To the Editor.--
The new American Academy of Pediatrics (AAP) Task Force on Circumcision statement is seriously flawed. The body of the statement indicates neonatal circumcision to have both potential benefits and risks, neither one being more compelling than the other. It logically would follow that the conclusion should simply state these benefits and risks, as did the 1989 Task Force, allowing the parents to choose with physician advice. Instead, the Task Force concluded "these data are not sufficient to recommend routine neonatal circumcision," implying that the AAP is now opposed to neonatal circumcision. Indeed this is how it was perceived in the media.1,2 The AAP should have had sufficient media savvy to foresee this and choose more appropriate, neutral language.
The statement claims that the report is "evidence-based," yet the Task Force clearly courted anti-circumcision forces, which may have unduly influenced the analysis. The AAP invited anti-circumcision activist Robert Van Howe to appear before it in June 1997. Van Howe subsequently claimed that he served as a consultant to the Task Force 3. I have contacted the individuals who have been most directly involved in research concerning the link between the foreskin and penile cancer, urinary tract infections, and sexually transmissible diseases (including HIV). Neither these individuals nor others who have studied potential medical advantages of circumcision, were asked to appear before the Task Force. It seems only fair to have both sides queried; why was one side invited but not the other?
The Task Force review of the literature was quite superficial, ignoring relevant studies and citing obsolete data. Furthermore, it often placed greater emphasis on those studies that showed only minimal benefits to circumcision. Regarding penile cancer, the Task Force improperly compares various countries using non-standardized data from incompatible studies.4 Moreover, the Task Force ignored the WHO data published in Cancer Incidence in Five Continents.5 Had it utilized the WHO data and properly compared populations of opposite circumcision status it would have found that Israel (almost all circumcised) has an annual incidence of 0.1 per 100,000 (age standardized world rate) which is 1/10 that of Denmark (mostly uncircumcised) in the years 1983-1987. The same source indicates even greater differences between third world circumcised nations such as Nigeria and uncircumcised nations such as Uganda and Puerto Rico. The international epidemiological WHO data clearly indicates that circumcision confers substantial protection against penile cancer--far more than the small three-fold difference cited from a single center that improperly mixed invasive cancer with carcinoma in situ.6
The new pamphlet, "Circumcision: Information for Parents", is also flawed. If the Task Force intended the pamphlet to be "evidence-based," why does it contain such items as "the belief that circumcision makes the tip of the penis less sensitive, causing a decrease in sexual pleasure later in life..." Such "beliefs," devoid of scientific support, have no place in an AAP pamphlet.
In conclusion, the Task Force constructed a flawed study, allowed itself to be exposed to undue anti-circumcision pressure, used inadequate data, and produced a statement all too easily misconstrued. Furthermore, the AAP pamphlet for new parents contained "beliefs" of no scientific merit.
Stefan A. Bailis
Research and Education Association on Circumcision Health Effects Des Moines, IA-50393
1 No significant benefits to circumcision. Associated Press, March 1st, 1999.
2 Circumcision no longer recommended. USA Today, March 2nd, 1999.
3 Van howe RS. Is circumcision healthy? No. Priorities. 1997;9(4):25-29.
4 Pediatrics 1999;103:686-693, references 90-94.
5 Cancer Incidence in Five Continents, published first by the International Union Against Cancer, later by the International Agency for Research on Cancer division of the World Health Organization. 1966 (Volume 1) to 1997 (Volume 7).
6 Maden C, Sherman KJ, Beckmann AM, Hislop TG, Teh C-Z, Ashley RL, Daling JR. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. J Nat Cancer Inst 1993;85:19-24.
Letter published in Pediatrics 2000; 105(3):620