Abstract
Male circumcision has been in the spotlight this year. The United States has a burgeoning anticircumcision movement and a German court recently declared that male circumcision constituted grievous bodily harm. In contrast, the state of CA, the US government (and other national governments), and world religious groups have defended parents’ right to circumcise boys, and the World Health Organization has included the surgery in its arsenal against HIV in Africa. In the wake of this global controversy, the American Academy of Pediatrics (AAP) released a revised policy statement on neonatal male circumcision (or routine infant circumcision (RIC)) in August. This latest statement revises the 1999 (2005) policy, incorporating new research on HIV and sexually transmitted infections, insurance coverage, and practitioner training. The recent AAP statement, endorsed by the American College of Obstetrics and Gynecology, responds to the contentiousness of circumcision. However, although the international discourse on circumcision has changed dramatically, the AAP statement does not represent a radical departure from its previous circumcision policy.
Until 1999, the AAP had endorsed RIC as beneficial and recommended it for all infant boys. In 1999, the AAP acknowledged that there was not sufficient evidence for recommending the procedure; subsequently, many private insurance companies and Medicaid discontinued coverage for RIC and the United States saw a decrease in male circumcision rates. The August 2012 statement states that there is evidence supporting circumcision’s health benefits. But, the AAP still does not recommend the procedure; it merely suggests that the benefits are enough to warrant parents’ continued access to the procedure. Basically, it protects a parent’s right to seek circumcision for his or her son. It also suggests that the benefits to the individual and the public justify third-party (insurance) coverage.
Even though the new statement does not significantly depart from previous policies, it warrants some investigation. The new statement draws on a narrow body of medical/scientific studies of the RIC’s health benefits and risks to answer an equally limited set of questions about epidemiology, techniques, risks and benefits, analgesia and anesthesia, parental decision making, morbidity and sexual function/satisfaction, medical training, and payment. In order to standardize the literature review, the Task Force excluded case studies, animal studies, theoretical analyses, and “rational conjecture,” focusing primarily on RCTs and cohort studies. This limited selection criteria is different from earlier policy statements, which incorporated a wide range of evidence. This delimited scope also means that certain information is left out of the review: fatalities and extreme complications are infrequent, so they are only reported as case studies; studies of sexual complications have only been undertaken recently, with the rise of an organized movement against circumcision, and have been limited to small or self-selected populations. Excluding evidence of harms severely limits the reliability of the AAP’s cost–benefit analysis.
There is another glaring absence in the statement. Given the global context of disputes over circumcision, this policy and the literature review that it draws on are strikingly silent on the question of medical ethics. The question of human rights (like the issue of bodily integrity raised by the German court) is entirely absent. 1 The only ethics discussed are not those of the men who are to be circumcised, but those of parents considering RIC—they may have religious, ethical, and cultural considerations that outweigh the medical benefits and should therefore be counseled in an unbiased manner. Again, it is unclear how the AAP can adequately assess the costs and benefits without considering human rights, bodily integrity, and patient consent.
The AAP set out with a laudable goal—to address the class inequities in access to male circumcision. The 1999 statement led to the withdrawal of third-party funds for circumcision; this reduced circumcision rates, especially among economically disadvantaged groups. If, as the AAP seems to believe, male circumcision carries a number of health benefits for both individuals and communities, then this class disparity could lead to poorer health conditions among the underprivileged (especially when the possible benefits include reducing the risk of diseases that already disproportionately affect poor people). However, the AAP fails to engage with the broader ethical questions surrounding circumcision. Medical institutions must figure what it means to “first, do no harm” in a world where bodily and cultural politics seem to conflict.