Circumcision and the American Academy of Pediatrics: Should Scientific Misconduct Result in Trade Association Liability?

Iowa Law Review, Volume 85, Issue 4: Pages 1507-1568, May 2000.

II. THE 1999 AAP REPORT

In the wake of the 1989 task force report and a decade of increasing controversy surrounding the medical practice of circumcision, the AAP issued the findings of a third Task Force on Circumcision on March 1, 1999.¹³⁸ On the surface, the 1999 task force appeared to take a step toward opposing circumcision. It reported that the data was insufficient to endorse circumcision, and that "the procedure is not essential to the child's current well-being."¹³⁹ The 1999 AAP report made no mention of cervical cancer. Thus, the AAP appears to have fully exonerated the foreskin for cervical cancer. Notwithstanding these improvements, the AAP devoted the overwhelming majority of the report, once again, to asserting that "[e]xisting scientific evidence demonstrates potential medical benefits of newborn male circumcision."¹⁴⁰

Unlike the silence concerning cervical cancer, the 1999 AAP report, like its predecessor, links the risk of penile cancer to an intact foreskin. While evidence had accumulated since 1989 that clearly demonstrated that neonatally circumcised men were not immune to penile cancer, the 1999 report presented the "strong association" and "threefold risk" for developing penile cancer from foregoing neonatal circumcision as authoritative.¹⁴¹ The task force reported this elevated risk, notwithstanding its own admission that "there have been few rigorous hypothesis testing investigations," and "it is difficult to estimate accurately the magnitude of this risk based on existing studies."¹⁴²

The 1989 presumption that neonatal circumcision provided virtual immunity from penile cancer was thoroughly refuted when a single 1993 study on subjects from the state of Washington and British Columbia found twenty-two cases of penile cancer among men circumcised at birth.¹⁴³ This study, while surmising that circumcision status may play some role in the etiology of penile cancer concluded, "at least some cases of cancer occur in circumcised men as well."¹⁴⁴ Some of these "other conditions," which all produced a higher risk for penile cancer than did lack of circumcision, included a history of genital warts, penile tear, penile rash, smoking and more than thirty sexual partners.¹⁴⁵ Interestingly, in reporting the statistical effect of circumcision status, the authors only adjusted the results for the variables of age and penile tear, but not with the other concurrent variables.¹⁴⁶ A statistical adjustment of the variable of circumcision status with the variables of the number of lifetime partners and a history of viral STDs was a necessity in order to assess fully the role of circumcision status, because the other variables were more strongly correlated with penile cancer. Still, due largely to these findings, the 1999 task force had to acknowledge that circumcised men get penile cancer, the the overall incidence of penile cancer is extremely low, and that other factors such as cigarette smoking, viral STDs, and sexual promiscuity are risk factors.¹⁴⁷

Although the AAP report contained a sentence addressing the wide differences in penile cancer among countries where circumcision is not performed,¹⁴⁸ the 1999 task force, like its counterpart in 1989, did not cite statistics gathered by the International Agency for Research on Cancer for the World Health Organization's publication, Cancer Incidence in Five Countries, vol. IV, from 1982, listed the non-circumcising Scandinavian countries reporting incidences of penile cancer equal to or less than the incidence in the United States.¹⁴⁹ In volume VI, from 1992, this same publication listed the incidence of penile cancer in Israel and Japan--where Israel circumcises at birth while Japan does not--both with lower cancer rates than the United States.¹⁵⁰ Because of this wide variation between nations, and the fact that the figures do not clearly group according to whether a country does or does not practice neonatal circumcision, it was untenable for the AAP to assert or imply that circumcision status was a casual variable for penile cancer. Genetic predispositions, exposure to causative agents, and cultural practices other than circumcision must account for susceptibility to penile cancer.

As with the long-standing suspected link between circumcision status and penile cancer, the possibility of a link between circumcision status was once again addressed in the 1999 AAP task force's report. The 1999 AAP report's section on STDs admitted that evidence for a possible relationship between STDs and circumcision is complex and conflicting."¹⁵¹ This complexity has increased since the 1989 report, because the 1999 task force had to address HIV, in addition to the other STDs.

Since 1989, circumcision advocates had added HIV to the list of STDs from which circumcision supposedly offered some protection. The 1999 AAP report focused on studies that asserted a prophylactic effect for circumcision against HIV, while ignoring evidence of methodological flaws in such studies.¹⁵² The report did not cite a thorough editorial review by researchers Isabelle de Vincenzi and Theiry Mertens, in the journal AIDS.¹⁵³ This article noted that articles published on the geographical distribution of AIDS in Africa had used outdated data on circumcision from "anthropological studies of rural areas written between 1930 and 1950."¹⁵⁴ This article detailed other methodological flaws in AIDS and circumcision studies such as a "lack of distinction between susceptibility and infectivity, inadequote control for confounding variables, potential selection bias and misclassification of exposure, inappropriate choice of a comparison group, and publication bias."¹⁵⁵ De Vincenzi and Mertens further noted that "the magnitude of the association, when present, varie[d] strongly between studies, and its crude measure [wa]s overestimated in some reports by the use of OR [odds ratio instead of RR [relative risk]."¹⁵⁶ They found that this problem in the statistical measuring may have been "misleading toward causality."¹⁵⁷ De Vincenzi and Mertens ultimately concluded that circumcision was not warranted as a measure to combat the spread of HIV.¹⁵⁸

Returning to other STDs, the 1999 AAP report selectively reported only those findings suggesting circumcision's prophylactic effect. One example was the report's omission of the results reported in an article by researchers Laumann et al., which found a higher rate of chlamydia among circumcised men, while no higher STD rates occurred in intact men.¹⁵⁹ Even though the 1999 AAP task force cited this article, it was only mentioned to support the general statement that the "relationship of circumcision to STD in general is complex and conflicting."¹⁶⁰ Thus a reader of the report would be unaware that the Laumann article found that circumcision conferred no benefit against any STD, and may, in fact, have been a risk factor for contracting chlamydia. This was STD information that the 1999 task force should have included in its report.

While circumcision provides no clear benefits in protecting against the contraction of STDs, like the 1989 AAP report, the 1999 report found UTI prevention as the best reason to defend circumcision. However, by 1999, Wiswell's poorly designed studies were superceded by the less spectacular, but more reliable results of a 1998 article by a Canadian research team, which used a large prospective three-year research design.¹⁶¹ These Canadian researchers found that foregoing a neonatal circumcision produced a 3.7 relative risk of hospital intake for UTI over the first three years of a boy's life, which was much less than the 10.1 to 19.8 risk factor Wiswell had obtained in methodologically problematic retrospective studies.¹⁶²

Moreover, unlike previous studies on circumcision and UTI, which addressed inpatient care, the Canadian researchers also examined physician billing records to estimate outpatient UTI treatment rates. Here, the heightened risk from not circumcising resulted in only a 1.73 relative risk for a UTI.¹⁶³ The finding was that, "for every circumcised infant admitted for UTI, there were 11 outpatient billings for UTI compared with five for the uncircumcised infants."¹⁶⁴ The article noted the lack of any information that UTI severity differed between circumcised and intact boys.¹⁶⁵

The almost negligible relative risk observed in outpatient records may indicate that physicians were biased toward hospitalizing intact baby boys, instead of circumcised boys, for UTIs. Further research on physician treatment decisions for UTIs in boys might reveal that the treatment recommendations for intact boys include circumcision. This surgery would probably involve general anesthesia,¹⁶⁶ due to the boy's age, and possibly also due to the awakened physician sensitivity for reducing behavioral disturbance to the attachment between the now communicative child and his parents. In contrast, the option of circumcision was already performed on the neonatally circumcised boys, so physicians might have required a more serious UTI before recommending hospitalization. The possible confounding effect of physician bias was left out of the 1999 AAP report. Likewise, neither the Canadian article nor the 1999 AAP report considered inappropriate physician, or parental forced retraction of the foreskin as a possible causal variable for UTIs in intact boys.

Potential confounding variables that might have intervened in measuring circumcision's effect on UTI rates, recognized in the 1999 AAP report, were prematurity, lack of breastfeeding, and method of urine collection.¹⁶⁷ The report conceded that one Italian case-control study demonstrated that breastfeeding had "a threefold protective effect on the incidence of UTI in a sample of uncircumcised infants."¹⁶⁸ In the next sentence, the 1999 AAP report appeared to hide the significance of breastfeeding by stating that "breastfeeding has not been evaluated systematically in studies assessing UTI and circumcision status."¹⁶⁹ Assuming the 3.7 relative risk for UTI in foregoing neonatal circumcision, as Dr. David Alwin observed, a circumcision is an unfavorable preventive strategy since the protective effect of breastfeeding is roughly equivalent to that of circumcision but poses no risk."¹⁷⁰

D. COMPLICATIONS

Contrary to the relatively large amount of new material regarding the supposed benefits of neonatal circumcision between 1989 and 1999, there was little new material published concerning circumcisions. Unfortunately, twenty-four years after the first AAP task force report on circumcision and a decade after the 1989 report, the AAP still could not authoritatively cite a complication rate for circumcision. The task force once again provided an estimated complication rate of 0.2% to 0.6%, citing the figures obtained by Harkavy and Gee & Ansell.¹⁷¹ First, the AAP again avoided or missed the fact that the Gee and Ansell study had already discounted the occurrence of what were considered minor (but signficant beyond the normal tissue trauma to warrant intervention and recording) complications.¹⁷² Second, following the AAP report's lead, the 1999 AAP report ignored the 4% immediate complication rate and the 13% late complication rate, published in the 1993 Metcalf article.¹⁷³ the task force failed to take seriously the phenomena of surgical corrections of circumcision such as that which led to Dustin Evan's Jr.'s death in October of 1998, terming them "isolated case reports" and failing to list death as a possible outcome.¹⁷⁴ Finally, the 1999 task force completely ignored a comprehensive 1993 review of estimates for circumcision's complication rates authored by British researcher's N. Williams and L. Kapila.¹⁷⁵ If the AAP task force had found the study's conclusion that "realistic figure [for the complication rate] is 2-10 percent"¹⁷⁶ was flawed, it should have at least cited the study and provided reasons for not crediting it.

Interestingly, in stating that the "data are not sufficient to recommend" circumcision as routine care, the 1999 report essentially concluded that the risks of circumcision outweigh the benefits.¹⁷⁷ The report, therefore, essentially admitted that leaving a boy intact could not be proven to be a sufficient risk factor for UTIs, STDs and penile cancer warranting the intervention of circumcision. However, the task force provided no cost-benefit studies or figures to support this ultimate conclusion. The 1999 AAP report did not cite Robert S. Thompson's 1990 UTI/circumcision risk/benefit analysis,¹⁷⁸ yet Thompson's article would appear to support the report's conclusion that the data on the benefits of circumcision were not sufficient to recommend routine neonatal circumcision."¹⁷⁹ After expounding for almost the entire length of the report on the alleged benefits of circumcision, the AAP incongruously concluded that the data was insufficient to recommend the procedure. The AAP appeared to be inviting physicians to credit a lengthy and heavily cited recitation of alleged benefits and to find the task force's brief and final recommendation insufficient. Due to the lack of cited support for the report's ultimate conclusion, it seemingly encouraged physicians to continue the amputation of normal, healthy, functional foreskins. One possible motive that could explain this approach was a disingenuous attempt to shield the AAP from liability while still listing medical sources supporting circumcision. The 1999 AAP report will likely result in the perpetuation of the "cultural" preference for circumcision among medical practitioners and parents.

Unlike the paucity of new material coming from the medical profession concerning circumcision's true physical complication rates, in the decade following the 1989 AAP talk force report, psychological investigators conducted numerous studies and published a great deal on infant abilities in memory, including memory of pain. For example, in 1998, researcher Charles Nelso electronically recorded brain activity in infants during memory experiments.¹⁸⁰ He discussed his results and reviewed various studies conducted in the 1990s, most notably that of psychologist Carolyn Rovee-Collier, which demonstrated that three-month-old infants can remember a picture for weeks after a brief exposure.¹⁸¹ Nelson came to the conclusion that infants have "covert" long-term memory. "even if there no overt evidence of such memory."¹⁸² Proposing that more work should be performed measuring brain activity in infants, he expressed the hope that "we may be able to examine how early life experiences come to shape our brain and ultimately our behavior."¹⁸³ However, the 1999 AAP talk force, like its predecessors, neglected to devote any meaningful effort toward examining the research on long-term behavioral effects of painful experiences in infancy.

The 1999 task force's omission of psychological research was all the more shocking in light of the findings of a 1997 article, which it did cite.¹⁸⁴ Researchers Anna Taddio et al., demonstrated that neonatal circumcision increased the pain exposure of infants to vaccination at four and six months.¹⁸⁵ This result held even for those boys given Emla cream as a pain prevention measure during their neonatal circumcisions.¹⁸⁶ This article soundly proved that neonatal circumcision does have long-term behavioral aspects. Despite the results of this study and the task force's admission that even the most effective pain measure, the subcutaneous ring block, also failed to fully eliminate operative pain, the report concluded, "analgesia is safe and effective in reducing the procedural pain."¹⁸⁷ Although the 1999 task force no longer claimed, like the 1989 task force, that behavioral effects are short-term and transitory, the 1999 task force's dismissive treatment of Taddio's findings was irresponsible.¹⁸⁸ In light of these results, the 1999 task force should have instituted a literature search into long-term psychological effects of infant pain. This should have lead them to the findings of Jacobsen et al.,¹⁸⁹ concerning choice of suicide method and its relation to perinatal pain.

Another moderation of the 1989 AAP position, but one that also failed to fully relate the evidence, was the 1999 taskforce's abandonment of circumcision as the treatment of choice for phimosis. The report stated, "[m]edical therapy has been successful [i.e. medication] has been successful in resolving both secondary phimosis and paraphimosis, but surgical intervention is sometimes indicated.'¹⁹⁰ An article electronically published by the AAP itself, compared the phimosis treatments of topical steroids, prepucial plasty [surgery which does not amputate the foreskin], and circumcision for cost effectiveness.¹⁹¹ This article found topical steroid treatment to be the most cost effective and circumcision to be least cost effective.¹⁹² However, this article was not cited in the 1999 AAP report, nor did the report mention the non-circumcision surgical alternatives examined in this article.

The 1999 task force also unprofessionally dismissed the growing body of evidence that foreskin tissue has characteristics beyond that of regular skin. The report presented the research of J.R. Taylor as merely suggesting the presence of specialized sensory cells on the inner foreskin.¹⁹³ The 1999 AAP task force report distinguished the foreskin from outer penile skin only because it did not characterize the foreskin simply as "skin".

However, although the 1999 AAP task force report in Pediatrics did not label the foreskin simply "skin," the AAP continues to refer to it simply as "skin" in the information it provides to specifically to parents. At the AAP web-site, the online brochure Circumcision: Information for Parents omits any mention of the specialized tissues and structures that constitute the foreskin. The online brochure simply calls the foreskin, "skin that covers the end of the penis."¹⁹⁴

This online brochure suffers from other mischaracterizations as well. The brochure presents a ten-fold UTI risk factor, reflecting the results of Wiswell's retrospective studies, rather than the more methodologically sound 3.7 relative risk figure.¹⁹⁵ The online brochure downplays complications as "rare and usually minor,"¹⁹⁶ with no mention of the possibility of serious complications. The brochure neither presents complication rates, nor does it provide any explanation for the profession's lack of knowledge about such rates.

Additionally, in its section labeled Reasons Parents May Choose Not to Circumcise, the brochure overlooks the growing number of parents and professionals that consider infant male circumcision a human rights issue.¹⁹⁷ This section also incorrectly characterizes the statement that the foreskin is necessary to protect the tip of the penis," as a belief."¹⁹⁸ However, the AAP disseminated a similar position as fact in the 1980s¹⁹⁹ Likewise the word "belief" in the heading appears to be strategically placed by the AAP so as to cast doubt on and downplay statistically proven informaton which relates to the increased risk for meatitis and meatal stenosis after circumcision.²⁰⁰ Additionally, the 1999 AAP online brochure erroneously claims that available pain measures are "effective," implying that they can eliminate the pain of circumcision. Additionally, the online brochure fails to advise parents that long-term behavioral effects have been demonstrated, the extent of which are unknown.

The 1999 AAP online brochure ends with a section on female circumcision. The brochure lists some of the cultural reasons why some immigrant parents from Africa desire the range of female genital alterations.²⁰¹ It fails to mention that many medical practitioners, as well as parents form these cultures, assert unproven rationales of health and cleanliness--similar to rationales which are presented in this country in support of male circumcision.²⁰²

The AAP Committee on Bioethics published a 1998 position statement entitled Female Genital Mutilation (FGM) in which the AAP specifically "encourage[d] its members to … decline performing all medically unnecessary procedures to alter female genitalia."²⁰³ There are varying degrees of FGM. However, the AAP noted that the rough equivalent to male circumcision, removing only the clitoral hood, as well as simply a ceremonial incising of any part of the female genitalia, would likely be held as violation of United States criminal law.²⁰⁴

This encouragement to practitioners was in congruence with the approach of another AAP Committee on Bioethics article on informed consent and parental permission in pediatric care … ."²⁰⁵ Similarly, the authors of Caring for Gravely Ill Children, also published in Pediatrics, were quite aware that "professionals must maintain an independent obligation to protect the child's interests," not those of the parents.²⁰⁶ Encouragement to place the best interests of the child over the cultural wishes of parents was justly present for any type of FGM, yet such encouragement to avoid surgery was utterly lacking from the now admittedly medically unnecessary alteration of male genitalia. The AAP apparently considered awareness of ethical conflicts, particularly regarding an awareness of to whom the physician owes a duty (the child, i.e., the patient, not to the parents), as pertinent in the case of an immigrant cultural practice such as female circumcision. This consideration appears to be considered by the AAP as immaterial in the case of our own culture's practice of not-medically-necessary infant male circumcision.

Ironically, what may have ultimately induced the grudging change in the AAP's policy on circumcision may not have been a sense of professional responsibility, but a growing sense of international professional isolation. The 1999 AAP task force cited position statements of Canadian and Australian medical organizations in 1996, which found no medical rationale for the support of routine infant male circumcision.²⁰⁷ The Fetus and Newborn Committee of the Canadian Paediatric Society examined and cited, existing cost-benefit analyses for circumcision in relation to UTI and penile cancer.²⁰⁸ Even with the inflated and flawed UTI risk information available in 1996, the Society recommended simply and clearly in the abstract of their report that "[c]ircumcision of newborns should not be routinely be performed."²⁰⁹

References

138. See AAP 1999, supra note 19, at 686- 691 (stating findings).
139. Id. at 691.
140. Id.
141. Id. at 690-91.
142. Id.
143. See Christopher Maden et al., History of Circumcision, Medical Conditions, and Sexual Activity and Risk of Penile Cancer, 85 J. NAT'L CANCER INST. 19, 20-22, tbl. 6 (1993) (surveying 110 penile cancers in the Pacific Northwest).
144. Id. at 24.
145. Id. at 21-22.
146. Id. at 22 tbl 6.
147. See AAP 1999, supra note 19, at 690-91 (addressing the possible link between penile cancer and circumcision status and citing Maden et al., supra note 143). Additionally, the 1999 task force received a letter from two Vice Presidents of the American Cancer Society. See Fathermag.com, Letter from the American Cancer Society (visited Mar. 9, 2000) (relating a public letter from Hugh Shingleton, M.D. National Vice President Detection & Treatment American Cancer Society, and Clark W. Heath, Jr. M.D., Vice President Epidemiology and Surveillance Research American Cancer Society, to Dr. Peter Rappo, Committee on Practice and Ambulatory Medicine, American Academy of Pediatrics (February 16, 1996)). The letter stated:

     Portraying routine circumcision as an effective means of prevention distracts the public from the task of avoiding behaviors proven to contribute to penile and cervical cancer; especially cigarette smoking, and unprotected sexual relations with multiple partners. Perpetuating the mistaken belief that circumcision prevents cancer is inappropriate.

     Id.
148. See AAP 1999, supra note 19, at 690 (mentioning penile cancer rates obtained from Denmark, Brazil, and India).
149. Compare 4 INTERNATIONAL AGENCY FOR RESEARCH ON CANCER AND INTERNATIONAL ASSOCIATION OF CANCER REGISTRIES, CANCER INCIDENCE IN FIVE CONTINENTS 751 (1982) (listing available incidences of penile cancer in Finland at 0.5 to 0.6 per 100,000 men, in Norway at 0.6 to 0.7 per 100,000 men, and in Sweden at 0.9 per 100,000 men), with AAP 1989, supra note 3, at 388 (providing a incidence in the United States at 0.7 to 0.9 per 100,000 men)
150. Compare 6 INTERNATIONAL AGENCY FOR RESEARCH ON CANCER AND INTERNATIONAL ASSOCIATION OF CANCER REGISTRIES, CANCER INCIDENCE IN FIVE CONTINENTS 974 (1992) (listing Israel's incidence of penile cancer at 0.2 to 0.9 per 100,000 men and Japan's at 0.4 to 0.7 per 100,000 with AAP 1999, supra note 19, at 690 (listing the U.S. incidence of penile cancer at 0.9 to 1.0 per 100,000 men).
151. AAP 1999, supra note 19, at 691.
152. See id. ("In addition, there is a substantial body of evidence that links noncircumcision in men with risk of HIV infection.") (citations omitted).
153. See Isabelle de Vincenzi & Theirry Mertens, Male Circumcision: A Role in HIV Prevention?, 8 AIDS 153 (1994) (analyzing studies asserting a linkage between circumcision status and HIV transmission in Africa).
154. Id. at 156.
155. Id. at 157.
156. Id.
157. Id.
158. See de Vincenzi & Mertens, supra note 153, at 159 (stating that "[a]s the safety, expected benefits, feasibility and acceptability of mass circumcision are all questionable … [neither circumcision non controlled studies would be defendable options before there is stronger evidence from observational studies in different settings that show a lack of male circumcision may be a genuinely independent risk factor for the transmission of HIV").
159. See Edward O. Laumann et al., Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice, 277 JAMA 1052, 1054-55 (1997) (finding statistical significance that 26 cases of chlamydia occurred in 1033 circumcised men, but none occurred in 353 intact men).
160. See AAP 1999, supra note 19, at 691 (citing only generally to Laumann et al., supra note 159.
161. See AAP 1999, supra note 19, at 689 (citing the results of Teresa To et al., Cohort Study on Circumcision of Newborn Boys and Subsequent Risk of Urinary-Tract Infection, 352 LANCET 1813 (1998)); see also supra notes 67-71 and accompanying text (delineating the flaws of the Wiswell research).
162. See To el al., supra note 161, at 1813 delineating the findings and methodology of this study); see also id. at 1815 tbl. 2 (comparing the relative risk figures of their own research to figures obtained by other researchers, including Wiswell).
163. See id. at 1815 (analysing the data on outpatient UTIs of boys from physician-billing records).
164. Id.
165. See id. (noting that no study has addressed any possible difference in severity between the UTIs in the two groups).
166. See AAP 1999, supra note 19, at 688 (noting that general anesthesia becomes a normal procedure when performing a circumcision beyond the neonatal period).
167. See id. at 689-90 (noting possible methodological problems).
168. Id. at 689 (citing Alfredo Pisacane et al., Breastfeeding and Urinary Tract Infection, 120 J. PEDIATRICS 87 (1992)).
169. See AAP 1999, supra note 19, at 689 (downplaying the results of Piscane et al. unnecessarily). Italy does not engage in routine infant circumcision. Piscane et al.'s entire subject pool was presumably intact. One could compare the result of breastfeeding intact boys against the effect of circumcising intact boys. One would not have to compare the effect of breastfeeding or not breastfeeding on intact and circumcised boys, as the 1999 task force was apparently suggesting.
170. See David Alwin, The Urinary Tract Infection Myth Revealed (visited Apr. 30, 1999) (assuming the 3.7 relative risk factor established by To et al., supra note 161).
171. See AAP 1999, supra note 19, at 688 (admitting that the complication rate can only be roughly estimated and citing complication rates obtained by Harkavy, supra note 106, and Gee & Ansell, supra note 98).
172. See supra note 98 and accompanying text (relating the discounted complications); Gee & Ansell, supra note 98 at 825-27 (reporting the full range of complications at 2% within their graph and reporting the 0.2% figure as reflecting what the authors deemed "really significant" complications).
173. See Metcalf et al., supra note 96, at 577 (obtaining an immediate complication rate of 4% for a sample of 361 circumcised neonates, but also noting a 13% rate for later complications).
174. Compare Metcalf et al., supra note 96, at 577, 578 tbl. 3 (finding an immediate complication rate of 4%, including surgical problems at 1%, and a late complication rate of 13%, including foreskin adhesions (skin bridges) at 8%, meatitis at 1%, and surgical revision at 1%), with AAP 1999, supra note 19, at 688 (listing skin bridges, meatitis, urinary retention, and major surgical problems, etc., as "isolated case reports"). Dustin Evans Jr.'s problem surely would have to be classified as a complication: at least urinary retention or a major surgical problem, not to mention his death. See supra notes 1-2 and accompanying notes 1-2 and accompanying text (relating Dustin Evans, Jr.'s story).
175. See N. Williams & L. Kapila, Complications of Circumcision, 80 BRIT J. SURGERY 1231 (1993) (finding a realistic figure [for circumcision's complication rate] is 2-10 percent").
176. Id.
177. AAP 1999, supra note 19, at 691.
178. See Robert S. Thompson, supra note 68, at 194 (demonstrating that even accepting the faulty 0.2% circumcision immediate complication rate and Wiswell's faulty ten-fold relative risk of UTIs for remaining intact, medical utility is lacking for circumcision). With the more correct assumption of a 2-4% immediate complication rate and only a four-fold relative risk from being intact (this still ignores the 1.7 relative risk obtained by To et al., supra note 163 and accompanying text, in examining outpatient billings), the deficit of using routine circumcision as a treatment for UTIs is even more pronounced.
179. AAP 1999, supra note 19, at 691.
180. See generally Charles A. Nelson, The Nature of Early Memory, 27 PREVENTIVE MED. 172 (1998) (detailing the results of his research).
181. See id. at 172 (relating the experimental results of Carolyn Rowee-Collier, Development of Memory in Infancy, in THE DEVELOPMENT OF MEMORY IN CHILDHOOD (N. Cowan ed., 1996)).
182. Nelson, supra note 180, ah 179 (emphasis in original).
183. Id.
184. See AAP 1999, supra note 19, at 688 (citing Anna Taddio et al., Effect of Neonatal Circumcision on Pain Response During Subsequent Routine Vaccination, 349 LANCET 599 (1997)).
185. See Taddio el al., supra note 184, at 601-02 (finding that during vaccinations at four and six months of age, neonatally circumcised infants had a significantly stronger pain response than intact infants).
186. See id. at 599, 602 (nothing that lidocaine-prilocain 5%--Emla--cream only partially diminished the heightened pain response during later vaccinations and theorizing that aside from the fact that the Emla cream did not eliminate circumcision pain, it could not reduce post-operative pain while the wound healed in the following week).
187. See AAP 1999, supra 19, at 688-89 (discussing the effectiveness of various pain measures but progressing to a conclusion to a conclusion that does not address the problem of long-term behavioral effects implicated in the results of Taddio et al., supra note 184).
188. See AAP 1999, supra note 19, at 688-89 (citing the findings of Taddio et al., supra note 184, and following the citation with a lengthy description of the available pain measures, but failing to examine the significance of infant memory for pain and its behavioral effects, known and unknown).
189. See generally Jacobsen et al., supra note 18 (demonstrating that later suicide cases chose methods similar to the type of distress experienced perinatally).
190. AAP 1999, supra note 19, at 687.
191. See Robert S. Van Howe, Cost-effective treatment of Phimosis, 102 PEDIATRICS 966, abstract e43 (1998) (abstracting the results of a study on treatments for phimosis); see also Robert S. Van Howe, Cost-effective treatment of Phimosis (visited Mar. 9, 2000) (relating the full text of the article, abstracted in 102 PEDIATRICS, and comparing the cost-effectiveness of methods of treating phimosis).
192. See Robert S. Van Howe, Cost-effective treatment of Phimosis (visited Mar.9, 2000) (finding topical therapy to produce a "75% savings compared with circumcision").
193. See AAP 1999, supra note 19, at 687 (noting that Taylor's study "suggests that there may be a concentration of specialized sensory cells is specific rigid area of the foreskin but not in the skin of the penile shaft"). This statement misapprehends Taylor's clearly stated results. See Taylor et al., supra note 127 and accompanying text (finding that the presence of nerve endings similar to those in the finger-tips "firmly separate the foreskin from true skin).
194. American Academy of Pediatrics, Circumcision: Information for Parents (visited July 25, 1999) [hereinafter AAP 1999 online brochure].
195. See id. (providing a ten-fold risk figure); but cf. To et al., supra note 161 and accompanying text (providing a relative figure of 3.7).
196. AAP 1999 online brochure, supra note 194.
197. See infra Part III(G) (listing groups of physicians, nurses, lawyers, and others working to oppose routine neonatal circumcision).
198. AAP 1999 online brochure, supra note 194.
199. See supra note 121 and accompanying text (relating information contained in a 1984 AAP Brochure on caring for the uncircumcised penis).
200. Compare AAP 1999, supra note 19, at 687 (observing that "circumcised infant boys had a significantly higher risk of penile problems such as meatitis)"), with AAP 1999 online brochure, supra note 194 (putting a spin on the statements that circumcision increases the risk of meatitis and meatal stenosis by leading with the word "belief").
201. See AAP 1999 online brochure, supra note 194 (closing with a paragraph on female circumcision).
202. See RONALD GOLDMAN, CIRCUMCISION: THE HIDDEN TRAUMA 73-74 (1997) (comparing and contrasting the attitudes held by defenders of male and female circumcision, listing as justifications notions of cleanliness and health); Abbie J. Chessler, Justifying the Unjustifiable: Rite v. Wrong, 45 BUFF. L. REV. 555 (1997) (same).
203. American Academy of Pediatrics Committee on Bioethics, Female Genital Mutilation, 102 PEDIATRICS 153 (1998).
204. See id. at 153, 155 (referring to Department of Defense Omnibus Appropriations Act, 18 U.S.C.A. § 116 (1998)). The text of § 116 is as follows:
     1. Except as provided in subsection (b), whoever knowingly circumcises,
        • excises, or infibulates the whole or any part of the labia majora or labia
        • minora or clitoris of another person who has not attained the age of 18
        • years shall be fined under this title or imprisoned not more than 5 years,
        • or both.
     2. A surgical operation is not a violaton of this section if the operation is-
        1. necessary to the health of the person on whom it is performed, and is performed by a person licensed in the place of its performance as a medical practitioner; or
        2. performed on a person in labor who has just given birth and is performed for medical purposes connected with that labor or birth by a person licensed in the place of its performance as a medical practitioner, midwife, or person in training to become such a a practitioner or midwife.
     3. In applying subsection (b)(1), no account shall be taken of the effect on the person on whom the operation is performed, or any other person, that the operation is required as a matter of custom or ritual.
205. American Academy of Pediatrics Committee on Bioethics, Informed Consent, Parental Permission, and Assent in Pediatric Practice, 95 PEDIATRICS 314, 314 (1995).
206. Alan R. Fleischman, et al., Caring for Gravely Ill Children, 94 PEDIATRICS 433, 433 (1994). The author further stated, "[T]he authority society gives parents to control their children's lives is not absolute. Because children are no longer considered the property of their parents, and society recognizes that children may have interests independent of their families, limits to parental authority are justified when necessary to protect a child's well-being." Id. at 434 (citation omitted).
207. See AAP 1999, supra note 19, at 686 (citing the 1996 reports of the Australian College of Paediatrics, the Australian Association of Paediatric Surgeons, and the Canadian Paediatric Society).
208. See Fetus and Newborn Committee, Canadian Paediatric Society, Neonatal Circumcision Revisited, 154 CANADIAN MED. ASS'N J. 769, 775-76 (1996) (devoting two pages of the report to cost-benefit analysis and citing numerous cost-benefit analyses including those of Ganiats et al., supra note 133, and Robert S. Thompson, supra note 68).
209. Fetus and Newborn Committee Canadian Paediatric Society, Neonatal Circumcision Revisited, 154 CANADIAN MED. ASS'N J. 769, 769 (1996).

• Matthew R. Giannetti, Circumcision and the American Academy of Pediatrics: Should Scientific Misconduct Result in Trade Association Liability. 85 Iowa L. Rev. 1507 (2000).

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