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The AAP Task Force on Neonatal Circumcision: a call for respectful dialogue
  1. The AAP Task Force on Circumcision 2012
  1. Correspondence to Dr Douglas S Diekema, Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, C9S-6, 1900 Ninth Avenue, Seattle, WA 98101, USA; diek{at}u.washington.edu

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The American Academy of Pediatrics (AAP) Task Force on Circumcision published its policy statement and technical report on newborn circumcision in September 2012.1 ,2 Since that time, some individuals and groups have voiced objections to the work of the Task Force, while others have conveyed their support. The AAP task force is pleased that the policy statement and technical reports on circumcision have stimulated debate on this topic and welcomes respectful discussion and dialogue about the scientific and ethical issues that surround neonatal circumcision. We believe this is a complex issue that does not lend itself to simplistic solutions. The Task Force encourages those of all viewpoints to contribute to a vibrant, thoughtful and respectful evidence-based dialogue. We appreciate that the free exchange of competing ideas is a necessary component of scientific discovery. We also recognise that all clinical decisions carry ethical dimensions and that a respectful and thoughtful dialogue about these issues is important. However, the Task Force also feels strongly that this debate and the academic literature are demeaned when those with an ideological agenda disseminate inaccurate information, misapply scientific principles, make accusations that are unsupported, communicate in a vitriolic tone, and attempt to discredit and mischaracterise alternative views and those who hold them. Healthy debate and dialogue should be encouraged, but attempts to mislead and discredit have no place in the academic literature.

The Task Force report and policy statement do not present an extreme view. Based on the scientific review outlined above, the Task Force found that male circumcision has been shown to have significant health benefits which include: a lower risk of acquiring HIV, syphilis, human papillomavirus and genital herpes; a lower risk of cervical cancer in sexual partners; a lower risk of penile cancer over a lifetime; and a lower risk of urinary tract infection in the first year of life. These benefits were felt to outweigh the risks of the procedure. The reader is encouraged to review our technical report and the primary sources, and draw their own conclusions.1 Although Task Force members did not find the data sufficiently compelling to justify a recommendation for routine neonatal circumcision, we did find that the benefits are substantial enough to allow parents to make this decision for their male children. This stance, rather than putting our review at odds with the rest of the developing world, is very similar to that of The Canadian Medical Society,3 the British Medical Association,4 the Royal Australasian College of Physicians5 and the American Medical Association.6 In addition, the WHO has concluded that the data strongly support a benefit of male circumcision with regard to prevention of HIV infection and has issued guidelines for its use in adults, adolescents and neonates.7

The AAP Task Force's review process was systematic, objective, comprehensive and transparently documented in its technical report.1 Members of the AAP Task Force on Circumcision were recruited on the basis of area of expertise. There was no consideration or knowledge of the individuals’ beliefs concerning circumcision at the time of their appointment. Unlike other published policy statements and reports on circumcision, the Task Force did not selectively choose which articles to review, but reviewed all of the available literature identified in a comprehensive search and evaluated those manuscripts using previously established, internationally recognised guidelines to determine the quality of the data being reviewed.8 Some papers were reviewed, but not cited in the technical report, because they were not data-based studies, the quality of the study was seriously flawed, or the findings of the study did not meaningfully address the specific area of Task Force inquiry. We did not exclude studies on the basis of geography or preferentially include studies that showed a benefit. The literature search and review were updated at intervals throughout the writing process (through Spring of 2012), with any important additions included in the final report. Although most of the analysis did not include case reports and case series (which is common practice in systematic reviews), we included case reports and case series for purposes of identifying rare, but serious, complications of circumcision. These rare complications are discussed in the technical report with the sources cited.1

We stand behind our findings as published in both the policy statement and technical report and urge those interested in this topic to review the two works in their entirety.1 ,2 It should be noted that the critique of our work that appears in this Journal makes no attempt to be systematic, comprehensive or unbiased. We have previously published a commentary responding to some of the substantive concerns regarding our work, and, rather than repeat our response here, we refer the reader to that commentary.9 Our work is intended to serve the clinical and educational needs of the AAP membership—dedicated paediatricians, most of whom work in the USA, who seek to provide the most up to date, unbiased, scientific information to their patient families. The Task Force has no preconceived cultural or economic motives and it advocates only for the well-being of children and families.

By their nature, clinical guidelines are always a work in progress. As scientific knowledge advances, they continuously evolve. The AAP remains committed to providing the most up to date information and continuously monitors the literature for major discoveries that necessitate re-evaluation. It is our fervent hope that, through the combined efforts of well-intentioned, open-minded researchers, we will achieve greater understanding so as to better serve our young patients.

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Footnotes

  • The AAP Task Force on Circumcision 2012 Susan Blank, MD, MPH, Chairperson; Michael Brady, MD, Representing the AAP Committee on Pediatrics AIDS and Committee on Infectious Disease; Ellen Buerk, MD, Representing the AAP Board of Directors; Waldemar Carlo, MD, Representing the AAP Committee on Fetus and Newborn and is a Director of Mednax; Douglas Diekema, MD, MPH, Representing the AAP Committee on Bioethics; Andrew Freedman, MD, Representing the AAP Section on Urology; Lynne Maxwell, MD, Representing the AAP Section on Anesthesiology; Steven Wegner, MD, JD, Representing the AAP Committee on Child Health Financing; Charles LeBaron, MD, Liaison from the Centers for Disease Control and Prevention; Lesley Atwood, MD, Liaison from the American Academy of Family Physicians; Sabrina Craigo, MD, Liaison from the American College of Obstetricians and Gynecologists.

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

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