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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 and Winberg.5 When Schoen published in this journal in 1997,6 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) taskforce on circumcision that published in 1989,11 he did not serve on the AAP taskforce on circumcision that published in 1999.12 That second taskforce distanced the AAP from the views published by Schoen’s taskforce11 a decade earlier.
Schoen’s present views on circumcision are strikingly similar to those of Wolbarst,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 states: “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% of male infants in Canada were circumcised in 2003.18 Data provided by the National Hospital Discharge Survey indicate that the percentage of male infants circumcised in the United States declined to 55.1% in 2003.19 One expects to see further declines in the popularity of circumcision as newer data are reported. Many health maintenance organisations 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 breast feeding to reduce the incidence of UTI in all infants.20 It says that procedures that “may traumatize the infant” or otherwise interfere with breast feeding initiation should be avoided.20 Circumcision, a highly traumatic procedure, which apparently produces an “infant analogue of post-traumatic stress disorder”,21 works against breast feeding initiation and ultimately against optimum child health and development as well as establishment of UTI protection by breast feeding.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 healthcare providers have a general duty to consider the “best interests” of the whole child.23 This must include sexual and psychological wellbeing24 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 characterise Schoen’s personal view as representing the North American view. North America has moved on.