To the Editor: The United South African Neonatal Association (USANA) takes the opportunity to respond to the article by Vawda and Maqutu entitled ‘Neonatal circumcision – violation of children’s rights or public health necessity’.1 In their article the authors concluded that the rights of neonates to bodily integrity should not be tampered with lightly, and that only a severe public health hazard such as the HIV/AIDS pandemic may justify incursion into this constitutionally protected right. USANA is concerned by this last-mentioned conclusion and wishes to address it.
Neonatal circumcision may be common practice in South Africa, but it is not a standard practice in our healthcare system. Healthcare governing bodies of major Western countries have rejected this practice of non-therapeutic, non-religious, prophylactic circumcision of newborn males to protect against the possible acquisition of HIV/AIDS in later life. These official viewpoints include those of the American Academy of Pediatrics (AAP) Task Force on Circumcision (2005),2 , 3 the American Medical Association,4 the American College of Obstetrics and Gynecology,5 the Royal Dutch Medical Association (KNMG) (2010) – this includes endorsement by several major Dutch scientific associations (the Netherlands Association of Paediatric Surgeons, the Netherlands Association of Paediatric Medicine, the Netherlands Urology Association),6 and the Royal Australasian College of Physicians (RACP).7
The AAP recommends that under circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child. The use of prophylactic medical interventions in children is usually justified on two grounds: (i) best interests of the child – the benefits of the intervention to the child outweigh the harms posed by the procedure; (ii) public health – the benefits of the intervention accrue primarily to the general society rather than to the individual, who is left with the burden of harms generated by the intervention.
The World Health Organization (WHO) concluded that three trials (performed in adult males engaging in heterosexual intercourse) demonstrated a population-level (public health) benefit and supports mass circumcision programmes throughout sub-Saharan Africa.8 These trials showed that adult male circumcision reduces HIV infection in men by about 60%, but also that male circumcision does not reduce HIV infection transmission from men to women or between men. It is reasoned that, at best, the gathered information shows that adult male circumcision is of relative, but not absolute, benefit.9
USANA emphasises that children, especially infants, are uniquely vulnerable as a result of inability to provide informed consent. Routine neonatal male circumcision to prevent later-in-life acquisition of HIV is reasoned to be unethical. It takes advantage of the infant’s inability to refuse and submits him to a medically unnecessary surgical procedure that a competent adult might refuse. The sexual transmission of HIV depends on adult lifestyle choices that cannot be determined in the neonatal period. The infant is unable to provide informed consent and proxy consent is invalid because of the lack of medical necessity.
The Children’s Act (April, 2010)10 emphasises the child’s ‘best interests’ as being the main criterion affecting decisions about children and that the best interests of the child must guide every decision reached in all matters concerning the child. With regard to medical circumcision, the law provides that circumcision of male children under the age of 16 years is prohibited unless it is done for medical or religious reasons.
USANA reasons that on the evidence to date, non-therapeutic prophylactic neonatal male circumcision to prevent future HIV acquisition does not fulfil the following ‘in the best interest’ of the newborn criteria: (i) the condition for which it is advocated is not a condition/disease which the infant currently has and is not likely to develop;11 (ii) the procedure is not without risks; (iii) the institution of routine male neonatal circumcision is not based on any scientific evidence11 , 12 – it is based on the extrapolation of scientific data obtained from three studies performed in adult males; (iv) there is no immediate or short-term net benefit and only hypothetical future benefit to the patient because it is not known who will and who will not be exposed to the possibility of acquiring HIV through heterosexual contact in the distant future.
In the case of neonatal male circumcision, in general, international scientific organisations seem to support the following actions/concepts: (i) informed consent regarding risks and benefits must be obtained from parents – parents decide on best interests of their child; (ii) the procedure must be carried out in hygienic clinical conditions; (iii) if it is performed, it should be done under proper anaesthesia.
In summary, USANA is of the opinion that currently the human rights burden posed to the individual infant is not outweighed by appreciable public health gain and that existing scientific evidence is insufficient to recommend routine/mass roll-out of non-therapeutic prophylactic and non-religious neonatal male circumcision for the prevention of HIV in later life. The decision to act in the child’s ‘best interest’ may lie with the parents in this regard and should therefore be left with them, following counselling about risks and benefits of such a procedure.
1. Vawda YA, Maqutu LN. Neonatal circumcision – violation of children’s rights or public health necessity? South African Journal of Bioethics and Law 2011;4:36-41.
2. Lannon CM, Bailey A, Fleischman A, Shoemaker C, Swanson J. Circumcision debate: Task Force on Circumcision, 1999-2000. Pediatrics 2000;105:641-642.
3. American Academy of Pediatrics. AAP publications retired and reaffirmed. Pediatrics 2005;116:796.
4. American Medical Association, Chicago, Illinois, July 6, 2000. Report 10 of the Council on Scientific Affairs (I-99). http://www.nocirc.org/position/ama2000.php
5. American College of Obstetricians and Gynecologists. Circumcision. Obstet Gynecol 2001;98:707-708.
6. Royal Dutch Medical Association (KNMG). Non-therapeutic circumcision of male minors. Utrecht: KNMG, 2010. http://www.knmg.nl/jongensbesnijdenis
7. Royal Australasian College of Physicians. Policy statement on circumcision. http://www.nocirc.org/position/racp2002.php
8. WHO/UNAIDS. New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications. Geneva: WHO/UNAIDS, 2007. http://data.unaids.org/pub/Report/2007/mc_recommendations_en.pdf
9. Sawires SR, Dworkin SL, Fiamma A, et al. Male circumcision and HIV/AIDS: challenges and opportunities. Lancet 2007;369:708-713.
10. Sloth-Nielsen J. The Children’s Act and the health care worker. Cape Town: University of the Western Cape and Department of Social Development (Western Cape), 2010.
11. Hodges FM, Svoboda JS, van Howe RS. Prophylactic interventions on children: balancing human rights with public health. J Med Ethics 2002; 28: 10-16.
12. Fox M, Thomson M. HIV/AIDS and circumcision: lost in translation. J Med Ethics 2010;36:798-801.
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