1. The statement takes a position of not recommending circumcision. Consistent with all previous AAP reports, no proven, actual benefits for circumcision are found. The claims of potential medical benefits are discussed in more detail that the last report (1989) and shown to be insignificant. The debate about medical benefits is over.
    
2. The report recognizes the extreme pain and trauma caused by circumcision as evidenced by large increases in heart rate, blood pressure, and stress hormone levels during circumcision. The AAP notes that according to a recent study, circumcised infants exhibit a stronger pain response to vaccination at six months than uncircumcised infants, demonstrating that the effects of circumcision are not short-lived. By calling for pain medication, in the form of injection into the infant’s penis, the AAP acknowledges that this extreme pain and trauma of circumcision are serious. 
    
3. The AAP statement acknowledges that the foreskin contains "a concentration of specialized sensory cells" and reports that "penile sensation and sexual satisfaction are decreased for circumcised males." 
    
4. The statement references a report that circumcised men are more likely to engage in various sexual practices such as masturbation and heterosexual oral sex. This finding suggests that without a foreskin to contribute to sexual pleasure, circumcised men seek alternative forms of stimulation to compensate for their loss.
    
5. The report identifies 20 different possible circumcision complications. The 1989 report only mentioned bleeding, infection, and death as possible complications.
    
6. It warns physicians that parents should not be coerced by medical professionals to choose circumcision, suggesting that some medical professionals have coerced parents to choose circumcision. In fact, some infants have been circumcised even though parents explicitly requested no circumcision.
    
7. As in previous reports, hygiene is not an issue. According to the report, "there is little evidence to affirm the association between circumcision status and optimal penile hygiene."

DEFICIENCIES

1. The evidence calls for a stronger statement than "the procedure is not essential to the child’s … well-being." See Position Statements of Other Medical Societies
    
2. The statement lacks balance. It uses about 10 times more space discussing potential benefits as compared to potential harm, specifically sexual and psychological harm. See Recent Medical Studies.
    
3. It fails to acknowledge that there is much about circumcision that we do not know. For example, it does not answer or even ask about the potential connection between circumcision and impotence. This connection has been noted in the medical literature.
    
4. According to the statement, pain medication is "safe and effective in reducing the procedural pain associated with circumcision." For any other elective surgery, "reducing the pain" is unacceptable. In any case, there is no enforcement mechanism for this recommendation. Infants will continue to be circumcised with no pain medication.
    
5. Various studies have found that short-term effects of circumcision include changed sleep patterns, activity level, and mother-infant interaction, more irritability, and disruptions in feeding and bonding. Long-term behavior changes are not known. This information is not included in the report.
    
6. The AAP attempts to shift responsibility for circumcisions to the parents, but physicians are the ones doing the cutting. This is the only instance where laypeople make the decision about whether or not to operate. 
    
7. The report notes that informed consent "obligates the physician to explain any procedure or treatment and to enumerate the risks, benefits, and alternatives." A physician cannot do this if the physician is not aware of this information. Some physicians describe circumcision as not painful, just causing "discomfort." Few physicians know the functions of the foreskin and are aware of the sexual and psychological effects of circumcision.
    
8. The AAP does not instruct physicians on the proper care of the natural penis, which is to leave the foreskin alone. Some misinformed physicians forcefully retract the foreskin of a young boy and cause extreme pain and tissue damage.
    
9. Cutting off an important, healthy, and irreplaceable part of a child's body without medical justification raises serious ethical questions. 

• The AAP Committee on Bioethics report states, "Pediatric health care providers … have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses… .[T]he pediatrician’s responsibilities to his or her patient exist independent of parental desires or proxy consent." For these reasons, some physicians and nurses refuse to circumcise for ethical reasons. Yet the AAP Circumcision Policy Statement concluded that it is "legitimate" to circumcise if the parent requests it for nonmedical reasons. These two reports of the AAP are in conflict. This office wrote to a member of the AAP Committee on Bioethics requesting comment on this conflict. No response was received.
   
• Circumcision violates the Golden Rule. Adults would not consent to having a healthy genital part cut off, with or without pain medication. Yet adults put a helpless, vulnerable, sensitive newborn child through this painful ordeal.
   
• According to an article in the medical literature, circumcision violates all seven principles of Medical Ethics. (Denniston, G., "Circumcision and the Code of Ethics," Humane Health Care International 12 (1996): 72-74)
   

AAP News Release