American Academy of Pediatrics

Emblem of the American Academy of Pediatrics

The American Academy of Pediatrics (AAP) is a 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.

Contents

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 one of its task forces, so personal knowledge and understanding of a normal body part has been lacking on its various task forces, perhaps believing 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.

Second policy (1975)

The simple 1971 statement that dismissed 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, 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-unecessary, non-therapeutic circumcision could still be performed and doctors could continue to profit thereby and anesthesia for surgery 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.

This statement claimed for the first time that "potential medical benefits exist. One should understand that potential means to Capable 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 on 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 Poland, a member of the task force published a dissent in the New England Journal of Medicine.

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, MD, MPH, to produce a new, more appropriate, and less embarrassing policy statement on non-therapeutic child circumcision.

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. 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 might follow that inability to do so means that proceeding with an intervention that could be harmlessly deferred constitutes needless violation of 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 World Health Organization (WHO), in a very poor and misguided decision in 2007, 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 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, MD, representing the board of directors of the AAP.
• Michael Brady, MD, a HIV specialist with pro-circumcision views.
• Waldemar Carlo, MD, 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, MD, a pain control specialist.
• Steven Wegner, MD, JD, 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, MD, representing the Centers for Disease Control and Prevention, where biased doctors had been working to produce a pro-circumcision policy since 2008.
• Sabrina Craigo, MD, representing the American College of Obstetricians and Gynecologists, whose fellows make extra money by performing non-therapeutic circumcisions on newborn baby boys.
• Lesley Atwood, MD, 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 2020, the AAP has had no official circumcision policy for three years.

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, 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, J. Steven, Van Howe, Robert S.. 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.

• Commentary on American Academy of Pediatrics 2012 Circumcision Policy Statemeni , Doctors Opposing Circumcision. (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, Robert. 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.

The AAP briefly endorses female genital cutting

On April 26, 2010, the AAP changed its long-held stance against female genital cutting. In their report, chiefly authored by Dena Davis, a professor at Cleveland-Marshall College of Law at Cleveland State University, the AAP advised doctors to inform families that the procedure is medically unnecessary and even dangerous. The AAP raised the idea of legalizing a less-severe ritual cutting, which they compared to an ear piercing, the reasoning being that female circumcision had symbolic or ceremonial aspects for many parents, and offering a "ritual nick" might dissuade parents that were resolute, from sending their daughters to their home countries, thereby avoiding greater harm. The AAP had deviated from a much more forceful statement published in 1998, which unequivocally condemned FGC in any form.

The Girls Protection Act, which would make it illegal to take a minor outside the U.S. to seek female circumcision, was introduced in Congress on the same day the AAP published its new recommendation. New York Representative Joseph Crowley, one of the bill's sponsors, condemned the AAP's move as "the wrong step forward on how best to protect young women and girls" by creating confusion about the acceptability of FGM in any form. Davis of the AAP countered that such a law would be difficult to enforce.

The AAP's endorsement of a "ritual nick" sparked a backlash which was swift and universally negative. The AAP's recommendation had been perceived by many as a tacit endorsement of the "ritual nick," and an effort to appease parents who threatened to subject their daughters to worse procedures. In short, the AAP was forced to retract its endorsement, and on May 1, Judith Palfrey, President of the AAP, released a statement that read in part, “the AAP does not endorse the practice of offering a ‘clitoral nick’. This minimal pinprick is forbidden under federal law and the AAP does not recommend it to its members”. Palfrey reiterated this stance in an interview with The Lancet, saying “we want to make it clear to the international community we are opposed to any form of female genital cutting, and that includes the ritual nick.” The AAP has since withdrawn the committee's report and is re-writing it completely.

The AAP wrote the following in their 2010 FGC Policy:

“

The American Academy of Pediatrics policy statement on newborn male circumcision expresses respect for parental decision-making and acknowledges the legitimacy of including cultural, religious, and ethnic traditions when making the choice of whether to surgically alter a male infant's genitals.(119) – Committee on Bioethics (AAP Policy Statement on Ritual Genital Cutting of Female Minors (April, 2010).)

This was a segue into the following sentence:

“	But parental rights have limits -- FGC is damaging so it should be disallowed. But maybe we should change the law for the mild alterations.(119) – Committee on Bioethics (AAP Policy Statement on Ritual Genital Cutting of Female Minors (April, 2010).)

In other words, they were using the fact that MGM is accepted as an argument in favor of "milder" FGM.

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.

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 puts 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 from its numerous circumcision policy statements. Medical societies outside of the United States are in near total disagreement with the AAP and its 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 their lawyers forbid it.

See also

• AAP Circumcision Task Force 2012
• Circumcision study flaws

External links

• (2016). AAP waves white flag as Vikings storm fortress circumcision, Circinfo.org. Retrieved 31 December 2019.

• AAP.org - American Academy of Pediatrics (Official Website)