eLetters to:

COMMENTARIES: Patricia Flynn, Peter Havens, Michael Brady, Patricia Emmanuel, Jennifer Read, Laura Hoyt, Lisa Henry-Reid, Russell Van Dyke, and Lynne Mofenson Male Circumcision for Prevention of HIV and Other Sexually Transmitted Diseases Pediatrics 2007; 119: 821-822 [Full text] [PDF]

eLetters: Submit a response to this article

eLetters published:

Use of Federal Funds for Medicaid Non-Therapeutic Circumcision is Unlawful

George Hill, John V. Geisheker, George C. Denniston   (27 June 2007)

Misrepresentation of the literature

Jake H Waskett   (2 July 2007)

Use of Federal Funds for Medicaid Non-Therapeutic Circumcision is Unlawful 27 June 2007
George Hill, Vice-President for Bioethics and Medical Science DOC, John V. Geisheker, George C. Denniston Send letter to journal: Re: Use of Federal Funds for Medicaid Non-Therapeutic Circumcision is Unlawful iconbuster{at}earthlink.net George Hill, et al.	To the Editor: Flynn et al. argue that Medicaid should pay for medically-unnecessary non-therapeutic infant circumcision.1 There are, however, clinical, ethical, and legal problems with this claim. The most fundamental problem is that proxy consent necessary for the non-therapeutic circumcision of children exceeds parental power. Parental rights derive from their duty toward their children. In a landmark British case, Lord Scarman (citing Blackstone2), commented; “The principle of the law … is that parental rights are derived from parental duty and exist only so long as they are needed for the protection of the person and property of the child.”3 With no clear and present medical indication of need, no parental duty or right to consent to circumcision can exist. Medical indications for male circumcision never exist in the newborn period.4,5 The Committee on Bioethics of the American Academy of Pediatrics has long recognized that parental permission is limited to diagnosis and treatment of disease.5 If no disease is present, then there is no parental power to grant permission for removal of healthy tissue. Flynn et al. argue that circumcision is beneficial because it prevents HIV infection. This argument is outmoded. Talbott demonstrated that the real cause of the HIV pandemic is the high number of female commercial sex workers. When circumcision RCTs are adjusted for the percentage of commercial sex workers in the female population, the value of male circumcision in preventing HIV infection becomes insignificant.6 Even if circumcision were found to be effective at preventing sexual transmission of HIV, infant circumcision would be of no value for at least 15 years.7 More than 30 HIV vaccines are now under development.8 Some have advanced to stage IIB trials and are likely to become available between 2015 to 2020.8 A child born in 2007 has an excellent chance of being vaccinated against HIV before he reaches sexual maturity, so infant or child circumcision cannot be recommended on epidemiological grounds. The United States is not in Africa. The disease vectors are different in the United States, being primarily needle-sharing and homosexual contact, not heterosexual contact, so circumcision would not offer protection.9 Neonatal circumcision to prevent future HIV infection is not indicated for the United States.9 The foreskin should be preserved because the Langerhans cells produce Langerin that blocks the uptake of HIV.10 Flynn et al. rely on the anomalous paper by Fergusson et al. for evidence that circumcision prevents STD infection.10 Numerous other papers do not support Fergusson’s findings,11-17 and Fergusson himself withdrew his conclusion 18 Non-therapeutic neonatal circumcision exposes infant boys to increased risk of CA-MRSA infection and should be avoided.19,20 Death is an ever-present risk of male neonatal non-therapeutic circumcision as parents have learned to their everlasting sorrow.21,22 Medicaid is paid in part through federal funds. By law these funds must be used medically necessary services.23 Medically-unnecessary non-therapeutic circumcision does not qualify for federal funds. The 16 states that have stopped paying for non-therapeutic circumcision are in compliance with the law. The 34 states that have not changed their policies are out of compliance. The proposal by Flynn et al. that all states should pay to gratify improper, and merely cultural, parental whims is poor medical policy,24 poor disease control, as well as unlawful. John V. Geisheker, J.D., LL.M George C. Denniston, M.D., M.P.H. George Hill References Flynn P. Havens P, Brady M, et al. Male circumcision for prevention of HIV and other sexually transmitted diseases. Pediatrics. 2007;119;821-822 Blackstone’s Commentary on the Laws of England, Book I, Chapter 16: p. 434 (1765-9) Gillick v West Norfolk and Wisbech Area Health Authority [1985] 3 All ER 402. Available at: http://www.swarb.co.uk/c/hl/1985gillick.shtml Foetus and Newborn Committee. FN 75-01 Circumcision in the Newborn Period. CPS News Bull Suppl. 1975; 8(2):1-2. Committee on Fetus and Newborn: Standards and Recommendations for Hospital Care of Newborn Infants, Sixth Edition. American Academy of Pediatrics; Evanston, IL, 1977:66-67 Talbott JR. Size matters: the number of prostitutes and the global HIV/AIDS pandemic. PLoS ONE 2007;2(6): e543. Available at: http://www.plosone.org/article/fetchArticle.action?articleURI=info:doi/10.1371/journal.pone.0000543 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. Available at: http://adc.bmj.com/cgi/content/extract/77/3/194 Johnson LF, Dorrington RE. Assessment of HIV vaccine requirements and effects of HIV vaccination in South Africa: report prepared for the South African Vaccine Initiative. Capetown: Centre for Actuarial Research, 2006. Available at: http://www.commerce.uct.ac.za/Research_Units/CARE/RESEARCH/PAPERS/AvaccineAssessment5.pdf CDC HIV/AIDS Science Facts: Male circumcision and risk for HIV transmission: implications for the United States. Atlanta: Centers for Disease Control, March 2007 de Witte L, Nabatov A, Pion M, et al. Langerin is a natural barrier to HIV-1 transmission by Langerhans cells. Nat Med. 2007;13:367-371 Fergusson DM, Boden JM, Horwood LJ. Circumcision status of sexually transmitted infection in young adult males: an analysis a longitudinal birth cohort. Pediatrics. 2006;118:1971-1977 Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States. JAMA. 1997;277(13):1052-7 Dave SS, Johnson AM, Fenton KA, et al. Male circumcision in Britain: findings from a national probability sample survey. Sex Trans Infect. 2003;79:499-500 Available at: http://sti.bmj.com/cgi/content/full/79/6/499 Richters J, Smith AMA, de Visser RO, et al. Circumcision in Australia: prevalence and effects on sexual health. Int J STD AIDS. 2006;17:547-54 Cook LS, Koutsky LA, Holmes KK. Circumcision and sexually transmitted diseases. Am J Public Health. 1994; 84: 197-201 Donovan B, Bassett I, Bodsworth NJ. Male circumcision and common sexually transmissible diseases in a developed nation setting.. Genitourin Med. 1994; 70: 317-20 Van Howe RS. Does circumcision influence sexually transmitted diseases?: A literature review. BJU Int. 1999; 83, Suppl 1:52-62 Available at: http://www.blackwell-synergy.com/links/doi/10.1046/j.1464-410x.1999.0830s1052.x/pdf/ Fergusson DS, Boden JM, Horwood LJ. Responses to post-publication peer reviews: circumcision and sexually transmitted infection. Pediatrics. P3R, 21 November 2006 Available at: http://pediatrics.aappublications.org/cgi/eletters/118/5/1971#4725 Van Howe RS, Robson WLM. The possible role of circumcision in newborn outbreaks of community-associated methicillin-resistant Staphylococcus aureus. Clin Pediatr. (Phila.) 2007;46(4):356-8 Nguyen DM, Bancroft E, Mascola L, et al. Risk factors for neonatal methicillin-resistant Staphylococcus aureus infection in a well-infant nursery. Infect Control Hosp Epidemiol. 2007;28:(4)406-11 Newell TEC. Judgement of inquiry into the death of McWillis, Ryleigh Roman Bryan. Burnaby, B.C.: British Columbia Coroner's Service, Monday, 19 January 2004. Available at: http://www.doctorsopposingcircumcision.org/pdf/BCcoroner_2004.pdf Paediatric Death Review Committee: Office of the Chief Coroner of Ontario. Circumcision: a minor procedure. Paediatr Child Health. 2007;12(4):311-2. Available at: http://www.pulsus.com/Paeds/12_04/Pdf/zwol_ed.pdf 42 U.S.C. 1396. Available at: http://www.law.cornell.edu/uscode/html/uscode42/usc_sec_42_00001396----000-.html Van Howe RS. A cost-utility analysis of neonatal circumcision. Med Decis Making. 2004;24:584-601 Conflict of Interest: None declared
Misrepresentation of the literature 2 July 2007
Jake H Waskett, Founder Circumcision Independent Reference and Commentary Service Send letter to journal: Re: Misrepresentation of the literature jake{at}waskett.org Jake H Waskett	To the Editor: Geisheker et al. of Doctors Opposing Circumcision argue that without "clear and present medical indication of need, no parental duty or right to consent to circumcision can exist."[1] Such an argument is weak at best. If we consider vaccination, there is no immediate 'need', yet clearly parents can (and arguably should) consent to the procedure. We must, therefore, consider not only immediate need, but also the best interests of the child in the future. Describing arguments that circumcision is beneficial because it prevents HIV infection as "outmoded", Geisheker et al. rely upon a study by Talbott.[2] This study was an ecological analysis, in contrast to the more rigorous randomised controlled trials,[3-5] and Talbott did not even directly include circumcision status in his analysis. Geisheker et al. misrepresent the findings of this study, which did not, as they claim, adjust data from randomised controlled trials. Geisheker et al. speculate that effective HIV vaccines might become available in future. They continue to misrepresent their sources by citing a CDC report[6] in support of their claim that "circumcision would not offer protection" in the United States. The report, however, states that "Male circumcision may also have a role for the prevention of HIV transmission in the United States."[6] Describing a paper by Fergusson et al. as "anomalous", Geisheker et al. claim that numerous papers do not support Fergusson's findings that circumcision is associated with a reduction in STDs. Again they misrepresent at least one of their sources, which concluded that "Uncircumcised men were more likely than circumcised men to have syphilis and gonorrhea and were less likely to have visible warts."[7] They further claim that Fergusson withdrew his conclusion. Once again, they misrepresent their source, which in fact states "that it would be premature to dismiss our findings on the grounds of sample size, measurement error, or perinatal confounding."[8] Such blatant misrepresentation of the literature is inappropriate in any situation. References 1 Geisheker JV, Denniston GC, Hill G. Use of Federal Funds for Medicaid Non-Therapeutic Circumcision is Unlawful. Pediatrics. P3R, 27 June 2007. Available at: http://pediatrics.aappublications.org/cgi/eletters/119/4/821#9715 2 Talbott JR. Size matters: the number of prostitutes and the global HIV/AIDS pandemic. PLoS ONE 2007;2(6): e543 3 Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet. 2007 Feb 24;369(9562):657-66. 4 Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet. 2007 Feb 24;369(9562):643-56. 5 Auvert B, Taljaard D, Lagarde E, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005 Nov;2(11):e298 6 CDC HIV/AIDS Science Facts: Male circumcision and risk for HIV transmission: implications for the United States. Atlanta: Centers for Disease Control, March 2007. Available at: http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm 7 Cook LS, Koutsky LA, Holmes KK. Circumcision and sexually transmitted diseases. Am J Public Health. 1994; 84: 197-201 8 Fergusson DS, Boden JM, Horwood LJ. Responses to post-publication peer reviews: circumcision and sexually transmitted infection. Pediatrics. P3R, 21 November 2006 Available at: http://pediatrics.aappublications.org/cgi/eletters/118/5/1971#4725 Conflict of Interest: None declared