AAP is Against Routine Circumcision

MEDICAL TRIBUNE, Volume 30: Page 16,
8 June 1989.



By James Trager

Newspaper headlines across the country in early March [1989] rang variations on the theme that circumcision had regained favor in the eyes of the medical establishment. Wrong: the American Academy of Pediatrics still opposes routine circumcision for male infants. Its 1971 position, that it finds "no valid medical indications" for routine circumcision, remains intact.

"We have not reversed our position," said Donald W. Schiff, M. D., professor of pediatrics at the University of Colorado in Denver and president of the AAP. "We've changed it a bit, but its really just a bit. I think that the distinction we're making is that there is some new data which suggests that the subject needs reexamination and further examination and further examination but that, and I think I said that, there may be some advantage to doing circumcision, but I think the data is still indefinite enough that we're not making a real change of any significance. We're making a slight change. We sort of opening the door a crack, so to speak saying, "We need to reexamine on the issue and reidentify the data so that we know just what the facts are. We don't have them all yet."

What the AAP did was throw a sop to advocates of routine circumcision. According to the academy's statement, the procedure "has potential medical benefits and advantages." The New York Times seized upon this and headlined its story, "Pediatricians Find Medical Benefit to Circumcision." Said a subhead: "The group reverses an earlier position. "Other papers followed the same line. But there was no reversal. If circumcision has potential medical benefits and advantages," it also has inherent disadvantages and risks," according to the AAP statement.

In reviewing retrospective studies conducted in 1985 at U. S. Army hospitals, in which Thomas E. Wiswell, M. D., and colleagues found a decreased incidence of urinary tract infections in circumcised male infants, the AAP found possible methodological flaws. The Canadian Paediatric Society looked at the same research data and in December 1988 reaffirmed its stand against routine circumcision.

Opponents of nonreligious circumcision were dismayed last year when the California Medical Association (CMA) by a voice vote, passed a resolution declaring circumcision to be an effective public health measure. Aaron Fink, M. D., a urologist, had submitted the resolution in 1987, but the CMA's scientific board was unable to find any scientific basis for claims that circumcision served to guard against venereal disease, herpes, and AIDS. In 1988, Dr. Fink's resolution was not sent to the scientific committee for review.

James L. Snyder, M. D., a past president of the Virginia Urologic Society, expressed surprise at the CMA's adoption of the Fink resolution. Speaking on March 4, 1989, two days before the AAP released its statement, Dr. Snyder said, "Each of these diseases has a known etiologic agent, and as a physician in the United States Navy I have treated circumcised American servicemen for each of these conditions, using specific and effective antibiotics to cure what circumcision did not prevent.

Protection Claim 'Stretches Reason'

As for "recent speculation" that routine circumcision could reduce urinary tract infections or "prevent infection due to the AIDS virus. "Dr. Snyder declares, that this stretches reason. More than 99% of male children have never had urinary tract infections regardless of the state of their foreskins… . [as for AIDS], American parents want to know why thousands of their children, brothers, and cousins in Los Angeles, San Francisco, New York, Miami were not protected from AIDS infection by the fact that 60-90% of them have been circumcised at birth since 1940.

A resolution introduced by John W. Hardebeck, M. D., that the CMA resolution failed, however, "Newborn-male circumcision is a procedure without factual, demonstrable, supportable medical indications in the overwhelming majority of cases." From March 1 to 3, just before the CMA session, the First International Symposium on Circumcision convened at Anaheim. Among the speakers was Martin Altschul, M. D., a Salem, Ore. pediatrician who reviewed the pediatric case histories at six Kaiser Permanente hospitals in the Bay Area and found no indication of increased urinary tract infections among uncircumcised male infants.

Marilyn F. Milos, executive director of the National Organization of Circumcision Information Resource Centers (NOCIRC) of San Anselmo, Calif. organized the symposium. The speakers included Paul Fleiss, M. D., a Los Angeles pediatrician, who expressed concern about the unreported incidences of complications due to circumcision, including severe infection.

Postprocedural infection was mentioned in a piece on circumcision aired March 27 on PBS's "MacNeil-Lehrer News Hour." Interviewed were Stephen and Valerie Creek of suburban Seattle whose son Daniel had been born in October. Two days after coming home from the hospital Daniel developed an "odd rash." Mrs. Creek took him to her pediatrician and was told, "Go to Children's Hospital immediately. Go to the emergency room," Said Mrs. Creek, "They told us that they didn't know if Daniel was going to survive, that he had this infection, it was real bad, and that he was very very sick." The week-old baby had to have extensive areas of skin and fat removed and spent time in a hyperbaric chamber before the infection disappeared.

Asked what they would do if they had a second son, the Creeks were not sure they would have him circumcised. Said Mrs. Creek, "It's a tough decision. On the one hand I'd say yes … because the other boys are, and again … to see what he went though, if it doesn't have to be done … I would say no, don't do it."

An expectant mother interviewed in the report said, "I can very easily see where the decision to circumcise is a weak one, but I think emotionally, inside, I feel it's the right decision to make. There are still cultural things we adhere to. You know I shave my legs. People in other countries don't do that. Why do I do it? Because that's what American women do.

The Public Television reporter in Seattle found a Jewish physician who performed ritual circumcision and who said, "We don't strap [the baby] down. we put him on a loved one's lap. We give him some wine. We wait a little bit for it to take effect." But the doctor does not recommend surgery to parents who have no religious reason for doing it. (Muslims as well as Jews practice ritual circumcision.)

A Seattle pediatrician David Springer, M. D., asked his rabbi to find a way to avoid having his son circumcised. Dr. Springer's first son had died of a heart problem, and he did not want to expose his son to unnecessary risk. "I saw no scientific reason for it. My own experience with circumcision was traumatic for my mother, and hence the trauma got projected onto me." But Dr. Springer and his wife wanted to enter their son into the covenant with God that circumcision symbolizes. Said Rabbi James Morrell, As a rabbi, I don't want to turn people away who on very legitimate grounds, decide not to circumcise their sons because of medical or psychological considerations." So the Springers and their rabbi worked out a substitute ceremony. "We gave him a Jewish name. We drew some blood - a normal newborn blood exam called the TKU. We did that as a celebration of his commitment to the Jewish people. We had our Jewish community there. The Rabbi composed a meaningful service for us that fit our particular situation, and I very happy with the decision.

`Small Price to Pay'

Macneil-Lehrer interviewed Julian Ansul, M. D. a urologist in at the University of Washington, who accepts the validity of the Wiswell studies. "the brief period of discomfort that the child has and experiences, although real and not to be denied is worth the price of being sure that they don't have or much less likely to have urinary tract infections." said Dr. Ansul. "I think its a small price to pay for the fact that you will not face, or be very unlikely to face, the possibility of having cancer of the penis when you're in your 40s and 50s and may die of that."

Penile cancer is rare in the United States, observed Michael Rothenberg, M. D., coauthor with Benjamin Spock, M. D. of Baby and Child Care. Speaking on MacNeil-Lehrer, Dr. Rothenberg said "Its a horrible thing that's happening to parents in this country. Parents as a group have been made to feel horribly uncomfortable about this circumcision issue."

A Swedish group, meanwhile, had suggested in the Lancet (March 18) that the prepuce or foreskin, was not "a mistake of nature" but perhaps presented a problem in societies. where childbirth was attended by good hygiene. Jan Winberg et al. accepted the Wiswell finding as "persuasive" and said, "IF they are correct, this will be the first known instance of a common, potentially lethal disease being preventable by extirpation of a piece of normal tissue." Trying to reconcile the prepuce "with existing views of evolution and biology, Winberg et al. suggest that "in biologically natural settings," mothers give birth in squatting or kneeling position and often defecate during delivery, thus colonizing the baby with their own aerobic and anaerobic intestinal flora.

In sanitary hospital maternity units, on the other hand, the baby's gastrointestinal tract and genitals may be colonized by Echerichia coli strains "of non-maternal origin to which the baby has no passive immunity". Instead of circumcising newborns, said the Swedish pediatricians, "early infantile male UTI could be prevented by more natural colonization, either by more strict rooming in of the baby with his mother's anaerobic gut flora."

About 58% of boys are still circumcised in the United States - far too many for opponents of the procedure. Said Ms. Milos of NOCIRC, "We now have 40% of American boys who are intact without problems. The grass-roots movement [against routine circumcision] is winning.

"What's amazing to me [about the AAP statement] is that they work so hard to sit squarely on both sides of the fence on this issue. They've given the parents the responsibility to figure out what they (1) couldn't figure out or (2) couldn't take a stand on. The sad part is that babies will suffer because of the scare tactics of those who have a vested interest in perpetuating the practice."


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