IOWA LAW REVIEW, Volume 85, Number 4: Pages 1507-1568,
May 2000.

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CIRCUMCISION AS MEDICAL PRACTICE UNDER THE 1989 AAP REPORT

         Following more than a decade of argument in the wake of an equivocal 1975 AAP task force statement, the 1989 Report re-examined the medical justifications for infant circumcision. Most of the utility claimed for circumcision was of a preventive nature. The maladies supposedly reduced or prevented by circumcision consisted of various STDs, cancers, UTIs, and abnormal conditions of the foreskin. Preventive surgery is not troubling if proven benefits of the procedure outweigh the costs and risks, as reflected through reliable complication rates. However, in the case of circumcision, the American medical profession has failed for half a century to institute a sufficiently comprehensive prospective research and evaluation program.

A.   PHIMOSIS

         In adulthood, the foreskin is able to retract back from the glans down onto the shaft of the penis. Phimosis is the abnormal condition of a non-retractable foreskin, diagnosed from the occurrence of the hardening of opening of the foreskin or from prolonged adherence of the foreskin to the glans.31 Circumcision has long been recommended to parents as a preventive measure for phimosis.32

         Edward Wallerstein, a former Communications Coordinator in the Department of Community Medicine at the Mount Sinai School of Medicine, in his book Circumcision: An American Health Fallacy, forcefully argued that circumcision as both a curative and preventive therapy for phimosis is unwarranted.33 He cited the groundbreaking 1949 study by the British researcher Douglas Gairdner, which demonstrated that foreskin retraction is a gradual process of development that can take years.34 Gairdner concluded that a diagnosis of phimosis "cannot be properly applied to the infant."35 Additionally, Wallerstein cited an eight-year study of 1,968 intact36 Danish boys that found 63% of the six to seven year-old boys did not have fully retractable foreskins.37 The study also found that by sixteen to seventeen years of age only 3% of these boys could not fully retract their foreskins.38 Out of the total of 1,968 boys, only three (.15%) eventually were circumcised to correct phimosis.39 In retrospect, the author of the study, Dr. Jakob Oster, was not convinced that circumcision was necessary even in the three cases where it had been performed.40

         The 1975 AAP report stated neonatal phimosis "is not a valid medical indication for circumcision."41 The 1989 AAP report, without preventing any new information that clearly called for circumcision to prevent phimosis, simply warned that circumcision later in life "may be a more complicated procedure."42 The 1989 AAP task force was aware of Gairdner's article and findings because it cited him for his information concerning the progressive development of foreskin retractability.43 However, the 1989 AAP report does not mention Dr. Oster's findings or conclusions regarding phimosis.44 The logical inference from the AAP's omissions is that it is better to perform painful, unanesthestized surgery within the first several days of every infant boy's life than to circumcise a rare few later in life. The AAP task force did not weigh the incidence of foreskin condition, such as phimosis against the complication rates for neonatal circumcision. Likewise, the task force failed to examine any alternative therapies for phimosis. As a result, the 1989 AAP task force could not justifiably use the prevention of phimosis to support its alteration of the 1975 AAP statement.

B.   CANCER

         Although the threat of phimosis might not be enough to convince parents to circumcise, the threat of cancer obviously ought to be more influential. The rationale of using circumcision to prevent cancer had been around since the 1930s, but the 1975 AAP report found no solid support for using circumcision to prevent cervical or prostate cancer and found that good hygiene was a preferable method for preventing penile cancer.45 However, the 1989 AAP report resurrected the rationales of using circumcision to prevent both penile and cervical cancer.

1. Cervical Cancer

         The 1989 AAP report omitted two well-designed studies that found no statistical effect between a husband's circumcision status and the incidence of cervical cancer in his wife.46 In addition, the 1989 AAP report did not review the international epidemiological evidence contained in Edward Wallerstein's book on circumcision, which eventually renders any link between male circumcision status and cervical cancer unsupported.47 The 1989 task force did observe that cervical cancer appears to be related to the age that a woman begins sexual relations and the number of sexual partners she has throughout life.48 The 1989 AAP task force, in making this observation did not give any citation. Thus readers of the 1989 AAP report were not alerted to sources of evidence unfavorable to theories linking a male partner's circumcision status to cervical cancer.

         Aside from its omissions of pertinent evidence, the 1989 AAP report used language that appears to have been chosen to induce readers to make faulty inferences. Were it not for the misleading sentence construction in the summary section of the 1989 report which stated, "[a]n increased incidence of cancer of the cervix has been found in sexual partners of uncircumcised men infected with the human papillomavirus,"49 the report would have clearly acknowledged a stronger linkage of cervical cancer to viral STDs. The sentence appears to have been constructed to draw attention to "uncircumcised men" and to rhetorically conceal "infected with the human papillomavirus." Thus the summary section fails to reiterate better supported hypotheses that human papillomavirus and other viral STDs are causal agents of cervical cancer in women, irrespective of the circumcision status of their partners.50

         The section of the 1989 report addressing cervical cancer contained further misleading language. The 1989 AAP report stated:

Human papillomavirus types 16 and 18 are the viruses most commonly associated with cancer of the cervix; Herpes simplex virus type 2 has also been linked with cervical cancer. Although human papillomavirus types 16 and 18 are also associated with cancer of the penis, evidence linking uncircumcised men to cervical cancer is inconclusive.51
The second sentence leads with a clause addressing the linkage between human papillomavirus infection and cancer of the penis, but the second part of this sentence substituted "uncircumcised men" for men infected with the human papillomavirus, without supporting an equivalence for the two groups. Reliable evidence for a higher rate of viral infection due to lack of circumcision was not presented anywhere in the report's section on STDs.52 The section of the 1989 AAP report devoted to penile cancer did cite a Brazilian study that reported finding human papillomavirus in 31 of 53 cases of penile cancer.53 However, the penile cancer section of the report did not cite this study to support the proposition that viral STD infections are higher in intact men.54 The word "although" which begins the sentence further conceals the rhetorical substitution. These rhetorical maneuvers appear to have been designed to divert attention from the "inconclusive"55 linkage between cervical cancer and circumcision status, while subtly reinforcing a suspicion of linkage between foreskins and human papillomavirus, and, consequently, a male with a foreskin and cervical cancer in his partner.

2. Penile Cancer

         Although the prevention of cervical cancer through the circumcision of male infants has always been questionable, the prevention of penile cancer has always been circumcision advocates strongest argument.. The 1989 AAP report stated that penile cancer "occurs" almost exclusively in uncircumcised men," and continued by stating that "in five major reported series since 1932, not one man had been circumcised neonatally.56 The report cites a 1975 article by researchers Elliot Leiter and Albert Lefkovits to support the contention that circumcision provides virtual immunity from penile cancer.57 However, the main purpose of the Leiter and Lefkovits article, which was labelled a "case report" was to report penile cancer in a man circumcised neonatally and to cite other reported cases.58 It appears that the 1989 AAP task force in failing to enumerate the nine "reported" cases that occurred in men circumcised neonatally, was uncritically parroting an industry opinion. Additionally, the task force appears not to have considered the possibility that there were only nine reported cases due to an industry-wide reporting bias. This failure to consider reporting bias as a possible confounding variable could result in readers erroneously concluding that circumcised men are immune to penile cancer.

         The 1989 report, citing a 1980 estimate derived in a study by Mosze Kochen and Steven McCurdy, then stated that one in six hundred intact men will develop penile cancer in their lifetime.59 Kochen and McCurdy based their estimate on the assumption that all cases of penile cancer would occur in intact men.60 The 1989 AAP task force reported the estimate even though it was based on this assumption. In the very next paragraph, however, the task force, citing an article by Edward Wallerstein, admitted that countries which do not routinely circumcise have rates less than, equal to, and greater than the rate in the U.S.--whereas the majority of males are circumcised.61 It was not valid for the 1989 task force to report a one in six hundred lifetime risk for penile cancer among intact males when a major premise for the estimate, that only intact males get penile cancer, was clearly erroneous.

         Additionally, Edward Wallerstein identified multiple incidences of faulty research design and wild hypothesizing in the search for a link between the retention of an intact foreskin, the presence of smegma, and the occurrence of penile cancer.62 It was irresponsible for the 1989 AAP task force, as reviewers of medical research, to have uncritically parroted a conclusion that neonatal circumcision provides virtual immunity from penile cancer in light of the pattern of researcher bias that Wallerstein exposed. The task force's underreporting of penile cancer cases in neonatally circumcised males, unfortunately, fit well into this historical pattern of bias on the part of the American medical profession.63

3. Prostate Cancer

         Whereas penile cancer made it onto the first page of the 1989 AAP report, cancer of the prostate was not even mentioned. The 1975 report mentioned it, but solely for the purpose of debunking any theory that prostate cancer occurs more frequently among intact men.64 As with theories linking circumcision with other cancers, Wallerstein demonstrated that findings connecting circumcision to prostate cancer were the result of badly designed and conducted research.65 By failing to present the fact of the discredited link between circumcision status and prostate cancer, the 1989 AAP task force, unlike its 1975 counterpart, did not alert the medical community to the full magnitude of the panacean claims for circumcision. Thus, a physician relying on the AAP's analysis was not put on guard in reviewing the claims for circumcision in the fight against cancer.

C.   URINARY TRACT INFECTIONS

         For many decades, circumcision advocates tried to use the prevention of cancer to justify circumcision. A new justification emerged in the 1980s--the prevention of urinary tract infections (UTIs) The 1989 AAP Task Force on Circumcision modified the 1975 statement, primarily using the reduction of urinary tract infections as its rationale, by stating in the introductory section, "[n]ew evidence has suggested possible medical benefits from newborn circumcision. Preliminary data suggest the incidence of urinary tract infection in male infants may be reduced."66 However, the section of the report devoted to UTIs ended with the admission that the UTI studies suggesting the utility of circumcision "are retrospective and may have methodologic [sic] flaws," and "the study population may have been influenced by selection bias."67 A 1990 article by Robert Thompson more thoroughly explained the methodological flaws in these UTI studies.68 He noted that these studies neither controlled for population variables among the boys' families nor accounted for "differences in the health-care-providing behavior of physicians."69

         Notwithstanding the AAP's own worries over methodological flaws, the results of these UTI studies formed the impetus for the 1989 AAP review of circumcision.70 Once again, it appears that when the benefit of circumcision was the topic of investigation, the AAP task force was willing to overlook methodological flaws in research. The task force used the UTI findings to support their change in the position statement, even when such flaws consisted of failure to control subject variables, failure to control for physician biases, and the elimination of data that provided problems for the hypotheses.71

         Additionally, the 1989 AAP task force readily adopted a theory championed by Thomas Wiswell--the main author of these problematic studies asserting UTI benefits from circumcision.--that the presence of a foreskin provides a site for bacterial colonization leading to UTIs.72 A hypothetical alternate explanation could be that some UTIs result from a lack of proper information on the care of the foreskin. Well meaning, but misinformed parents might have attempted to forcefully retract the foreskin's for cleaning underneath due to a lack of understanding of the foreskin's natural structural development. Forced retraction might have resulted in tissue irritation and avenues of entry for the germs that caused the UTIs. Neither Dr. Wiswell nor the AAP appear to have considered this possibility as an intervening causal variable in the results.

         The AAP was aware of the forced retraction problem in 1989. In 1984 it had published a brochure called Care of the Uncircumcised Penis, largely to address the shocking lack of knowledge physicians displayed in surveys conducted in the early 1980s.73 The AAP brochure may have begun to educate physicians and parents to stop forcibly retracting children's foreskins and to stop unnecessarily cleaning under the foreskin with cotton swabs and antiseptics. However, the problem has not disappeared,74 and the AAP still suggests the daily use of soap under the foreskin once retraction has occurred.75 Anne Briggs, in Circumcision: What Every Parent Should Know, relates the story of Dr. William Mitchell, who was warned that smegma was a carcinogen, while attending medical school during the 1940s, and subsequently started washing under his foreskin with soap daily.76 It was only after changing from a daily rinse with water to this cleansing method that he developed his first foreskin infection.77 The ensueing series of infections and constant irritation unfortunately led him to choose circumcision as a cure.78 Dr. Paul M. Fleiss, in a 1997 article published in the magazine Mothering, recommends simply rinsing underneath the foreskin with water once it is retractable79--the method that kept Dr. Michell free of problems for 29 years.80 In view of its knowledge of the forced retraction problem, and the possibility that some cleaning behaviors themselves may be at fault, the AAP should have remained skeptical of Wiswell's causal hypothesis for UTIs.

D.   SEXUALLY TRANSMITTED DISEASES

         Another non-cancer rationale for circumcision, but one which has been proposed since the nineteenth century, is the prevention of sexually transmitted diseases (STDs). Even though the 1989 AAP report retained a section addressing circumcision a possible preventive measure for STDs, the task force admitted that the "[e]vidence regarding the relationship of circumcision to sexually transmitted diseases is conflicting."81 Two studies that the report cited indicated that both gonorrhea and nonspecific urethritis occurred with greater frequency in intact men.82 However, in the next sentence of the report described both of these studies as inconclusive due to methodological problems.83 Other studies cited in the 1989 report, purporting to link intact penises to higher rates of viral STDs, such as human papillomaviruses and genital herpes are also listed as likely to have methodological flaws.84 In fact, every study that the task force cited for the proposition that circumcision lessens the risk of contracting STDs was also cited as methodologically troubled.85

         The 1989 task force as also void of an analysis of the availability and cost effectiveness of alternate means of treatment and prevention of STDs. The analysis further lacked any comparison of medical utility between neonatal circumcision and alternate therapies. These two omissions served to undermine any implication that circumcision should be considered as prophylactic therapy for STDs. In view of the uncertainty in the data that purported to link circumcision status and numerous STDs, a responsible health organization should have reiterated the fact that avoiding sexual promiscuity and using condoms are the best methods of protection against STDs. The 1989 AAP report failed to do this.

         The only methodologically non-problematic study cited in the STD section of the report found no difference in the incidence of gonorrhea between circumcised and intact groups and, in fact found "a higher incidence of nonspecific urethritis in circumcised men."86 Based on its own cited material, the 1989 task force could have scientifically concluded that avoiding circumcision confers a benefit against the risk of contracting STDs. In any case, similar to the situation for UTIs, the flawed studies, claiming circumcision reduced the risk of contracting an STD, failed to justify the 1989 task force's change in policy on circumcision.

E.   PHYSICAL COMPLICATIONS OF CIRCUMCISION

         Turning from a benefit examination of circumcision to a risk examination of circumcision, the 1989 AAP report continued the practice of ignoring sound evidence while crediting flawed evidence supporting the procedure. The report stated that "[t]he most common complications are local infection and bleeding."87 Though severe complications following circumcisions are rare, they should have been mentioned in the AAP's report when it mentioned three deaths that were openly attributed to circumcision complications in the last forty years.88 The report failed to warn that infections resulting from a circumcision can become quite serious and have impacts on other parts of the body. This has been documented in a four-year case study of four infants who were admitted to one Australian hospital for meningitis following their circumcisions and in a press release concerning the Alaskan lawsuit of Jacob Sweet.89 The AAP should have warned parents that infections from this type of surgery do not always remain local.

         Aside from "local infection and bleeding," there is a striking range of complications that can result from circumcision. Rosemary Romberg, in her 1985 book, Circumcision: The Painful Dilemma, devoted over thirty pages to reviewing reports of various clinical conditions and surgical mishaps that can occur as a result of circumcision and can result in the loss of part or all of the penis.90 The 1989 report did not cite Romberg's book and failed to address the lengthy list of complications that she compiled from the medical literature.

         At the very least, the 1989 report should have included what was mentioned in the "Surgical Risks and Aftermaths of the 1975 report, which informed parents and physicians that "[t]he immediate hazards of circumcision include local infection which may progress to septicemia, significant hemorrhage, and mutilation."91 The 1989 AAP report skipped directly from, "the most common complications are local infection and bleeding to mentioning three reported deaths in the last forty years.92 Thus, the AAP appeared to imply that there was no range of harmful effects between the two extremes.

         Even though it postdated the 1989 AAP report on circumcision, the 1995 AAP Committee on Bioethics statement, entitled Informed Consent, Parental Permission, and Assent in Pediatric Practice, recommended that all known potential risks should be presented to parental decision makers:

[P]atients should have explanation, in understandable language, of the nature of the ailment or condition; the nature of the proposed diagnostic steps and/or treatment(s) and the probability of their success; the existence and nature of the risks involved; and the existence, potential risks of recommended alternative treatments (including the choice of no treatment)...[and] assurance... that the patient has the freedom to choose among the medical alternatives without coercion or manipulation.93

         This policy statement appeared to underscore the duty to avoid "manipulation" by omission, which was probably not different in 1989 just six years before. The 1975 AAP report explicitly stated that possible adverse outcomes should be discussed with parents "well in advance of delivery, when the capacity for clear response is more likely."94 The 1989 AAP task force should have been urging physicians to present parents with information concerning all possible adverse outcomes of the surgery, the uncertain nature of circumcision's benefits, and the benefits of remaining intact.

         In addition to failing to include a discussion of the full variety of complications that can result from circumcision, the 1989 AAP report also understated the statistical rate of complications. The report stated: "The exact incidence of post operative complications is unknown, but large series indicate that the rate is low, approximately 0.2 to 0.6%. The most common complications are local infection and bleeding."95 The AAP task force was able to provide this low estimate of complications by screening the research with the requirement of a "large series" study. It thereby avoided citation of an immediate complication rate of 4% on a smaller subject pool of 361 infants in Utah, published by researchers Thomas Metcalf et al. in 1983.96 The task force also neglected to report the phenomenena of "late" complications circumcision--those that manifest themselves farther into the first year of the infant's life--which Metcalf et al. reported at the astonishing rate of 13%.97

         Aside from omitting Metcalf's findings from its survey of published complication rates, the 1989 AAP report also misstated the results obtained by researchers William Gee and Julian Ansell in a 1976 retrospective study. The AAP apparently quoted a figure of 0.2% for "really significant" complications from the article's discussion section and abstract, without examining the information provided in the main body of the article which gave an overall immediate complication rate of 2.0% for the subject pool of 5882 infants.98 Ignoring the 2.0% figure, the 1989 AAP report then implied that the 0.2% complication figure can be discounted further because it included the "most common complications [which] are local infection and bleeding."99 However the task force failed to acknowledge that Gee and Ansell had already removed what they considered minor infections and bleeding from their total complication rate of 2.0%, to arrive at the 0.2% figure.100 In compiling their data, Gee and Ansell noted that "most complications were not indexed, and only by careful perusal of the nurses notes were they ferreted out."101 Amazingly, Gee and Ansell's decision to focus on what they characterized as "really significant" complications subsequently enabled the 1989 AAP task force to pare away many of the complications--complications that these two researchers had carefully ferreted out.

         Aside from citing Gee and Ansell, in providing a complication range of 0.2-0.6%, the 1989 AAP report also cited two 1987 letters to the editor of Pediatrics.102 Thomas Wiswell, who had conducted the methodologically problematic UTI studies which had led to the task force's change of policy, estimated a complication rate of 0.3% from a review of 175,000 male births in Army hospitals over ten years.103 His findings were later reported, adter the 1989 AAP report was published, to be a complication rate of 0.19% of over 100,000 male infants from a six-year period.104 Similar to Gee and Ansell's discounting of an overall rate of 2.0% to arrive at a reported rate of 0.2%, Wiswell's low rate, reviewer Thompson noted, may have also been due to a restrictive filtering and defining of complications as only those "complications specifically recorded as such" by medical persononnel.105 The upper end of the 1989 AAP report's complication range came from another letter to the editor in a 1987 issue of Pediatrics, submitted by a physician who reviewed the records of 4000 births in his hospital over at two year period.106

         The 1989 AAP task force displayed an unscientific selection bias in giving more weight to two letters to the editor--those of Wiswell and Harkavy--over the scientifically designed and published research of Metcalf et al. and Gee & Ansell. Presumably, the raw data and operations deficitions for complications of the Metcalf et al. and Gee & Ansell research were available for peer review by the AAP task force, whereas the data that Wiswell and Harkavy provided in their letters to the editor was not. Additionally, unlike George Kaplan's 1983 review of published literature on circumcision, the 1989 AAP report completely ignored complication rates gathered from other countries such as Canada, the United Kingdom, and Australia.107 The standard of medical care in those countries has to be comparable to that in the United States. To avoid an appearance of selection bias, researchers findings from those countries should also have been included in the task force's investigation of physical complication rates.

F.   BEHAVIORAL EFFECTS OF CIRCUMCISION

         In addition to the possibility of potentially devastating physical complications, circumcision has negative effects on behavior. Until the last couple of decades, the widespread belief was that an infant was either incapable of perceiving pain, or that, because such pain would not be remembered, it had no effect on behavior.108 The 1989 AAP task force, unable to avoid addressing this misconception concerning infant cognition, devoted a section of its report to infant pain.109 The 1989 authoritatively stated that infants can feel pain; it supported this conclusion with citation to the thorough 1987 review on infant pain authored by researchers Anand and Hickey in the New England Journal of Medicine.110

         However the 1989 AAP report went on to state that while behavioral changes occurred, such as crying from surgical trauma, irritability, altered sleep and feeding patterns, and altered maternal-child social interaction, "[t]hese behavioral changes were transient and disappear[ed] with in 24 hours after surgery."111 There is a great difference between the statement that experimentally measured behaviors return to pre-operative levels and the report's summary section conclusion that "[I]nfants respond[ed] to the procedure with transient behavioral and psychological changes."112 In addressing the question of neonatal memory, the 1989 task force missed or ignored Anand and Hickey's warning:

In the long term, painful experiences in neonates could possibly lead to psychological sequelae, since several workers have shown that newborns may have a much greater capacity for memory than was previously thought. . . .long-term memory requires the functional integrity of the limbic system and disencphalon. . . these structures are well developed and functioning during the newborn period . . . [M]emory and learning depend on brain plasticity, which is known to be highest during the prenatal and neonatal periods. Apart from excellent studies in animals demonstrating the long-term effects of sensory experience in the neonatal period, evidence for memories of pain in human infants must, by necessity, be anecdotal. Early painful experiences may be stored in the phylogenically old "procedural memory," which is not accessible to conscious recall.113
This warning should have discouraged the task force from making any affirmative statements that circumcision has no enduring effects.

         Indeed, during the 1980s, researchers had accumulated evidence of the remarkable abilities of infants to retain memory. In 1986, researchers Anthony DeCasper and Melanie Spence published the results of an experiment designed to to measure fetal and neonatal memory for speech sounds.114 They found that in utero subjects, who were read a target story twice daily by their mothers, would later as neonates respond perferentially to their target story as opposed to similar sounding stories, regardless of who recited it to them.115 By 1987 researchers had begun to see that the view that infants were incapable of experiencing memory or pain had more to do with the failings of researcher's study designs than it had to do with the failings of infants.116 the 1989 AAP task force should have at least investigated these studies and mentioned them in their report.

         Additionally, at the time of the 1989 AAP report, information was available that neonatal pain experiences might have a deleterious effect on future behavior. For example, a 1985 issue of the Lancet contained an article that found a significantly higher percentage of adolescent suicides among subjects that had experienced respiratory distress at birth, compared to adolescents who experienced no problems at birth.117 A pattern of distressed behaviors, similar to those of "of infants born at risk," occurs during the trauma of circumcision.118 In another retrospective epidemiological study conducted in Sweden, researchers also found a significant correlation between the type of suicide method chosen by suicide victims and the type of complications they experienced at birth.119 Researchers of both studies dealing with adolescent suicide carefully pointed out the correlational, rather than causal, certainty of their findings.120

         The lesson the 1989 AAP task force should have gleaned from these findings was that psychologists were only beginning to devise ways to measure infants' amazing ability for memory and its effects on later behavior. In view of these research findings, the 1989 task force either failed in its duty to investigate the state of knowledge on infant memory and perception or failed to report on its investigation. It also breached its duty of care to provide scientific guidance to physicians and parents, because it simply dismissed neonatal circumcision's behavioral effects as "transient" and "disappearing."

G. FUNCTIONS AND BENEFITS OF THE FORESKIN

         Returning to the physical issues surrounding the foreskin and circumcision, a logical scientific investigation should start with an inquiry into why nature created the foreskin. A short-lived paragraph in the 1984 AAP brochure Care of the Uncircumcised Penis described the protective functions of the foreskin and the adverse consequences of its loss after circumcision.121 That paragraph was deleted in subsequent printings of the brochure.122 The 1989 AAP report acknowledged, in its sections on local infections and STDs that certain clinical conditions are found more frequently in circumcised boys and men.123 It gave examples of meatitis, an inflammation of urinary opening, and nonspecific urethritis.124 However the AAP displayed a bias in favor of circumcision by altering its brochure for parents. The AAP also displayed bias in omitting the higher prevalence of meatitis and non-specific urethritis in circumcised men from its introductory and summary sections of the 1989 report, while supposed lesser rates of UTI and cancer.

         The AAP task force did not inquire into nature's reasons for the foreskin, but some medical researchers are seeking to understand why the foreskin is more than just skin, continuing the efforts pioneered by the British researcher Douglas Gairdner in the late 1940s.125 In a 1997 article published in Mothering magazine, physician Paul M. Fleiss reviewed the accumulated knowledge about the specialized tissue of which the foreskin is made, and the functions it serves.126 A study in the British Journal of Urology noted that the presence of "Meissner's corpuscles firmly separate prepucial [meaning of the foreskin] epithelium from true skin," and that these specialized receptors are comparable "with similar nerve-endings in the finger-tips and lips"127

         Medical practitioners should have at least some knowledge of what it is they are surgically removing. However, for many years the AAP and the profession as a whole have viewed the prepuce as merely extra skin.128 To view the foreskin as a mistake of nature is analogous to attitudes formerly held concerning tonsils and adenoids.129 However, whereas the AAP has corrected the rush among physicians to surgically remove the tonsils,130 the AAP has failed to correct this same clinical mistake for the foreskin. The AAP should have inquired for what purpose nature created the foreskin before classifying it as a perilous mistake.

H. COST-BENEFIT ANALYSIS OF CIRCUMCISION AS MEDICINE

         Any examination of the medical efficacy of circumcision should also have included some reference to cost-benefit analysis. The 1989 AAP report did not refer to or engage in, or call for any cost-benefit analysis. In response to the 1989 AAP report, physician Robert S. Thompson applied risk-benefit analysis to Thomas Wiswell's assertion that circumcision lessens the occurrence of UTIs.131 Thompson found that when accounting for Metcalf's 1% figure for late complications requiring surgical revision--which the AAP task force had failed to consider--Wiswell's UTI benefit would not outweigh the surgical risks, even accepting Wiswell's immediate complication rate at 0.2%.132 Two other economic cost-benefit analyses were published in 1991, but neither could find utility for routine circumcision in assessing essentially the same data that would have been before the 1989 task force.133

         Prior to the issuance of the report from the 1989 task force, the AAP appears to have been aware of the necessity to justify circumcision, like any other preventive therapy, on a cost-benefit basis. This is demonstrated in the AAP's own publications. The AAP authored, in conjunction with ACOG, three book editions of Guidelines for Perinatal Care, in 1983, 1988, and 1992.134 Both the 1983 and 1988 editions maintained that "there is no absolute medical indication for circumcision in the neonatal period"--thereby reflecting the findings of the 1975 task force.135 However, the 1988 edition mentioned the pending report from the AAP Task Force on Circumcision to be published the following year: "the present policy. . .will be modified only if data conclusively demonstrates the value of the procedure."136 Wiswell's methodologically problematic studies hardly qualified as data "conclusively demonstrat[ing] the value of the procedure." Nevertheless, the AAP, in the 1992 edition of Guidelines for Perinatal Care, adopted the view of circumcision's value reflected in the 1989 task force's report.137 Thus, the AAP as a whole, with respect to cost-benefit analysis, failed to scrutinize the 1989 task force report as it professed it would, and instead proceeded directly to disseminate its findings.


         31. See WALLERSTEIN, supra note 1, at 62, 65 (offering definitions of the term); AAP 1989, supra note 3, at 388 (same).
         32. AAP 1989, supra note 3, at 388. If a foreskin is removed, possible conditions of the foreskin will not occur. However, this justification holds for any body organ or part. It would be more prudent to inquire into the incidence of foreskin conditions, their severity, alternative therapies, and the complication rates of each therapy, in order to render judgment as to the utility of any one therapy.
         33. See WALLERSTEIN, supra note 1, at 62-66 (arguing that phimosis is over-diagnosed in American infants and children).
         34. See id. at 63-64; Gairdner, supra note 6, at 1433-34 (presenting analysis of then existing research).
         35. Gairdner, supra note 6, at 1435.
         35. Gairdner, supra note 6, at 1435. 36. The term "intact" will be used throughout this note to refer to "uncircumcised" individuals, because it more accurately reflects the fact that having a foreskin is the natural and, therefore, truly "normal" condition for men. The term "uncircumcised" carries with it an implication that to be circumcised is natural and normal.
         37. See WALLERSTEIN, supra note 1, at 64 (citing Jakob Oster, Further Fate of the Foreskin, 43 ARCHIVES OF DISEASES OF CHILDHOOD 200 (April 1968)).
         38. See WALLERSTEIN, supra note 1, at 64 (citing Oster).
         39. See WALLERSTEIN, supra note 1, at 64 (citing Oster's study). As will be demonstrated in Part I(E), this percentage is less than the likely percentage of complications attendant to circumcision.
         40. Id.
         41. AAP 1975, supra note 10, at 610.
         42. See AAP 1989, supra note 3, at 388 (implying that circumcision should be done as a preventative on infants instead of curative for the few cases of phimosis which can only be diagnosed later in life.).
         43. Id. at 388, 391 (citing Gairdner, supra note 6).
         44. The 1989 AAP task force cites Wallerstein's article, Circumcision: The Uniquely American Medical Enigma, supra note 23, in which Wallerstein cites at least three times to Oster. See supra note 37. The task force on circumcision was also most likely aware of Wallerstein's book, CIRCUMCISION: AN AMERICAN HEALTH FALLACY, supra note 1, wherein Oster is cited repeatedly.
         45. See AAP 1975, supra note 10, at 610-11 (declining to recommend circumcision for the prevention of cancer.
         46. See Jean Aiken-Swan & D. Baird, Circumcision and Cancer of the Cervix, 19 BRIT. J. OF CANCER 217, 226-27 (1965) (finding no correlation between the circumcision status of husbands and the cervical cancer rate of their wives); See also Milton Terris et al., Relation of Circumcision and Cancer of the Cervix, 117 AM. J. OF OBSTETRICS AND GYNECOLOGY 1056 (1973) ("No significant differences were found in the circumcision status of marital partners of cases and controls.").
         47. See generally WALLERSTEIN, supra note 1, at 95, 96, 99 (citing international epidemilogical data that do not support the hypothesis that an intact penis is more likely to cause cervical cancer in female sexual partners).
         48. Compare AAP 1989, supra note 3, at 389 (stating without attribution that "[t]he strongest predisposing factors in cervical cancer are a history of intercourse at an early age and multiple sexual partners. The disease is virtually unknown in nuns and virgins."), with WALLERSTEIN, supra note 1, at 99 (stating with attribution to sources critical of a circumcision correlation to cervical cancer, that "[n]uns rarely develop the disease, while prostitutes usually have a very high incidence rate.").
         49. See AAP 1989, supra note 3, at 390 (emphasis added) (leaving it to the reader to note that circumcision status may be irrelevant due to the presence of the virus, while implying that circumcision status is the root cause of cervical cancer).
         50. Id. at 389 (admitting growing evidence linking viral STD infection to cervical cancer).
         51. Id. (emphasis added).
         52. See infra Part I(D) (delineating how all of the studies cited by the 1989 task force finding higher STD rates among intact males were also found by the task force to be methodologically unsound).
         53. See AAP 1989, supra note 3, at 389 (citing D.J. McCance et al., Human Papillomavirus Types 16 and 18 in Carcinoma of the Penis from Brazil, 37 INT'L J. CANCER 55,57. (1986)).
         54. See AAP 1989, supra note 3, at 389 (beginning the paragraph which cites the McCance article with, "[f]actors other than circumcision are important in the etiology of penile cancer.").
         55. See AAP 1989, supra note 3, at 389 (beginning any linkage as inconclusive).
         56. Id. at 388.
         57. See id. (citing Elliott Leiter & Albert M. Lefkovits, Circumcision and Penile Carcinoma, 75 N.Y. ST. J. MED. 1520 (1975)). Letier and Lefkovits stated, "[t]hat circumcision in infancy virtually guarantees immunity from penile carcinoma is a well known fact." Id. at 1520.
         58. See Leiter & Lefkovits, Circumcision and Penile Carcinoma, 75 N.Y. ST. J. MED. 1520, 1520 (1975) ("We should like to report a sixth case of carcinoma of the penis in a Jewish male circumcised eight days after birth.").
         59. See AAP 1989, supra note 3, at 388 (citing Mosze Kochen & Stephen McCurdy, Circumcision and the Risk of Cancer of the Penis, 134 AM. J. DISEASES CHILDREN 484 (1980)).
         60. See Kochen & McCurdy, supra note 59, ah 484 ("We assumed that virtually all of the reported cancers occurred in uncircumcised males. We therefore adjusted the rates for the estimated fraction of the population that was uncircumcised in each age group.")
         61. See AAP 1989, supra note 59, at 484 ("We assumed that virtually all the reported cancers occurred in uncircumcised males. We therefore adjusted the rates for the estimated fraction of the population that was uncircumcised in each age group.").
         62. See WALLERSTEIN, supra note 1, at 111-12 (demonstrating outright misstatements of numerical figures as well as unsupported assertions by circumcision advocates); see also id. at 96-97 (discussing studies concerning smegma); Wallerstein, supra note 23, at 127 (citing a horribly flawed study in the medical literature which purported to prove that smegma was carcinogenic).
         63. See generally WALLERSTEIN, supra note 1, at 108-09 (relating the successive reporting in medical literature of no penile cancer among neonatally circumcised men). Cf. AAP 1989, supra note 3, at 388 (citing Abraham L. Wolbarst, Circumcision and Penile Cancer, LANCET, Jan. 16, 1932, at 150, for the conclusion that "[c]ancer of the penis does not occur in Jews circumcised at infancy. There is no case on records.") Leiter & Lefkovits, supra note 57, at 1520-21 (1975) (same). Both the 1989 AAP report and Leiter and Lefkovits cite to Wolbarst's statement, even after Leiter and Lefkovits reported six such cases.
         64. See AAP 1975, supra note 10, at 610 ("There is presently no convincing scientific evidence to substantiate the assertion that circumcision reduced the eventual incidence of cancer of the prostate.").
         65. See generally WALLERSTEIN, supra note 1, at 100-04 (tracing the development of the theory and the scientific flaws in the research done on prostate cancer).
         66. AAP 1989, supra note 3, at 388.
         67. Id. at 389.
         68. See generally Robert S. Thompson, Routine Circumcision in the Newborn: An Opposing View, 31 J. FAM. PRAC. 189-92 (1990) (delineating flaws in studies by Thomas E. Wiswell et al. Decreased Incidence of Urinary Tract Infections in Circumcised Male Infants, 75 PEDIATRICS 901 (1985); Thomas E. Wiswell & John D. Roscelli, Corrobarative Evidence for the Decreased Incidence of Urinary Tract Infections in Circumcised Male Infants, 78 PEDIATRICS 96 (1986); Thomas E. Wiswell et al. Declining Frequency of Circumcision: Implications for Changes in the Absolute Incidence and Male to Female Sex Ratio of Urinary Tract Infections in Early Infancy, 79 PEDIATRICS 388 (1987)).
         69. Robert S. Thompson, supra note 68, at 191.
         70. See AAP 1989, supra note 3, at 388 (stating that "[s]ince the 1975 report . . .[p]reliminary data suggest the incidence of urinary tract infection in male infants may be reduced [by neonatal circumcision]"); see also Robert S. Thompson, supra note 68, at 189 (claiming that "[l]argely because of these [UTI studies'] data, the [AAP] convened a task force on circumcision" to revise the statement of the 1975 task force)
        . 71. See Robert S. Thompson, supra note 68, at 189-92 (delineating problems involving failures to control for age, race, education, or income," to control for differences in the health-care-providing behavior of physicians," and the dropping of data which did not fit into the researchers' hypotheses).
         72. See AAP 1989, supra note 3 at 389 nn.5, 25, 26 (citing three separate studies conducted by Wiswell and co-authors, supra note 68, resulting in a hypothesis that the foreskin provides a site for bacterial colonization leading to UTI).
         73. See Wallerstein, supra note 23, at 128 (citing studies showing only 3-49% of physicians in the early 1980s were aware that the foreskins of infants should not be forcibly retracted). Additionally, over 50% of physicians were unaware that the newborn's non-retractable foreskin is normal. Id.
         74. Unfortunately, a signficant percentage of pediatricians still attempt to forcibly retract the foreskin. See National Organization of Circumcision Information Resource Centers, Survey Reveals Need for Pediatrician Education, NOCIRC ANNUAL REPORT 1,8 Spring 1999). According to NOCIRC, an informal survey of pediatricians at the 1999 AAP national convention revealed that 22% did not know the proper care of the foreskin. Id. See also David J. Llewellyn, Legal Remedies for Penile Torts, THE COMPLEAT MOTHER, Winter 1995, at 13 (relating how that author's wife had to pull her son away from a pediatrician who was attempting to forcibly retract a boy's foreskin); Amanda Schneider, My Son Clayton (visited March 4, 1999) <http://faculty.washington.edu/~gcd/DOC/clayton.html> (relating the forcible retraction attempt by a nurse practitioner and a subsequent $100 small claims court default judgment against the nurse). One instance of a medical practitioner's ignorance is well known to the author of this note. While his nephew was at the office of a pediatrician in Texas, the pediatrician attempted to forcibly retract the nephew's foreskin. Thanks to the swift action of the boy's mother, the pediatrician was not successful and no harm was done.
         75. See AMERICAN ACADEMY OF PEDIATRICS BROCHURE NO. HE 0023R, NEWBORNS: CARE OF THE UNCIRCUMCISED PENIS (1992) (stating that "external cleaning with soap and water is all that is required . . . retracting the foreskin and cleaning beneatth it during his bath or shower.").
         76. See BRIGGS, supra note 1, at 46 (quoting personal correspondence wih Dr. William Mitchell, M.D.).
         77. See id. (quoting personal correspondence with Dr. William Mitchell, M.D.).
         78. See id. (relating how Dr. Michell retrospectively concluding that daily soaping of the inner foreskin irritated it and allowed infections to occur).
         79. See Paul M. Fleiss, The Case Against Circumcision, MOTHERING, Winter 1997, at 41 ("The best way to care for a child's penis is to leave it alone. After puberty, males can gently rinse their glans and foreskin with warm water."). This information mirros the common knowledge among women that a daily scrubbing with soap in the recesses of the female genitalia can be counter-productive.
         80. See BRIGGS, supra note 1, at 46 (relating the conclusions of Dr. William Mitchell concerning his foreskin problems and proper hygiene).
         81. AAP 1999, supra note 3, at 389.
         82. See id. at 389 (citing S.W. Parker et al. Circumcision and Sexually Transmitted Disease, 2 MED. J. AUSTL. 288 (1983); R.A. Wilson, Circumcision and Venereal Disease, 56 CAN. MED. ASS'N J. 54 (1947)).
         83. See AAP 1989, supra note 3, at 389 (citing the studies of Parker, supra note 82, and Wilson, supra note 3, at 389.
         84. AAP 1989, supra note 3, at 389.
         85. See id. (listing every study with a finding of a benefit from circumcision as also having methodological flaws).
         86. See id. (citing G.L. Smith et al., Circumcision as a Risk Factor for Urethritis in Racial Groups, 77 AM. J. PUB. HEALTH 452 (1987), and not citing it for methodological flaws, unlike every other source cited in the STD section of the report).
         87. AAP 1989, supra note 3, at 390.
         88. Id.
         89. See Jacqueline M. Scurlock & Patricia J. Pemberton, Neonatal Meningitis and Circumcision, 64 MED J. AUSTL. 332, 332-34 (1977) (describing the events and indications surrounding four circumcised boys admitted to the hospital for meningitis over a four-year period); see also Johnson Flora, Johnson Flora: Alaska Law Firm Settles Lawsuit With Family of Brain-Damaged Boy: Betrayed by Doctors and Lawyers in Alaska, Sweets Find Justice Through Seattle Malpractice Attorney (visited Mar. 9, 2000) <http://biz.yahoo.com/prnews/00308/wa_johnson_l.html> (publicizing the settlement of the case of Jacob Sweet who suffered seizures and brain damage following an infected circumcision). This press release notes that the parents fought a 13-year legal battle starting on January 25, 1986, the day their nine-day old son suffered seizures while under hospital care. Id. The parents lost the original medical malpractice suit when the attorney improperly handled the presentation of the evidence that the hospital had lost the medical records. Id. They finally received some compensation in their legal malpractice case. Id.
         90. See ROMBERG, supra note 1, at 198-234 (1985) (detailing the range of complications that can result from circumcision.; id. at 200 ("Meatal Ulceration"--urine burns that occur around the meatus because the foreskin is no longer there to protect it);id. at 204 ("Meatal Stricture"--the narrowing of the meatus resulting from recurrent meatal ulceration); id. at 206 ("Hemorrhage"--bleeding that can be minor or severe); id. at 208 ("Infection"--which can be minor or severe); id. at 211 ("Concealed Penis"-- a rare occurrence where the penile shaft retreats into the body requiring further surgery to correct); id. at 214 ("Urethral Fistula"--an abnormal hole on the urethra which is not the meatus); id. at 217 ("Urinary Retention"--blockage of urine flow usually the result of an overtight bandage); id. at 219 ("Excessive Skin Loss"--resulting from the excision too much foreskin); id. at 221 ("Skin Bridge"--a condition which results from the circumcision wound healing and adhering onto the glans); id. at 223 ("Laceration of Penile or Scrotal Skin"); id. at 223 ("Preputial Cysts")--a fluid-filled sack on what remains of the foreskin); id. at 223 ("Vomiting and Apnea"--trouble breathing); id. at 226 ("Keloid Formation"--thick red scar tissue); id. at 226 ("Lymphedema"--swelling of lymph vessels); id. at 228 ("Loss of Penis"--in two cases the remedy chosen was penile reconstruction, in two other cases gender reassignment was chosen) (emphasis added).
         91. AAP 1975, supra note 10, at 611 (emphasis added).
         92. See AAP 1989, supra note 3, at 390 (failing to note that reported complications and deaths do not equal the real incidence of adverse outcomes).
         93. See American Academy of Pediatrics Committee on Bioethics, Informed Consent, Parental Permission, and Assent in Pediatric Practice, 95 PEDIATRICS 314, 315 (1995) (discussing a statement of principles). This statement of principles would imply that parents should be told of all the adverse outcomes--such as those listed by ROMBERG, supra note 90--and also should be informed of the protective functions the foreskin would continue to provide with the option of no treatment.
         94. AAP 1975, supra note 10, at 610.
         95. AAP 1989, supra note 3, at 390.
         96. See Thomas J. Metcalf et al, Circumcision: A Study of Current Practices, 33 CLINICAL PEDIATRICS 575, 577 (1983) (listing 14 complications for 361 neonates, a 4% complication rate).
         97. See id. at 577 (listing delayed complications of circumcisions such as "[f]oreskin adhesions." "[p]oor hygiene," <[m]eatitis," and "[s]urgical revision," for a total of 13% of a subject pool of 230). The complication category of "poor hygiene" is problematic. It appears to be simply parental dissatisfaction with the eventual appearance and the irrational fear of smegma. Id. at 578. Even subtracting this category from the complications list would leave a complication rate of 10%. See id. at 577 tbl.3 (substracting the 3% for "poor hygiene" from the table yields 10%).
         98. See AAP 1989, supra note 3, at 390 (citing William G. Gee & Julian S. Ansell, Neonatal Circumcision: A Ten-Year Overview: With Comparison of the Gomco Clamp and the Plastibell Device, 58 PEDIATRICS 824 (1976)). Gee and Ansell state that out of 5882 infants, "[o]nly 14 complications (0.2%) are considered really significant--one life-threatening hemorrhage, four systemic infections, eight circumcisions of infants with hypospadias, and one complete denudation of the penile shaft." Gee & Ansell at 827. Complications included in the results which totaled 1.8%, but which were not accounted for in this "really significant" list included : hemorrhage at four to seventy-two hours after surgery requiring medical intervention; infection requiring care, and in four cases antibiotics; dehiscence; "[c]omplete separation of the penile skin from the mucous membrane" which had to be repaired with fine chromic gut"; partial denudation (excessive loss) of penile skin in two cases which were left to heal up on their own; edema (swelling) and cyanosis (bluing from lack of oxygenated blood), resulting from incorrectly performed Plastibell circumcisions; urinary retention; and "superficial" laceration of the glans. Gee & Ansell at 825-26.
         99. See AAP 1989, supra note 3, at 390 (characterizing compications as local infection and bleeding, after stating the complication rate at 0.2-0.6%).
         100. See supra note 98 and accompanying text (enumerating the complications that Gee and Ansell chose not to include in arriving at the figure of 0.2%).
         101. Gee & Ansell, supra note 3, at 390 (listing citations for complication rates).
         102. See AAP 1989, supra note 3 at 390 (listing citations for complication rates).
         103. See id. at 390 (citing Thomas E. Wiswell, 79 PEDIATRICS 649, 650 (1987) (letter to the editor) (estimating a complication rate of 0.3% for 175,000 births)).
         104. See Robert S. Thompson, supra note 68, at 194 (citing Thomas E. Wiswell & D.W. Geschke, Risks for Circumcision During the First Month of Life Compared with Those for Uncircumcised Boys, 83 PEDIATRICS 1011 (1989) (reporting a complication rate of 0.19% for 100,000 infants)).
         105. Robert S. Thompson, supra note 68, at 194 (noting that Thomas E. Wiswell's low overall complication rate of 0.19% reflected "the stringency of the criteria and recording practices of physicians involved").
         106. See AAP 1989, supra note 3, at 390 (citing Kenneth L. Harkavy, 79 PEDIATRICS 649 (1987) (letter to the editor)(reporting a 0.6% rate of "notifiable complications")).
         107. Compare AAP 1989, supra note 3, at 300 (citing only to information obtained in the U.S.), with George W. Kaplan, Complications of Circumcision, 10 UROLOGIC CLINICS OF N. AM. 543,545 (1983) (citing articles from Australia, Canada, and the U.K.).
         108. See WALLERSTEIN, supra note 1, at 135-44 (tracing the attitudes of many medical practitioners and medical sources, who downplayed or even denied that infants felt pain or that the pain had significance); Anand & Hickey, supra note 18, at 1321 (stating the fact that for many years there existed "a widespread belief in the medical community that the human neonate or fetus may not be capable of perceiving pain").
         109. Compare AAP 1989, supra note 3, at 389 (stating authoriatively that infants experience pain and that circumcision does cause pain), with AAP 1975, supra note 10, at 610-11 (recommending that the surgery not be routinely performed, but failing to mention any where that pain is a consideration in the equation).
         110. See AAP 1989, supra note 3, at 389 (citing Anand & Hickey, supra note 18).
         111. AAP 1989, supra note 3, at 389. The 1989 AAP report cited Richard E. Marshall et al., Circumcision: II Effects upon Mother-Infant Interaction, 7 EARLY HUM. DEV. 367, 373 (1982), for the proposition that experimentally measured feeding intervals and infant availability scrose reverted to pre-circumcision levels by 24 hours after surgery.
         112. AAP 1989, supra note 3, at 390.
         113. Anand & Hickey, supra note 18, at 1325-26.
         114. See DeCasper and Spence, supra note 18, at 142, 148 (relating their results).
         115. See id. at 143, 148 (concluding that the subjects had amazingly learned the acoustical characteristics of the target stories, not just the voice of the storyteller).
         116. See Nancy Angrist Myers et al., When They Were Very Young: Almost-Threes Remember Two Years Ago, 10 INFANT BEHAV. & DEV. 123, 123 (1987) ("The pursuit of such questions requires versitility and ingenuity in methodology, to say nothing of fortuity in opportunity.").
         117. See Salk et al., supra note 18, at 625, 627 (detailing the results of a study on the relationship between perinatal factors and suicide).
         118. See Fran Lang Porter, et al., Newborn Pain Cries and Vagal Tone: Parallel Changes in Response to Circumcision, 59 CHILD DEV. 495, 495, 502 (1988) (discussing alterations in "vagal tone" as measured by comparing heart period with breaths per minute (see id. at 498-99 n. 2) during circumcision and finding the patterns comparable to those exhibited by "medically compromised infants").
         119. See Jacobsen et al. supra note 18, at 367-68, 370 (tying the type of birth complication to later methods of suicide).
         120. See id. an 369 (admitting that "self-destructive behavior has many roots. Here perinatal factors only are considered.") Salk et al., supra note 18, at 627 (noting "[m]any babies survive adverse perinatal conditions, and therefore we do not suggest a direct relationship between perinatal adversity and eventual suicide").
         121. See BRIGGS, supra note 1, at 102 (quoting AMERICAN ACADEMY OF PEDIATRICS, CARE OF THE UNCIRCUMCISED PENIS (Newborn Series, 1984)):
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 [i.e., when circumcision is performed], the glans and especially the urinary opening can 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.
Id.
         122. See AMERICAN ACADEMY OF PEDIATRICS, BROCHURE NO. HE0023R, NEWBORNS: CARE OF THE UNCIRCUMCISED PENIS, GUIDELINES FOR PARENTS (1992) (omitting the paragraph from the 1984 pamphlet quoted supra note 121). This revised pamphlet was published after the 1989 AAP report on circumcision.
         123. See AAP 1989, supra note 3, at 388-389 (admitting, in the section of the report devoted to local infections, that "[m]eatitis is more common in circumcised boys." And in the section doveted to STDs, admitting "higher incidence of nonspecific urethritis in circumcised men").
         124. See id. at 389 (providing these two examples).
         125. Dr. Gairdner observed that:
[I]s often observed that the prepuce is a vestigal structure devoid of function. However, it seems to be no accident that during the years when the child is incontinent the glans is completely clothed by the prepuce, for, deprived of this protection, the glans becomes susceptible to injury. . . . Meatal ulcer is almost entirely confined to circumcised male infants.
Gairdner, supra note 6, at 1434.
         126. See Fleiss, supra note 3, at 388-389 (noting the immunologically significant presence of lysozyme and immunoglobins, the scientifically interesting presence of estrogen receptors and apocrene glands for the production of pheromones, the protective functions served through coverage and lubrication of the glans, and the lubricant preserving function of having the shaft of the penis move more within its own skin that having the penile skin move in and out of the female exposing her lubricant to drying in the air).
         127. J.R. Taylor et al., The Prepuce: Specialized Mucosa of the Penis and its Loss to Circumcision, 77 BRIT. J. OF UROLOGY. 291, 295 (1996).
         128. See AAP 1989, supra note 3, at 388 (stating simply that the foreskin "is the fold of skin covering the glans.").
         129. See AMERICAN ACADEMY OF PEDIATRICS, BROCHURE NO. HE0154, TONSILS AND ADENOIDS: GUIDELINES FOR PARENTS (1994) (Observing first that "having tonsils and adenoids removed was quite popular, "but late observing that now physicians know "[b]oth the tonsils and adenoids make antibodies to help fight infections").
         130. See id. ("Nowadays, doctors know more about when this surgery is really needed and when it should not be done. . . . These days, the American Academy of Pediatrics considers surgery absolutely necessary only under the following conditions [of abnormal breathing, swallowing and speech].") The AAP's challenge to the old established practice on this other "non-essential" but functional, normal, and healthy tissue should likewise have influenced the 1989 circumcision task force approach.
         131. See Robert S. Thompson, supra note 68, at 189-92 (describing the change in the AAP policy in response to Wiswell's findings on UTIs as the motivation for his risk-benefit review).
         132. See id. at 194 tbl.3 (comparing the possible nine per one thousand spared a UTI, according to Wiswell's conclusions, against an immediate complication rate of two per one thousand and late complication rate of ten per one thousand, using the data of Metcalf). For Metcalf's data, see supra notes 96-97 and accompanying text.
         133. See Theodore G. Ganiats et al., Routine Neonatal Circumcision: A Cost-Utility Analysis, 11 MED. DECISION MAKING 282, 288 (1991) (For routine neonatal circumcision, however, these advantages and disadvantages cancel each other."); see also Frank H. Lawler et al., Circumcision; a Decision Analysis of Its Medical Value, 23 FAM. MED. 587, 590 (1991).
         134. AMERICAN ACADEMY OF PEDIATRICS & AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS, GUIDELINES FOR PERINATAL CARE (3rd ed. 1992) [hereinafter AAP GUIDELINES 1992); AMERICAN ACADEMY OF PEDIATRICS & AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS, GUIDELINES FOR PERINATAL CARE (2d ed. 1988) [hereinafter AAP Guidelines 1988]; AMERICAN ACADEMY OF PEDIATRICS & AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS, GUIDELINES FOR PERINATAL CARE (1st. ed 1983) [hereinafter AAP GUIDELINES 1983].
         135. Compare AAP GUIDELINES 1988 supra note 134, at 94 (stating that "there is no absolute medical indication for circumcision in the neonatal period"), with AAP GUIDELINES 1983 supra note 134, at 87 ("There is no absolute indication for the routine circumcision of the newborn."), with AAP 1975, supra note 10, at 611 (There is no absolute medical indication for routine circumcision of the newborn.").
         136. AAP GUIDELINES 1988, supra note 134, at 93-94. One can only assume that the drafters of the 1988 guidelines were aware of continued debate regarding the efficacy of circumcision. In view of the demonstrated risks attendant to any surgery, as well as occasional severe complications reported in the medical literature, the drafters must have determined that the responsible course of action in lending advice to practitioners, and subsequently parents, would be to claim medical benefits for this elective surgery only if the 1989 AAP circumcision task force found research data that clearly supported such a claim. Until then, the guideline drafters decided to adhere to the established policy that the uncertainty of the data supported.
         137. See AAP GUIDELINES 1992, supra note 134, at 103 ("Circumcision may also result in a reduced incidence of urinary tract infection, although prospectively collected data in this regard are lacking.") The AAP 1992 guidelines classify circumcision as an elective procedure. Id. UTI prevention is the only benefit mentioned in the paragraph on circumcision contained in the guidelines. Yet this uncertain benefit, reported by the 1989 task force, supra notes 66-72 and accompanying text, somehow qualified as the "conclusively" demonstrated value that the 1988 guidelines professed to require of the 1989 task force report in order to change the AAP and ACOG's policy.

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