Sunday, September 30, 2012

Letter to AAP: Being honest about medical involvement that contravenes "first of all, do no harm", Susan Bewley

Following the retraction of its policy on female genital mutilation in 2010 (1,2,3,4), the American Academy of Pediatrics (AAP) seems determined to court controversy again (5). What is puzzling is that apparently "new scientific evidence shows the health benefits of newborn male circumcision outweigh the risks of the procedure" - sufficient to justify third party payment and endorsement by the American College of Obstetricians and Gynaecologists - and yet "the benefits are not great enough to recommend routine circumcision for all newborn boys"(6).
The AAP dithers between envisioning neonatal circumcision as a benefit rather than 'the lesser of two [harms] evils' and cannot have it both ways: Either infant male circumcision is better for health and thus has a 'therapeutic' indication for all or it isn't - and has to be classified as 'cultural', 'religious', 'habitual', 'cosmetic' or 'mutilation'. Prophylactic pediatric surgery arguments are weak - we would not accept disease eradication via routine tonsillectomy or appendicectomy, for example, just because some children avoid problems later and certainly not without randomised trial evidence. There are no comprehensive and reliable statistics on the known, albeit rare, serious risks of death and damage (7, 8). The literature on circumcision complications is subject to underreporting and bias as it relies on case reports and is probably compounded for non-hospital procedures. If neonatal circumcision is beneficial, it should be recommended for all (accepting that parents do not have to take the advice). If it is not beneficial (or risky or harmful), then society can either (i) allow some leeway for parents to harm their infants (with or without medical collusion), or (ii) disallow it until boys are of an age to make their own decisions. The latter makes particular sense as most purported benefits relate to possibly preventing diseases and disorders, such as HIV acquisition, that will not occur until maturity.
The key question is whether the AAP brings the medical profession into disrepute when reading the scientific literature in an unsystematic way and legitimising non-therapeutic procedures by 'medicalisation'. Should we be suprised to find the practice supported by those with a cultural, religious or financial vested interest? The conflict of interest statements are not published with the policy. In the UK National Health Service, despite similar official equivocation (9,10) OB-GYNs do not perform neonatal circumcision and only 0.2% of newborn boys are circumcised (11). Female genital cutting or mutilation is illegal in the UK as well as the USA (12,13,14). Do newborn boys not deserve equal protection?
1. AAP Board of Directors Ritual Genital Cutting of Female Minors Pediatrics Vol. 126 ( 1) 191-192, July 1, 2010. 2. Strandjord SE. Opportunity for Education Plus Protection of Minors. Pediatrics eLetter published May 17 2010 3.Bewley S. Sincerity, retraction and apology. Pediatrics eLetter published June 1 2010. 4.Bewley S. Female genital mutilation. BMJ 2010 Jun 2: 340:c2728. 5.AAP Task Force on Circumcision, Circumcision Policy Statement, Pediatrics 2012 Sept: 130:585-586 6. AAP Press Release August 27, 2012, Point-to-Greater-Benefits-of-Infant-Circumcision-But-Final-Say-is-Still-Up -to-parents-Says-AAP.aspx 7. Williams N. Complications of Circumcision. Br J Surg. 1993 Oct;80(10):1231 8. Circumcision Information and Resource Pages accessed September 6 2012 9. British Medical Association. The Law and ethics of male circumcision. Guidance for doctors. June 2006, work/ethics/children accessed September 6 2012 10. British Association of Paediatric Surgeons, The Royal College of Nursing, The Royal College of Paediatrics and Child Health, The Royal College of Surgeons of England and The Royal College of Anaesthetists. Statement on Male Circumcision March 6, 2007 11. Cathcart P, Trends in paediatric circumcision and its complications in England between 1997 and 2003. Br J Surg. 2006 Jul;93(7):885-90 12. Ending female genital mutilation United Nations Resolution E/CN.6/208/L.2/Rev.1 -%20advance%20unedited.pdf accessed September 6 2012 13. Public Law No. 104-208, 30 September 1996 [Sections 579, 644, and 645]. 1995 Prevention
of Female Genital Mutilation Act, (USA) 14. Female Genital Mutilation Act 2003 (UK)
  • Susan BewleyProfessor of Obstetrics
  • Sarah Strandjord, Professor of Pediatrics
Kings College London

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