Van Howe to AAP re: circumcision brochure

Letter to American Academy of Pediatrics. November 17, 1995

Ms. Mary Claire Walsh
Project Manager
American Academy of Pediatrics
141 Northwest Point Blvd.
P. O. Box 927
Elk Grove Village, IL 60009-0927

Dear Ms. Walsh,

I have just received a copy of the AAP brochure, "Circumcision: Pros and 
Cons," and after reading through its contents I cannot in good conscience 
distribute it to my parents. The brochure is strongly biased in favor of the 
procedure and laden with factual errors. Because of these multiple 
misrepresentations of the current medical literature, I fear distribution of 
this brochure to my parents may place myself at increased risk for 
litigation. As a fellow of the American Academy of Pediatrics, I am also 
concerned that the brochure may place the Academy at increased risk for 
successful litigation.

To help in the effort to provide accurate information to parents considering 
circumcision for their sons, I have the following observations:

1)There is no mention in brochure what is being removed by circumcision.
Parents need to be informed that the foreskin constitutes 30-50% of the 
penile skin system and is, based on histologic studies, the most highly 
innervated portion of the penis.[1] They need to know that the foreskin 
closely adheres to and protects the mucosal surface of the glans from outside 

2) The statement "Circumcision is one of the oldest known surgical procedures 
in medicine" is inaccurate. While it may be the oldest ritual procedure of
mankind, it was only rarely used as a medical procedure until the last
hundred years.

3) The statement "During circumcision the foreskin is removed so that the tip 
of the penis and the opening through which the baby urinates are exposed" is 
incomplete. It needs to be stated that there is no medical reason for 
exposing the tip of the penis. The penis functions perfectly well with the 
tip unexposed. It also needs to be stated that exposure of the tip can result 
in topical infections of the glans.

4) Any mention of religious practices is inappropriate. It gives the
impression that the AAP is proselytizing, which I am sure is not the intent 
of the Academy.

5) The statement, "After the circumcision, the tip of the penis may seem
raw," is inaccurate. By stating that the penis *may seem* raw, the Academy is 
minimizing the trauma wrought from this procedure. Circumcision forcibly 
separates the mucosal surface of the foreskin that adheres to the mucosal 
surface of the glans. The tip of the penis is always raw after circumcision. 
To illustrate this in terms parents will understand, it may be best to equate 
it with having a fingernail ripped off the nail bed.

6) The section "Are there problems that can happen after circumcision?" is 
woefully incomplete and only addresses the more common, immediate 
complications of circumcision. Very common problems such as coronal adhesions 
(which occur in 25% of circumcised boys), the glans being covered by skin 
leading some parents to have the procedure redone (17%), entrapped epithelial 
debris (16%), and topical infections (7%) are not addressed.[2] Parents need 
to be informed that infant boys who have their foreskins do not experience 
these problems.

To be more balanced, death as a complication to circumcision needs to be 
mentioned if cancer of the penis is mentioned. Both of these entities happen 
with approximately the same frequency.[3]

The psychological effects, which have been well documented, are not 
mentioned. It is important to point out that circumcision has been shown to 
adversely affect a newborns behavior for up to one week after the 
procedure,[4] that boys who were circumcised at birth cry longer and louder 
when receiving their immunizations,[5] and that genital trauma on children 
has been demonstrated leave a permanent mark on the brain.[6-7]

It also needs to be mentioned that the adverse physical, sexual and 
psychological impact of infant circumcision on adult males has not been 

7) The information given under the heading, "Circumcision – pros and cons," 
is misleading and reflects a pro-circumcision bias. It needs to be mentioned
that the circumcision rate in the United States if falling and at the current 
trend circumcised boys may soon be in the minority. Including the statement 
that "Many parents choose to have their sons circumcised because 'all the 
other men in the family were circumcised' or because they don't want their 
son to feel 'different,'" grants legitimacy to these vain considerations. As 
such, this statement encourages cosmetic surgery on  non-consenting 
individuals. This is completely at odds with the Academy's most recent 
position on informed consent and violates most standards of medical ethics. 
Parents also need to be informed that half of circumcised infants will not 
look like the circumcised men in their family for the first several years of

It is also prejudicial to suggest that parents would need to justify their 
decision to leave their son's foreskin in place while no suggestion is given 
that parents tell their circumcised son why the end of their penis is 

8) The statement, "Circumcision lowers your son's chances of getting a 
urinary tract infection (UTI) in the first year of life," is inaccurate. At 
best the retrospective studies that have been performed show a possible
association. It would be more accurate to state that "Some studies have 
suggested that circumcision *may* lower your son's chances of getting a 
urinary tract infection (UTI) in the first year of life, but further study in 
this area is needed. Fortunately, UTIs are rare and easily treated with oral

9) A discussion of penile cancer should not be part of this brochure because 
it is so incredibly rare. Also new studies have cast doubt over whether 
circumcision plays a role in preventing penile cancer.[9-10] If cancer is 
mentioned as a reason for circumcising, then death needs to be mentioned as a 

10) The statement, "Research shows that males who are circumcised have a 
slightly lower risk of getting sexually transmitted diseases (STDs)," is 
completely untrue. Several new studies have shown that circumcised males are 
at higher risk for developing genital warts,[11-2] gonorrhea, syphilis,[13] 
non-gonococcal urethritis,[14-5] and HIV infections.[16-8]

11) The statement, "Circumcision eliminates foreskin infections that occur at 
the peak age of 3-5 years," is completely untrue and has never been 
documented in the medical literature. In an ongoing prospective study, which 
I am conducting, the opposite has been found.[19] In addition, a 
retrospective study found more penile problems in circumcised boys at these 
younger ages than those left intact.[20]

12) The statement, "Circumcision prevents phimosis, a narrow opening that 
makes it impossible to retract the foreskin at a later age," is pure 
unsubstantiated speculation and has never been documented in the medical 
literature. From the accurate incidences published in the medical literature 
the percentage of intact boys developing "true" phimosis and those boys who 
are circumcised who develop phimosis are nearly identical.[21-4]

13) The statement, "Genital hygiene, which is particularly important in 
unsanitary conditions, may be easier after circumcision," is likewise pure 
speculation. My ongoing prospective study has shown the exact opposite to be 
the case. The reason for this is simple. The foreskin has smooth muscle near
the tip that puckers it shut, thus preventing stool and feces from entering. 
The circumcised boy does not have such protection.

14) The statement, "Circumcision may be risky if done later in life," is 
inaccurate. The complication rates reported in the medical literature for 
neonatal and post-neonatal circumcision indicate the complication rate for 
neonatal circumcision may be higher.[25-32]

15) The statement, "parents should try to make a decision about 
circumcision," assumes that parent can ethically implement their decision 
about circumcision. This is contrary to most international statements on
human rights and United States legal precedents.[33] It is also contrary the 
AAP's position on informed consent.[34] To date the AAP has not adequately 
addressed this issue and urgently needs to do so. To assume that parents have 
the right to make this decision when legally and ethically they may not, is a 
bias in favor of parental rights over a child's rights, which is out of 
character for the AAP and encourages unnecessary surgery.

16) The statement, "Infants who are circumcised without pain medication will 
feel some pain," is incredibly misleading. All of these infants experience 
*excruciating* pain. New evidence suggests that similar interventions on
newborns are more painful for them than older infants and children.[35] 
Sucking on a sugar solution has been shown to decrease the crying associated 
with circumcision[36] but the humoral changes associated with the stress of 
the procedure are not ameliorated.[37] Minimizing the pain related aspects of
the procedure again reflects the pro-circumcision bias of this brochure. 
Parents should be encouraged to seek out a physician who uses anesthesia.

17) The statement, "The Academy is absolutely opposed to this practice 
[female genital mutilation] in all forms as it is disfiguring and has no 
medical benefit," is hypocritical because the same language applies to male 

18) The statement, "boys should be taught the importance of washing 
underneath the foreskin everyday to remove the smegma – a white cheese-like 
substance that is found under the foreskin," is unbalanced. In my ongoing 
prospective study 17% of circumcised infants had a "white cheese-like 
substance" between their glans and remnant foreskin while none of the intact 
boys did.[38] The statement incorrectly implies that only intact boys can 
develop can develop a "white cheese-like" substance.

19) The brochure closes by saying, "Circumcisions are often done for 
religious, social, and cultural reasons. The Academy suggests parents talk to 
their pediatrician about circumcision and make a decision after looking at 
the facts." This encourages parents to seek advice from physicians in areas 
in which they have no expertise. As a pediatrician I feel comfortable 
discussing the medical aspects of circumcision, but I am sure I will dispense 
inaccurate information concerning the social, religious, and cultural aspects 
of this ritual.

While the Academy had the best of intentions in producing "Circumcision Pros 
and Cons: Guidelines for Parents," the results are unfortunate. The obvious 
pro-circumcision bias of the brochure only propagates the disrespect the 
Academy earned when it released the equally biased, inaccurate Task Force 
report in 1989. Pediatricians and parents look to the Academy for accurate
unbiased information, this brochure falls far short of this expectation.

What is more important, the brochure places both the pediatrician and the
Academy at risk for litigation. The untruths, inaccuracies, and misleading 
statements noted above make it appear as though the Academy was purposely 
covering up the truth to let infant circumcision continue at the present 
rate. This procedure nets physicians and hospitals on the order of 
$200,000,000.00 per year. Do the interests of the Academy rest with the what 
is best for the infant boy or the physician's bottom line? The content of 
this brochure makes a strong case that the rights of infant boys have been 
sold out for cold cash. I do not think this was the Academy's intent, but it 
is obviously the result. Knowingly publishing inaccurate information can only
get the Academy in trouble.

For the most part I am proud to be a fellow of the AAP, especially when 
Academy has acted as the champion of children's rights, but this brochure is 
an embarrassment.

I implore you to revise this brochure, and this time try telling the truth in 
a balanced fashion.


Robert S. Van Howe, M.D. FAAP


  1. Taylor J. The prepuce: what, exactly, is removed by circumcision? Br J Urol [in press]
  2. Van Howe R. Variability in penile appearance and penile problems: a prospective study. [submitted for publication] copy enclosed
  3. Gellis SS. Circumcision. Am J Dis Child 1978; 132: 1168-9.
  4. Dixon S, Snyder J, Holve R, Bromberger P. Behavioral effects of circumcision with and without anesthesia. J Dev Behav Pediatr 1984; 5: 246-50.
  5. Taddio A, Goldbach M, Ipp M, Stevens B, Koren G. Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet 1995; 345: 291-2.
  6. Goleman, D Adolescent violence is traced to abuse and neglect in childhood. Early Violence Found to Be Etched in the Brain. New York Times, October 3, 1995, B5.
  7. Bremner JD. Science News 3 June 1995; 147: 340.
  8. Van Howe, op cit.
  9. Maden C, Sherman KJ, Beckmann AM, Hislop TG, Teh CZ, Ashley RL, Daling JR. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. J Natl Cancer Inst 1993; 85: 19-24.
  10. Holly EA, Palefsky JM. Factors related to risk of penile cancer: new evidence from a study in the Pacific Northwest. J Natl Cancer Inst 1993; 85: 2-4.
  11. Cook LS, Koutsky LA, Holmes KK. Circumcision and sexually transmitted diseases. Am J Public Health 1994; 84: 197-201.
  12. Cook LS. Koutsky LA. Holmes KK. Clinical presentation of genital warts among circumcised and uncircumcised heterosexual men attending an urban STD clinic. Genitourin Med 1993; 69: 262-264.
  13. Donovan B, Bassett I, Bodsworth NJ. Male circumcision and common sexually transmissible diseases in a developed nation setting. Genitourin Med 1994; 70: 317-20.
  14. Newell J, Senkoro K, Mosha F, Grosskurth H, Nicoll A, Barongo L, Borgdorff M, Klokke A, Changalucha J, Killewo J et al. A population-based study of syphilis and sexually transmitted disease syndromes in north-western Tanzania. 2. Risk factors and health seeking behaviour. Genitourin Med 1993; 69: 421-6.
  15. Smith GL, Greenup R, Takafuji ET. Circumcision as a risk factor for urethritis in racial groups. Am J Public Health 1987; 77: 452-4.
  16. Van de Perre P, Carael M, NzVanaramba D, Zissis G, Kayihigi J, Butzler JP. Risk factors for HIV seropositivity in selected urban-based Rwandese adults. AIDS 1987; 1: 207-11.
  17. Chao A, Bulterys M, Musanganire F, Habimana P, Nawrocki P, Taylor E, Dushimimana A, Saah A. Risk factors associated with prevalent HIV-1 infection among pregnant women in Rwanda. National University of Rwanda-Johns Hopkins University AIDS Research Team. Int J Epidemiol 1994; 23: 371-80.
  18. Guimaraes M, Castilho E, Ramos-Filho C, et al. Heterosexual transmission of HIV-1: a multicenter study in Rio de Janeiro, Brazil. VII International Conference on AIDS. Florence, June 1991 [abstract MC3098].
  19. Van Howe, op cit.
  20. Fergusson DM, Lawton JM, Shannon FT. Neonatal circumcision and penile problems: an 8-year longitudinal study. Pediatrics 1988; 81: 537-41.
  21. Kaweblum YA, Press S, Kogan L, Levine M, Kaweblum M. Circumcision using the Mogen clamp. Clin Pediatr Phila 1984; 23: 679-82.
  22. Wiswell TE, Tencer HL, Welch CA, Chamberlain JL. Circumcision in children beyond the neonatal period. Pediatrics 1993; 92: 791-3.
  23. Gordon A, Collin J. Save the normal foreskin: Widespread confusion over what the medical indications for circumcision are. Br Med J 1993; 306: 1-2.
  24. Van Howe, op cit.
  25. Walfisch S, Ben-Zion YZ, Gurman G. [Circumcision of new immigrants] Harefuah 1994; 126: 119-21, 176.
  26. Wiswell, op cit.
  27. Williams N, Kapila L. Complications of circumcision. Br J Surg 1993; 80: 1231-6.
  28. Gee WF, Ansell JS. Neonatal circumcision: a ten-year overview: with comparison of the Gomco clamp and the Plastibell device. Pediatrics 1976; 58: 824-7.
  29. Metcalf TJ, Osborn LM, Mariani EM. Circumcision: a study of current practices. Clin Pediatr 1983; 22: 575-9.
  30. Moreno CA, Realini JP. Infant circumcision in an outpatient setting. Tex Med 1989; 85: 37-40.
  31. Kaweblum, op cit.
  32. O'Brien TR, Calle EE, Poole WK. Incidence of neonatal circumcision in Atlanta, 1985-1986. South Med J 1995; 88: 411-5.
  33. Bonner CA, Kinane MJ. Circumcision: the legal and constitutional issues. The Truth Seeker 1989. July/August: S1-S4.
  34. Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995; 95: 314-7.
  35. Anand KJS. Impact of pain in critically ill newborns: principles of pain management. Child Health 2000, Vancouver, British Columbia. June 1, 1995.
  36. Blass EM, Hoffmeyer LB. Sucrose as an analgesic for newborn infants. Pediatrics 1991; 87: 215-8.
  37. Gunnar MR, Connors J, Isensee J, Wall L. Adrenocortical activity and behavioral distress in human newborns. Dev Psychobiol 1988; 21: 297-310.
  38. Van Howe, op cit.

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