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First, Do No Harm

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The American Academy of Pediatrics describes itself as "dedicated to the health and well-being of infants, children, adolescents and young adults." Unfortunately, its new Circumcision Task Force report, published last month in the journal Pediatrics, reveals instead a trade association agenda that desperately seeks to justify and secure reimbursement for a medically-unnecessary surgery that harms children and violates their basic human rights. The self-interest and selective blindness of the AAP report is especially remarkable given the growing condemnation of child circumcision by physician groups and even courts in European and Commonwealth countries, which view the surgery as an outmoded American ritual that serves no therapeutic purpose and causes both short- and long-term harm.

In actuality, the AAP report stops short of recommending circumcision, even as it claims the surgery's benefits outweigh the risks. Yet it states repeatedly that those risks are unknown and devotes not a word to the function and purpose of the foreskin, a normal and integral part of the penis and one that approximately 70 percent of all men worldwide have retained. The United States is virtually alone among developed countries in surgically altering the bodies of baby boys as a routine medical procedure. Rates of male circumcision in European countries are around 10 percent.

Not only does the Task Force report blatantly ignore the ethical obligation of physicians to respect their patients' autonomy and do no harm, it repeatedly calls for doctors to be paid by private insurance or Medicaid for removing healthy, functioning tissue from an infant baby boy who cannot consent to this permanent alteration to his body.

Specifically, the report says:

"Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns."

The Task Force says that it's the parents' responsibility to decide whether their particular newborn might benefit from being circumcised, though no guidance is given on how parents should make this decision.

In fact, 18 states do not cover circumcisions under Medicaid, and many insurance plans do not cover what the American Medical Association has referred to as a "non-therapeutic" procedure. The newborn circumcision rate is falling steadily in the United States, with current estimates placing it at about 50 percent -- as compared with around 80 percent only a few decades ago.

The decline is attributable to a number of factors, among these, immigration from countries where intact boys and men are considered normal and healthy and a growing awareness among parents that the surgery is unnecessary and -- indeed -- painful, risky, and harmful. These parents are as loathe to circumcise their infant sons as they would be to assent to the genital cutting of their daughters, a practice popular in parts of Africa and the Muslim world but outlawed in most Western countries, including the United States.

Nonetheless, for 2012 alone, the toll of American baby boys tied down and surgically altered will number 1 million (no baby "consents" to circumcision, as a fleeting glance at an infant circumcision on video or in the flesh will make clear). This is a human rights violation on a massive scale.

In justifying the perpetuation of infant circumcision, the AAP Task Force cites studies conducted among sexually-active adults in parts of sub-Saharan Africa with very high HIV prevalence. These studies looked at the role circumcision might play in retarding transmission of the HIV virus. They claim to have found a reduction in transmission from females to males, though not from men to women. Circumcision has not been conclusively found to reduce transmission of HIV in men who have sex with men, which together with intravenous needle-sharing, account for most cases of HIV in the United States.

Whether or not circumcision actually plays a role in reducing HIV transmission among some adults in sub-Saharan Africa has no relevance to baby boys in the United States. Babies are not sexually active and are therefore at no risk of sexually-transmitted HIV or any other venereal disease. In my opinion, these African studies are being used as after-the-fact justification for a custom that is increasingly being rejected by those who see it as violating children's rights to bodily autonomy and their own future freedom of religion.

As the AAP so comfortably supports infant and child circumcision, physicians abroad are stepping up to give baby boys the same kinds of human rights protection extended routinely to girls who might otherwise face the threat of female genital mutilation. The Royal Dutch Medical Association has recommended against routine male circumcision, the organization's medical ethicist Gert Van Dijk calling it a medically-unnecessary form of surgery.

"The patient has to give consent, but children can't give consent and we feel that is wrong and a violation of the child's right," Van Dijk said of circumcision. "In our code of medical ethics, it states that you must not do harm to the patient, but with this procedure this is exactly what you're doing."

In Denmark, the Prime Minister has commissioned an investigation into whether non-medical circumcision procedures violate its health code. In Germany, a court ruled in June that non-therapeutic male circumcision amounted to bodily injury and violated human rights provisions of the country's laws. The judge explicitly ruled that the parents' religious freedom cannot override the child's right to physical integrity and self-determination.

"The body of the child is irreparably and permanently changed by a circumcision," the judge wrote. "This change contravenes the interests of the child to decide later on his religious beliefs."

Following the German court's decision, hospitals in Austria and Switzerland suspended all medically-unnecessary infant circumcisions. Political discussion continues in Germany over whether religious circumcisions might be allowed, but no European physician organization is contending that there is any medical justification for routinely circumcising babies or children.

All of this -- together with the insistence that parents bear the burden (and therefore the liability) of deciding whether or not to have their sons circumcised -- makes it clear to me that the American Academy of Pediatrics Task Force report is all about justifying past practice, perpetuating it into the future, disclaiming responsibility for any adverse consequences, and ensuring a revenue stream for doctors.

Intactivists -- those of us who argue for the human right of infant boys to remain whole until they can make their own informed decisions -- plan to be in New Orleans this October when the AAP presents its Task Force report. We will be asking pediatricians to respect their first ethical obligation to their patients, which is to do no harm.