Sunday, August 28, 2016

Where They Stand: Straddling the Great Divide Between Non-Therapeutic Circumcision and Pain-Prevention in Neonates

by David Balashinsky

Earlier this year, the AAP published a revised policy statement regarding procedural pain in neonates.  The very first recommendation, as it appears in the Abstract section of the new policy statement (AAP Gateway, Pediatrics; February 2016, Volume 137 / Issue 2) is that "The prevention of pain in neonates should be the goal of all pediatricians and health care professionals who work with neonates. . . ."  In the Background section, the revised policy also states, in part, "The prevention and alleviation of pain in neonates . . . is important not only because it is ethical but also because exposure to repeated painful stimuli early in life is known to have short- and long-term adverse sequelae."  The AAP's policy also states (again, returning to the Abstract): "every health care facility caring for neonates should implement . . . a pain-prevention program that includes strategies for minimizing the number of painful procedures performed. . . ."  

I take it as axiomatic that the starting point for "preventing or minimizing pain" is avoiding unnecessary pain in the first place.  That being the case, one wonders how the AAP reconciles these humane and common-sense recommendations with its continued support for  nontherapeutic infant circumcision.

Nontherapeutic infant circumcision, which is still routinely practiced in the United Sates, in contrast to most of the developed world, and which is overwhelmingly practiced here for reasons of custom or cosmesis, is a medically unnecessary surgery that violates the four most basic and important principles of medical ethics.  First, not to do harm.  Second, not to provide a treatment in the absence of a medical problem (such as a disease or harmful congenital deformity). Third, to opt for the least invasive or aggressive treatment available when there is a disease or other medical problem.  And, fourth, to obtain consent from the patient before rendering care unless the patient is incapable of providing consent and the treatment is required urgently to save life or limb. Nontherapeutic infant circumcision violates every one of these principles.  Every one of the "health benefits" on the basis of which  infant circumcision is rationalized can be achieved through the use of non-painful and non-invasive means, such as the practice  of basic hygiene, the administration of the HPV vaccine, the use of a condom in order to prevent the spread of STIs, or the use of antibiotics or other non-painful and minimally invasive treatments when a pathological condition, such as a UTI for example, does occur - in other words, exactly the same prophylactic and remedial approach to genitourinary health as is employed with girls.   Even something as simple as not smoking has been proven to have a greater effect upon reducing a man's chances of developing penile cancer than circumcision has.  

Above and beyond all this, circumcision causes extreme pain and distress to the neonate who is subjected to it.  For generations, circumcision was routinely performed without any pain-relief whatsoever in the absurd belief that infants are incapable of experiencing pain. Today, with over one million circumcisions still performed annually in the United States, the application of adequate or even any pain relief is by no means universal nor is it mandated by law.  By some estimates, even now, only 25% of children who are subjected to circumcision receive adequate anesthesia.

The AAP concedes that "existing scientific evidence is not sufficient to recommend routine circumcision."  And yet, lacking sufficient evidence-based medical justification for nontherapeutic circumcision, the position of the AAP, as articulated in its most recent policy statement (2012) is that "the final decision should still be left to parents to make in the context of their religious, ethical and cultural beliefs."  Why does the AAP, an organization of medical professionals that professes to be "dedicated to the health, safety, and well being of infants," continue to defend a painful and medically unnecessary surgery on the basis of "religious, ethical, and cultural beliefs"?  How is subjecting male infants to circumcision for cultural or religious reasons ethically any different from subjecting girls to "female circumcision," which is also performed for cultural and religious reasons?  Defenders of infant male circumcision in the United States are quick to claim that male genital cutting and female genital cutting are fundamentally dissimilar - but isn't this just a form of cultural arrogance?   It amounts to claiming "It's okay when we do it."  But it is merely the distorting lens of one's own cultural context that makes these two practices appear to be fundamentally different.  In a culture in which male circumcision has been normalized but female circumcision has not, the two practices are simply judged by different yardsticks.  Yet there is no rational scientific or medical basis for hypothesizing and studying the potential health benefits of surgical modification to male genitalia while denying a priori any comparable health benefits of surgical modification to female genitalia.  

This raises an important question:  If studies were to suggest that the "benefits" of female genital cutting outweigh the "risks," would the AAP likewise endorse "access to this procedure for families who choose it" (to use the AAP's parlance)?  That is not a farfetched hypothetical question.  In Egypt, where female genital cutting remains common, its defenders include physicians who claim, just as the AAP does on behalf of male circumcision, that female circumcision is medically justified.  It is probably not a coincidence that female circumcision is now, in the 21st century, increasingly becoming "medicalized" (that is, performed in hospitals under aseptic conditions and justified on medical grounds) just as male circumcision became medicalized in Great Britain and North America in the 19th century and is now becoming medicalized in Africa. (Indeed, one might reasonably speculate that the defenders of female circumcision have now taken a page from the AAP's book.)   Nor is it a coincidence that the "benefits" of female circumcision closely parallel the myriad claims that are routinely made in defense of male circumcision, including "improved aesthetics and hygiene."  The inescapable conclusion of all this is that the AAP endorses what is essentially a cultural practice that harms infants and causes them excruciating pain needlessly even as it acknowledges that there is insufficient medical evidence to support routine infant circumcision (RIC) and even though, as the AAP now acknowledges in its latest policy statement on neonate pain management, "there are significant research gaps regarding the assessment, management, and outcomes of neonatal pain; and there is a continuing need for studies evaluating the effects of neonatal pain and pain-prevention strategies on long-term neurodevelopmental, behavioral, and cognitive outcomes."

As controversial as nontherapeutic circumcision is, there remains one fact about it that is not in dispute that, to my knowledge, the AAP has never addressed.  This is that no infant ever consents to his own circumcision.  Consider again the AAP's position statement that "the procedure's benefits justify access to this procedure for families who choose it."  But, of course, it is not "families" who choose circumcision but parents.  The individual himself  - the one who is actually being circumcised and, therefore, the only person whose opinion should actually matter - has no say at all.  But by what right of parental authority is it ethical or appropriate for a parent to order the medically unnecessary amputation of a part of his or her child's body?  And by what principle of medical ethics does the AAP endorse such a parental prerogative?  Throughout the AAP's deliberations regarding its official stance on circumcision, how much weight was given to the right of the individual himself not to have part of his penis amputated without his consent?  Where is the AAP's recognition that every human being is born with an innate and sacrosanct right to ownership and control of his own body?   Infants, after all, do not remain infants forever. Circumcision, on the other hand, is permanent.  (And, of course, there is absolutely nothing to prevent an intact adult male from choosing for himself  to undergo a circumcision once he is old enough to weigh for himself the costs and potential benefits of circumcision.)  Where is there any acknowledgement by the AAP that the man the circumcised infant will one day become may object to having had a functional and erogenous part of his penis amputated on the basis of nothing more substantial than an amalgamation of superstition, cultural norms, religious beliefs, and tenuous medical justifications?  Was there ever even a passing consideration by the AAP's task force on circumcision  that that man may prefer to have experienced life with his body whole and his penis intact?   The AAP equivocates about the "risks" of circumcision (while conceding that no one actually knows for certain what those risks are) yet refuses to acknowledge even now that circumcision is a harm in and of itself.   If the AAP's refusal to recognize this fact is predicated on its dismissal of the functions and importance of the male prepuce, including its role in sexual sensation for both male and female and its functional role during coitus, it is predicated even more fundamentally on the AAP's apparent disdain for the right of the individual to decide for himself which parts of his body are important to him -  and to decide for himself which parts of his body he gets to keep and which parts get cut off. 

It's time for the AAP to live up to the lofty ideals of its professed mission "to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents and young adults."  The AAP has an ethical duty to protect children; that ethical duty is incumbent upon each of its members, as well.  That duty includes refraining from subjecting neonates to painful and unnecessary surgeries, especially a surgery that results in the permanent loss of a functional and sensitive body part that every neonate, every infant, every child, every adolescent, and every man has a right to retain and to have retained into adulthood.  Revising its policy on circumcision so as to bring it into conformity with the AAP's recent policy statement on neonate pain-prevention - to say nothing of bringing it into conformity with the principles of medical ethics and into conformity with a basic respect for infants' and men's fundamental human right to physical integrity - would bring the AAP a long way toward realizing its stated goal of "preventing or minimizing pain in neonates."

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