Policy statements by medical organizations

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This article has originally been created for and published on the CIRP website and is still available there unter https://www.cirp.org/library/statements/.

Policy statements by medical organizations

This directory contains official policy statements of various medical organizations regarding non-therapeutic male circumcision, along with discussions of these positions. All known statements by national medical organizations are accessible from this page. No statement recommends the practice of non-therapeutic child circumcision.

Introduction

Medical organizations in the various English speaking nations have found it appropriate to issue policy statements for the information of the medical community and the public. The Circumcision Reference Library has collected these official policy statements, both old and new, from the various English speaking nations. The medical societies of non-English speaking nations do not issue circumcision policy statements because neonatal male circumcision is not a practice of those countries. The older statements may not reflect current policy but are presented for reference purposes.

Conflict of interest

Medical organizations are political associations of doctors that have a duty to represent the interests of their doctor members, of whom some may profit by performing circumcision. The protection of the income and estates of the members may be given high priority. This duty to the members may in some instances prevent complete candor about the effects of non-therapeutic circumcision. Generally, the alleged prophylactic benefits of male circumcision are overstated while the risks, complications, certain injury, and other drawbacks are understated. Human rights, legal, and ethical issues are usually glossed over. The content of circumcision policy statements may also be influenced by religious and political considerations.

Statements

Australia

The Royal Australasian College of Physicians published a new position statement, prepared under the supervision of Professor David A. Forbes of the University of Western Australia, regarding the non-therapeutic circumcision of male infants in September 2010. The statement says:

“ After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.
– RACP (Circumcision of Male Infants. Sydney: Royal Australasian College of Physicians, 2010.)[1]

In September 2002, under the lead of the Royal Australasian College of Physicians (RACP), Paediatrics and Child Health Division, six major medical societies of Australasia developed a unified position statement on male circumcision. All six medical societies (the RACP, Australian Association of Paediatric Surgeons, New Zealand Society of Paediatric Surgeons, Urological Society of Australasia, Royal Australasian College of Surgeons, and Paediatric Society of New Zealand) have now corroborated the Canadian Paediatric Society, declaring that circumcision of newborn males should not be routinely performed. The new statement firmly declares: "There are no medical indications for routine male circumcision." This statement was slightly revised in September 2004. This statement was retired in 2010.

  • REFdocument Beasley, S. / B. Darlow / J. Craig / D. Mulcahy / G. Smith: Position statement on circumcision (archive URL) PDF, Royal Australasian College of Physicians (Sydney). (September 2004).

In 1998, the former Australian College of Paediatrics (ACP) was absorbed into the Royal Australasian College of Physicians (RACP) as the Division of Paediatrics and Child Health. In 1971, 1983, and 1996, The ACP and its predecessor organisations had issued prior statements regarding male circumcision. The 1971 statement affirmed that there is no medical indication for neonatal circumcision. In 1983, the ACP declared an official policy discouraging circumcision. In 1996, the organization went further, expressing concern that neonatal circumcision may violate human rights. In this statement the ACP disclosed the traumatic nature of circumcision, recommending that parents should be given more complete facts about the procedure.

For more analysis of the 1996 statement, see this newspaper article.

The Australasian Association of Paediatric Surgeons (AAPS) issued its first statement on circumcision in 1996. The AAPS does not support or condone the practice of child circumcision.

The Federal Council of the Australian Medical Association (AMA) has approved the position statement (1996) of the Australian College of Pediatrics with the provision that the circumcision of male infants continue to be discouraged.

The Australian Pædiatric Association passed a resolution on April 24, 1971 that neonatal circumcision should not be performed as a routine measure (in the absence of a medical indication). That resolution was reported in a letter published in the Medical Journal of Australia on May 22, 1971.

Canada

Canadian Paediatric Society

The Canadian Paediatric Society issued its first statement on neonatal circumcision in 1975. It issued a supplement in 1982 and again in 1989 in response to the Wiswell claims regarding UTI that appeared in the medical literature. These statements are collected into one file. The CPS issued a completely new policy statement in 1996 which is in its own file.

This statement rejects the claim of Drs. Warner and Strashin that neonatal circumcision is a cost-effective procedure.

The following statement by the Canadian Paediatric Society was issued especially to reject the contentions of Thomas E. Wiswell, MD, concerning the value of neonatal circumcision in preventing urinary tract infection.

This is the very good 1996 CPS policy statement by lead author Dr. Eugene Outerbridge:

The CPS recommended that "Circumcision of newborns should not be routinely (i.e.,in the absence of medical indication) performed." Since there are no medical indications for circumcision in the newborn period, in effect, the CPS is saying that newborn circumcisions should not be performed.

The CPS updated its current circumcision statement in 2015. Sadly, it appears to have been influenced by the now discredited 2012 AAP statement.

College of Physicians and Surgeons of British Columbia

The College of Physicians and Surgeons of British Columbia (CPSBC) issued policy statements/guidance on circumcision in 2002, 2004 and 2009.

  • In their current (2009) policy, British Columbia states that:
“ The matter of infant male circumcision is particularly difficult in regards to human rights, as it involves consideration of the rights of the infant as well as the rights of the parents. Under the Canadian Charter of Rights and Freedoms and the United Nations Universal Declaration of Human Rights, an infant has rights that include security of person, life, freedom and bodily integrity. Routine infant male circumcision is an unnecessary and irreversible procedure. Therefore, many consider it to be 'unwarranted mutilating surgery.[2]
“ Many adult men are increasingly concerned about whether their parents had the right to give consent for infant male circumcision. They claim that an infant's rights should take priority over any parental rights to make such a decision. This procedure should be delayed to a later date when the child can make his own informed decision. Parental preference alone does not justify a non-therapeutic procedure.[2]
  • The CPSBC's previous official circumcision policy statement was issued in June 2004. This position strongly cautioned physicians against the performance of unnecessary elective non-therapeutic circumcision of a child. If an unnecessary elective non-therapeutic circumcision is to be performed, this statement requires physicians to obtain the consent of both parents before performing an unnecessary elective non-therapeutic circumcision of a child.
  • The CPSBC issued a preliminary guidance to B.C. doctors on circumcision in 2002:

College of Physicians and Surgeons of Manitoba

The College of Physicians and Surgeons of Manitoba (CPSM) issued a policy statement on circumcision in 1997, and a caution in 2002:

  • Manitoba says that "specific medical indications for the performance of circumcision in the neonate are rare."
  • It also says, "the degree of benefit is small and does not support a decision to circumcise neonates."

College of Physicians and Surgeons of Saskatchewan

The College of Physicians and Surgeons of Saskatchewan (CPSS) issued two memos to the physicians and surgeons of Saskatchewan regarding male non-therapeutic neonatal circumcision. These memos strongly caution against performing non-therapeutic neonatal circumcisions.

Finland

Central Union for Child Welfare

The Central Union for Child Welfare (Lastensuojelun Keskusliitto) has issued a strong statement in opposition to the proposal to offer ritual circumcision in public hospitals.

Netherlands

Royal Dutch Medical Association

The Royal Dutch Medical Association (In Dutch Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst or KNMG) published a seventeen-page position statement in English regarding the circumcision of male childen on May 27, 2010. That statement cites many problems of male circumcision and says that the operation violates the human rights of the child. It goes on to say that the KNMG would not oppose making the circumcision of male children unlawful. The document is available in a PDF file on the KNMG website.

New Zealand

Paediatric Society of New Zealand

The Paediatric Society of New Zealand and the New Zealand Society of Paediatric Surgeons have participated with other medical societies in Australasia in adopting a new position statement of circumcision in 2002 (see Australia.)

  • REFdocument Beasley, S. / B. Darlow / J. Craig / D. Mulcahy / G. Smith: Position statement on circumcision (archive URL) PDF, Royal Australasian College of Physicians (Sydney). (September 2004).

United Kingdom

British Medical Association

The British Medical Journal (BMJ) is published by the British Medical Association (BMA). Editorials in the BMJ are considered to represent the policy of the BMA. The BMJ has published two editorials on male child circumcision.

The first editorial (1979) took a position against non-therapeutic neonatal circumcision of boys.

The second editorial (1993) took a position against post-neonatal circumcision of boys.

The British Medical Association felt compelled to issue a "guidance" for doctors in 1996 due to widespread questions about the ethics and lawfulness of neonatal circumcision. This statement does not address medical issues but does discuss ethical and legal issues. The statement recognizes the right of physicians to be conscientious objectors to the practice of male circumcision. It recommends that doctors obtain the consent of both parents before carrying out a circumcision operation. This now outmoded statement is retained for reference purposes.

The 1996 guidance on circumcision is outmoded by legal developments in the United Kingdam and has been replaced by a new statement in April 2003. This statement was revised in 2006 to reflect further legal challenges to the lawfulness of non-therapeutic circumcision in the United Kingdom.

General Medical Council

The General Medical Council (GMC) of the United Kingdom is the semi-official body that regulates medical care within the United Kingdom. Rising concern about the ethics and lawfulness of child circumision has caused the GMC to issue an interim statement for the guidance of doctors in the United Kingdom. The GMC has also asked to Royal College of Paediatrics and Child Health and the British Association of Paediatric Surgeons to produce a guidance on the medical aspects of male circumcision, (1997) A statement eventually was produced in 2001. (See below).

British Association of Paediatric Surgeons

The British Association of Paediatric Surgeons (BAPS) issued a statement in 1997 in response to the GMC Guidance above.

The BAPS issued a second statement in 2001. This statement strongly emphasizes the need to obtain the consent of both parents for the surgical procedure.

This joint statement by the 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, was produced pursuant to a 1997 request of the General Medical Council (GMC). The statement is limited to the medical aspects of non-therapeutic circumcision of male children. The lawfulness and bioethics of male non-therapeutic circumcision were outside the scope of this statement. Apparently, the GMC plans to address the the issues of the ethics and lawfulness of non-therapeutic circumcision of male children after receiving this medical statement.

  • REFdocument 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 / The Royal College of Anaesthetists: Statement on Male Circumcision (London). (6 March 2001).

The British Association of Pediatric Surgeons (BAPS) issued yet another statement regarding the management of foreskin conditions, which includes a discussion of circumcision, in 2007.

United States of America

American Academy of Pediatrics

The American Academy of Pediatrics (AAP) issued a brief statement within its 1971 hospital care manual. An ad hoc committee issued a longer statement in 1975. More information was contained in the 1978 hospital care manual. A supplement to the 1975 statement was issued in 1989 by a task force assembled for that purpose. This 1989 supplement recognized the pain of neonatal circumcision for the first time. The 1989 statement reaffirmed the previous position that there is no medical indication for neonatal circumcision and reported new information on the role of the HPV virus in cervical cancer. The 1997 statement emphasized the elective nature of child circumcision. The Circumcision Reference Library has combined these statements into one file. The AAP statements dated prior to 1999 have been superseded by the 1999 policy statement. The 1999 policy statement has its own file.

The penultimate policy statement of the AAP is the 1999 Circumcision Policy Statement. The AAP does not recommend routine (performed in the absence of medical indication) circumcision of the newborn. The statement emphasizes the need for well-informed consent of the parents (plural).

The AAP also issued a statement on female genital mutilation in 1998. AAP policy for male genital altering surgery is inconsistent with the policy for female genital altering surgery.

The AAP has also issued several other statements relevant to the consideration of male circumcision. The first is its statement on neonatal anesthesia which was issued in 1987. This statement anticipates the new AAP position that pain control is required for circumcision pain.

The AAP statement on breastfeeding which was issued in 1997 is relevant because it recommends breastfeeding as a preventive measure against urinary tract infection. Previously, the AAP recommended circumcision as a preventive measure against urinary tract infection. This is an important policy change.

Furthermore, the AAP statement on breastfeeding contains an implicit advice against circumcision: It states that "procedures that may interfere with breastfeeding or traumatize the infant should be avoided or minimized." Neonatal circumcision is the most common traumatic procedure carried out on newborns.

The 1999 AAP Circumcision Policy Statement's position on the medical ethics of circumcision is inconsistent with major AAP Committee on Bioethics policy statements. The AAP completely revised its policy on informed consent in 1995 to bring their policy into conformity with the provisions of the UN Convention on the Rights of the Child (1989). The 1995 statement of the Committee on Bioethics says that parents may only grant permission for diagnosis and treatment. This would exclude consent for non-therapeutic neonatal circumcision which is neither diagnosis nor treatment. The statement also calls for the delay on non-essential procedures until the child is developmentally capable of granting consent.

The 1999 AAP Circumcision Policy Statement's section on medical ethics is also inconsistent with the AAP Committee on Bioethics statement on Religious Objections to Medical Care:

This statement affirms that children have a right to grow up free from preventable disease or injury (circumcision is a preventable injury). The statement recognizes important limitations on the parent's right to force their religious practices onto a child, if those practices might harm the child's health. Consistent with this view, the AAP Committee on Bioethics states that religion is not a defense when a child is harmed. These statements are also in conformity with the provisions of the United Nations Convention on the Rights of the Child (1989), which states that children have a right to grow up free of traditional practices that are prejudicial to health.

AAP 2012 Circumcision Policy Statement
The American Academy of Pediatrics issued a two part statement in the September 2012 issue of Pediatrics, its controlled medical journal.

The two statements have been poorly received. The 2012 statement has received an extraordinary level of critical comment. The AAP's position on male circumcision is markedly different from the positions of other medical societies. The two papers listed above should be viewed with extreme caution.

The Circumcision Reference Library believes that the critical comment should be published along with the statements and that the public should read the critical comment before drawing any conclusions about the contents of the Circumcision Policy Statement and its supporting Male Circumcision statement.

  • Staff. (2012) Commentary on American Academy of Pediatrics 2012 Circumcision Policy Statement. Doctors Opposing Circumcision. Seattle.
  • REFweb Young H (2012). Comment, The Intactivism Pages.
  • REFjournal Svoboda JS, Van Howe RS. Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision. J Med Ethics. 2013; 00: 1–8. DOI.
  • REFjournal Frisch M, Aigrain Y, Barauskas V, et al. Cultural bias in the AAP’s 2012 technical report and policy statement on male circumcision. Pediatrics. 2013; 131(4): 1-5. DOI.

American Academy of Family Physicians

The American Academy of Family Physicians (AAFP) has withdrawn its previous cautious, legalistic statement that emphasizes the lack of therapeutic benefit, controversial nature of male neonatal circumcision, and the need for well-informed consent of the parents (plural). The current (2002) statement also emphasizes lack of therapeutic benefit and likens neonatal circumcision to a "cosmetic" procedure and expresses ethical concerns about non-therapeutic neonatal circumcision:

American Medical Association

The American Medical Association (AMA) has issued its first ever statement on neonatal non-therapeutic circumcision. The statement calls for the re-training of American physicians and improved information to parents in hopes of reducing the unacceptably high rate of non-therapeutic neonatal circumcision.

  • REFdocument AMA Council on Scientific Affairs: Neonatal circumcision, American Medical Association (Chicago). (December 1999).

American College of Obstetricians and Gynecologists

The American College of Obstetricians and Gynecologists (ACOG) first issued a semi-official statement on male neonatal circumcision in 1978 with the publication of this article in the official journal of ACOG's official journal.

The ACOG issued a new policy statement on male neonatal circumcision in October 2001. The statement emphasizes the need for well-informed consent of the parents (plural). The ACOG policy statement may be found in medical libraries. The citation is:

[CIRP note: ACOG has not placed the full text of their circumcision policy online. It is available on their website only to their members. Therefore, the Circumcision Reference Library has prepared a summary of ACOG's position, for readers who do not have access to a medical library.]

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists periodically issue a joint publication, Guidelines for Perinatal Care, which provides guidance on the care of the newborn in hospital. The most recent guidelines classify neonatal circumcision as "elective", not "routine." Circumcision of infants should be performed only "at the request of the parents. Breastfeeding, on the other hand, is encouraged.

International Coalition for Genital Integrity

The International Coalition for Genital Integrity (ICGI) published a position statement on September 25, 2007.

Doctors Opposing Circumcision

Doctors Opposing Circumcision published a new policy statement in June 2008.

Future statements

The Canadian Paediatric Society (CPS) has announced its intent to revise its 1996 policy statement.

References

  1. ↑ REFdocument Royal Australasian College of Physicians: Circumcision of Infant Males (archive URL) PDF (Sydney). (September 2010).
  2. ↑ a b REFdocument CPSBC 2009 circumcision policy PDF. (2009).
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