Changes

The expired American Academy of Pediatrics (AAP) position statement on male circumcision (2012) has attracted significant critical commentduring its brief life, including from the AAP itself.

}}</ref> They attribute this to cultural bias since non-therapeutic male circumcision is prevalent in the United States. They also criticized the strength of the health benefits the statement had claimed, such as protection from [[HIV]] and other STIs.<ref name="frisch2013"/> The American Academy of Pediatrics responded that because about half of American males are [[circumcised ]] and half are not, there may be a more tolerant view concerning circumcision in the US, but that if there is any cultural “bias” among the AAP task force who wrote the Circumcision Policy statement, it is much less important than the bias Frisch et al. may hold because of clear prejudices against the practice that can be found in Europe. The AAP elaborately explained why they reached conclusions regarding the health benefits of circumcision that are different from the ones reached by some of their European counterparts.<ref>{{REFjournal

The Committee on Medical Ethics of the [[British Medical Association ]] (2003) published a paper to guide doctors on the law and ethics of circumcision. It advises medical doctors to proceed on a case by case basis to determine the best interests of the child before deciding to perform a circumcision. The doctor must consider the child's legal and [[human rights]] in making his or her determination. It states that a physician has a right to refuse to perform a non-therapeutic circumcision.<ref name="bma2006"/> The College of Physicians and Surgeons of British Columbia took a similar position.<ref name="cpsbc">{{REFweb

Fox and Thomson (2005) state that in the absence of "unequivocal evidence of medical benefit", it is "ethically inappropriate to subject a child to the acknowledged risks of infant male circumcision." Thus, they believe, "the emerging consensus, whereby parental choice holds sway, appears ethically indefensible".<ref name="fox-thomson"/> <!--[[Brian J. Morris|Morris]] et al. (2014) argued that "...failure to circumcise a baby boy may be unethical because it diminishes his right to good health."<ref>{{REFjournal |last=MorrisFox |init=BJ |authorlink=Brian J. MorrisM |last2=BailisThomson |init2=SA |last3=Wiswell |init3=TEM |title=Circumcision rates in A covenant with the United States: rising or fallingstatus quo? What effect might Male circumcision and the new affirmative pediatric policy statement have?BMA guidance to doctors |journal=Mayo Clinic ProceedingsJournal of Medical Ethics |date=2014-052005 |volume=8931 |issue=58 |pages=677463-686469 |url=http://jme.bmj.com/content/31/8/463.full |DOI=10.10161136/j.mayocp.2014jme.012004.001009340 |pubmedID=2470273516076971 |pubmedCID=1734197}}</ref>-->

}}</ref> The process is irreversible, has no medical justification in most cases, and is performed on minors unable to give their own permission, according to the committee. Paul Schotsmans of the {{UNI|University of Leuven|UCLouvain}}, on behalf of the committee, noted "the child’s right to physical integrity, which is protected by the Convention on the Rights of the Child, and in particular its protection from physical injury."<ref name="bulletin2017"/> The Belgian minister of health replied that the federal institute Federal Institute for health insurance Health Insurance cannot check and know whether in (individual cases) a circumcision is medically justified or not and that she will continue to reimburse circumcision of minors as the safety of the child is her primary concern and she wants to avoid botched circumcisions by non-medical circumcisers.<!--<ref>{{REFweb |url=https://www.standaard.be/cnt/dmf20170920_03084394 |title=De Block blijft besnijdenis terugbetalen |last=Vergauwen |first=Eveline |website=De Standaard |language=nl-BE |access-date=2019-06-14}}</ref>--><!--==HIV in southern and eastern Africa=={{Main|Circumcision and HIV}} Rennie et al. (2007) remark that the results of three randomised controlled trials in sub-Saharan Africa, showing reduced risk of [[HIV]] among circumcised men, "alter the terms of the debate over the ethics of male circumcision."<ref name="rennie2007">{{REFjournal |last=Rennie |first=Stuart |init=S |authorlink= |last2=Muula |first2=Adamson S. |init2=AS |last3=Westreich |first3=Daniel |init3=D |date=2007-06 |title=Male circumcision and HIV prevention: ethical, medical and public health tradeoffs in low-income countries |journal=Journal of Medical Ethics |volume=33 |issue=6 |pages=357-361 |pubmedID=17526688 |url=http://jme.bmj.com/cgi/content/full/33/6/357 |accessdate= |pubmedCID=2598273 |quote= |DOI=10.1136/jme.2006.019901}}</ref> However, the methodology of the African RCTs has been severely criticised, thereby invalidating claims that circumcision reduces the sexual transmission of [[HIV]].<ref>{{REFbook |last=Boyle |first=Gregory J. |init=GJ |author-link=Gregory Boyle |year=2013 |chapter=Critique of African RCTs into Male Circumcision and HIV Sexual Transmission. |editors=[[George C. Denniston]], [[Frederick M. Hodges]], [[Marilyn Fayre Milos]] |title=Genital Cutting: Protecting Children from Medical, Cultural, and Religious Infringements |location=Dordrecht, The Netherlands |publisher=Springer Science+Business Media |DOI=10.1007/978-94-007-6407-1_15 |isbn=978-94-007-6406-4}}</ref> Supporters of circumcision argue that using circumcision and other available means to halt the spread of [[HIV]] is in the common good (but overlook the fact that [[HIV]] is transmitted in the seminal fluid). Rennie et al. argue that "it would be unethical to not seriously consider one of the most promising—although also one of the most controversial—new approaches to [[HIV]]-prevention in the 25-year history of the epidemic."<ref name="rennie"/> However, there clearly remains a risk of transmitting or acquiring [[HIV]] while engaging in unprotected sex and other high risk behaviors (circumcised or not). The [[World Health Organization]] (2007) states that provision of circumcision should be consistent with "medical ethics and [[human rights]] principles." They state that "[i]nformed consent, confidentiality and absence of coercion should be assured. ... Parents who are responsible for providing consent, including for the circumcision of male infants, should be given sufficient information regarding the benefits and risks of the procedure in order to determine what is in the best interests of the child."<ref>WHO/UNAIDS Technical Consultation. [http://www.who.int/entity/hiv/mediacentre/MCrecommendations_en.pdf Male Circumcision and [[HIV]] Prevention: Research Implications for Policy and Programming]. Montreux, 6–8 March 2007</ref> However, since babies and children are not sexually active, sexually-transmitted [[HIV]] infection is not a relevant concern. Critics of non-therapeutic circumcision argue that advocating circumcision to prevent [[HIV]] infection may detract from other efforts to prevent the spread of the virus such as using condoms. If the adult chooses to remain celibate or if a couple remain monogamous, or if [[HIV]] is eliminated by the time the child is an adult, the sexual reduction surgery would not have been needed. Moreover, they argue that circumcising a child purportedly to partially protect him from [[HIV]] infection in adulthood may be seen as granting permission to engage in dangerous sexual practices. Obviously baby boys do not need such protection and can choose for themselves as consenting adults if they want a circumcision.<ref name="Somerville"/> This stance, however, does not take into account the fact that adult men may already have contracted [[HIV]] before getting circumcised.<ref>{{REFjournal |last=Harmon |first=Katherine |init=K |title=Can male circumcision stem the AIDS epidemic in Africa? |url=http://www.nature.com/news/can-male-circumcision-stem-the-aids-epidemic-in-africa-1.9520 |journal=Nature News |language=en |DOI=10.1038/nature.2011.9520 |date=2011}}</ref> The UK National Health Service ([[NHS]]) has stated that the African studies have "important implications for the control of sexually transmitted infections in Africa", but that in the United Kingdom practising safe sex including condom use is the best way to prevent sexually-transmitted disease when having sex.<ref>{{REFweb |url=https://www.nhs.uk/news/lifestyle-and-exercise/circumcision-and-stis/ |title=Circumcision and STIs |date=2009-03-26}}</ref>-->

}}</ref> Some believe that consent Consent for a non-therapeutic operation offends the principle of autonomy, when granted by a surrogate.

There is was an unresolved question whether surrogates may grant effective consent for non-therapeutic child circumcision.<ref name="povenmire">{{REFjournal

}}</ref> <ref name="conundrum"/><ref name="Adler">{{REFjournal |last=Adler |first=Peter W. |init=PW |author-link=Peter W. Adler |url=http://rjolpi.richmond.edu/archive/Adler_Formatted.pdf |title=Is Circumcision Legal? |volume=16 |issue=3 |journal=Richmond J. L. & Pub. Int. |page=439 |date=2013}}</ref> Richards (1996) argues that parents may only consent to medical care, so are not empowered to grant consent for non-therapeutic circumcision of a child because it is not medical care.<ref name="richards">{{REFjournal

}}</ref> <!--The Canadian Paediatric Society (2015) recommends that circumcisions done in the absence of a [[medical indication]] or for personal reasons "should be deferred until the individual concerned is able to make their own choices."<ref name="CPS2015">{{REFjournal |last=Sorakan |init=ST |last2=Finlay |init2=JC |last3=Jefferies |init3=AL |title=Newborn male circumcision |journal=Paediatr Child Health |date=2015 |volume=20 |issue=6 |pages=311-315 |url=http://www.cps.ca/en/documents/position/circumcision |pubmedID=26435672 |pubmedCID=4578472}}</ref>-->

Regardless of these issues, the unethical general practice of the medical community in the United States is to receive surrogate informed consent or permission from parents or legal guardians for non-therapeutic circumcision of children.<ref name="bma2006povenmire"/><ref name="povenmireconundrum"/>

== The emerging consensus on surrogate consent for non-therapeutic newborn, infant, and child circumcision ==The power of parents and other surrogates to grant consent is dependent upon the existence of a physical or medical condition in a minor child that requires diagnostic and/or treatment.<ref name="richards"/> <ref name="aap1995">{{REFjournal |last=Committee on Bioethics |etal=no |title=Informed consent, parental permission, and assent in pediatric practice |trans-title= |language= |journal=Pediatrics |location= |date=1995-02 |volume=95 |issue=2 |article= |page= |pages=314-7 |url=http://www.cirp.org/library/ethics/AAP/ |archived= |quote= |pubmedID=7838658 |pubmedCID= |DOI= |accessdate=2023-05-26}}</ref> The right to grant surrogate consent cannot exist in the absence of such a condition. The AAP Committee on Bioethics (2016) now states: "A parent’s authority is not absolute but constrained by respect for the child."<ref name="aviva2016">{{REFjournal |last=Committee on Bioethics |etal-no |title=Informed Consent in Decision-Making in Pediatric Practice |trans-title= |language= |journal=Pediatrics |location= |date=2016-08 |volume=138 |issue=2 |article= |page=e20161484. |pages= |url=https://publications.aap.org/pediatrics/article/138/2/e20161484/52512/Informed-Consent-in-Decision-Making-in-Pediatric?autologincheck=redirected |archived= |quote= |pubmedID=27456514 |pubmedCID= |DOI= |doi=10.1542/peds.2016-1484 |accessdate=2023-05-27}}</ref> This may mean that the AAP now recognizes the child as a person with legal rights of his/her own. Boys are born with a healthy [[foreskin]] that is free of disease. There are no medical indications for a neonatal [[circumcision]]. The [[medical trade association| medical trade associations]] and other promoters have put forward various alleged benefits from neonatal circumcision for decades to develop business for their physican-members. The validity of surrogate consent for non-therapeutic circumcision of boys has been questioned for decades.<ref name="povenmire"/> <ref name="richards" /> <ref name="hill2003">{{REFjournal |last=Hill |first= |init=G |author-link=George Hill |title=Can anyone authorize the nontherapeutic permanent alteration of a child's body? |journal=The American Journal of Bioethics |date=2003 |volume=3 |issue=2 |pages=16-8 |url=https://www.researchgate.net/profile/George-Hill-3/publication/371599857_Can_Anyone_Authorize_the_Nontherapeutic_Permanent_Alteration_of_a_Child's_Body/links/648b8819c41fb852dd0949be/Can-Anyone-Authorize-the-Nontherapeutic-Permanent-Alteration-of-a-Childs-Body.pdf |quote= |pubmedID=14635628 |pubmedCID= |DOI=10.1162/152651603766436342 |format=PDF |accessdate=2023-07-11}}</ref> Bioethicists Myers & Earp (2020) exhaustively reviewed the evidence for and against the alleged health benefits to a healthy person claimed for non-therapeutic circumcision of a neonate, infant or child. They balanced this against the [[pain]], [[trauma]], and loss of body tissue and function. They concluded the claimed health benefits are insufficient to support surrogate consent for non-therapeutic circumcision. Given this, only the subject can grant consent for a non-therapeutic circumcision, after he reaches the right age for circumcision, which does not occurs until a male reaches the age of consent in his jurisdiction which may vary from 16 to 18 years of age. The present practice in the [[United States]] and elsewhere of parental consent for non-therapeutic circumcision is entirely unethical.<ref name="myers2020">{{REFjournal |last=Myers |first= |init=A |author-link=Alex Myers |last2=Earp |first2= |init2=BD |author2-link=Brian D. Earp |etal=no |title=What is the best age to circumcise? A medical and ethical analysis |trans-title= |language= |journal= Bioethics |location= |date=2020 |volume=34 |issue=7 |pages=645-63 |url=https://www.researchgate.net/profile/Brian-Earp-2/publication/337720859_What_Is_the_Best_Age_to_Circumcise_A_Medical_and_Ethical_Analysis/links/5f815f61a6fdccfd7b555395/What-Is-the-Best-Age-to-Circumcise-A-Medical-and-Ethical-Analysis.pdf |archived= |quote=Based on a careful consideration of the relevant evidence, arguments and counterarguments, we conclude that medically unnecessary penile circumcision-like other medically unnecessary genital procedures, such as 'cosmetic' labiaplasty-should not be performed on individuals who are too young (or otherwise unable) to provide meaningful consent to the procedure. |pubmedID=32068898 |pubmedCID= |DOI= |doi=10.1111/bioe.12714 |format=PDF |accessdate=2020-05-27}}</ref> Moreover, non-therapeutic circumcision of boys may also be unlawful,<ref name="Adler">{{REFjournal |last=Adler |first=Peter W. |init=PW |author-link=Peter W. Adler |url=http://rjolpi.richmond.edu/archive/Adler_Formatted.pdf |title=Is Circumcision Legal? |volume=16 |issue=3 |journal=Richmond J. L. & Pub. Int. |page=439 |date=2013}}</ref> if a court should accept Adler's arguments. ==Observations==

|quote=As they the saying goes, follow the money. Now you know why neither the [[American Academy of Pediatrics]], American Medical Association, [[American Academy of Family Physicians]], or the [[American Congress of Obstetricians and Gynecologists| American College of Obstetricians and Gynecologists]] haven’t condemned this unnecessary surgery, and why their physician members are quick to recommend the procedure to expectant parents.}}</ref> [[Third-party payment]] is a major support to the performance of this medically-unnecessary surgery. If parents could not grant consent for non-therapeutic circumcision, then no one could grant consent for the non-therapeutic circumcision of a child, so the $2 billion annual business would collapse. The American [[Medical trade association| medical trade associations]], more than those of other nations, have been unwilling to recognize the child's right to bodily [[physical integrity]], to security of the person, and the right to personal autonomy. 

|accessdate=2023-05-27}}</ref></ref>