Dear Editor:
We dispute the claim that
Schoen represents the North American view.1
We think that he represents only his personal view
and that of a few disciples.
Schoen’s claims have been rejected wherever he
goes. When he published in the New England Journal
of Medicine in 1990,2
his views were opposed by Poland.3
When he published in Acta Paediatrica
Scandinavia in 1991,4
his views were rebutted by Bollgren & Winberg.5
When Schoen published in this journal in 19976
his views were countered by Hitchcock7
and also by Nicoll.8
In the present instance, his views are offset by
Malone.9
When the Canadian Paediatric Society published
their position statement on neonatal circumcision in
1996,10
they followed the views of Poland,3
not those of Schoen.2
Although Schoen was chairman of the American Academy
of Pediatrics (AAP) task force on circumcision that
published in 1989,11
he did not serve on the AAP task force on
circumcision that published in 1999.12
That second task force distanced the AAP from the
views published by Schoen’s task force11
a decade earlier.
Schoen’s present views on circumcision are
strikingly similar to Wolbarst’s,13
which were published nearly a century ago. This
suggests that Schoen’s views are founded in a desire
to preserve his culture of origin, not in medical
science. Goldman writes:
One reason that flawed studies are published
is that science is affected by cultural
values. A principal method of preserving
cultural values is to disguise them as
truths that are based on scientific
research. This 'research' can then be used
to support questionable and harmful cultural
values such as circumcision. This explains
the claimed medical 'benefits' of
circumcision.14
The present North American view is that neonatal
circumcision is not of medical value and that any
benefits are more than offset by the risks,
complications, and disadvantages of non-therapeutic
infant circumcision. The Canadian Paediatric Society
says, “Circumcision of the newborn should not be
routinely performed.”10
The American Academy of Family Physicians described
neonatal circumcision as “cosmetic” in nature.15
More recently, the College of Physicians and
Surgeons of British Columbia reported:
Infant male circumcision was once considered
a preventive health measure and was
therefore adopted extensively in Western
countries. Current understanding of the
benefits, risks and potential harm of this
procedure, however, no longer supports this
practice for prophylactic health benefit.
Routine infant male circumcision performed
on a healthy infant is now considered a
non-therapeutic and medically unnecessary
intervention.16
A recent North American cost-utility study
concluded:
Neonatal circumcision is not good health
policy, and support for it as a medical
procedure cannot be justified financially or
medically.17
The statistics provided by Schoen on the
incidence of circumcision in North America are out
of date. The popularity of non-therapeutic infant
circumcision is declining. The Association for
Genital Integrity reports that only 13.9 percent of
male infants in Canada were circumcised in 2003.18
Data provided by the National Hospital Discharge
Survey indicates that the percentage of male infants
circumcised in the United States declined to 55.1
percent in 2003.19
One expects to see further declines in the
popularity of circumcision as newer data are
reported. Many health maintenance organizations in
the USA and most Canadian health insurance plans no
longer pay for non-therapeutic circumcision of
infant boys.
With regard to prevention of urinary tract
infection (UTI), the only North American
recommendation we can find is that of the Section on
Breastfeeding of the AAP, which recommends
breastfeeding to reduce the incidence of UTI in all
infants.20
It says that procedures that “may traumatize the
infant” or otherwise interfere with breastfeeding
initiation should be avoided.20
Circumcision, a highly traumatic procedure, which
apparently produces an “infant analogue of
post-traumatic stress disorder,”21
works against breastfeeding initiation and
ultimately against optimum child health and
development as well as establishment of UTI
protection by breastfeeding.22
The most recent AAP task force on circumcision does
not recommend circumcision to prevent UTI or for any
other reason.12
Both parents and health care providers have a
general duty to consider the “best interests” of the
whole child.23
This must include sexual and psychological
well-being24
and the child’s interest in preserving his legal
right to bodily integrity.25
Most discussions of the alleged value of
circumcision in preventing UTI usually take an
excessively narrow view.
One should not characterize Schoen’s personal
view as representing the North American view. North
America has moved on.
George Hill, Bioethicist
Executive Secretary
|
|
John V. Geisheker, J.D., LL.M.
General Counsel |
Doctors Opposing Circumcision
Suite 42
2442 NW Market Street
Seattle, Washington 98107-4137
USA
Website:
http://www.doctorsopposingcircumcision.org
References:
- Schoen
EJ. Circumcision for preventing urinary tract
infections in boys: North American view. Arch
Dis Child 2005;90:772-3. [Full
Text]
- Schoen
EJ. Sounding Board. The status of circumcision
of newborns. N Engl J Med 1990; 322:1308-12.
-
Poland RL. The question of routine neonatal
circumcision. N Eng J Med 1990; 322:1312-5.
-
Schoen EJ. Is it time for Europe to reconsider
newborn circumcision? Acta Paediatr Scand
1991;80;573-5.
-
Bollgren I, Winberg J. Letter. Acta Paediatr
Scand 1991; 80: 575-7.
-
Schoen EJ. Benefits of newborn circumcision: Is
Europe ignoring medical evidence? Arch Dis Child
1997;77:358-60. [Full
Text]
-
Hitchcock R. Commentary. Arch Dis Child
1997;77:260. [Full
Text]
- Nicoll
A. Routine male neonatal circumcision and risk
of infection with HIV-1 and other sexually
transmitted diseases. Arch Dis Child
1997;77:194-5. [Full
Text]
- Malone
PSJ. Circumcision for preventing urinary tract
infection: European view. Arch Dis Child
2005;90:773-4. [Extract]
- Fetus
and Newborn Committee, Canadian Paediatric
Society. Neonatal circumcision revisited. Can
Med Assoc J 1996; 154(6): 769-80. [Full
Text]
- Task
Force on Circumcision. Report of the Task Force
of Circumcision. Pediatrics 1989;84(4):388-91.
-
Task Force on Circumcision. Circumcision Policy
Statement. Pediatrics 1999;103(3):686-93. [Full
Text]
-
Wolbarst AL. Universal Circumcision as a
sanitary measure. JAMA 1914;62(2):92-7.
-
Goldman R. The psychological impact of
circumcision. BJU Int 1999;83 Suppl. 1:93-103.
-
Commission on Clinical Policies and Research.
Position Paper on Neonatal Circumcision.
Leawood, Kansas: American Academy of Family
Physicians, 2002. [Full
Text]
-
College of Physicians and Surgeons of British
Columbia. Infant Male Circumcision. In: Resource
Manual for Physicians. Vancouver, BC: College of
Physicians and Surgeons of British Columbia,
2004. [Full
Text]
- Van
Howe RS. A cost-utility analysis of neonatal
circumcision. Med Decis Making 2004;24:584-601.
[Abstract]
-
Association for Genital Integrity. Circumcision
practices in Canada (2004). URL:
http://www.courtchallenge.com/refs/yr99p-e.html
- Jeff
Brown. Personal communication. 2004.
-
Section on Breastfeeding. Breastfeeding and the
use of human milk. Pediatrics
2005;115(2):496-506. [Full
Text]
-
Taddio A, Katz J, Ilersich AL, Koren G. Effect
of neonatal circumcision on pain response during
subsequent routine vaccination. Lancet
1997;349(9052):599-603.
-
Hill G. Breastfeeding must be given priority
over circumcision. J Hum Lact 2003;19(1):21.
-
British Medical Association. The law and ethics
of male circumcision: guidance for doctors. J
Med Ethics 2004:30:259-63. [Full
Text]
-
Boyle GJ, Goldman R, Svoboda JS, Fernandez E.
Male circumcision: pain, trauma and psychosexual
sequelae. J Health Psychol 2002;7(3):329-43.
-
Richards D. Male circumcision: medical or
ritual? J Law Med 1996;3(4):371-6.