The AAP Needs a Unified Position on Genital Modifications

I’m continuing to draw alt-tarot cards from The Fantod Pack, created and illustrated by Edward Gorey. If you’re new to my blog, check out my Re:Introduction to get to know me. Today I’m talking about the American Academy of Pediatrics (AAP) and gender, but first, the reading…

The Tarot

As usual, I shuffled the tarot deck and fanned out the cards. Today, there was one card that refused to fan out, and thus created a gap right in the middle of the fan. This is the card. This is the moment. I draw in a deep breath and I flip the card.

Hmm. The Urn. Ok. I’m not sure what this is supposed to symbolize but my first guess is death, like the ashes of a loved one kept safe in an urn. Let’s see what Edward thought.

Incredible! There’s a lot here, but also a lot that’s not here, e.g., restless leg syndrome. Alginuresis I had to look up; it’s painful urination or inability to urinate / lack of urine production. Great. Love that for us. TGIF! Now I’m still not a believer in fate, but I will admit that this card is a serendipitous pull for today’s post.

End the Mumbling Sickness

Transgender people are in a tough place in 2023. Transgender and gender non-conforming children are the objects of intense debate (and thus often not treated as subjects in their own lives). A good portion of this debate was deliberately created by right-wing heteroactivists for political purposes, but the conversation has erupted and lurched past that point. Well intentioned people, including many cisgender gay and lesbian people, are “just asking questions” about transgender people, especially children. The net result is that state legislatures are taking legal actions to radically restrict the freedom of transgender people, calling the AAP “very political” to dismiss the 2018 recommendations. The public conversation remains quite hostile to people who don’t fit into cisgender or heterosexual expectations even in supposedly liberal or progressive spheres.

The AAP, after voting to affirm that its 2018 statement on care for transgender and gender-diverse children also announced it would undertake a new review of the evidence on the subject. This review is expected, as the AAP’s positions typically last 5 years and then they expire. This move by the AAP was welcome news, despite how some media outlets spun it (see reactions and commentary well-documented by Evan Urquhart at Assigned Media). The public conversation needs to move forward for everyone’s safety, most of all for the well-being of children. I believe in being clear about values, and the AAP needs to speak clearly for the autonomy and bodily rights of all children.

Until the AAP articulates a unified policy on gendered genital modifications, the organization will fail to shake the criticisms that its policy positions subject children to gender policing and medically unnecessary, non-consensual genital surgeries based on faulty science and a desire to appease the parents’ beliefs about sex and gender. To successfully defend the autonomy and dignity of all children, the AAP should issue a position statement addressing surgeries on children with intersex traits, penile circumcision, and all other religious rites that involve non-therapeutic modifications to children’s healthy genitals. The AAP needs to clarify whether a parent’s metaphysical beliefs are sufficient justification to make alterations to a child’s healthy genitals without that child’s explicit and uncoerced informed consent. It’s my hope that the AAP will take a stand for the rights of children, but the AAP’s past history on these issues has historically championed paternalism, cisheteronormativity, and benevolent sexism, at the expense of children’s freedoms.

Broken Communications on Sexual Dilemmas

The AAP has had prior opportunities to address the issue of gendered genital modifications. Intersex Awareness Day is on October 26, the date that intersex people first publicly demonstrated in North America. That October demonstration was at the AAP’s annual conference, and the intersex people were seeking to deliver an address, “on long-term outcomes and to challenge their still-prevailing opinion that cosmetic surgery to ‘fix’ intersexed genitals was the best course of action.” Instead, the clinicians and researchers of the AAP shut out the very patients affected by the AAP’s medical decision making and released a statement in support of non-consensual cosmetic surgeries on children with intersex traits.

Unlike the American Academy of Family Physicians (AAFP), the AAP has never reversed this position, despite the loud objections of victims of unwanted surgeries and accumulated evidence showing that non-consensual genital surgeries on children with intersex traits are not in the child’s best interests. Researchers and advocates have been calling on the AAP to follow in the AAFP’s footsteps and align its policy on childhood gender-imposing intersex surgeries with its policies on Assent, Informed Permission and Consent, and on female genital mutilation. In 2020, one medical institution made the historic step of publicly apologizing for participating in the violation of human rights by carrying out gender-imposing surgeries. Still, no action to be seen from the AAP on this issue. They should take this opportunity to right their past wrongs. The existence of the nonbinary gender category is essential to ending epistemic injustice for people whose bodies and genitals vary beyond existing cultural norms (PDF).

A Forged Invitation for Penile Circumcision

Technically, the AAP does not have an active position on male or penile circumcision. Their last policy statement was released in 2012, to immense criticism from non-American medical societies and organizations pointing out significant bias, dodgy evidence, and illogical reasoning. It is awkward to point out that also in 2012, a German court ruled that infant circumcision is bodily assault, emphasizing how out of step American physicians are with both bioethicists and non-American physicians. Those groups identify forced circumcision (and all infant circumcisions are, by definition, forced upon the child) as a violation of human rights: the right to bodily integrity and the right to autonomy. Circumcision’s legal status is as a religious exemption to assault laws and ritual child abuse laws. It is legal to punish a boy by circumcising him, echoing the biblical use of circumcision as a violent weapon of social control, stigma, and shame.

The AAP’s position statement on male circumcision, which was that “the true incidence of complications after newborn circumcision is unknown,” expired in 2017, leaving parents and practitioners hanging in the wind. Since then, new studies have cast doubt on the fragile evidence used to support the AAP’s conclusions. It also came to light that the authors of the AAP position statement had ulterior motives: to preserve the right of parents to circumcise their male children.

“In fact, it is not entirely clear to what extent such appeals are really sincere. After all, defenders of cultural or religious male circumcision, at least, have long supposed that the practice was morally (and ought to be legally) permissible, even before any meaningful evidence of health benefits was available.”

Brian D. Earp

It is important to note that the authors included no men who had intact penises, though they did include a doctor who circumcised his own son on his kitchen table in a religious rite, and a doctor who supports surgical genital modifications on female children as well.

“I circumcised [my son] myself on my parents’ kitchen table on the eight day of his life. But I did it for religious, not medical reasons. I did it because I had 3000 years of ancestors looking over my shoulder.”

Andrew Freedman

The AAP’s policy position on male circumcision was a political statement that inappropriately mixed medical considerations with religious and cultural ones in order to forward the political position that insurance companies should pay for a non-therapeutic religious rite. A new statement is needed that acknowledges the bodily rights of male children and explicitly rejects inappropriate religious influence on medical decision making.

Research shows that at least 1 in 7 American men who were circumcised as infants resent the nonconsensual interference by a doctor to what should be the most private part of their bodies. In the US, about 20 to 400 boy infants die every year due to circumcision and infant circumcision is associated with higher rates of death from Sudden Infant Death Syndrome (SIDS) or otherwise unexplained death. The past AAP statement on male circumcision said more about women’s deaths from cervical cancer than it did about boys’ deaths from surgery complications. It’s been more than a decade since the AAP addressed the harms of penile circumcision. The AAP must clarify: what level of pain and risk (including risk of regret or death) is it acceptable to expose infants to in order to make a boy’s genitals conform to his parent’s metaphysical beliefs?

Female Genital Miscalculation

To be honest, I dislike the phrase “genital mutilation” and I try to avoid it where I can. I haven’t always felt this way, but realizing how the phrase casts implicit judgments on other people’s bodies made me quit using it. So yes, the initialism FGM stands for Female Genital Mutilation, and that’s what the AAP calls it, but I prefer to use FGMo: Mo for Modification. My reasoning is simple: people usually don’t like it when you say their genitals are mutilated. Don’t shame people’s bodies ’cause that’s not nice. By the way, have you ever thought about why genital cutting is labeled as mutilation when the clitoris is pricked or nicked to draw blood, but call it circumcision when it’s done on a penis, despite circumcision entailing removal of up to 50% of the skin system of the penis?

However you put it, the AAP’s policy on FGMo contradicts their expired positions on penile circumcision and on “gender-normalizing” surgeries on children with intersex traits. This may be because the AAP’s documents reflect sexual and gender stereotypes based on cultural beliefs rather than medical or historical facts. Right wing reactionaries have latched onto the language of anti-FGMo activism to launch heteroactivist campaigns attacking care for transgender and gender-diverse children . Those hate campaigns are often grounded in value expressions about women’s purity, sometimes as a dog whistle for white supremacist beliefs. Anti-FGMo legislation poses a unique danger to the safety and autonomy of nonbinary people and transmasculine people.

For the AAP to call relatively non-invasive religious rituals of one group “mutilation”, while green-lighting insurance payments for invasive genital modification religious rituals of a different group is problematic, to say the least. As ethicists have repeatedly pointed out, the contradiction reflects unquestioned assumptions about genitals, identity, and consent.

Recall that intersex surgeries are a special exception to anti-FGMo laws: if a female child is born with intersex traits, those intersex traits serve to strip her of the protection from surgical interference that would otherwise be afforded to her. Thus it is not really true that infant girls are protected from unwanted, gender-imposing genital surgeries: it’s been medicalized in America, sometimes under the label “disorder of sexual development”. Our culture offers up its own cultural explanation for the cutting we do, but Americans still cut female genitals to uphold the gender binary.

Furthermore, the popularity of cosmetic labiaplasty is on the rise, and some of those labiaplasty surgeries are being performed on cisgender, white teenage girls by white American doctors who are not being prosecuted for FGM. Does whiteness confer a special immunity from the stigma of “mutilation”? Or is it the medicalization of the female genital cutting that linguistically transforms the act?

One must wonder what the goal of the AAP’s anti-FGM position statement is and whether it is successfully meeting that goal. It deserves another look from the AAP. Is the anti-FGM position in conflict with the policy on Assent, Informed Permission and Consent? Does it reflect unquestioned xenophobic attitudes? What about unquestioned cisnormative or transnormative attitudes?

Preserving Choices for When Children Reach Adolescence

Some readers might be thinking to themselves about now: Why should the transgender taskforce address genital surgeries on children when gender affirming surgeries on children are so rare as to essentially be nonexistent? The moral panic about transgender and gender-diverse kids is manufactured around the myth that doctors are routinely performing risky surgeries on children based on harmful beliefs about sex and gender. It’s not real, so why burden transgender people with this baggage?

But what if gender-affirming surgeries are the most common surgeries performed on American children? In March of 2023, emails from the American College of Pediatricians (ACPeds) leaked. These emails contained communications and strategizing by ACPeds members as they fomented a campaign to attack transgender people. In the leaked emails, Quentin Van Meter asked “Just to play devil’s advocate, how can we justify male circumcision when the medical benefits of such are equivocal?” To which Patrick Lappert replied, “the key element to be remembered is that in all cases it is intended to serve the “gender” of the boy.”

Does the AAP agree? Is infant circumcision primarily justifiable through its metaphysical affirmation of the child’s gender? What about other forms of genital modifications? Can those be justified by the parent’s beliefs about gender?

I sincerely hope that the AAP takes a unified approach to gendered genital modifications. So long as the AAP keeps contradictory policies depending on the child’s visible sex traits, it will be dogged by perceptions that it is too permissive of non-therapeutic childhood genital surgeries with unknown risks. I hope that the AAP will consider that every child deserves the right to make decisions about their body. Perhaps the AAP might even apologize for it’s past mistakes, but given their decades of silence, it might be best not to hold one’s pee. I mean breath.

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