Saturday, May 29, 2010

New AAP policy must discourage male circumcision

Times have changed, and American Academy of Pediatrics need to get with them. Originating before children were believed to feel pain or have rights, male circumcision became a social custom in the United States. Since then medical justifications were invented with fervor and at great expense, but they always fall under scrutiny. The latest group of physicians to put this in writing are Royal Dutch Medical Association (KNMG), dating to 1849.

Speculation that AAP might take the unprecedented action of recommending newborn circumcision rests on studies conducted in Africa on HIV transmission. But KNMG--and several other physicians organizations--have issued statements since publication of those studies and found the data not compelling.

"In recent decades, evidence has been published which apparently shows that circumcision reduces the risk of HIV/AIDS, but this evidence is contradicted by other studies.

Moreover, the studies into HIV prevention were carried out in sub-Saharan Africa, where transmission mainly takes place through heterosexual contact. In the western world, HIV transmission is much more frequently the result of homosexual contact and the use of contaminated needles. That the relationship between circumcision and transmission of HIV is at the very least unclear is illustrated by the fact that the US combines a high prevalence of STDs and HIV infections with a high percentage of routine circumcisions. The Dutch situation is precisely the reverse: a low prevalence of HIV/AIDS combined with a relatively low number of circumcisions. As such, behavioural factors appear to play a far more important role than whether or not one has a foreskin."
Uncertain for adults, not relevant for newborns:
"Insofar as there are medical benefits, such as a possibly reduced risk of HIV infection, it is reasonable to put off circumcision until the age at which such a risk is relevant and the boy himself can decide about the intervention, or can opt for any available alternatives."
Babies don't have sex.

But they do have rights, which AAP learned the hard way after issuing a statement suggesting a "nick" to the genitals of young girls if it may avoid more severe cutting. People were outraged. Girls have rights--their bodies, certainly their genitals, are not to be modified, however slightly. AAP buckled under intense pressure from Intact America and others. After a very short career they "retired" the controversial policy statement. This is the 21st century: Children have rights.

KNMG had never before issued a policy on male circumcision. Why did they do so now? They explain,
"The reason for our adoption of an official viewpoint regarding this matter is the increasing emphasis on children’s rights. It is particularly relevant for doctors that children must not be subjected to medical proceedings that have no therapeutic or preventative value. In addition to this, there is growing concern regarding complications, both minor and serious, which can occur as a result of circumcising a child. A third reason for this viewpoint is the growing sentiment that there is a discrepancy between the KNMG’s firm stance with regard to female genital mutilation and the lack of a stance with regard to the non-therapeutic circumcision of male minors, as the two have a number of similarities."
American Academy of Pediatrics exhibits discrepancy of a more serious nature. They have policies pertaining to both males and females, but--if we believe all children have the same rights--they are in conflict. As KNMG state:
"Non-therapeutic circumcision of male minors conflicts with the child’s right to autonomy and physical integrity."
AAP now have an opportunity to narrow the discrepancy by taking a stance discouraging non-therapeutic circumcision of boys. The right trajectory for children's rights is more. When AAP issue a new policy, it must be aimed squarely in that direction. Recognizing boys' rights to freedom from non-therapeutic circumcision--even if like KNMG they don't recommend it's abolition--will align AAP, medically and ethically, with their physician colleagues worldwide.

AAP should be keen to avoid repeating their recent mistake of shifting policy in the wrong direction--the direction of less autonomy, less physical integrity for their young patients. It's time they close the policy gap with their peers. It's time American Academy of Pediatrics discourage newborn male circumcision.

KNMG Viewpoint Non-therapeutic circumcision of male minors

Saturday, May 1, 2010

Girls Protection Act provides girls less protection than MGMBill

Two amendments have been proposed to the U.S. FGM Law of September 30, 1996. H.R. 5137, Girls Protection Act of 2010 was introduced in the 111th Congress on April 26, 2010. MGMBill, Genital Mutilation Prohibition Act has not yet been sponsored in Congress. There are some similarities and differences between the two amendments, which I will refer to as GPABill and MGMBill.

Both amendments address the problem of female genital cutting outside the borders of the United States, but cover different circumstances and have different penalties. GPABill makes it a crime to knowingly transport a female outside of the United States for the purpose of medically unnecessary genital cutting while under the age of 18. GPABill provides for a penalty of a fine or up to 5 years in prison, or both. MGMBill makes it a crime to arrange, plan, or procure medically unnecessary genital cutting on a female under the age of 18 outside of the United States. MGMBill provides for a penalty of a fine or up to 14 years in prison, or both.

This means that that MGMBill provides more girls protection under a wider variety of circumstances in which female genital cutting may occur, and provides a longer potential prison term for violators than GPABill. Under GPABill, it is only a crime to arrange the genital cutting of a female minor outside the United States if doing so involves international transport of the child. For example, GPABill does not prohibit an American from arranging the genital cutting of a young female family member who resides outside the United States. An American could even travel outside the United States to personally facilitate one or more acts of female genital cutting without penalty. However in all of these cases, MGMBill provides for up to 14 years in prison. MGMBill also provides a longer potential prison sentence than GPABill for female genital cutting within the United States.

MGMBill is a stronger, more comprehensive amendment than GPABill for the protection of girls. MGMBill is also a stronger, more comprehensive amendment than GPABill for the protection of boys. MGMBill provides equal protection from medically unnecessary genital cutting for males and females under the age of 18. GPABill does not provide equal protection under the law for male and female minors.

To provide strong, comprehensive protection of children from Americans who would cause their genitals to be cut without medical necessity at home or abroad, Congress should be urged to pass GPABill and MGMBill into law. Alternatively, a similar level of protection for children could be achieved by passage of MGMBill alone.

Dialog on AAP's new Female Genital Cutting policy

The American Academy of Pediatrics has released it's Policy Statement on Ritual Genital Cutting of Female Minors. What little response I've seen to it thus far has come from individuals and groups which take a position on some or all medically unnecessary genital cutting on children. The response indicates controversy over the policy.

I have a lot of thoughts on this which I haven't fully sorted out. I intend to write several blog posts about it, and your comments will help shape the direction of the discussion.

Exemplifying the controversial statements in the policy is the following:
Most forms of FGC are decidedly harmful, and pediatricians should decline to perform them, even in the absence of any legal constraints. However, the ritual nick suggested by some pediatricians is not physically harmful and is much less extensive than routine newborn male genital cutting.
This statement troubles those who take a zero tolerance view of applying sharp objects to the genitals of children without medical necessity. It also seriously disturbs individuals and groups who would build a "wall of separation" between male and female genital cutting practices and find any comparison between male and female genital cutting to be offensive.

Here are some of my initial thoughts and questions.

Why has the AAP issued a policy statement on FGC at all? The practice is forbidden by law in the United States, which is the only nation they represent.

Is this news reported by Equality Now really just a random coincidence?
On 26 April 2010, ironically on the same date as the issuance of the AAP Statement, the United States Congress introduced new legislation amending the 1996 federal law prohibiting FGM to make it illegal to transport girls out of the country for purposes of FGM, also known as the “vacation provision.”
Will the sponsor and co-sponsor of the "vacation provision" amendment, Rep. Joseph Crowley (D-NY) and Rep. Mary Bono Mack (R - CA), also introduce MGMBill, which not only extends protection to American girls outside the borders of the United States but also extends protection to boys?

Does this policy signal anything about the stance the AAP will take on genital cutting of male minors when they release their policy on it?