American Academy of Pediatrics

Emblem of the American Academy of Pediatrics

Note: The AAP does not recommend non-therapeutic infant circumcision. The AAP is regularly cited with its 2012 circumcision policy as a major US medical organization recommending non-therapeutic infant circumcision. The 2012 policy expired in 2017 and has not been renewed or re-affirmed since.

The American Academy of Pediatrics (AAP) is a medical trade association of American pediatricians, headquartered in Elk Grove Village, Illinois. Almost all U.S. pediatricians are members.

The AAP advances the financial and business interests of its members. Hundreds of millions of dollars are paid out by third-parties to physicians, including pediatricians, obstetricians, and family physicians to provide medically unnecessary non-therapeutic circumcision of minor boys. Their slogan is: "Dedicated to the Health of All Children," however the protection of the income of its fellows ("members") overrides their duties to children. Preservation of that income stream has always been a fundamental policy of the AAP.

The AAP has not recognized the human rights of children that were granted by the International Covenant on Civil and Political Rights (1966) and the Convention on the Rights of the Child (1989), nor has it recognized the legal right of children to physical integrity.

The AAP publishes Pediatrics.

History of AAP circumcision policy

Introduction

The AAP evidently has an apparent long standing policy of appointing members of its various circumcision task forces who are believed by reason of published statements and/or ethnicity to be biased in favor of non-therapeutic male circumcision. Some such members are:

• Susan Blank
• Michael Brady
• Douglas Diekema
• Andrew Freedman
• Edgar J. Schoen

It is thought that the AAP chooses circumcised doctors who don't have a foreskin to its various task forces on circumcision, so personal knowledge and understanding of a normal body part has been lacking on its various task forces. Perhaps the AAP believes that such doctors will be biased in favor of circumcision. The AAP apparently hopes to continue to produce statements in favor of circumcision so that the collection of revenue, usually by third-party payment, from circumcision can continue.

First policy (1971)

The first policy was a one-sentence statement in a book on care of the newborn that stated:

“	There are no valid medical indications for circumcision in the neonatal period.

The policy cited the 1970 landmark paper by E. Noel Preston as its authority.

Second policy (1975)

The simple 1971 statement that dismissed non-therapeutic circumcision as a medical procedure did not sit well with the AAP, so efforts were made to walk back that statement. An "ad hoc" task force of four male physicians was formed to develop a new statement that was released in 1975. The new statement attempted to shift responsibility and legal liability from the physician to the parents. The statement claimed that "traditional, cultural, and religious factors" could be considered in making a decision to perform non-therapeutic circumcision upon a boy. The statement did not recognize the boy as a person with human and legal rights to bodily integrity and security of the person, nor did it consider pain control. There was no mention of the numerous functions of the foreskin or of risks and complications of circumcision. The statement contained not a single reference. The result was that medically-unnecessary, non-therapeutic circumcision could still be performed and doctors could continue to profit thereby and anesthesia for surgical pain was not required.

Third policy (1989)

The 1975 policy was considered outmoded so a new "task force on circumcision" with circumcision promoter Edgar J. Schoen as chairman was formed. It is believed that five of the six members of the task force, or 83 percent, were Jewish and none had an intact foreskin.

This statement claimed for the first time that "potential" medical benefits exist. One should understand that potential means to be [c]apable of being but not yet in existence; latent or undeveloped, therefore the use of the word potential means the medical benefits discussed do not actually exist. The use of the word potential may be misleading to parents.

This statement acknowledged that infants feel pain but minimized the effects of pain and declined to recommend the use of analgesia or anesthesia for foreskin amputation.

Based on methodologically flawed studies by circumcision promoter Thomas E. Wiswell, the statement falsely claimed a reduction in the incidence of urinary tract infection (UTI) could be obtained by non-therapeutic infant circumcision.

The statement does not recognize baby boys as human beings with rights that should be respected.

Although the 1989 statement speaks favorably about non-therapeutic circumcision of infant boys, a careful reading shows that it does not actually recommend circumcision, perhaps for avoidance of legal liability.

The statement was not well received. Professor Ronald L. Poland, a member of the task force, published a dissent in the New England Journal of Medicine.

Statement on medical ethics

The Committee on Bioethics of the AAP issued a statement on bioethics and consent in 1995 that has caused great difficulty for the promoters of male non-therapeutic circumcision of non-consenting infants at the AAP. The statement provides in part:

“

We now realize that the doctrine of "informed consent" has only limited direct application in pediatrics. Only patients who have appropriate decisional capacity and legal empowerment can give their informed consent to medical care. In all other situations, parents or other surrogates provide informed permission for diagnosis and treatment of children with the assent of the child whenever appropriate.

Non-therapeutic circumcision of children is neither diagnosis nor treatment, so the statement means that parents do not have a right to consent to non-therapeutic circumcision of children. This has caused problems for future advocates of male non-therapeutic circumcision at the AAP, so they have adopted a work-around policy. Future statements regarding male non-therapeutic circumcision resorted to citing a non-germane statement on the medical ethics of sick and dying children. Non-therapeutic circumcision of children, however, is performed only on healthy children who can withstand the pain, trauma, and stress of the amputation.

Fourth policy (1999)

The American Academy of Pediatrics had been acutely embarrassed by the faults of Edgar Schoen's horrific circumcision policy statement, so a new task force was convened under the direction of Carole Marie Lannon, M.D., M.P.H., to produce a new, more appropriate, and less embarrassing policy statement on non-therapeutic child circumcision which was published in Pediatrics in September 1999.

The AAP asserted in their 1999 Circumcision Policy Statement that parents have a right to decide to circumcise their children based on cultural or religious factors (although they removed any mention of esthetics as a possible parental motivation, despite previous inclusion in their 1989 statement). No further substantiation of this right was offered. Whether or not a medical benefit was required for parents to make this choice was also not addressed.

The following statement appeared in its 1999 Policy Statement:

“

In the pluralistic society of the United States in which parents are afforded wide authority for determining what constitutes appropriate child-rearing and child welfare, it is legitimate for the parents to take into account cultural, religious, and ethnic traditions, in addition to medical factors, when making this choice.(119) – Committee on Bioethics (1999 AAP Circumcision Policy Statement (re-affirmed 2005))

The above sentence cited Caring for Gravely Ill Children as its source. The Fleishman article addresses the ethics of caring for gravely ill and dying children. The pain of circumcision is very stressful, so it is performed only on babies who are stable and healthy. It is totally irrelevant to the care and non-therapeutic circumcision of well-babies. That document says the following, which the AAP's "hands-off" position on circumcision might contradict:

“

This patient-centered "best interest" standard, which has been accepted by a broad spectrum of groups and commentators, [n9,n10] emphasizes that children ought to be valued as individuals and protects children in situations involving conflict between what is best for the child and what is best for the family or society. (Caring for Gravely Ill Children (1994))

The AAP 1999 Policy Statement also includes this statement on informed consent:

“

The process of informed consent obligates the physician to explain any procedure or treatment and to enumerate the risks, benefits, and alternatives for the patient to make an informed choice. For infants and young children who lack the capacity to decide for themselves, a surrogate, generally a parent, must make such choice.(118) (1999 AAP Circumcision Policy Statement (re-affirmed 2005))

The above sentences cited informed consent, Parental Permission, and Assent in Pediatric Practice, a policy guide by AAP's Bio-ethics Committee. However, those sentences appear to contradict the document they cited, which says:

“

Such providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses. [...] the pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent. (AAP Committee on Bioethics - Informed Consent, Parental Permission, and Assent in Pediatric Practice)

That document also says:

“

A patient's reluctance or refusal to assent should also carry considerable weight when the proposed intervention is not essential to his or her welfare and/or can be deferred without substantial risk. (AAP Committee on Bioethics - Informed Consent, Parental Permission, and Assent in Pediatric Practice)

The AAP has no official position on whether a baby can refuse a procedure, nor does it specify if crying in pain counts as reluctance or refusal. However, they do write that a patient's discomfort should be taken into account, and that children should have the necessity of a procedure communicated to them. (It would follow that inability to do so means that proceeding with an intervention that could be harmlessly deferred constitutes needless violation of patient autonomy, or inadequate consent):

“

Although very young children may be unable to envision the future benefits of treatment that may justify its associated burdens (eg, pain, discomfort, and hospitalization), their perceptions of those burdens should not be ignored. [...] Regardless of the child's level of participation in planning care, he or she should be given as much control over the actual treatment as possible. (Caring for Gravely Ill Children (1994))

Fifth policy (2012)

Genesis

Several state Medicaid organizations had delisted medically-unnecessary, non-therapeutic male circumcision as a covered procedure, which caused alarm at the AAP. The corrupt World Health Organization (WHO), in a very poor and misguided decision in 2007, falsely claimed that male circumcision would reduce infection with human immunodeficiency virus (HIV). The AAP saw this as an opportunity to protect third-party payment for non-therapeutic circumcision.

The AAP allied itself with the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP) to produce a new circumcision policy that would claim a medical benefit. A new task force was named with Susan Blank, a Jewish doctor with pro-circumcision credentials, as chairwoman. The task force was an unusually large eight-member task force with an unusual constitution. It included:

• Ellen Buerk, M.D., representing the board of directors of the AAP.
• Michael Brady, M.D., an HIV specialist with pro-circumcision views.
• Waldemar Carlo, M.D., a specialist in the care of the newborn.
• Andrew Freedman, a Jewish urologist from Los Angeles who circumcised his own son on the kitchen table.
• Douglas Diekema, a pediatric medical ethicist.
• Lynne Maxwell, M.D., a pain control specialist.
• Steven Wegner, M.D., J.D., a medical insurance specialist, who evidently was appointed to the task force to preserve and protect third-party payment.

The addition of a member to represent the board of directors and an insurance specialist was most unusual and illustrates the importance that the administration of the AAP placed on preservation and protection of third-party payment.

The task force also included representatives from other pro-circumcision organizations:

• Charles LeBaron, M.D., representing the Centers for Disease Control and Prevention, where biased doctors had been working to produce a pro-circumcision policy since 2008
• Sabrina Craigo, M.D., representing the American College of Obstetricians and Gynecologists, whose fellows make extra money by performing non-therapeutic circumcision on newborn baby boys, although males are outside of their practice area.
• Lesley Atwood, M.D., representing the American Academy of Family Physicians. whose fellows also make extra money by performing non-therapeutic circumcision.

Discussion

The AAP, in association with ACOG and AAFP, issued a circumcision policy statement in 2012. That statement was heavily criticized by many due to its obvious bias toward obtaining and preserving third-party payment for non-therapeutic child circumcision.

The AAP policy regarding its statements is to give each statement a five-year life, after which the statement expires unless it is reaffirmed. The 2012 Circumcision Policy Statement has not been reaffirmed, so it expired in 2017. As of 2023, the AAP has had no official circumcision policy for six years, although it misleadingly continues to publish its long expired policy on its website.

Although the patients of the fellows of the AAP are children, the AAP consistently has failed to acknowledge the human rights of its child patients.

From the Wikipedia:

"In a 2012 position statement, the Academy stated that a systematic evaluation of the medical literature shows that the "preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure" and that the health benefits "are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns," but "are not great enough to recommend routine circumcision for all male newborns". The Academy takes the position that parents should make the final decision about circumcision, after appropriate information is gathered about the risks and benefits of the procedure. By doing this, the AAP attempts to shift the liability for the certain injury of child non-therapeutic circumcision from the doctor to the parents.

The 2012 statement is a shift in the Academy's position from its 1999 statement in that the Academy now says the health benefits of the procedure outweigh the risks, and supports having the procedure covered by insurance. The 2012 position statement is an obvious effort to preserve third-party payment to physicians, without which most non-therapeutic circumcisions would not be done.

Criticism

After the release of the position statement, there was a substantial immediate critical comment by Brian Earp.

• Earp BD. The AAP report on circumcision: bad science + bad ethics = bad medicine. Practical Ethics. 2012; Retrieved 25 December 2020.

Shorty thereafter a debate appeared in the journal Pediatrics and the Journal of Medical Ethics between the AAP and an ad-hoc group of Western doctors, ethicists and lawyers, who questioned the evidence and ethics of the AAP position statement, and accused the AAP of "cultural bias".

• Svoboda JS, Van Howe RS. Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision. J Med Eth (Published online first). 13 March 2013; 39(7): 434-41. PMID. DOI. Retrieved 16 April 2020.

• Hill, George: Commentary on American Academy of Pediatrics 2012 Circumcision Policy Statemeni , Doctors Opposing Circumcision (D.O.C.). (1 April 2013). Retrieved 16 April 2020.

• In 2013, international physicians protested against American Academy of Pediatrics’ policy on infant male circumcision. This protest was organized by Morten Frisch and led to an article in Pediatics, signed by an international group of 38 physicians from 16 European countries.

The AAP received further criticism from activist groups that oppose circumcision."

• Darby R. Risks, Benefits, Complications and Harms: Neglected Factors in the Current Debate on Non-Therapeutic Circumcision. Kennedy Institute of Ethics Journal. April 2015; 25(1): 1-34. PMID. DOI. Retrieved 16 April 2020.

From IntactWiki

The American Academy of Pediatrics (AAP) currently advises parents on its "Healthy Children" website that "The existing scientific evidence is not sufficient to recommend routine (non-therapeutic) circumcision. Be that as it may, they still say that they "...recommend that the decision to circumcise is one best made by parents in consultation with their pediatrician." While not recommending circumcision, the AAP shirks responsibility by refusing to take a clear stand and state anything more directly negative than saying "the scientific evidence is not sufficient to recommend." The evidence, of which there is not enough for the AAP to come to a concrete conclusion, must apparently still be considered by parents, placing them in the awkward position of doing what the AAP could not do. Many view the AAP's policy as a "cover your ass" move: an awkward attempt shield itself and its members (doctors), from possible future legal repercussions, by distancing them as far as possible from any ethical considerations in the decision of parents to circumcise (while allowing its members to continue profiting from the procedure).

The current text was drafted in 2014. It is based on the 2012 Circumcision Policy Statement which is discredited and has now expired.

An annotated version is now available.

AAP‘s pamphlet on intact care

• 1984 - The AAP's pamphlet on intact care stated:

The function of the foreskin and the glans at birth is delicate and easily irritated by urine and feces. The foreskin shields the glans. With circumcision this protection is lost. In such cases, the glans and especially the urinary opening (meatus) may become irritated or infected, causing ulcers, meatitis (inflammation of the meatus) and meatal stenosis (a narrowing of the urinary opening.) Such problems virtually never occur in uncircumcised penises. The foreskin protects the glans throughout life.

• 1990 - The AAP removed the above with no explanation.

The AAP and premature forcible retraction of the foreskin

It is now self-evident that many, perhaps most, of America's child care doctors, including pediatricians and family doctors, do not know how to care of a boy's intact penis. The foreskin an an infant boy is non-retractable by design. An attempt to forcibly retract a non-retractable foreskin of a boy can only lead to a painful injury to the boy. There are frequent reports of attempts by ignorant physicians to retract a boy's non-retractile foreskin.

The AAP is the nation's leading child care organization, but it has taken no action to educate its pediatrician members and other doctors on the proper care of the infant foreskin, so as to avoid iatrogenic injury of boys.

American Academy of Pediatrics Lawsuit

A major lawsuit was filed on February 5th, 2021 against the American Academy of Pediatrics and Princeton Medical Group alleging constructive and intentional fraud around a botched circumcision.

• The AAP had a number of undisclosed biases, including a financial bias, and made false claims in their 1989 Report of the Task Force on Circumcision Guidance.
• This Guidance induced the Plaintiffs to provide consent for circumcisions without all of the necessary medical facts and information to make an informed decision, which the AAP has a fiduciary obligation to provide.
• The AAP owes a duty to the general public, including the Plaintiffs, to tell the truth, the whole truth and nothing but the truth when issuing reports, policy statements, and guidelines for medical care and procedures.

Removal to Federal Court

This lawsuit by the Lavine family, which alleges fraud, has been removed from the New Jersey state court to the United States District for New Jersey based on "diversity of citizenship". The case number is 3:21-CV-17099. The presiding judge is Zahid N. Quraishi.

Comment

Giannetti (2000) argues that scientific misconduct in the American Academy of Pediatrics circumcision policy statements should expose the AAP to trade association liability.

The AAP's difficulties with a child circumcision policy are largely of its own doing. The AAP continues to put its members' financial well-being ahead of the human rights and well-being of its child patients, which it does by omission of significant information and distortion of the medical facts in its numerous circumcision policy statements. Medical societies outside of the United States are in near total disagreement with the AAP and its American allies with regard to non-therapeutic child circumcision.

Although the AAP speaks very highly of non-therapeutic circumcision, a close reading indicates that it has never made an actual overt recommendation for circumcision, probably because its lawyers forbid it. Nevertheless, a suit has been filed against the AAP that alleges fraud in its circumcision statements.

See also

• AAP Circumcision Task Force 2012
• AAFP
• ACOG
• Circumcision study flaws
• Financial incentive
• Penis
• Position statements on infant circumcision
• United States of America

External links

• (2016). AAP waves white flag as Vikings storm fortress circumcision, Circinfo.org. Retrieved 31 December 2019.
• Chapin, Georgeanne (7 March 2017). Calling the American Academy of Pediatrics to Account, Intact America. Retrieved 2 April 2021.
• AAP.org - American Academy of Pediatrics (Official Website)