Send letter to journal:
Re: Edgar Schoen does not represent the North American view of male circumcision
 

Email George Hill, et al.
 

Dear Editor:

We dispute the claim that Schoen represents the North American view.1 We think that he represents only his personal view and that of a few disciples.

Schoen’s claims have been rejected wherever he goes. When he published in the New England Journal of Medicine in 1990,² his views were opposed by Poland.³ When he published in Acta Paediatrica Scandinavia in 1991,⁴ his views were rebutted by Bollgren & Winberg.⁵ When Schoen published in this journal in 1997⁶ his views were countered by Hitchcock⁷ and also by Nicoll.⁸ In the present instance, his views are offset by Malone.⁹

When the Canadian Paediatric Society published their position statement on neonatal circumcision in 1996,¹⁰ they followed the views of Poland,³ not those of Schoen.² Although Schoen was chairman of the American Academy of Pediatrics (AAP) task force on circumcision that published in 1989,¹¹ he did not serve on the AAP task force on circumcision that published in 1999.12 That second task force distanced the AAP from the views published by Schoen’s task force¹¹ a decade earlier.

Schoen’s present views on circumcision are strikingly similar to Wolbarst’s,¹³ which were published nearly a century ago. This suggests that Schoen’s views are founded in a desire to preserve his culture of origin, not in medical science. Goldman writes:

One reason that flawed studies are published is that science is affected by cultural values. A principal method of preserving cultural values is to disguise them as truths that are based on scientific research. This 'research' can then be used to support questionable and harmful cultural values such as circumcision. This explains the claimed medical 'benefits' of circumcision.¹⁴

The present North American view is that neonatal circumcision is not of medical value and that any benefits are more than offset by the risks, complications, and disadvantages of non-therapeutic infant circumcision. The Canadian Paediatric Society says, “Circumcision of the newborn should not be routinely performed.”¹⁰ The American Academy of Family Physicians described neonatal circumcision as “cosmetic” in nature.¹⁵ More recently, the College of Physicians and Surgeons of British Columbia reported:

Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention.¹⁶

A recent North American cost-utility study concluded:

Neonatal circumcision is not good health policy, and support for it as a medical procedure cannot be justified financially or medically.¹⁷

The statistics provided by Schoen on the incidence of circumcision in North America are out of date. The popularity of non-therapeutic infant circumcision is declining. The Association for Genital Integrity reports that only 13.9 percent of male infants in Canada were circumcised in 2003.¹⁸ Data provided by the National Hospital Discharge Survey indicates that the percentage of male infants circumcised in the United States declined to 55.1 percent in 2003.¹⁹ One expects to see further declines in the popularity of circumcision as newer data are reported. Many health maintenance organizations in the USA and most Canadian health insurance plans no longer pay for non-therapeutic circumcision of infant boys.

With regard to prevention of urinary tract infection (UTI), the only North American recommendation we can find is that of the Section on Breastfeeding of the AAP, which recommends breastfeeding to reduce the incidence of UTI in all infants.²⁰ It says that procedures that “may traumatize the infant” or otherwise interfere with breastfeeding initiation should be avoided.²⁰ Circumcision, a highly traumatic procedure, which apparently produces an “infant analogue of post-traumatic stress disorder,”²¹ works against breastfeeding initiation and ultimately against optimum child health and development as well as establishment of UTI protection by breastfeeding.²² The most recent AAP task force on circumcision does not recommend circumcision to prevent UTI or for any other reason.¹²

Both parents and health care providers have a general duty to consider the “best interests” of the whole child.²³ This must include sexual and psychological well-being²⁴ and the child’s interest in preserving his legal right to bodily integrity.²⁵ Most discussions of the alleged value of circumcision in preventing UTI usually take an excessively narrow view.

One should not characterize Schoen’s personal view as representing the North American view. North America has moved on.

George Hill, Bioethicist Executive Secretary

John V. Geisheker, J.D., LL.M. General Counsel

Doctors Opposing Circumcision
Suite 42
2442 NW Market Street
Seattle, Washington 98107-4137
USA
Website: http://www.doctorsopposingcircumcision.org

References:

1. Schoen EJ. Circumcision for preventing urinary tract infections in boys: North American view. Arch Dis Child 2005;90:772-3. [Full Text]
2. Schoen EJ. Sounding Board. The status of circumcision of newborns. N Engl J Med 1990; 322:1308-12.
3. Poland RL. The question of routine neonatal circumcision. N Eng J Med 1990; 322:1312-5.
4. Schoen EJ. Is it time for Europe to reconsider newborn circumcision? Acta Paediatr Scand 1991;80;573-5.
5. Bollgren I, Winberg J. Letter. Acta Paediatr Scand 1991; 80: 575-7.
6. Schoen EJ. Benefits of newborn circumcision: Is Europe ignoring medical evidence? Arch Dis Child 1997;77:358-60. [Full Text]
7. Hitchcock R. Commentary. Arch Dis Child 1997;77:260. [Full Text]
8. Nicoll A. Routine male neonatal circumcision and risk of infection with HIV-1 and other sexually transmitted diseases. Arch Dis Child 1997;77:194-5. [Full Text]
9. Malone PSJ. Circumcision for preventing urinary tract infection: European view. Arch Dis Child 2005;90:773-4. [Extract]
10. Fetus and Newborn Committee, Canadian Paediatric Society. Neonatal circumcision revisited. Can Med Assoc J 1996; 154(6): 769-80. [Full Text]
11. Task Force on Circumcision. Report of the Task Force of Circumcision. Pediatrics 1989;84(4):388-91.
12. Task Force on Circumcision. Circumcision Policy Statement. Pediatrics 1999;103(3):686-93. [Full Text]
13. Wolbarst AL. Universal Circumcision as a sanitary measure. JAMA 1914;62(2):92-7.
14. Goldman R. The psychological impact of circumcision. BJU Int 1999;83 Suppl. 1:93-103.
15. Commission on Clinical Policies and Research. Position Paper on Neonatal Circumcision. Leawood, Kansas: American Academy of Family Physicians, 2002. [Full Text]
16. College of Physicians and Surgeons of British Columbia. Infant Male Circumcision. In: Resource Manual for Physicians. Vancouver, BC: College of Physicians and Surgeons of British Columbia, 2004. [Full Text]
17. Van Howe RS. A cost-utility analysis of neonatal circumcision. Med Decis Making 2004;24:584-601. [Abstract]
18. Association for Genital Integrity. Circumcision practices in Canada (2004). URL: http://www.courtchallenge.com/refs/yr99p-e.html
19. Jeff Brown. Personal communication. 2004.
20. Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2005;115(2):496-506. [Full Text]
21. Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet 1997;349(9052):599-603.
22. Hill G. Breastfeeding must be given priority over circumcision. J Hum Lact 2003;19(1):21.
23. British Medical Association. The law and ethics of male circumcision: guidance for doctors. J Med Ethics 2004:30:259-63. [Full Text]
24. Boyle GJ, Goldman R, Svoboda JS, Fernandez E. Male circumcision: pain, trauma and psychosexual sequelae. J Health Psychol 2002;7(3):329-43.
25. Richards D. Male circumcision: medical or ritual? J Law Med 1996;3(4):371-6.