Sunday, March 31, 2013

TU QUOQUE: The AAP Fends Off Accusations of Bias

I knew that sooner or later there would be backlash against the AAP for publishing such a shallow, poorly written, poorly argued, self-serving position statement on circumcision, because despite not arriving at the recommendation many were hoping for, the AAP took an unfounded position against the best medical authorities in the West.

What struck me as odd was that, out of all the other international journals they could have chosen, non-American medical authorities would seek to publish their joint statement in the publication of the pediatric association, whose policy on circumcision they were going to openly reject, and that the publication, Pediatrics, would actually agree to publish such a statement.

Perhaps the AAP agreed because they wanted the opportunity to be the first to respond? It certainly gave them the power to publish the article conveniently after the Bundestag issued its ruling to exempt forced male circumcision from German Common Law, and it certainly gave them enough time to try and think up a response in their defense.

The international article rejecting the latest AAP position statement on circumcision has been published in Pediatrics, along with a response from the so called "circumcision task force" at the AAP, and I'd have to say, I'm not sure if it's better, or worse than their original position statement and technical report. I've read it, and it only seems to serve to highlight and reiterate their bias, willful myopia, and their arrogant intent on contradicting the rest of modern medicine.

(The AAP "task force" comeback response can be read in full here.)

I've taken the liberty take apart the AAP's response on my blog.

Let's begin...

Skipping ahead of the formalities:

"The central claim of these authors is that the conclusions of the task force report are culturally biased, leading the task force to a flawed understanding of what constitutes trustworthy evidence and to conclusions that are far from those reached by physicians in most other Western countries. The "obvious" cultural bias to which they refer apparently has its genesis in "the normality of non-therapeutic male circumcision in the US."

So far so good.

Watch how they respond:

"All of the commentary authors hail from Europe, where the vast majority of men are uncircumcised and the cultural norm clearly favors the uncircumcised penis."

Notice how the corresponding author acts as if having anatomically correct genitalia were some sort of "cultural norm" as having been circumcised; as if men were born circumcised from the womb, and European doctors were going around sewing foreskins onto the penises of newborns.

The AAP is engaging in a logical fallacy known as "tu quoque," commonly known as "appeal to hypocrisy," or "you're another." In other words, they are trying to dismiss the position against them, based on the claim that the other party is being inconsistent. The claim of hypocrisy may or may not be true, but even if it is, it does not discredit another party's position.

To add to their logical fallacy, the "task force" tries to paint itself as "impartial" and "dispassionate," by presenting a false reality regarding the status of circumcision in the United States:

"In contrast, approximately half of US males are circumcised, and half are not."

The AAP "taskforce" is either trying to deliberately lie about the number of circumcised adult males in the US, or it is really that incompetent so as to conflate infant circumcision rates with circumcision prevalence amongst adult American men.

The rate of infant circumcision, according to the CDC, in the US is 56% and falling. According a chart in the AAP's very own policy statement, however, 80% of all adult males in the US are circumcised from birth.

"Although that heterogeneity may lead to a more tolerant view toward circumcision in the United States than in Europe, the cultural "bias" in the United States is much more likely to be a neutral one than that found in Europe, where there is a clear bias against circumcision."

A "heterogeniety" that does not exist.

Far from "tolerant," or "neutral," the view of circumcision in the United State is one such that it is to be expected.

Circumcision in the US is "normal" or "ordinary," while having anatomically correct genitals is seen as "weird," "dirty" or "disgusting." American textbooks rarely show the anatomically correct male organ with a foreskin, as it should, and the foreskin is often described as "an extra flap of skin that covers the head of the penis, which is usually removed by circumcision." When a child is born, even if a parent hasn't given circumcision much thought, physicians and/or nurses are sure to bring it up, and remind parents that unless their son is circumcised, he will be made fun of in the locker room, and be rejected by potential sex partners.

In contrast, in Europe, and pretty much the rest of the world, the default position is to simply do nothing. Circumcision is treated like any other surgery, being administered as the necessity for it arises, where all other methods of treatment have been exhausted.

This isn't any kind of "bias" as it is standard medical practice for every other surgical procedure.

Having a foreskin is not the result of some peculiar European custom of sewing a fold of flesh onto the penises of children at birth, and European countries don't have any sort of special "Foreskin Task Force" producing reports every number of years on why having a foreskin is a good thing.

"Yet, the commentary's authors have, at no point, recognized that their own cultural bias may exist in equal, if not greater, measure than any cultural bias that might exist among the members of the AAP Task Force on Circumcision."

If applying the same standard of care to all therapeutic surgery can actually be called a "cultural bias."

The European authors make a clear case:

"It is commonly accepted that medical procedures always need to be justified because of their invasive nature and possible damaging effects. Preventive medical procedures need more and stricter justification than do therapeutic medical procedures, as they are aimed at people who are generally free of medical problems. Even stricter criteria apply for preventive medical procedures in children, who cannot weigh the evidence themselves and cannot legally consent to the procedure.

The most important criteria for the justification of medical procedures are necessity, cost-effectiveness, subsidiarity, proportionality, and consent. For preventive medical procedures, this means that the procedure must effectively lead to the prevention of a serious medical problem, that there is no less intrusive means of reaching the same goal, and that the risks of the procedure are proportional to the intended benefit. In addition, when performed in childhood, it needs to be clearly demonstrated that it is essential to perform the procedure before an age at which the individual can make a decision about the procedure for him or herself."

This isn't "bias" as it is standard medical practice for any other surgery, and the correct ethical stance.

The bias of the AAP is clearly tilted toward cutting children unnecessarily.

The AAP "task force" continues:

"If cultural bias influences the review of available evidence, then a culture that is comfortable with both the circumcised penis and the uncircumcised penis would seem predisposed to a more dispassionate analysis of the scientific literature than a culture with a bias that is either strongly opposed to circumcision or strongly in favor of it."

That is, if viewing the circumcised penis as a given, and the foreskin as a congenital birth defect that must be removed immediately can be called "comfortable."

The AAP is engaging in both logical fallacies of "division" and "construction"; first, they attempt to paint a false American reality. And then, they seem to imply that, as part of this American reality where people are "comfortable" with anatomically correct genitals, they themselves espouse these (imagined) "neutral" views.

Let's assume for the sake of argument that American culture is "comfortable" with both circumcised and intact genitals. (Notice how they can't refer to the anatomically correct penis as anything other than "uncircumcised." Their bias is showing...)

What does this (false) reality tell us about the members of the "task force" themselves?

It's almost comical to watch the AAP "task force" ride on the airs of a false reality.

American culture is NOT "comfortable" with both the intact and shorn penis.

Americans are NOT predisposed to a more "dispassionate" analysis of the scientific literature, but to a more myopic one, searching for just the ones that justify circumcision, if not outright make it indispensable, and not just any circumcision, but particularly the forced circumcision of infants.

"The task force's process was systematic, objective, comprehensive, and transparently documented in its technical report."

Or so they claim. That they were not is at the crux of the argument.

So far, their response has been, "Yes we were. We're not biased, and if we were, you're more biased than us."

Apparently, favoring conservative methods of treatment and prevention over prioritizing surgical removal is a "cultural bias."

"Members of the AAP Task Force on Circumcision were recruited on the basis of area of expertise."

And wouldn't you have it, they are all "experts" on defending infant circumcision!

The very idea of a "task force on circumcision" is preposterous, as there isn't a "task force" for say, the removal of labia. The sole purpose of the AAP "task force" seems to be to preserve the American pseudo-medical practice of infant circumcision.

"There was no consideration or knowledge of the individuals' beliefs concerning circumcision at the time of their appointment."

And, to ensure that claims and conclusions actually be "neutral," "objective" and "dispassionate" (as if a "task force on circumcision" weren't conspicuous enough), there should have been.

It is generally well accepted that sources who seek to convince by a claim of authority or by personal observation need to be objective and impartial, and that an audience can only evaluate information from a source if they know about any conflicts of interest that may taint the objectivity of a source.

None of the AAP Task Force admits any ethical conflict of interest, although Susan Blank and Andrew Freedman are both Jewish, where circumcision is a heavily defended cultural value. Susan Blank is the chairperson for the "task force," and Andrew Freedman is a mohel who circumcised his own son on his parents' kitchen table. Douglas Diekema is not Jewish, but he has religious influence. He was the spokesperson for the AAP's Bioethics Committee that proposed to allow a token, "ritual nick much less extensive than neonatal male genital cutting" for girls, until public outrage forced them to back-pedal. Michael Brady is an outspoken advocate for infant circumcision. It is unknown which of the "task force" members have anatomically correct genitalia, or are spouses to men with anatomically correct genitals.

"Unlike other published policy statements and reports on circumcision, the task force did not selectively choose which articles to review, but reviewed all of the available literature identified in a comprehensive search and evaluated those manuscripts by using previously established, nationally recognized guidelines to determine the quality of the data being reviewed."

So they claim. This is what is in dispute.

38 pediatricians, urologists, epidemiologists, and professors, representing 20 medical organizations and 15 universities and hospitals in 17 countries are taking the AAP to task.

Is the 8 member "task force" on circumcision on the AAP the only group that is able to analyze medical data and come up with the "correct" interpretation?

They certainly seem to think so.

"Some articles were reviewed but not cited in the technical report, either because they were not data-based studies, the quality of the study was seriously flawed, or the findings of the study did not meaningfully address the specific area of task force inquiry."

That's interesting; that's not what the physicians in these other countries found...

"Frisch et al present opinions that reflect a review of the literature that is not comprehensive, systematic, or unbiased."

Frisch et al. are 38 different physicians from around the world.

But apparently, the 8 physicians from the AAP are the only physicians who can "get it right."

"For example, the authors dismiss the data related to urinary tract infection on the grounds that no randomized controlled trial has been performed, despite the fact that there is good evidence from other studies that suggest a preventive benefit of circumcision."

The authors don't seem to think what the AAP thinks is "good evidence" is actually "good evidence." Isn't there a problem when peer groups and physicians fail to find the same "benefit" from the same body of medical literature?

No. Only the AAP is capable of comprehensive evaluation.

"At the same time, they readily dismiss 3 randomized controlled trials and 11 other studies that provide good to fair evidence of a reduction in HIV acquisition associated with circumcision. They claim that these data are "contradicted by other studies, which show no relationship between HIV infection rates and circumcision status," yet support that claim with only a single reference to a review article authored by the vice president of an organization opposed to circumcision."

Perhaps because they, the 30 or so authors, deem the article to be itself well-referenced and researched?

Here, again, the AAP "task force" displays arrogance. They, and only they, are capable of comprehensive evaluation. While other groups deem the evidence the "task force" presents to be poor, they are not, by virtue that their members don't think so.

"We would refer the reader to the task force's technical report for a comprehensive review of the literature related to the potential benefits of circumcision."

Begging the question.

This "report," along with the AAP statement is precisely what is being challenged.

"Notably, the World Health Organization has concluded that the data strongly support a benefit of male circumcision with regard to prevention of HIV infection and has issued guidelines for its use, both for adults/adolescents and for neonates."

The AAP would have you believe that there is this world campaign to circumcise males in the name of HIV prevention.

Let's note that the same organization supports VOLUNTARY male circumcision with regard to the prevention of HIV prevention, in high-risk countries in AFRICA, and no where else.

Since the WHO began to promote circumcision as HIV transmission, using the so-called "trials" in Africa, the US is the only industrialized nation where physicians have been eager to promote infant circumcision for their population.

(Actually, the "mass circumcision campaigns" in Africa are being largely funded by American money.)

What is the reason the AAP is using "research" and "data" from Africa, and transplanting it to the US, where the situation is vastly different, as pointed out by Frisch et al?

"Frisch et al charge that members of the AAP Task Force on Circumcision "consider the foreskin to be a part of the male body that has no meaningful function in sexuality."

This is one claim,

"They additionally claim, "Recent studies... suggest that circumcision desensitizes the penis and may lead to sexual problems in circumcised men and their partners."

...and this is another.

And why do they discount the sexual value of the foreskin found by some studies?
"In fact, many of these studies were reviewed by members of the task force but were not cited in the technical report, either because the findings were equivocal, they did not support a benefit or detriment with regard to sexual function and pleasure, or because the relevance to individuals undergoing circumcision during infancy was questionable."

Notice the complete arrogance and bias in these rationale.

Obviously, physicians in other parts of the world didn't think that findings in the research the AAP "task force" failed to mention were "equivocal." Contrary to the AAP "task force," physicians in other parts of the world thought they were relevant with regard to sexual function and pleasure.

"[T]he relevance to individuals undergoing circumcision during infancy was questionable," the AAP says.

And the individuals not undergoing circumcision during infancy?

You know, the half of the AAP's imagined American male population who are "tolerated?"

This treatment of male genital organs as "circumcised by default," and the complete disregard for anatomically correct organs is what the AAP calls "neutral" and "dispassionate."

It should be interesting to the onlooking bystander how relevance of circumcision studies carried out in adults is suddenly an issue when it comes to the sensitivity studies of the AAP's choosing; this "relevance" is, apparently, not an issue when considering the African "trials" upon which their policy on *infant* circumcision is entirely based.

"For example, the authors cite 5 studies to support the claim that 'the foreskin is a richly innervated structure that protects the glans and plays an important role in the mechanical function of the penis during sexual acts.' Of these 5 studies, 4 were histologic studies that were not designed to correlate anatomic findings with physiologic or functional roles. Members of the task force appreciate that the foreskin has nerve fibers: the task force clearly recommends adequate pain control for infants undergoing circumcision."

In layman's terms, the AAP is forced to acknowledge that the foreskin has nerve fibers, because studies have found them. (Histologic refers to the study of tissues on the microscopic level.) But the only function of these nerves that they will "appreciate" is that of pain reception, for which they recommend pain control during a circumcision.

"However, the task force did not move beyond what these studies actually reveal (the foreskin has nerve bundles and pain fibers, the foreskin contains Meissner corpuscles, the inner surface of the foreskin resembles a mucous membrane) to speculate about the effect that circumcision might have on sexual function or pleasure."

The 38 European critics need not "speculate"; its male members or their male partners most probably have foreskins, and know first hand about the sensations they give. Perhaps the members of the AAP circumcision "task force" are unable to "appreciate" the sensations given and received by the foreskin, because they're all circumcised, or spouses to circumcised husbands.

One might mistake the members of the AAP circumcision "task force" for never having studied mucous membrane before; of course the inner foreskin resembles a mucus membrane, because it is one.

The lips, being another mucous membrane, also have nerve fibers and Meissner corpuscles which are sensitive to light touch, but no physician's first concern regarding them would be "how to minimize the pain of their removal." Nobody doubts that the nerves of the lips are intimately involved in the pleasure of kissing, to the point where "studies" are necessary to prove it.

To underline the AAP's biased cherry-picking further, readers may realize that, while the "task force" won't "move beyond histological studies to hypothesize about the functions of the structures of the foreskin," they did consider correlation studies performed on adult men in high-risk areas in AFRICA, as evidence that infant circumcision may prevent HIV transmission, even in the absence of a definite causal link.

"In sum, of the 5 studies, not one sought to evaluate whether the foreskin protects the glans or whether it "plays an important role in the mechanical function of the penis during sexual acts."

Argumentum ad ignorantiam.

In sum, while it looks like the AAP has finally been forced to acknowledge that the foreskin is laden with nerves, and that circumcision removes them, again, the only function that they will acknowledge is that of pain reception. They will continue to claim, out of willful ignorance, that they play absolutely no role in the mechanical function of the penis during sexual acts.

"The authors cite 2 articles as evidence that "circumcision desensitizes the penis." One of these is not a study and does not present data. The other revealed that perception sensitivity to vibration decreases after circumcision."

The study in question is the Sorrells study, which is the only study that actually attempted to measure the sensitivity of the foreskin itself, and the AAP ignores, both in its policy and in this response to its critics, its main finding; that male circumcision removes the most sensitive part of the penis.

"Finally, Frisch et al cite 7 studies to support their contention that circumcision may lead to sexual problems in circumcised men and their partners. Four of the studies involved only men circumcised as adults or some men circumcised as adults. Men circumcised as adults most frequently have the procedure performed for medical reasons, which introduces both physical and psychological factors that may affect their reporting of sexual difficulties."

Except that, in studies involving men who were circumcised to remedy a problem, the men usually report *positively.* Circumcision advocates often try to use such studies to try and make the case that circumcision improves sex (without mentioning the fact that the men circumcised in these studies were suffering abnormal problems).

The assumption here is that all of the men in these studies were in fact circumcised for medical reasons; adult men may get circumcised to satisfy the religious premarital requirements in their partners, or because they buy into pro-circumcision propaganda, such as the claims that circumcision prevents HIV and other STDs.

"In 2 of the studies cited by Frisch et al, a significant number of men reported improved satisfaction after circumcision."

The men in these studies may in fact be men circumcised due to medical reasons. But notice here, that the men reporting negatively are being dismissed; only those whose circumcision improved satisfaction seem to matter to the AAP "task force."

"Interestingly, another of their cited studies concluded that circumcision had neither a negative nor a positive effect on the female partner's perception of sexual satisfaction, a conclusion that contradicts that of Frisch et al."

ONE study. Again, here, the AAP attempts to draw attention away from male satisfaction. The men may have experienced a negative effect, but that doesn't matter, because ONE study shows neither negative nor positive effect in the female partner's perception of sexual satisfaction.

"The shortcomings of the study by Sorrels et al. are discussed in our technical report."

Those who read the technical report will be aware that the AAP reference a study on penile sensitivity by Payne et al. as good to fair evidence (reference 136), which follows the same basic methodology as Sorrells. The key exception in the Payne study is that they didn't bother to measure sensitivity on the foreskin; only on the glans. For whatever reason, however, this didn't register on the AAP task force's radar as any kind of "shortcoming."

The only study that actually attempted to measure the sensitivity of the foreskin itself was the one conducted by Sorrells et al., and the AAP ignores, both in its policy and in this response to its critics, its main finding; that male circumcision removes the most sensitive part of the penis.

"Finally, the study by Frisch et al used a cross-sectional survey of Danish men that found that circumcised men were more likely to report sexual difficulties than uncircumcised men. Circumcised men represented only 5% of 2343 sexually experienced survey respondents, and only 15% of those circumcised men (n 5 17) had the procedure in the first 6 months of life. Attributing these findings to decreased penile sensitivity is a stretch."

What should the findings be attributed to, then?

This study was preceded by three other publications based on the same data set, dealing with sexual dysfunctions in Danish men and women in relation to socioeconomic factors, health factors and lifestyle factors, respectively. After adding the variable of male circumcision status to the analysis, the study showed, not only an excess of orgasm difficulties in circumcised men, but also significantly increased frequencies of orgasm difficulties, pain during intercourse and a sense of incomplete sexual needs fulfillment in women with circumcised spouses.

Perhaps something was wrong with the women too.

Here, the researchers try to invalidate Frisch's study by highlighting the small number of circumcised men found in the study, and further minimizing it by excluding men circumcised beyond 6 months of life. Muslims make up approximately 3% of the Danish population, and form the country's second largest religious community and largest minority religion, where Muslim boys are often circumcised at ages well past 6 months.

Here too, the AAP shows a partiality for men circumcised in infancy, and why not, most circumcised men in the US would be circumcised in the first days of life (by their fellows), correct? One must wonder why this 6 month cut-off date wasn't important when analyzing data from the African trials, where the men were circumcised as adults.

Analyzing the magical "60% HIV reduction" that is often touted by circumcision advocates would reveal an exaggerated absolute difference that was actually 1.3%. Out of 11,054 men who were part of the African circumcision "trials," only 201 men were infected, 137 of which had anatomically correct genitals, and 64 whom were circumcised at the beginning of the study. To say that these results were a direct result of circumcision, in the absence of a demonstrable causal link, would also be "a stretch," not to mention taking these "studies," which were conducted on adult men in high-risk areas in Africa, and applying them to newborns who will not be sexually active for at least 13 years in the US.

"It seems far more likely that the findings are attributable to the kinds of social bias the authors attribute to the AAP task force."

That is, if a predisposition to anatomically correct genitals, and viewing circumcision as any other surgery which should only be performed when medically necessary, can be called a "social bias."

Here, we see the AAP continue their tu quoque defensive. Although until one reads further, one would think the AAP were talking about Frisch et al.:

"Male circumcision is rare in Denmark, rare enough that circumcised males are epidemiologic outliers, which may lead some of them to feel "different," leading to anxiety about sexual experiences with women who perceive a circumcised penis as abnormal."

Here, the AAP engage once again in construction and division; not only are they accusing Frisch et al. of bias, but the entire society from which they hail.

The circumcised penis is not perceived as "abnormal," because it is, any way you slice it, abnormal. Circumcision may be common in the US but, it is not "normal."

Perhaps being circumcised may lead to some of them feeling "different," and perhaps it may lead to anxiety about sexual experiences with women who *might* perceive a circumcised penis as abnormal.

Or, they could feel as if sex isn't satisfying to them because they are unable to feel with their desensitized penises, as a result of removal of many nerve fibers.

But what about the women who report orgasm difficulties, pain during intercourse and a sense of incomplete sexual needs fulfillment with their circumcised partners?

Why would there be more women reporting these things more with circumcised partners, vs. intact partners? Could it be entirely due to a "bias" and negative perception of the circumcised penis? Or could it be, in fact, that the circumcised men with whom they sleep *are* desensitized, leading to rougher sex?

Unlike the arrogant "researchers" in Africa, and their repeaters in the AAP "task force," Frisch et al. are not claiming to be the end-all, be-all in sexual problems and circumcision; they invite other researchers to replicate their findings.

The "trials" in Africa cannot be replicated because their very own authors have deemed that attempting to do so would be "unethical."

"In addition, because many of the circumcised men had the procedure performed later in life, some likely for medical reasons, they are far from representative of a group of men circumcised as infants."

Do they mean like the group of men circumcised as adults in the African "trials" they are referencing?

And of course, only men circumcised in infancy, like the men circumcised by fellows at the AAP, count, correct?

"It should be noted that the findings of the Danish survey contrast starkly to those of 2 randomized controlled trials from Africa, which are discussed in the AAP technical report."

Immediately after objecting to Frisch's study on the grounds that the circumcised men are "far from representative of a group of men circumcised as infants," they contrast it with another study, which of course favors their view, which also does not represent "a group of men circumcised in infancy."

The males in the African "trials" mentioned were groups of adult men who agreed to get circumcised, once they were told that circumcision could help them prevent HIV transmission, and they were surveyed a year or so after their circumcisions, by the same people who conducted the "studies," who were aiming to prove "circumcision prevents HIV transmission," and begin "mass circumcision campaigns" immediately. These men are hardly representative of a group of men circumcised as infants, and would have had much less time being circumcised, where keratinization and desensitization have not yet begun to take effect.

"A central claim of Frisch et al is that if circumcision is to be performed before an age at which an individual can decide for himself, there must be a compelling reason for doing so."

So far, so good.

"They argue that there is no compelling reason for performing a circumcision before sexual debut and additionally claim that "sexually transmitted HIV infection is not a relevant threat to children."

And, it is not.

"Underlying the authors' views are several presuppositions that reflect the ideal, but not the reality, of human decision making."

We'll talk about idealism and reality in a little bit.

"The first of these is that the responsible use of condoms will "provide close to 100% reduction in risk for any STIs." We agree, and fully support efforts to make sexual activity as safe as possible through the routine use of condoms. However, despite huge educational efforts, many individuals around the world do not use condoms consistently. If they did, sexually transmitted infection and HIV would decline to the point of nonexistence."

Ideally, a country where 80% of the adult male population is circumcised could be used as an example of the efficacy of circumcision as HIV prevention.

The reality here is that, while adult male circumcision prevalence exceeds 80%, America has higher HIV transmission rates than 53 countries where circumcision is rare, according to the CIA factbook. Of countries where HIV is more prevalent than America, 26 of them have an adult circumcision prevalence of over 80%.

"The added protective benefit of circumcision exists precisely because responsible condom use is far from universal."

No, the "protective benefit of circumcision" cannot be observed in the real world. As mentioned already, America has higher HIV transmission rates than 53 countries where circumcision is rare, and, according to USAID, HIV transmission is higher among the *circumcised* in 10 out of 18 countries, not to mention other countries around the world where HIV transmission is prevalent in spite of a high circumcision rate.

When you ask circumcision advocates why this "protective benefit" cannot be observed in countries like America, where both circumcision and HIV transmission are prevalent, and why HIV transmission rates are lower in other countries where circumcision prevalence is low (under 20%), they will tell you that it is because "responsible condom use is far from universal," that sex education in America is poor, and not as good as European countries. In their own words, "because condoms and sex education isn't working."

The reasons why circumcision hasn't been effective in the US (sex education is absent or ineffective, and responsible condom use is far from universal), are the very same reasons why it is going to suddenly start working miracles in Africa.

"In 2011, 39.8% of sexually active high school students in the United States reported not using a condom during their last sexual intercourse. Condoms represent one of several tools for reducing the risk of infections transmitted during sexual contact. Circumcision is another."

And yet this "protective effect" is not observed in this country, where 80% of the adult male population is circumcised from birth.

Circumcision hasn't stopped HIV in our own country. And, it hasn't stopped other STDs either. In America, the majority of the male population is circumcised, approximately 80%, while in most countries in Europe, circumcision is uncommon. Despite these facts, our country does poorly.

In fact, AIDS rates in some US Cities rival hotspots in Africa. In some parts of the U.S., they're actually higher than those in sub-Saharan Africa. According to a 2010 study published in the New England Journal of Medicine, rates of HIV among adults in Washington, D.C. exceed 1 in 30; rates higher than those reported in Ethiopia, Nigeria or Rwanda.

The Washington D.C. district report on HIV and AIDS reported an increase of 22% from 2006 in 2009. According to Shannon L. Hader, HIV/AIDS Administration, Washington D.C., 2009, "[Washington D.C.'s] rates are higher than West Africa... they're on par with Uganda and some parts of Kenya." (Hader once led the Federal Centers for Disease Control and Prevention's work in Zimbabwe.)

One would expect for there to be a lower transmission rates in the United States, and for HIV to be rampant in countries where circumcision is rare; HIV transmission rates are in fact higher in the United States, where most men are circumcised, than in 53 countries where circumcision is rare. It is telling that the HIV epidemic struck in our country in the 1980s, when approximately 90% of the male population was already circumcised. Somehow, we're supposed to believe that what didn't work in our own country, or anywhere else, is going to start working miracles in Africa.

"The claim that "sexually transmitted HIV infection is not a relevant threat to children" is incorrect given the US data."

No, given US data, circumcision does not effectively prevent sexually transmitted HIV.

Given world data, the presence of anatomically correct genitals does not present the threat of sexually transmitted HIV infection.

The United States has higher HIV transmission rates than 53 countries where circumcision is rare. According to the AAP, HIV should be rampant in those countries.

But it is not.

"In 2011, sexual debut occurred at or before age 13 years for 6.2% of US high school students, and most people in the United States are sexually active before the age at which they would possess the legal authority to consent to a circumcision."

And, apparently, the mental ability to learn how to use a condom.

"A nationwide sample of adolescent females between the ages of 14 and 19 years estimated that 4 in 10 sexually active adolescent females have a sexually transmitted infection (defined as human papillomavirus, chlamydia, trichomoniasis, genital herpes virus, or gonorrhea)."

Which circumcision cannot prevent against; again, condoms are far more effective.

And, I reiterate; 80% of adult American males are circumcised from birth.

Where was the prevention that circumcision was supposed to afford these women?

"National HIV surveillance data show that, in 2008, there were at least 2266 HIV infections among US adolescents 13 to 19 years of age."

How many of these were circumcised males or partners to circumcised males?

Globally, the US, where 80% of the male population is circumcised, has higher STD transmission rates than its counterparts where circumcision is rare. Could the AAP "task force" bother to explain this phenomenon?

"Frisch et al claim that "the AAP report lacks a serious discussion of the central ethical dilemma with, on one side, parents' right to act in the best interest of the child... and, on the other side, infant boys' basic right to physical integrity in the absence of compelling reasons for surgery."

Not mentioned here is the ethical problem of removing normal, healthy body parts in healthy, non-consenting children, in the name of "benefits" that are already easily obtained through non-surgical means.

"The authors' argument about the basic right to physical integrity is an important one, but it needs to be balanced by other considerations."

The basic right to physical integrity is "an important one," yet the AAP does not talk about it in their policy statement and technical report.

"The right to physical integrity is easier to defend in the context of a procedure that offers no potential benefit, but the assertion by Frisch et al of 'no benefit' is clearly contradicted by the published scientific peer-reviewed evidence."

Evidence that has been found lacking by authors of the paper criticizing the AAP, and the medical organizations they represent.

"Although task force members did not find the data sufficiently compelling to justify a recommendation for routine neonatal circumcision, we did find that the benefits are substantial enough to allow parents to make this decision for their male children."

This reasoning places the cart before the horse.

If 8 task force members could not use the current body of medical evidence to recommend routine neonatal circumcision, how are lay parents expected to come to a more reasonable conclusion?

Why are physicians obliged to comply with a parental "decision" that not even the AAP could bring itself to endorse?

And why are they expected to be reimbursed by public coffers?

"This stance is very similar to that of The Canadian Medical Society, the British Medical Association, and the Royal Australasian College of Physicians."

Here, the AAP is seen groping for international support.

The Royal Australasian College of Physicians stated in 2010 that the foreskin "exists to protect the glans" and that it is a "primary sensory part of the penis, containing some of the most sensitive areas of the penis."

According to the Australasian Academy of Paediatric Surgeons:
"The Australasian Association of Paediatric Surgeons does not support the routine circumcision of male neonates, infants or children in Australia. It is considered to be inappropriate and unnecessary as a routine to remove the prepuce, based on the current evidence available."

"We do not support the removal of a normal part of the body, unless there are definite indications to justify the complications and risks which may arise. In particular, we are opposed to male children being subjected to a procedure, which had they been old enough to consider the advantages and disadvantages, may well have opted to reject the operation and retain their prepuce."

"Neonatal male circumcision has no medical indication. It is a traumatic procedure performed without anaesthesia to remove a normal functional and protective prepuce. At birth, the prepuce has not separated from the underlying glans and must be forcibly torn apart to deliver the glans, prior to removal of the prepuce distal to the coronal groove."

Interestingly, the British Medical Association says:
"Unnecessarily invasive procedures should not be used where alternative, less invasive techniques are equally efficient and available. It is important that doctors keep up to date and ensure that any decisions to undertake an invasive procedure are based on the best available evidence. Therefore, to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate. 

Male circumcision in cases where there is a clear clinical need is not normally controversial. Nevertheless, normal anatomical and physiological characteristics of the infant foreskin have in the past been misinterpreted as being abnormal. The British Association of Paediatric Surgeons advises that there is rarely a clinical indication for circumcision. Doctors should be aware of this and reassure parents accordingly."

Here, once again, having pushed the envelope as far as it could, we find the AAP trying to paint itself in line with the rest of Western medicine.

"Frisch et al appeal to the ethical precept "First, do no harm," but they fail to recognize that in situations in which a preventive benefit exists, harm can also be done by failing to act."

When and if circumcision is the only way to avert said "harm." Anatomically correct genitals present no more threat of "harm" than say, the presence of any other body part.

Using this logic, parents are doing "harm" to their children, by not removing their prostates, gall bladders, appendices, testicles, ovaries, or other parts of the body which could become diseased.

"Whereas there are rare situations in which a male will be harmed by a circumcision procedure..."

This, they claim, after admitting in their technical report, the precise risk and extent of complications of circumcision are unknown, and dismissing major complications and deaths as "case studies."

If the AAP would acknowledge the findings of the Sorrells study, they would have to consider that all circumcisions cause harm, as they invariably, and irreversibly, remove the most sensitive part of the penis. (Perhaps this is the reason why they so adamantly insist there be a firewall between "anatomic findings and physiologic or functional roles?")

" is also true that some males will be harmed by not being circumcised."

An entirely new, unmeasured and undocumented claim, for which the AAP offers no evidence whatsoever.

By this reasoning, anyone undergoing surgery to remove a diseased body part could claim that s/he was "harmed" by not having had the procedure performed in infancy. 

"Simply because it is difficult to identify exactly which individuals have suffered a harm because they were not circumcised should not lead one to discount the very real harms that might befall some men by not being circumcised."

More argumentum ad ignorantiam.

"Harms" that are simply not present in the countries from which the authors hail.

Additionally, the harms and risks of circumcision should be known before making the bold statement that "the benefits outweigh the risks."

"There is no easy answer to this issue ethically."

Or, rather, the AAP wishes to make the problem more complicated than it seems, because an easy, clear answer would put a great majority of their fellows, who circumcise otherwise healthy infants, into disrepute.

"Regardless of what decision is made on behalf of a young male, harm might result from that decision."

Harms that, according to the very AAP, are "unknown."

And, again, "harms" that do not manifest themselves in countries where circumcision is rare.

Nevertheless, "Harm might result regardless of the decision" is a slightly different tune than "the benefits outweigh the risks," as found in the AAP statement and technical report now, isn't it.

We've moved from "harms outweighing the risks," back to a 50/50 stance.

"That is precisely why the AAP task force members found that this decision properly remains with parents and that parents should have information about both potential benefits and potential harms as they make this decision for their child."

Backed into a corner, the AAP "task force" says absolutely nothing about their critics' case, based on the AAP's own policy, that the diseases which circumcision are supposed to reduce (namely UTIs, Penile Cancer, and STDs), are so rare, or of such late onset, or so easily prevented and/or treated, that circumcising infants to prevent them is a bad option, compared to letting the child grow up to decide the fate of his own genitals.

The claim in their policy statement, that "the benefits outweigh the risks" is now nowhere to be seen, and goes undefended.

Questions remain:
Given the current body of evidence, not even the AAP can bring itself to recommend infant circumcision.

8 circumcision "task force" members are unable to recommend infant circumcision given the current body of medical data, and 38 European pediatricians reject the claim that "the benefits outweigh the risks."

How, then, is it that lay parents will be better equipped to make a better decision for their child?

Why are doctors expected to oblige?

And why are public coffers expected to reimburse them?

"The cardinal medical question should not be whether circumcision can prevent disease, but how disease can best be prevented."
~Frisch et al.


  1. I need to start getting ready but have a quarter of literature left to read. Will continue..
    before I go, I wanted to chime in on this excellent bit here:

    "Male circumcision is rare in Denmark, rare enough that circumcised males are epidemiologic outliers, which may lead some of them to feel "different," leading to anxiety about sexual experiences with women who perceive a circumcised penis as abnormal."

    Here, the AAP engage once again in construction and division; not only are they accusing Frisch et al. of bias, but the entire society from which they hail.

    **Perhaps being circumcised may lead to some of them feeling "different," and perhaps it may lead to anxiety about sexual experiences with women who *might* perceive a circumcised penis as abnormal.**


    My opinion, their response is a LOUD projection of their own fears. This is big part of their reason for the "Lets get those circumcision rates back up: direct quote from Susan Blank on CNN" agenda.

  2. All that rebuttal proved is that Diekema is a bigger and more dangerous circ perv than Brian Morris could ever hope to be.

  3. @Joseph, thank you for this outstanding work. You have laid bare Diekema's arrogant belief that he and the Task Force are more scientifically competent than a large group of European medical authorities. Over and over, he commits the fallacy of begging the question, namely assuming the conclusion from the outset.

    Doctors, lawyers, and scientists have a large tool kit they use to disparage and rationalise away inconvenient evidence that contradicts an argument they wish to push. Diekema made us of that tool kit over and over.

    The claim that the USA has a more objective cultural perspective on routine circumcision because Americans are allegedly 50-50 cut and uncut, is an illogical catastrophe: adult white college educated middle class and middle aged Americans are at least 90% circumcised, a fact that is writ large all over the Task Force's work.

    @Judith: Unlike Morris, Diekema is a doctor, a professor of medical ethics, an authority on pediatrics, and hence more dangerous than Morris. He shares Morris's inability to appreciate the sexual value of what circumcision ablates.

  4. The AAP task force did not chose "experts" to analyze the literature or staff the committee. They deliberately chose those who supported the conclusion they hoped to reach: favoring male circumcision. I suppose they relied on Morris to provide them with analyses of research articles!?! These people on the task force are trying to make the Europeans look anti-semitic. But the task force is really guilty of their own bias against the intact normal penis. They are guilty of promulgating hate speech against males in this country, and around the world, who are complete. At least they mentioned the word "condom" and admit there may be some ethical concerns about violating human rights. It can be really dark in a tunnel of one's own making.