cultural bias of the AAP http://pediatrics.aappublications.org/content/early/2013/03/12/peds.2012-2896.full.pdf+html
here is the link to the sources so that you can choose to read and click links instead of trying to decipher my copy/pasting http://justasnip.wordpress.com/2013/03/18/aap-meets-strong-criticism-for-lack-of-ethics-and-flawed-medical-practice/
Eager to read the entire paper on AAP’s flawed ethics and methodology? Well, here it is. I acquired it just for you. Enjoy!
by Lena Nyhus
“Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision”
here is the entire article”
Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision
The American Academy of Pediatrics recently released its new Tech- nical 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 physi- cians and representatives of general medical associations and so- cieties 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 theoret- ical 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. Pediatrics 2013;131:796–800
Circumcision rates are steadily decreasing in most Western countries around the world, including the United States.1 Still, a majority of newborn male infants undergo the procedure in the United States. In its newly released Technical Report and Policy Statement on male cir- cumcision,2,3 the American Academy of Pediatrics (AAP) has changed from a neutral to a more positive attitude toward circumcision, claiming that possible health benefits now outweigh the risks and possible negative long-term consequences. The AAP does not recom- mend routine circumcision of all infant boys as a public health measure but asserts that the benefits of the procedure are sufficient to warrant third-party payment. In Europe, Canada, and Australia, where infant male circumcision is considerably less common than in the United States, the AAP report is unlikely to influence circumcision practices because the conclusions of the report and policy statement seem to be strongly culturally biased.
AUTHORS: Morten Frisch, MD, PhD,a Yves Aigrain, MD, PhD,b Vidmantas Barauskas, MD, PhD,c Ragnar Bjarnason, MD, PhD,d Su-Anna Boddy, MD,e Piotr Czauderna, MD, PhD,f Robert P.E. de Gier, MD,g Tom P.V.M. de Jong, MD, PhD,h Günter Fasching, MD,i Willem Fetter, MD, PhD,j Manfred Gahr, MD,k Christian Graugaard, MD, PhD,l Gorm Greisen, MD, PhD,m Anna Gunnarsdottir, MD, PhD,n Wolfram Hartmann, MD,o Petr Havranek, MD, PhD,p Rowena Hitchcock, MD,q Simon Huddart, MD,r Staffan Janson, MD, PhD,s Poul Jaszczak, MD, PhD,t Christoph Kupferschmid, MD,u Tuija Lahdes-Vasama, MD,v Harry Lindahl, MD, PhD,w Noni MacDonald, MD,x Trond Markestad, MD,y Matis Märtson, MD, PhD,z Solveig Marianne Nordhov, MD, PhD,aa Heikki Pälve, MD, PhD,bb Aigars Petersons, MD, PhD,cc Feargal Quinn, MD,dd Niels Qvist, MD, PhD,ee Thrainn Rosmundsson, MD,ff Harri Saxen, MD, PhD,gg Olle Söder, MD, PhD,hh Maximilian Stehr, MD, PhD,ii Volker C.H. von Loewenich, MD,jj Johan Wallander, MD, PhD,kk and Rene Wijnen, MD, PhDll
aDepartment of Epidemiology Research, Statens Serum Institut, Copenhagen and Center for Sexology Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; bDepartment of Pediatric Surgery, Hôpital Necker Enfants Malades, Université Paris Descartes, Paris, France; cLithuanian Society of Paediatric Surgeons, Kaunas, Lithuania; dDepartment of Pediatrics, Landspitali University Hospital, Reykjavik, Iceland; eChildren’s Surgical Forum of the Royal College of Surgeons of England, London, United Kingdom; fPolish Association of Pediatric Surgeons, Gdansk, Poland; gWorking Group for Pediatric Urology, Dutch Urological Association, Utrecht, Netherlands; hDepartments of Pediatric Urology, University Children’s Hospitals UMC Utrecht and AMC Amsterdam, Netherlands; iAustrian Society of Pediatric and Adolescent Surgery, Klagenfurt, Austria; jPaediatric Association of the Netherlands, Utrecht, Netherlands; kGerman Academy of Paediatrics and Adolescent Medicine, Berlin, Germany; lCenter for Sexology Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; mDepartment of Pediatrics, Rigshospitalet, Copenhagen, Denmark; nDepartments of Pediatric Surgery, Landspitali University Hospital, Reykjavik, Iceland, and Karolinska University Hospital, Stockholm, Sweden; oGerman Association of Pediatricians, Cologne, Germany; pDepartment of Pediatric Surgery, Thomayer Hospital, Charles University, Prague, Czech Republic; qBritish Association of Paediatric Urologists, London, United Kingdom;
(Continued on last page)
796 FRISCH et al
In this commentary, a different view is presented by non–US-based physi- cians and representatives of general medical associations and societies for pediatrics, pediatric surgery, and pediatric urology in Northern Europe.
CRITERIA FOR PREVENTIVE MEDICINE
It is commonly accepted that medical procedures always need to be justified because of their invasive nature and possible damaging effects. Preventive medical procedures need more and stricter justification than do thera- peutic medical procedures, as they are aimed at people who are generally free of medical problems. Even stricter criteria apply for preventive medical procedures in children, who cannot weigh the evidence themselves and cannot legally consent to the pro- cedure.4
The most important criteria for the justification of medical procedures are necessity, cost-effectiveness, sub- sidiarity, proportionality, and consent. For preventive medical procedures, this means that the procedure must effectively lead to the prevention of a serious medical problem, that there is no less intrusive means of reaching the same goal, and that the risks of the procedure are proportional to the intended benefit. In addition, when performed in childhood, it needs to be clearly demonstrated that it is essen- tial to perform the procedure before an age at which the individual can make a decision about the procedure for him- or herself.
The AAP technical report points to 4 health-related arguments in favor of circumcision: the reduced risks of urinary tract infections (UTIs), penile cancer, some traditional sexually trans- mitted diseases (STDs), and HIV infection and AIDS.
URINARY TRACT INFECTIONS
According to the literature reviewed, ∼1% of boys will develop a UTI within the first years of life.2 There are no randomized controlled trials (RCTs) linking UTIs to circumcision status. The evidence for clinically significant protection is weak, and with easy access to health care, deaths or long- term negative medical consequences of UTIs are rare. UTI incidence does not seem to be lower in the United States, with high circumcision rates compared with Europe with low cir- cumcision rates, and the AAP report suggests it will take ∼100 circum- cisions to prevent 1 case of UTI. Using reasonable European estimates cited in the AAP report for the frequency of surgical and postoperative compli- cations (∼2%), for every 100 cir- cumcisions, 1 case of UTI may be prevented at the cost of 2 cases of hemorrhage, infection, or, in rare instances, more severe outcomes or even death.
Circumcision fails to meet the criteria to serve as a preventive measure for UTI, even though this is the only 1 of the AAP report’s 4 most favored argu- ments that has any relevance before the boy gets old enough to decide for himself.
Penile cancer is 1 of the rarest forms of cancer in the Western world (∼1 case in 100 000 men per year), almost always occurring at a later age. When diagnosed early, the disease gener- ally has a good survival rate. Accord- ing to the AAP report,2 between 909 and 322 000 circumcisions are needed to prevent 1 case of penile cancer. Penile cancer is linked to in- fection with human papillomaviruses,5 which can be prevented without tissue loss through condom use and prophylactic vaccination. It is
remarkable that incidence rates of pe- nile cancer in the United States, where ∼75% of the non-Jewish, non-Muslim male population is circumcised,1 are similar to rates in northern Europe, where #10% of the male population is circumcised.6
As a preventive measure for penile cancer, circumcision also fails to meet the criteria for preventive medicine: the evidence is not strong; the disease is rare and has a good survival rate; there are less intrusive ways of preventing the disease; and there is no compelling reason to deny boys their legitimate right to make their own informed de- cision when they are old enough to do so.
According to the AAP report,2 there is evidence that circumcision provides protection against 2 common viral STDs: genital herpes and genital warts. However, the evidence in favor of this claim is based primarily on findings in RCTs conducted among adult men in sub-Saharan Africa. For other STDs, such as syphilis, gonorrhea, and chla- mydia, circumcision offers no con- vincing protection. The authors of the AAP report forget to stress that re- sponsible use of condoms, regardless of circumcision status, will provide close to 100% reduction in risk for any STD. In addition, STDs occur only after sexual debut, which implies that the decision of whether to circumcise can be postponed to an age when boys are old enough to decide for themselves.
HIV AND AIDS
From a public health perspective, what seems to be the AAP technical report’s most important argument is that circumcision may reduce the bur- den of heterosexually transmitted HIV
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infections in the United States.2 Three RCTs in Kenya, Uganda, and South Africa suggest that circumcision in adulthood may lead to a noticeable reduction in risk of heterosexual HIV acquisition in areas with extremely high HIV prevalence.7–9 Specifically, the African RCTs seemed to show that adult male circumcision halves het- erosexual men’s (but not women’s) risk of HIV infection in the first few years after the operation from 2.49% to 1.18% in high-endemic areas where viral transmission occurs mainly through heterosexual intercourse. This evidence, however, is contradicted by other studies, which show no relation- ship between HIV infection rates and circumcision status.10
However, there is no evidence that cir- cumcision, whether in infancy, child- hood, or adulthood, is effective in preventing heterosexual transmission in countries where HIV prevalence is much lower and routes of trans- mission are different, such as Europe and the United States. Sexually trans- mitted HIV infections in the West occur predominantly among men who have sex with men, and there is no evidence that circumcision offers any pro- tection against HIV acquisition in this group.11,12
The African findings are also not in line with the fact that the United States combines a high prevalence of STDs and HIV infections with a high per- centage of routine circumcisions. The situation in most European countries is precisely the reverse: low circum- cision rates combined with low HIV and STD rates. Therefore, other factors seem to play a more important role in the spread of HIV than circumcision status. This finding also suggests that there are alternative, less in- trusive, and more effective ways of preventing HIV than circumcision, such as consistent use of condoms, safe-sex programs, easy access to
antiretroviral drugs, and clean needle programs.
As with traditional STDs, sexual trans- mission of HIV occurs only in sexually active individuals. Consequently, from an HIV prevention perspective, if at all effective in a Western context, cir- cumcision can wait until boys are old enough to engage in sexual rela- tionships. Boys can decide for them- selves, therefore, whether they want to get circumcised to obtain, at best, partial protection against HIV or rather remain genitally intact and adopt safe-sex practices that are far more effective.
As with the other possible benefits, circumcision for HIV protection in Western countries fails to meet the criteria for preventive medicine: there is no strong evidence for effectiveness and other, more effective, and less in- trusive means are available. There is also no compelling reason why the procedure should be performed long before sexual debut; sexually trans- mitted HIV infection is not a relevant threat to children.
As mentioned in the AAP report,2 the precise risk and extent of complica- tions of circumcision are unknown. It is clear, however, that infections, hemor- rhages, meatal strictures, and other problems do occur. Incidental deaths and (partial) amputations of the penis have also been reported, but exact figures are not available. Although some studies suggest that circumci- sion can lead to psychological, pain- related, and sexual problems later in life,13–15 population-based prospective studies of long-term psychological, sexual, and urological effects of cir- cumcision are lacking.
It seems that the authors of the AAP report consider the foreskin to be
a part of the male body that has no meaningful function in sexuality. How- ever, the foreskin is a richly innervated structure that protects the glans and plays an important role in the me- chanical function of the penis during sexual acts.16–20 Recent studies, sev- eral of which were not included in the AAP report (although they were pub- lished within the inclusion period of 1995–2010), suggest that circumcision desensitizes the penis21,22 and may lead to sexual problems in circumcised men and their partners.23–29 In light of these uncertainties, physicians should heed the precautionary principle and not recommend circumcision for pre- ventive reasons.
The AAP’s extensive report2 was based on the scrutiny of a large number of complex scientific articles. Therefore, while striving for objectivity, the con- clusions drawn by the 8 task force members reflect what these individual physicians perceived as trustworthy evidence. Cultural bias reflecting the normality of nontherapeutic male cir- cumcision in the United States seems obvious. The conclusions of the AAP Technical Report and Policy Statement are far from those reached by physi- cians in most other Western countries. As mentioned, only 1 of the aforemen- tioned arguments has some theoreti- cal relevance in relation to infant male circumcision; namely, the questionable argument of UTI prevention in infant boys. The other claimed health benefits are also questionable, weak, and likely to have little public health relevance in a Western context, and they do not represent compelling reasons for sur- gery before boys are old enough to decide for themselves. Circumcision fails to meet the commonly accepted criteria for the justification of pre- ventive medical procedures in children.
798 FRISCH et al
The cardinal medical question should not be whether circumcision can pre- vent disease, but how disease can best be prevented.
The AAP report2 lacks a serious dis- cussion of the central ethical dilemma with, on 1 side, parents’ right to act in the best interest of the child on the basis of cultural, religious, and health- related beliefs and wishes and, on the other side, infant boys’ basic right to
- World Health Organization, Department of Reproductive Health and Research and Joint United Nations Programme on HIV/AIDS (UNAIDS). Male Circumcision. Global Trends and Determinants of Prev- alence, Safety and Acceptability. Geneva, Switzerland: World Health Organization; 2007
- American Academy of Pediatrics Task Force on Circumcision. Male circumci- sion. Pediatrics. 2012;130(3). Available at: http://www.pediatrics.org/cgi/content/full/130/ 3/e756
- American Academy of Pediatrics Task Force on Circumcision. Circumcision pol- icy statement. Pediatrics. 2012;130(3): 585–586
- BMA Ethics Committee. Consent, Rights and Choices in Health Care for Children and Young People. London, United Kingdom: BMJ Books, Wiley; 2000
- Backes DM, Kurman RJ, Pimenta JM, Smith JS. Systematic review of human papillo- mavirus prevalence in invasive penile cancer. Cancer Causes Control. 2009;20(4): 449–457
- Parkin DM, Whelan SL, Ferlay JLT, Thomas DB. Cancer Incidence in Five Continents. Vol VIII. Lyon: IARC Scientific Publications, No 155. Lyon, France: International Agency for Research on Cancer; 2002
- Auvert B, Taljaard D, Lagarde E, Sobngwi- Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male cir- cumcision for reduction of HIV infection risk: the ANRS 1265 Trial [published cor- rection appears in PloS Med. 2006;3:e298]. PLoS Med. 2005;2(11):e298
- Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in
physical integrity in the absence of compelling reasons for surgery. Phys- ical integrity is 1 of the most funda- mental and inalienable rights a child has. Physicians and their professional organizations have a professional duty to protect this right, irrespective of the gender of the child.
There is growing consensus among physicians, including those in the United States, that physicians should
Rakai, Uganda: a randomised trial. Lancet.
9. Bailey RC, Moses S, Parker CB, et al. Male
circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised con- trolled trial. Lancet. 2007;369(9562):643–656
10. Boyle GJ, Hill G. Sub-Saharan African randomised clinical trials into male cir- cumcision and HIV transmission: method- ological, ethical and legal concerns. J Law Med. 2011;19(2):316–334
11. Sánchez J, Sal Y Rosas VG, Hughes JP, et al. Male circumcision and risk of HIV acquisition among MSM. AIDS. 2011;25(4): 519–523
12. Millett GA, Flores SA, Marks G, Reed JB, Herbst JH. Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta- analysis. JAMA. 2008;300(14):1674–1684
13. Boyle GJ, Bensley GA. Adverse sexual and psychological effects of male infant cir- cumcision. Psychol Rep. 2001;88(3 pt 2): 1105–1106
14. Goldman R. The psychological impact of circumcision. BJU Int. 1999;83(suppl 1):93– 102
15. Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet. 1997;349(9052):599–603
16. Moldwin RM, Valderrama E. Immunochem- ical analysis of nerve distribution patterns within prepucial tissue [abstract]. J Urol. 1989;141(4 pt 2):499A
17. Podnar S. Clinical elicitation of the penilo- cavernosus reflex in circumcised men. BJU Int. 2012;109(4):582–585
18. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis
discourage parents from circumcising their healthy infant boys because non- therapeutic circumcision of underage boys in Western societies has no compelling health benefits, causes postoperative pain, can have serious long-term consequences, constitutes a violation of the United Nations’ Dec- laration of the Rights of the Child, and conflicts with the Hippocratic oath: primum non nocere: First, do no harm.
and its loss to circumcision. Br J Urol.
19. Tuncali D, Bingul F, Talim B, Surucu S, Sahin
F, Aslan G. Histologic characteristics of the human prepuce pertaining to its clinical behavior as a dual graft. Ann Plast Surg. 2005;54(2):191–195
20. Wu ZM, Chen YF, Qiu PN, Ling SC. Correlation between the distribution of SP and CGRP immunopositive neurons in dorsal root ganglia and the afferent sensation of pre- putial frenulum. Anat Rec (Hoboken). 2011; 294(3):479–486
21. Smith DK, Taylor A, Kilmarx PH, et al. Male circumcision in the United States for the prevention of HIV infection and other ad- verse health outcomes: report from a CDC consultation. Public Health Rep. 2010;125 (suppl 1):72–82
22. Yang DM, Lin H, Zhang B, Guo W. Cir- cumcision affects glans penis vibration perception threshold [in Chinese]. Zhonghua Nan Ke Xue. 2008;14(4):328– 330
23. Cortés-González JR, Arratia-Maqueo JA, Gómez-Guerra LS. Does circumcision has an effect on female’s perception of sexual satisfaction [in Spanish]? Rev Invest Clin. 2008;60(3):227–230
24. Fink KS, Carson CC, DeVellis RF. Adult cir- cumcision outcomes study: effect on erec- tile function, penile sensitivity, sexual activity and satisfaction. J Urol. 2002;167 (5):2113–2116
25. Frisch M, Lindholm M, Grønbæk M. Male circumcision and sexual function in men and women: a survey-based, cross-sec- tional study in Denmark. Int J Epidemiol. 2011;40(5):1367–1381
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- Kim D, Pang MG. The effect of male cir- cumcision on sexuality. BJU Int. 2007;99(3): 619–622
- Shen Z, Chen S, Zhu C, Wan Q, Chen Z. Erectile function evaluation after adult circumcision
[in Chinese]. Zhonghua Nan Ke Xue. 2004;10
28. Sorrells ML, Snyder JL, Reiss MD, et al.
Fine-touch pressure thresholds in the adult penis. BJU Int. 2007;99(4):864–869
29. Tang WS, Khoo EM. Prevalence and cor- relates of premature ejaculation in a primary care setting: a preliminary cross- sectional study. J Sex Med. 2011;8(7): 2071–2078
(Continued from first page)
rBritish Association of Paediatric Surgeons, London, United Kingdom; sCommittee on Ethics and Children’s Rights, Swedish Paediatric Society, Stockholm, Sweden; tEthics Committee of the Danish Medical Association, Copenhagen, Denmark; uEthics Committee of the German Academy of Pediatrics and Adolescent Medicine, Berlin, Germany; vFinnish Association of Pediatric Surgeons, Tampere, Finland; wDepartment of Pediatric Surgery, Helsinki University Children’s Hospital, Helsinki, Finland; xDepartment of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada; yEthics Committee of the Norwegian Medical Association, Oslo, Norway; zEstonian Society of Paediatric Surgeons, Tallinn, Estonia; aaNorwegian Paediatric Association, Tromsø, Norway; bbFinnish Medical Association, Helsinki, Finland; ccLatvian Association of Pediatric Surgeons, Riga, Latvia; ddDepartment of Pediatric Surgery, Our Lady’s Children’s Hospital, Dublin, Ireland; eeDepartment of Surgery, Odense University Hospital, Odense, Denmark; ffDepartment of Pediatric Surgery, Landspitali University Hospital, Reykjavik, Iceland; ggDepartment of Pediatrics, Helsinki University Children’s Hospital, Helsinki, Finland; hhSwedish Pediatric Society, Stockholm, Sweden; iiDepartment of Pediatric Surgery, Dr. v. Haunersches Kinderspital, Ludwig-Maximilians Universität, Munich, Germany; jjCommission for Ethical Questions, German Academy of Pediatrics, Frankfurt, Germany; kkSwedish Society of Pediatric Surgery, Stockholm, Sweden; and llDutch Society of Pediatric Surgery, Rotterdam, Netherlands
AIDS, HIV infection, male circumcision, penile carcinoma, sexually transmitted disease, urinary tract infection
AAP—American Academy of Pediatrics RCT—randomized controlled trials STD—sexually transmitted disease UTI—urinary tract infection
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees. http://www.pediatrics.org/cgi/doi/10.1542/peds.2012-2896
Accepted for publication Jan 3, 2013
Address correspondence to Morten Frisch, MD, PhD, Statens Serum Institut, Department of Epidemiology Research, 5 Artillerivej, Copenhagen S, DK-2300 Denmark. E-mail: firstname.lastname@example.org
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2013 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: Dr MacDonald declares World Health Organization advisor and consultant work on vaccines and vaccine safety; the other authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found on page 801, and online at http://www.pediatrics.org/cgi/doi/10.1542/peds.2013-0081.
800 FRISCH et al ”
continue with blog summary:
38 high-ranking medical doctors and professors from 17 western countries outside of the US strongly criticise the AAP stance on male circumcision in new medical article published in AAPs own journal Pediatrics (imagine that going through peer review). Danish medical Professor Morten Frisch is lead author on the paper..
I’m sure you’re eager to read the new article, but although they have promised to make the entire thing free to all readers, Pediatrics have only opened for the abstract. However, I got my hands on the whole thing. Read it herePediatrics-2013-Frisch-peds.2012-2896 (pasted above)
Don’t let anyone get the idea that these 38 widely respected medical professionals are alone. If you Google them, you’ll notice that they all represent major medical societies and other influential institutions in the European medical community and they’re backed up by statements made by several national medical associations in Europe, among them the Danish, Dutch and German.
And that’s not all. Several other articles have been written about the lack of ethics and flawed methods of medical analysis applied by AAP in their stance on male circumcision. Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision is an immensely interesting read and that goes forProphylactic interventions on children: balancing human rights with public health as well.
Basically, what they say is: Hands of the boys! There is no reason what-so-ever to cut into non-consenting healthy children, anyone who claims otherwise must have a strong cultural bias in stead of the objective conservative view, that all medical professionals should strive for.
Of course the AAP responded to the criticism, read their response herePediatrics-2013–peds.2013-0081 (pasted below)
(the AAP’s response)
Cultural Bias and Circumcision: The AAP Task Force on Circumcision Responds
AUTHOR: TASK FORCE ON CIRCUMCISION
circumcision, HIV, urinary tract infection, sexually transmitted infections
Accepted for publication Jan 17, 2013
Address correspondence to Douglas S. Diekema, MD, MPH, Seattle Children’s Research Institute, C9S-6, 1900 Ninth Ave, Seattle, WA 98101. E-mail: email@example.com
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2013 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: Dr Carlo is a Director of Mednax; the other authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found on page 796, and online at http://www.pediatrics.org/cgi/doi/10.1542/ peds.2012-2896.
The members of the American Academy of Pediatrics (AAP) Task Force on Circumcision appreciate the opportunity to respond to the concerns raised by Frisch et al in their commentary, “Cultural Bias in AAP’s 2012 Technical Report and Policy Statement on Male Circumcision.”
The central claim of these authors is that the conclusions of the task force report are culturally biased, leading the task force to a flawed understanding of what constitutes trustworthy evidence and to con- clusions that are far from those reached by physicians in most other Western countries. The “obvious” cultural bias to which they refer apparently has its genesis in “the normality of non-therapeutic male circumcision in the US.” All of the commentary authors hail from Europe, where the vast majority of men are uncircumcised and the cultural norm clearly favors the uncircumcised penis. In contrast, approximately half of US males are circumcised, and half are not.1 Although that heterogeneity may lead to a more tolerant view toward circumcision in the United States than in Europe, the cultural “bias” in the United States is much more likely to be a neutral one than that found in Europe, where there is a clear bias against circumcision. Yet, the commentary’s authors have, at no point, recognized that their own cultural bias may exist in equal, if not greater, measure than any cultural bias that might exist among the members of the AAP Task Force on Circumcision. If cultural bias influences the review of available evidence, then a culture that is comfortable with both the circumcised penis and the uncircumcised penis would seem predis- posed to a more dispassionate analysis of the scientific literature than a culture with a bias that is either strongly opposed to cir- cumcision or strongly in favor of it.
The task force’s process was systematic, objective, comprehensive, and transparently documented in its technical report.1 Members of the AAP Task Force on Circumcision were recruited on the basis of area of expertise. There was no consideration or knowledge of the individuals’ beliefs concerning circumcision at the time of their ap- pointment. Unlike other published policy statements and reports on circumcision, the task force did not selectively choose which articles to review, but reviewed all of the available literature identified in a comprehensive search and evaluated those manuscripts by using previously established, nationally recognized guidelines to determine the quality of the data being reviewed.2 Some articles were reviewed but not cited in the technical report, either because they were not data-based studies, the quality of the study was seriously flawed, or the findings of the study did not meaningfully address the specific area of task force inquiry.
Frisch et al present opinions that reflect a review of the literature that is not comprehensive, systematic, or unbiased. For example, the authors
PEDIATRICS Volume 131, Number 4, April 2013
dismiss the data related to urinary tract infection on the grounds that no randomized controlled trial has been performed, despite the fact that there is good evidence from other studies that suggest a preventive benefit of cir- cumcision. At the same time, they readily dismiss 3 randomized con- trolled trials and 11 other studies that provide good to fair evidence of a re- duction in HIV acquisition associated with circumcision. They claim that these data are “contradicted by other studies, which show no relationship between HIV infection rates and cir- cumcision status,” yet support that claim with only a single reference to a review article authored by the vice president of an organization opposed to circumcision. We would refer the reader to the task force’s technical report for a comprehensive review of the literature related to the potential benefits of circumcision.1 Notably, the World Health Organization has con- cluded that the data strongly support a benefit of male circumcision with regard to prevention of HIV infection and has issued guidelines for its use, both for adults/adolescents and for neonates.3
Frisch et al charge that members of the AAP Task Force on Circumcision “consider the foreskin to be a part of the male body that has no meaningful function in sexuality.” They addition- ally claim, “Recent studies … suggest that circumcision desensitizes the penis and may lead to sexual prob- lems in circumcised men and their partners.” In fact, many of these stu- dies were reviewed by members of the task force but were not cited in the technical report, either because the findings were equivocal, they did not support a benefit or detriment with regard to sexual function and pleasure, or because the relevance to
individuals undergoing circumcision during infancy was questionable. For example, the authors cite 5 studies to support the claim that “the foreskin is a richly innervated structure that protects the glans and plays an im- portant role in the mechanical func- tion of the penis during sexual acts.” Of these 5 studies, 4 were histologic studies that were not designed to correlate anatomic findings with phys- iologic or functional roles.4–7 Members of the task force appreciate that the foreskin has nerve fibers: the task force clearly recommends adequate pain control for infants undergoing circumcision. However, the task force did not move beyond what these studies actually reveal (the foreskin has nerve bundles and pain fibers, the foreskin contains Meissner cor- puscles, the inner surface of the fore- skin resembles a mucous membrane) to speculate about the effect that cir- cumcision might have on sexual func- tion or pleasure. The fifth study cited was designed to determine whether the absence of the penilo-cavernosus reflex is a reliable indicator of a path- ologic sacral lesion and did not evalu- ate implications for sexual function or pleasure.8 In sum, of the 5 studies, not one sought to evaluate whether the foreskin protects the glans or whether it “plays an important role in the me- chanical function of the penis during sexual acts.”
The authors cite 2 articles as evidence that “circumcision desensitizes the penis.” One of these is not a study and does not present data.9 The other revealed that perception sensitivity to vibration decreases after circumci- sion.10 Neither the clinical implications nor impact on sexual experience were evaluated.
Finally, Frisch et al cite 7 studies to support their contention that circum- cision may lead to sexual problems in circumcised men and their partners.
Four of the studies involved only men circumcised as adults11–14 or some men circumcised as adults.15 Men circumcised as adults most frequently have the procedure performed for medical reasons, which introduces both physical and psychological fac- tors that may affect their reporting of sexual difficulties. In 2 of the studies cited by Frisch et al, a significant number of men reported improved satisfaction after circumcision.11,13 In- terestingly, another of their cited studies14 concluded that circumcision had neither a negative nor a positive effect on the female partner’s per- ception of sexual satisfaction, a con- clusion that contradicts that of Frisch et al. The shortcomings of the study by Sorrels et al16 are discussed in our technical report. Finally, the study by Frisch et al used a cross-sectional survey of Danish men that found that circumcised men were more likely to report sexual difficulties than uncircumcised men.17 Circumcised men represented only 5% of 2343 sexually experienced survey respond- ents, and only 15% of those circum- cised men (n 5 17) had the procedure in the first 6 months of life. Attributing these findings to de- creased penile sensitivity is a stretch. It seems far more likely that the findings are attributable to the kinds of social bias the authors attribute to the AAP task force. Male circumcision is rare in Denmark, rare enough that circumcised males are epidemiologic outliers, which may lead some of them to feel “different,” leading to anxiety about sexual experiences with women who perceive a circumcised penis as abnormal. In addition, be- cause many of the circumcised men had the procedure performed later in life, some likely for medical reasons, they are far from representative of a group of men circumcised as infants. It should be noted that the findings of the Danish survey contrast starkly to
802 BLANK et al
those of 2 randomized controlled trials from Africa, which are discussed in the AAP technical report.18,19
AGE AT CIRCUMCISION
A central claim of Frisch et al is that if circumcision is to be performed before an age at which an individual can de- cide for himself, there must be a com- pelling reason for doing so. They argue that there is no compelling reason for performing a circumcision before sexual debut and additionally claim that “sexually transmitted HIV infection is not a relevant threat to children.”
Underlying the authors’ views are sev- eral presuppositions that reflect the ideal, but not the reality, of human de- cision making. The first of these is that the responsible use of condoms will “provide close to 100% reduction in risk for any STIs.” We agree, and fully support efforts to make sexual activity as safe as possible through the routine use of condoms. However, despite huge educational efforts, many individuals around the world do not use condoms consistently. If they did, sexually trans- mitted infection and HIV would decline to the point of nonexistence. The added protective benefit of circumcision exists precisely because responsible condom use is far from universal. In 2011, 39.8% of sexually active high school students in the United States reported not using a condom during their last sexual in- tercourse.20 Condoms represent one of several tools for reducing the risk of infections transmitted during sexual contact. Circumcision is another.
The claim that “sexually transmitted HIV infection is not a relevant threat to children” is incorrect given the US data. In 2011, sexual debut occurred at or before age 13 years for 6.2% of US high school students, and most people in the United States are sexually active before the age at which they would possess
the legal authority to consent to a circumcision.20 A nationwide sample of adolescent females between the ages of 14 and 19 years estimated that 4 in 10 sexually active adolescent females have a sexually transmitted infection (defined as human papillomavirus, chlamydia, trichomoniasis, genital herpes virus, or gonorrhea).21 National HIV surveillance data show that, in 2008, there were at least 2266 HIV infections among US adolescents 13 to 19 years of age.22
Frisch et al claim that “the AAP report lacks a serious discussion of the central ethical dilemma with, on one side, parents’ right to act in the best interest of the child … and, on the other side, infant boys’ basic right to physical integrity in the absence of compelling reasons for surgery.” The authors’ argument about the basic right to physical integrity is an im- portant one, but it needs to be bal- anced by other considerations. The right to physical integrity is easier to defend in the context of a procedure that offers no potential benefit, but the assertion by Frisch et al of ‘no benefit’ is clearly contradicted by the published scientific peer-reviewed ev- idence. Although task force members did not find the data sufficiently compelling to justify a recommenda- tion for routine neonatal circumcision, we did find that the benefits are substantial enough to allow parents to make this decision for their male children. This stance is very similar to that of The Canadian Medical Society, the British Medical Association, and the Royal Australasian College of Physicians. Frisch et al appeal to the ethical precept “First, do no harm,” but they fail to recognize that in sit- uations in which a preventive benefit exists, harm can also be done by failing to act. Whereas there are rare
situations in which a male will be harmed by a circumcision procedure, it is also true that some males will be harmed by not being circumcised. Simply because it is difficult to iden- tify exactly which individuals have suffered a harm because they were not circumcised should not lead one to discount the very real harms that might befall some men by not being circumcised. There is no easy answer to this issue ethically. Regardless of what decision is made on behalf of a young male, harm might result from that decision. That is precisely why the AAP task force members found that this decision properly remains with parents and that parents should have information about both potential benefits and potential harms as they make this decision for their child.
TASK FORCE ON CIRCUMCISION 2012
Susan Blank, MD, MPH, Chairperson Michael Brady, MD, Representing the AAP Committee on Pediatrics AIDS and Committee on Infectious Disease Ellen Buerk, MD, Representing the AAP Board of Directors
Waldemar Carlo, MD, Representing the AAP Committee on Fetus and Newborn Douglas Diekema, MD, MPH, Repre- senting the AAP Committee on Bio- ethics
Andrew Freedman, MD, Representing the AAP Section on Urology
Lynne Maxwell, MD, Representing the AAP Section on Anesthesiology
Steven Wegner, MD, JD, Representing the AAP Committee on Child Health Financing
Charles LeBaron, MD – Centers for Disease Control and Prevention
Lesley Atwood, MD – American Acad- emy of Family Physicians
Sabrina Craigo, MD – American College of Obstetricians and Gynecologists
PEDIATRICS Volume 131, Number 4, April 2013
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- Cummins RO, Hazinski MF. The most important changes in the international ECC and CPR guidelines 2000 [edito- rial]. Circulation. 2000;102(8 suppl):I371– I376
- World Health Organization; UNAIDS. New data on male circumcision and HIV pre- vention: policy and programme implica- tions. Geneva, Switzerland: World Health Organization; 2007. Available at: http://libdoc. who.int/publications/2007/9789241595988_eng. pdf. Accessed January 7, 2013
- Moldwin RM, Valderrama E. Immunochem- ical analysis of nerve distribution patterns within prepucial tissue (abstract). J Urol. 1989;141(4 pt 2):499A
- Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol. 1996;77(2):291–295
- Tuncali D, Bingul F, Talim B, Surucu S, Sahin F, Aslan G. Histologic characteristics of the human prepuce pertaining to its clinical behavior as a dual graft. Ann Plast Surg. 2005;54(2):191–195
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