This encourages parents to seek advice from physicians in areas in which they have no expertise. As a pediatrician I feel comfortable discussing the medical aspects of circumcision, but I am sure I will dispense inaccurate information concerning the social, religious, and cultural aspects of this ritual.

While the Academy had the best of intentions in producing "Circumcision Pros and Cons: Guidelines for Parents," the results are unfortunate. The obvious pro-circumcision bias of the brochure only propagates the disrespect the Academy earned when it released the equally biased, inaccurate Task Force report in 1989. Pediatricians and parents look to the Academy for accurate unbiased information, this brochure falls far short of this expectation.

What is more important, the brochure places both the pediatrician and the Academy at risk for litigation. The untruths, inaccuracies, and misleading statements noted above make it appear as though the Academy was purposely covering up the truth to let infant circumcision continue at the present rate. This procedure nets physicians and hospitals on the order of $200 million per year. Do the interests of the Academy rest with the what is best for the infant boy or the physician's bottom line? The content of this brochure makes a strong case that the rights of infant boys have been sold out for cold cash. I do not think this was the Academy's intent, but it is obviously the result. Knowingly publishing inaccurate information can only get the Academy in trouble.

For the most part I am proud to be a fellow of the AAP, especially when Academy has acted as the champion of children's rights, but this brochure is an embarrassment.

I implore you to revise this brochure, and this time try telling the truth in a balanced fashion.

Sincerely,

Robert S. Van Howe, M.D., FAAP
References

1. Taylor J. The prepuce: what, exactly, is removed by circumcision? Br J Urol [in press]

2. Van Howe R. Variability in penile appearance and penile problems: a prospective study. [submitted for publication] copy enclosed

3. Gellis SS. Circumcision. Am J Dis Child 1978; 132: 1168-9.

4. Dixon S, Snyder J, Holve R, Bromberger P. Behavioral effects of circumcision with and without anesthesia. J Dev Behav Pediatr 1984; 5: 246-50.

5.Taddio A, Goldbach M, Ipp M, Stevens B, Koren G. Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet 1995; 345: 291-2.

6. Goleman, D Adolescent violence is traced to abuse and neglect in childhood. Early Violence Found to Be Etched in the Brain. New York Times, October 3, 1995, B5.

7. Bremner JD. Science News 3 June 1995; 147: 340.

8. Van Howe, op cit.

9. Maden C, Sherman KJ, Beckmann AM, Hislop TG, Teh CZ, Ashley RL, Daling JR. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. J Natl Cancer Inst 1993; 85: 19-24.

10. Holly EA, Palefsky JM. Factors related to risk of penile cancer: new evidence from a study in the Pacific Northwest. J Natl Cancer Inst 1993; 85: 2-4.

11. Cook LS, Koutsky LA, Holmes KK. Circumcision and sexually transmitted diseases. Am J Public Health 1994; 84: 197-201.

12. Cook LS. Koutsky LA. Holmes KK. Clinical presentation of genital warts among circumcised and uncircumcised heterosexual men attending an urban STD clinic. Genitourin Med 1993; 69: 262-264.

13. Donovan B, Bassett I, Bodsworth NJ. Male circumcision and common sexually transmissible diseases in a developed nation setting. Genitourin Med 1994; 70: 317-20.

14. Newell J, Senkoro K, Mosha F, Grosskurth H, Nicoll A, Barongo L, Borgdorff M, Klokke A, Changalucha J, Killewo J et al. A population-based study of syphilis and sexually transmitted disease syndromes in north-western Tanzania. 2. Risk factors and health seeking behaviour. Genitourin Med 1993; 69: 421-6.

15. Smith GL, Greenup R, Takafuji ET. Circumcision as a risk factor for urethritis in racial groups. Am J Public Health 1987; 77: 452-4.

16. Van de Perre P, Carael M, NzVanaramba D, Zissis G, Kayihigi J, Butzler JP. Risk factors for HIV seropositivity in selected urban-based Rwandese adults. AIDS 1987; 1: 207-11.

17. Chao A, Bulterys M, Musanganire F, Habimana P, Nawrocki P, Taylor E, Dushimimana A, Saah A. Risk factors associated with prevalent HIV-1 infection among pregnant women in Rwanda. National University of Rwanda-Johns Hopkins University AIDS Research Team. Int J Epidemiol 1994; 23: 371-80.

18. Guimaraes M, Castilho E, Ramos-Filho C, et al. Heterosexual transmission of HIV-1: a multicenter study in Rio de Janeiro, Brazil. VII International Conference on AIDS. Florence, June 1991 [abstract MC3098].

19. Van Howe, op cit.

20. Fergusson DM, Lawton JM, Shannon FT. Neonatal circumcision and penile problems: an 8-year longitudinal study. Pediatrics 1988; 81: 537-41.

21. Kaweblum YA, Press S, Kogan L, Levine M, Kaweblum M. Circumcision using the Mogen clamp.Clin Pediatr Phila 1984; 23: 679-82.

22. Wiswell TE, Tencer HL, Welch CA, Chamberlain JL. Circumcision in children beyond the neonatal period. Pediatrics 1993; 92: 791-3.

23. Gordon A, Collin J. Save the normal foreskin: Widespread confusion over what the medical indications for circumcision are. Br Med J 1993; 306: 1-2.

24. Van Howe, op cit.

25. Walfisch S, Ben-Zion YZ, Gurman G. [Circumcision of new immigrants] Harefuah 1994. ; 126: 119-21, 176.

26. Wiswell, op cit.

27. Williams N, Kapila L. Complications of circumcision. Br J Surg 1993; 80: 1231-6.

28. Gee WF, Ansell JS. Neonatal circumcision: a ten-year overview: with comparison of the Gomco clamp and the Plastibell device. Pediatrics 1976; 58: 824-7.

29. Metcalf TJ, Osborn LM, Mariani EM. Circumcision: a study of current practices. Clin Pediatr 1983; 22: 575-9.

30. Moreno CA, Realini JP. Infant circumcision in an outpatient setting. Tex Med 1989; 85: 37-40.

31. Kaweblum, op cit.

32. O'Brien TR, Calle EE, Poole WK. Incidence of neonatal circumcision in Atlanta, 1985-1986. South Med J 1995; 88: 411-5.

33. Bonner CA, Kinane MJ. Circumcision: the legal and constitutional issues. The Truth Seeker 1989. July/August: S1-S4.

34. Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995; 95: 314-7.

35. Anand KJS. Impact of pain in critically ill newborns: principles of pain management. Child Health 2000, Vancouver, British Columbia. June 1, 1995.

36. Blass EM, Hoffmeyer LB. Sucrose as an analgesic for newborn infants. Pediatrics 1991; 87: 215-8.

37. Gunnar MR, Connors J, Isensee J, Wall L. Adrenocortical activity and behavioral distress in human newborns. Dev Psychobiol 1988; 21: 297-310.

38. Van Howe, op cit.


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