The AAP's brochures on circumcision for parents

In 2001, the American Academy of Pediatrics issued a brochure on circumcision, based on its 1999 task force report, that is filled with misleading statements and pro-circumcision bias. A shorter brochure, issued in 2003, is less pro-circumcision, but has many of the same biases.

All text in red on this page is the author's commentary or added emphasis.

(2001)
Circumcision:
Information for Parents

Circumcision is a surgical procedure in which the skin [and mucosa, nerves, sensitive receptors and dartos muscle] covering the end of the penis is removed. [Not "covering the end of the penis" but covering the glans. In the average male, the foreskin is the end of the penis. This might seem just a quibble, but this very first sentence defines the foreskin as if it were not an integral part of the penis, setting the tone for the whole brochure.] Scientific studies show some medical benefits of circumcision. [This is a gross over-simplification, not to say distortion of the truth. Some studies seem to show some benefits - mainly slight reductions in rare diseases, which can often be treated without surgery, or do not strike until late in life - and these studies are frequently flawed and show a clear bias towards circumcision.] However, these benefits are not sufficient for the American Academy of Pediatrics to recommend that all infant boys be circumcised [- which should lead it to recommend that no infant boys be circumcised by a doctor unless there is a medical need.]. Parents may want their sons circumcised for religious, social, and cultural reasons. [They may, but ethical doctors should have nothing to do with that, since it is not medicine.] Since circumcision is not essential to a child's health, parents should choose what is best for their child by looking at the benefits and risks. [Since circumcision is not essential to a child's health, a healthy child should not be circumcised.] This brochure answers common questions you may have about circumcision. Use this as a guide to help you decide what is best for your baby boy. [The best person to decide whether your baby boy should keep all of his penis is your son, when he is old enough. He almost certainly will.]

What is Circumcision?

At birth, boys have skin that covers the end of the penis, called the foreskin. [As above, the foreskin is an integral part of the penis. Does your car's bumper cover the front of your car?] Circumcision surgically removes the foreskin, exposing the tip [no, the head (glans)] of the penis. Circumcision is usually performed by a doctor in the first few days of life. [Only in the US. In the Muslim world it is done by barbers on older boys, but in most of the world it is not usually done.] An infant must be stable and healthy to safely be circumcised. [But that's no guarantee.]

Many parents choose to have their sons circumcised because "all the other men in the family were circumcised" [which means that the habit can continue forever with no reason. How much time in his life does a boy spend looking at his father's penis? When he does, what he will most notice is its size.] or because they do not want their sons to feel "different." [Depending where he is born or lives later, he may be and feel "different" if he is circumcised. He may prefer to feel "different" than know that part of his penis is missing.] Others feel that circumcision is unnecessary [...harmful, dangerous, unethical and/or a breach of his human rights...] and choose not to have it done. Some groups such as followers of the Jewish and Islamic faiths, practice circumcision for religious and cultural reasons. Since circumcision may be more risky if done later in life [a claim with no basis; a man's full-sized penis is easier to operate on accurately], parents may want to decide before or soon after their son is born if they want their son circumcised. [This falsely assumes that it will eventually have to be done. In fact, in non-circumcising cultures, the rate of necessary circumcision is 1% or less.]

Reasons Parents May Choose Circumcision

Research studies suggest that there may [or may not] be some medical benefits to circumcision. These include the following:

  • A slightly lower risk of urinary tract infections (UTIs). A circumcised infant boy has about a 1 in 1,000 chance of developing a UTI in the first year of life; an uncircumcised infant boy has about a 1 in 100 chance of developing a UTI in the first year of life.
    [Another wasy of expressing that is that "circumcision seems to reduce the rate of UTIs by 0.9%". But this figure is based on the work of Dr Thomas Wiswell, which the AAP itself has described as "methodologically flawed" and who has publicly lauded the financial benefits to doctors of circumcision. Other studies give a much smaller difference, and the UTI rate in girls is much greater than boys, whether circumcised or not. UTIs can be treated without surgery - as they always are in girls, of course - and breastfeeding (by colonising the baby's urethra with the mother's healthy flora) has been shown to reduce the incidence of UTIs. Circumcision has a detrimental effect on the establishment of breastfeeding.]
     
  • A lower risk of getting cancer of the penis. However, this type of cancer is very rare in both circumcised and uncircumcised males. [...and rarer in some non-circumcising countries such as Denmark and Japan than the circumcising US.]
     
  • A slightly lower risk of getting sexually transmitted diseases (STDs) [except the commonest, chlamydia, where circumcised men may be at a higher risk], including HIV, the AIDS virus.
     
  • Prevention of foreskin infections. [Yes, that has to be conceded. They've got us there. Circumcision absolutely prevents all foreskin infections. Well, duh! What else could we not cut off on that basis?]
     
  • Prevention of phimosis, a condition in uncircumcised males that makes foreskin retraction impossible. [Often caused by mistakenly attempting to force the foreskin back before it has naturally separated. Not necessarily a problem. Phirmosis may also occur in badly circumcised boys.]
     
  • Easier genital hygiene. [Cleaning an intact penis could hardly be easier.]
Reasons Parents May Choose Not to Circumcise

The following are reasons why parents may choose NOT to have their son circumcised:

  • Possible [no, actual] risks. As with any surgery, circumcision has some risks. [But most surgery has necessity or major benefit, or is chosen by the patient.] Complications from circumcision are rare and usually minor. [Note the soothing tone. The complications can be major, up to and including death.] They may ["may"? They do] include bleeding, infection, cutting the foreskin too short [which can never be completely corrected, of course] or too long, and improper healing. [...not to mention cutting the glans and other ugly and dangerous results of various kinds. Minor aesthetic blemishes are surprisingly common.]
     
  • The belief that the foreskin is necessary [or just "of some value"] to protect the tip of the penis. [As before, the foreskin is the tip of the penis.] When [the foreskin is] removed, the tip [no, the glans] of the penis may become irritated and cause the opening of the penis to become too small. [Correct! This (meatal stenosis) is one of the commonest complications of circumcision.] This can cause urination problems that may need to be surgically corrected. [So why is this fact downgraded to a "belief"?]
     
  • The belief that circumcision makes the tip of the penis less sensitive, causing a decrease in sexual pleasure later in life. [The cut-off tip, the foreskin, certainly loses all its sensitivity, which is considerable. The sexual role of the foreskin itself is usually ignored in these discussions. There is also no doubt that the exposed glans hardens and becomes less sensitive, though when this is done to a baby his body may learn to compensate for this loss.]
     
  • Almost all uncircumcised boys can be taught proper hygiene that can lower their chances of getting infections, cancer of the penis, and sexually transmitted diseases. [This seems to have been included only for its scare-value. Washing under his foreskin is as big an issue as washing behind his ears.]
     
  • [The fact that the foreskin is an integral, complex part of the penis, with an unusual rolling action, which clearly means that it has a function, even if we don't fully understand it]
     
  • [Concern for the right of their son to decide for himself whether to have part of his sexual organs irrevocably cut off.]
     
  • [Because it ain't broke.]
[But no reason at all is needed not to cut part of a baby's genitals off.]
  Common Questions About Circumcision

Is circumcision painful?

When done without pain medicine, circumcision is [excruciatingly] painful. There are pain medicines available that are [usually] safe and [partially] effective. The American Academy of Pediatrics recommends that they be used to reduce pain from circumcision. Local anesthetics can be injected into the penis to lower pain and stress in infants. There are also topical creams that can help. Talk to your pediatrician about which pain medicine is best for your son. Problems with using pain medicine are rare and not usually serious.

What should I expect for my son after circumcision?

After the circumcision, [what is now] the tip of the penis may seem raw or yellowish. ["Seem"? No, it is raw. The inner layer of the foreskin had to be torn away from it before the foreskin could be cut off.] If there is a bandage, it should be changed with each diapering to reduce the risk of the penis becoming infected. Petroleum jelly should be used to keep the bandage from sticking. [So circumcision does not make the penis "maintenance-free".] Sometimes a plastic ring is used instead of a bandage. The plastic ring that is left on the tip of the penis usually drops off within 5 to 8 days. It takes about 1 week to 10 days for the penis to fully heal after circumcision.

Are there any problems that can happen after circumcision?

Problems after a circumcision are very rare. [That is, YES.] However, call your pediatrician right away if

  • Your baby does not urinate normally within 6 to 8 hours after the circumcision.
     
  • There is persistent bleeding. [A newborn baby has only about a breakfast-cupful of blood in his body. He needs a blood-transfusion after losing only about a large serving-spoonful of blood.]
     
  • There is redness around the tip of the penis that gets worse after 3 to 5 days.
     
It is normal to have a little yellow discharge or coating around the head of the [circumcised] penis, but this should not last longer than a week. [A reminder that the glans was attached to the foreskin by the synechia, and was torn away leaving a raw surface.]

What if I choose not to have my son circumcised?

If you choose not to have your son circumcised, talk to your pediatrician about how to keep your son's penis clean. [But don't expect him to know: a paediatrician who'd been circumcising for 25 years asked in the March 2000 issue of Pediatrics "What is meant by penile hygiene?"] When your son is old enough, he can learn how to keep his penis clean just as he will learn to keep other parts of his body clean.

The foreskin usually does not fully retract for several years and should never be forced. [Bravo! Forcing the foreskin back is one of the main causes of phimosis, which in turn results in the "need" for circumcision.] The uncircumcised [intact, whole, not "un-" anything] penis is easy to keep clean by gently washing the genital area while bathing. You do not need to do any special cleansing, such as with cotton swabs or antiseptics. [In fact that could be harmful.]

Later, when the foreskin fully retracts, boys should be taught how to wash underneath the foreskin every day. Teach your son to clean his foreskin by

  • Gently pulling it back away from the head of the penis
     
  • Rinsing the head of the penis and inside fold of the foreskin with [very mild] soap [if any] and warm water
     
  • Pulling the foreskin back over the head of the penis
See the AAP brochure Newborns: Care of the Uncircumcised Penis for more details. See your pediatrician if you notice any signs of infection such as redness, swelling, or foul-smelling drainage.

Female "Circumcision"

Female genital mutilation, sometimes called female circumcision, is common in many cultures. It involves removing part or all of a female's clitoris. [or just her clitoral hood, the part corresponding to the male foreskin, though the clitoral hood may not be as sensitive.] It may also involve sewing up the opening of the vagina. It is often done without any pain medicine. The purpose of this practice is to prove that a female is a virgin before she gets married, reduce her ability to experience sexual pleasure after marriage, and promote marital fidelity. [Male circumcision was introduced for similar reasons.] There are many serious side effects, including the following:

  • Pelvic and urinary tract infections
     
  • Negative effects on self-esteem and sexuality [yet in many cultures, it is the women who have themselves been circumcised who insist on it for their daughters...]
     
  • Inability to deliver a baby vaginally
     
  • [Gross breach of her human right to an intact body and the undisturbed possession of all her genitals...]

The Academy is absolutely opposed to this practice in all forms as it is disfiguring [Do we know that circumcised women necessarily think so? Beauty is in the eye of the beholder; some - perhaps including your son - will say male circumcision is disfiguring; in many cases it unquestionably is] and has no medical benefits [that US medicine recognises: Egyptian doctors claim medical benefits for it. Depending on the actual procedure, FGM unquestionably prevents all labial, vulval and/or clitoral infections].

[The contrast in tone between these two statements, male and female, rather speaks for itself. Whatever happened to equality of the sexes?]

The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

The actual 2001 brochure can be found at the Medem medical library site.

 

This strangely garbled information sheet came out in 2003. (All the spelling and grammar is sic.) While it is less pro-circumcision than the AAP's previous efforts, it is still seriously flawed.

 

JUST THE FACTS...................... CIRCUMCISION

[The very fact of starting by considering circumcision instead of intactness puts the cart ahead of the horse.]

After looking at almost 40 years of research on the benefits and risks of circumcision, the AAP concluded that we can not recommend a policy of routine newborn circumcision.

[And there there matter should end: don't do it. But "Routine" is ambiguous, and nobody recommends circumcision without consulting anybody. What follows falls far short of the other meaning of "not ... routine" - recommending leaving the healthy baby's penis alone.]

While circumcision is not essential to a child's well being at birth [Of course it's not! How could it be, when we went 100,000 years without it?], it does have potential medical benefits["potential" is a weasel word - any amputation has potential benefits if it means you don't suffer some other misfortune to that part, no matter how rare.]. We do recommend that parents discuss the benefits and risks of circumcision with their pediatrician and then make an informed decision about what's in the best interest of their child.

[This suggests that the decision must be tailored to each child. Yet each child has a standard-issue penis (if there are variations, neither parents or doctors are aware of them). This is a covert way of encouraging circumcising by making parents think that their decision to circumcise is especially "caring". Why not just recommend not doing it?]

Finally, if a decision for circumcision is made [translation: if you decide to cut a healthy part off your son's penis], it is essential that pain relief be provided for the infant during the procedure [yet the pain persists for days afterwards].

We agree that parents should make an informed decision after discussing the risks [no mention of the inevitable losses] and benefits of circumcision with their pediatrician.

There are potential medical benefits to circumcision. And, it's legitimate for parents to take into account religious, cultural and ethnic traditions. [Yet it's illegal if the baby is a girl, regardless of "religious, cultural or ethnic traditions". So is it ethical?]

The research shows that circumcised males have fewer urinary tract infections [and all males have fewer UTIs than females - yet we don't cut anything off girl babies]. They also have a lesser chance of developing penile cancer, which is a [very] rare problem.

The evidence is now clear that infants experience pain. And, according to numerous studies, there are several safe and effective methods to reduce [but by no means eliminate] the pain and stress associated with circumcision.

New research involving thousands of babies has shown pain control to be safe and effective in reducing the pain associated with circumcision. These include EMLA cream [which until very recently was deemed unsafe and ineffective for newborns], dorsal penile nerve block, and a subcutaneous ring block. In one study comparing these three forms of analgesia, the ring block appeared to be the most effective [or rather, the least ineffective - especially compared with leaving the baby alone].

Parents who decide to leave their son's foreskin intact should feel comfortable with this decision. There really is no data on psychosocial ramifications. ["Paychosocial ramifactions" of having a whole penis are a bogey concocted by the circumcising lobby. Many circumcised men suffer severe psychosocial ramifications from having part of their penis missing.] Urinary tract infections are usually not life threatening and are easily treated in most cases. Uncircumcised infant males have a four to ten-times higher risk of urinary tract infection during the first year of life compared to circumcised infant males. [Giving only the relative rate instead of the absolute rate - very low for both - is a dishonest use of the statistics] However, studies vary on the rate of the urinary tract infections in boys. [Why no mention of the much higher rate in girls?]

Whether boys are circumcised or not, penile cancer is very rare. [So why even mention it?] Studies suggest that there is at least a three-time higher risk of penile cancer in uncircumcised males; however, penile cancer is very rare, so increasing the risk several fold still means that penile cancer in uncircumcised males is still very rare [and occurs so late in life that the great majority of men die before they can get it.].

There is some suggestion in the literature that hygiene may affect the risk of penile cancer. But it's really unclear. Parents have to teach a child good hygiene whether a boy is circumcised or uncircumcised. It's just a matter of teaching the proper way to keep the area clean.

Circumcision is generally a very safe procedure [but you have no guarantee that your son won't be one of the unlucky ones]. Most complications associated with circumcision are minor. [Again the soothing tone. In fact, many complications are overlooked.]

The vast majority of uncircumcised boys do very well and it's unlikely that an uncircumcised infant will require circumcision later in life.

Circumcision is generally a very safe procedure. [The lady doth protest too much, methinks.] One can estimate that there is a 1 in 200 to 1 in 500 chance of complication from the circumcision procedure. [One can, but one would be wrong.] And even these complications are minor, such as soreness or bruising. [Why expose your perfect newborn baby to even soreness or bruising when there is no need?]

Medical reports suggest that the complication rate is between 0.2 and 0.6%, and that most of these complications are minor.

[This is a gross underestimate. These studies indicate the complication rate is 2-5%:

  1. Williams N, Kapila L. Complications of circumcision. Br J Surg. 1993; 80:1231-1236.
  2. de la Hunt MN. Paediatric Day Care surgery: a hidden burden for primary care?. Ann Royal Coll Surg Engl. 1999; 81:179-82.
  3. Patel H. The problem of routine circumcision. Can Med Ass J. 1966; 95:576-581.
  4. Ozdemir E. Significantly Increased Complication Risks with Mass Circumcisions. BJU Int. 1997; 80:136-139.
  5. Shah T, Raistrick J, Taylor I, Young M, Menebhi D, Stevens R. A circumcision service for religious reasons. BJU Int. 1999; 83(7):807-9. ]

We've known since 1989 that infants experience pain [many people with their eyes open have known for much, much longer], but there was concern that there was not enough data available to ensure that anesthesia safe for newborns. For example, baby's who received analgesia during circumcision showed less sensitivity to pain at their four-month shot than babies who received no analgesia. [This is not an example, it's a completely different issue.] But that's why it's important that baby boys receive some form of pain relief during the procedure. [That's yet another reason they should not have to undergo "the procedure".]

Parents have to teach a child good hygiene whether a boy is circumcised or uncircumcised. It's just a matter of teaching the proper way to keep the area clean.

There are no medical benefits to female circumcision. In fact, the Academy has a policy strongly opposes this practice. [The difference between the two policies is a blot on the AAP.]

C 2003 - American Academy of Pediatrics

The original of the 2003 information is at http://www.aap.org/mrt/factscir.htm.

 

An alternative brochure, with intactness as a norm instead of circumcison, is on this site.

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