Medicare should not pay for medically unnecessary circumcision

A recent review of Medicare found evidence that between 2 and 3 billion dollars are spent inappropriately each year. The review, by Dr Tony Webber as Director of the Professional Services Review, noted that Medicare’s no-questions-asked policy led to serious financial abuses and failed to take account of the medical business environment. “The MBS [Medical Benefits Schedule] is riddled with misdirected incentives for practitioners … and has many examples of good public policy being thwarted by the MBS rules”, Webber writes. Among the scandals, he mentions cases where “the Safety Net was used in effect to subsidise cosmetic procedures such as surgery for designer vaginas at $5000-$6000 each” (Tony Webber, “What is wrong with Medicare?”, Medical Journal of Australia, 16 January 2012.)

What is equally scandalous about Medicare is that it continues to subsidise cosmetic procedures such as surgery for “designer penises” – namely, non-therapeutic (medically unnecessary) circumcision of male infants and boys. There is no reason at all why the over-stretched health budget should continue to waste taxpayers’ money by paying for an operation, usually on non-consenting children, that medical authorities judge to be medically unnecessary, risky, potentially harmful, and contrary to accepted principles of medical ethics and human rights, including the principle of gender equity. The Commonwealth Sex Discrimination Act, Section 3 (b), states that the Act applies to the administration of Commonwealth laws and programs, while Section 22 (b) makes it illegal to discriminate on the basis of sex in the provision of goods, services and facilities. It could be argued that the exclusion of female circumcision from the MBS is a breach of this provision, since it denies to women a benefit given to men; whether or not circumcision is regarded as a benefit or a deprivation, it is certainly anomalous that the MBS specifically denies coverage for cutting procedures on the female genitals while providing no-questions-asked coverage for comparable procedures on the genitals of boys.

Medicare should never have covered a non-therapeutic procedure such as circumcision. When Medibank was first introduced in 1975, Australian medical authorities had already determined that boys should not be circumcised; and when it was re-established as Medicare by the Hawke government in 1984-85 they had reaffirmed and strengthened their policy. Unfortunately, the politicians and health bureaucrats seem to have been behind the times. It is high time that medically unnecessary (non-therapeutic) circumcision was dropped from the Medical Benefits Schedule, and Medicare confined to its stated requirement to cover only “procedures that are clinically necessary”.

On this page

1.   Dr Robert Darby’s letter to the Medical Journal of Australia in response to Tony Webber’s article

2.   Medicare should not pay for medically unnecessary circumcision: Our viewpoint

3.  A comparable argument in Colorado, USA

4.  The Hawke government and the Medicare rebate

5.  Sydney Morning Herald Question: Should elective circumcision continue to be covered by Medicare

6.  ANU law student writes on why Medicare should not continue to pay for non-therapeutic circumcision

1. Medicare should not cover non-therapeutic circumcision

Dr Robert Darby’s letter to Medical Journal of Australia in response to Tony Webber’s article

Any review of Medicare arising from Tony Webber’s critique [1] must reconsider its coverage of non-therapeutic circumcision. Australia is the only country in the world to provide a no-questions-asked rebate for such procedures, despite the fact that most have no medical indication and in defiance of Medicare’s own guidelines. These state that benefits are not payable for “medical services that are not clinically necessary”, nor “surgery for cosmetic reasons”. [2]

A medical procedure is clinically necessary only if required to correct a diagnosed disease, injury or other pathological condition that cannot be treated conservatively. Surgery for any other reason, particularly cultural or social reasons, is cosmetic surgery, intended merely to alter the appearance of the body part in question. As the Royal Australasian College of Surgeons points out, “male non-therapeutic circumcision is not clinically necessary as it does not treat an underlying pathological process.” [3] The issue is doubly serious in that most circumcision procedures are on infants and other minors, few of whom present any pathology requiring surgery, thus contradicting the policy of the Royal Australasian College of Physicians that routine circumcision is not warranted. Since minors cannot give consent, payments for such operations are questionable from a bioethical and human rights perspective, and may even be unlawful. [4]

There have been several calls to delete non-therapeutic circumcision from the Medical Benefits Schedule, including Spilsbury et al, who point out that “the potential savings to the public purse would be considerable if elective and discretionary circumcision was removed from the Medicare schedule in line with other cosmetic surgeries, leaving rebates for the genuine medically indicated circumcision.” [5] In 1985 the government did drop circumcision from the MBS, only to reinstate it after objections from Jewish community leaders, leading to the myth that the original decision aroused a community backlash. Recent research has established that the decision represented sound public policy, was widely supported, and that the objections were based on a sense of discrimination: their real concern was that the rebate was deleted only for boys younger than six months. [6]

It is not clear why the government, rather than restoring the rebate, did not resolve the problem by requiring a medical indication at all ages, as would have been the simplest and most equitable course of action. It now has the opportunity to rectify this mistake. Medicare should no more fund the designer penises created by circumcision than the designer vaginas created by other cosmetic procedures.

References

1. Webber, TD. What is wrong with Medicare? Med J Aust 2012; 196 (1): 18-19.

2. “What does Medicare cover?”, at http://www.medicareaustralia.gov.au/public/claims/what-cover.jsp. Accessed 21 January 2012.

3. Australian Safety and Efficacy Registry of New Interventional Procedures – Surgical. Report No. 65: Male non-therapeutic circumcision. Adelaide: Royal Australasian College of Surgeons, 2008.

4. Adler, P. Is it lawful to use Medicaid to pay for circumcision? J Law Med 2011; 19: 335-353.

5. Spilsbury K, Semmons JB, Wisniewski ZS, Holman CD. Routine circumcision practice in Western Australia 1981–1999. ANZ J Surgery 2003; 73(8): 610-614.

6. Darby, R. Scientific advice, traditional practices and the politics of health-care: The Australian debate over public funding of non-therapeutic circumcision, 1985. Hygiea Internationalis: An Interdisciplinary Journal for the History of Public Health 2011; 10: 53-73. Available at http://www.ep.liu.se/ej/hygiea/. Accessed 21 January 2012.

(This letter was sent to the Medical Journal of Australia in response to Tony Webber’s article, but was not published.)

2. Medicare should not pay for medically unnecessary circumcision: Our viewpoint

Although Australian medical authorities do not recommend circumcision as a routine or prophylactic procedure, Medicare continues to provide an automatic rebate for such operations, whether medically required or not. The propriety, ethics and even the lawfulness of this policy have been questioned in two recent studies, one by an American legal expert who argues that payments for non-therapeutic circumcision by the United States health insurance program Medicaid are unlawful; and the other by Australian medical historian Dr Robert Darby, who has examined the attempt by the Hawke government to drop circumcision from the Medical Benefits Schedule in 1985. He dispels the myth that the decision aroused widespread protest and shows, on the contrary, that it represented sound public policy and was widely supported. Taken together, these analyses raise serious questions about current Medicare policy on the circumcision rebate; here Robert Darby argues that, for reasons of consistent public policy, financial prudence and respect for established principles of human rights and gender equity, the rebate should be abolished except for cases of proven medical need.

Introduction

The Australian government is under pressure to balance budgets, give more recognition to individual human rights, promote gender equity and protect children from harm. One simple way to make progress on all these fronts is to drop non-therapeutic circumcision from the Medical Benefits Schedule. Medicare currently provides an automatic, no-questions-asked rebate for circumcision, despite the fact that the vast majority of these operations have no medical indication, and in defiance of Medicare’s own guidelines. These state that benefits are not payable for “medical services which are not clinically necessary”, nor “surgery for cosmetic reasons”.

A medical procedure is clinically necessary only if it is essential to correct a diagnosed disease, injury, deformity or other pathological condition that has not responded to conservative (non-surgical) treatment. As the Royal Australasian College of Surgeons points out, “male non-therapeutic circumcision is not clinically necessary as it does not treat an underlying pathological process.” Surgery for any other reason, particularly cultural or social reasons, is essentially cosmetic surgery, intended to alter the appearance of the body part in question. According to its own published guidelines, Medicare should not cover such procedures.

Opinions of medical authorities

It is strange that it still does so, considering that Australian medical authorities have sought to discourage routine (medically unnecessary) circumcision since the early 1970s. In fact, the government did drop circumcision from the MBS in 1985, only to restore it a few weeks later, for obscure reasons, explained below. Nonetheless, Australian medical authorities have maintained their opposition to the practice, with the result that the incidence of circumcision in Australia continues to decline. The most recent statement (October 2010) by the Royal Australasian College of Physicians states clearly: “After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.”

Stronger statements have been issued by the British Medical Association, the Canadian Pediatric Society, the Royal Dutch Medical Association, the South African Medical Association, and medical authorities in Denmark, Finland, Norway and Sweden. Even in the United States, where circumcision is deeply entrenched as a medicalised cultural ritual, the American Academy of Pediatrics does not recommend the operation or regard it as medically desirable, much less as necessary.

This being the case, a study by a US legal expert argues that payments for non-therapeutic (medically unnecessary) circumcision by the United States health insurance scheme Medicaid violate the protocols for benefits under this program and are thus unlawful. The article, in the December 2011 issue of the Journal of Law and Medicine, shows that the federal and state Medicaid acts stipulate that physicians and patients can use Medicaid to pay for medical services only when they are clinically necessary. This provision clearly excludes non-essential medical services, and some states expressly exclude cosmetic surgery from the list of covered treatments. In addition, federal and state Medicaid law require diagnosis of a medical condition and recommendation of an effective treatment before any benefit is payable.

Medicare has not been the subject of such a study, but it is quite possible (given the guidelines) that its own payments for non-therapeutic circumcision are not authorised by Parliament and are thus unlawful.

Why Medicare should not pay for circumcision

There are at least five other main reasons why non-therapeutic circumcision should be dropped from the MBS. These relate to the absence of a convincing health case; conformity with international practice; principles of ethics and human rights; gender equity; and financial prudence.

1. No health case for routine circumcision

It is not only the authorities mentioned above that have examined the medical literature and concluded that there is no health case for routine circumcision of infants or boys. A survey by British experts Malone and Steinbrecher acknowledged the medical claims for routine circumcision, but concluded that the only definite indications in childhood were phimosis caused by balanitis xerotica obliterans and recurrent balanoposthitis. Preputial adhesions, ballooning on urination, and a non-retractile foreskin do not require treatment. Relative indications (meaning that therapeutic circumcision could be warranted in individual cases) were recurrent urinary tract infections plus an abnormal tract. They point out that most circumcisions are done for religious cultural reasons, and that complications “are well documented and can be drastic”. A study by researchers in Adelaide, published in Annals of Family Medicine, subjected the claims of the circumcision lobby to an exhaustive review, and concludes that its value for child health was close to zero. When the literature is considered as a whole (rather than cherry picked for papers supporting a particular thesis) there is no proof that circumcision provides any significant protection against urinary tract infections, sexually transmitted infections or cancer of the penis

The only evidence for prophylactic efficacy came from Africa, where there was evidence that adult males who got themselves circumcised had a slightly lower risk of contracting HIV through unprotected intercourse with an infected female partner. And I say “slightly lower risk” because I do not consider a risk reduction of between 40 and 60 per cent to be impressive, particularly when compared with the 90 to 95 per cent protection offered by a condom.

As the authors of the paper comment, Africa has unique health problems. The circumcision trials were on adult men and can no more be applied to children than the World Health Organisation recommendations for the underdeveloped world can be transferred to a developed country like Australia. In Australia, unlike Africa, HIV-AIDS is not a heterosexual epidemic, but a relatively rare disease confined to specific sub-cultures – homosexual men and injecting drug users. It is well established that these groups can derive no protection from circumcision at all. In any case, because it is a disease of promiscuous adults, children are not at any risk of infection – unless, of course, by surgery. When they become sexually active boys are old enough to understand the issues and make their own decisions about how to manage the risks of sexual activity with others.

The Australian Federation of AIDS Organisations has stated that circumcision has no relevance to Australia’s HIV problem, and their conclusion has been endorsed by a paper in the Australian and New Zealand Journal of Public Health, which argues that circumcision is not a surgical vaccine and is not appropriate as an HIV control tactic in developed countries such as Australia.

2. International practice

Australia is the only country in the world that provides automatic coverage of circumcision through the health budget. This policy is despite the fact that most State governments (Victoria, Western Australia, Tasmania, New South Wales and South Australia) do not provide free coverage of circumcision in public hospitals, and it is in sharp contrast with the practice of comparable developed nations.

Circumcision is not funded by the governments of Israel, Turkey, Indonesia, Iran or any other predominantly Islamic country where the procedure is widely practised as a cultural/religious ritual, not even when the operation is performed in hospitals rather than (as is traditional) in the boy’s home. The Dutch national health insurance service withdrew coverage of non-therapeutic circumcision in 2004 when it was realised that 90 per cent of the procedures were done for religious/cultural rather than for health-related reasons.

3. Ethics and human rights

For a surgical intervention to be ethically acceptable (and indeed legal) the fundamental requirement is that the person must give informed consent. An adult male can consent to having himself circumcised (it’s his choice), but the question becomes difficult when parents wish to circumcise their children because minors can no more consent to surgery than to sexual relations with adults. Circumcision of children thus deprives them of choice and amounts to coercion. The problem is especially relevant to Medicare, since the vast majority of the circumcision procedures that it covers involve children. In FY 2010-11, of 25,842 circumcision procedures funded by Medicare, 22,491 (88%) were on boys aged under 10 years, and of these 18,503 (71% of the total) were aged less than 6 months. Very few of these operations could be regarded as therapeutic or clinically necessary. An additional 2641 procedures were on males aged 10 years or more, but Medicare provides no breakdown as to how many of these are adults and how many are still minors, though it is clear enough that very few adult males elect to have themselves circumcised.

Surrogate consent for surgery on minors is valid only for life-saving medical treatment, or where the procedure is manifestly in the best interests of the child and passes the imputed judgement test – that is, it is an operation the child would choose for himself if he were a competent adult. It has been strongly argued that, in the absence of a life-threatening disorder, surrogate consent for non-therapeutic surgery such as circumcision is ethically problematic and may not be legally valid. When there is no urgency to intervene, it is best to wait until the child can make his own choice.

In addition to informed consent, leading bioethicists propose five conditions that must be met in order for a medical procedure to be ethically permissible.

Beneficence — Does the proposed procedure provide a net therapeutic benefit to the patient, considering the risk, pain, and loss of normal function?

Non-maleficence — Does the procedure avoid permanently diminishing the patient in any way that could be avoided?

Proportionality — Will the final result provide a significant net benefit to the patient in proportion to the risk undertaken and the losses sustained?

Justice — Will the patient be treated as fairly as we would all wish to be treated?

Autonomy — Lacking life-threatening urgency, will the procedure honour the patient’s right to his or her own likely choice? Could it wait for the patient’s assent?

Non-therapeutic circumcision of minors fails all these tests. It is not beneficent because it does not provide a therapeutic benefit (nor even a relevant prophylactic benefit, since a child is at zero risk of sexually transmitted infections ). It is malefic because it diminishes the genitals. It is disproportional because the net gain (if any) is out of proportion to the loss, harm and risk of complications. It is unjust because adult preferences show clearly that if he had a choice in the matter the boy would refuse the operation. Finally, circumcision fails to respect the boy’s autonomy and preserve his future options as an adult individual.

The British Medical Association and the Royal Dutch Medical Association have issued particularly strong warnings that non-therapeutic circumcision of minors is likely to breach accepted principles of bioethics and potentially of the law. In its policy statement (May 2010) the latter states: “Non-therapeutic circumcision of male minors is contrary to the rule that minors may only be exposed to medical treatments if illness or abnormalities are present, or if it can be convincingly demonstrated that the medical intervention is in the interest of the child, as in the case of vaccinations”; and further that such interventions violate “the child’s right to autonomy and physical integrity.”

The RACP agrees: “The option of leaving circumcision until later, when the boy is old enough to make a decision for himself does need to be raised with parents and considered. … The ethical merit of this option is that it seeks to respect the child’s physical integrity, and capacity for autonomy by leaving the options open for him to make his own autonomous choice in the future.”

International instruments are also relevant. Article 8 of the UNESCO Declaration on Human Rights and Bioethics (2005) states that “In applying and advancing scientific knowledge, medical practice and associated technologies, human vulnerability should be taken into account. Individuals and groups of special vulnerability should be protected and the personal integrity of such individuals respected.” Children certainly fall into this category. Given the government’s commitment to enhancing Australia’s commitment to individual human rights, it is highly anomalous that it allows Medicare to subsidise and thus encourage a disfiguring operation that denies them to so many children.

4. Gender equity

Australia’s obligations under the Sex Discrimination Act 1984 and as a signatory to the United Nations Convention on the Rights of the Child require the national and State governments to treat males and females equally and without discrimination on the basis of sex, and to take action to eradicate traditional practices harmful to children. Article 24 (3) of the Convention requires parties to take “all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children.” In pursuance of this development several States passed laws to prohibit any form of female circumcision, and in 1995 the Commonwealth specifically excluded such procedures from the Medical Benefits Schedule. Although there was nothing in the wording of the Convention to suggest that it did not include male children, no action has yet been taken to protect boys. This failure is increasingly recognized, in Ranipal Narulla’s words, as “a hidden human rights violation”.

The Commonwealth Sex Discrimination Act, Section 3 (b), states that the Act applies to the administration of Commonwealth laws and programs, while Section 22 (b) makes it illegal to discriminate on the basis of sex in the provision of goods, services and facilities. It could be argued that the exclusion of female circumcision from the MBS is a breach of this provision, since it denies to women a benefit given to men; whether or not circumcision is regarded as a benefit or a deprivation, it is certainly anomalous and inconsistent that the MBS specifically denies coverage for cutting procedures on the female genitals while providing a no-questions-asked rebate for comparable procedures on the genitals of boys. The situation is doubly discriminatory in that girls are denied a "benefit" that is given to boys, while boys are denied a protection from harm that is enjoyed by girls. The simplest way to remove such discrimination and restore the principle of equal treatment is to limit coverage of male circumcision to cases of proven medical necessity.

5. Economy and financial prudence

All government welfare programs should be targeted at genuine need and be administered with prudence and economy. An open-slather approach to funding a medically unnecessary procedure is wasteful and invites over-servicing. It also acts as a signal that circumcision is a socially acceptable and even medically recommended operation, thus encouraging more parents to seek to have it done. Assuming 15,000 unnecessary circumcision procedures per year at a cost of between $100 and $1600 each, Katrina Spilsbury and colleagues have estimated that the removal of medically unnecessary circumcision from the MBS would save between $1.5 million and $24 million per year. They state that “the potential savings to the public purse would be considerable if elective and discretionary circumcision was removed from the Medicare schedule in line with other cosmetic surgeries, leaving rebates for the genuine medically indicated circumcision.”

According to figures available on the Medicare website, the total cost of the rebate for all circumcision procedures in FY 2010-11 was $1,577,754, nearly half of which went to subsidise operations on infants less than 6 months old, almost none of whom could have had a genuine medical indication. This is not a large sum in the overall budget context, but the real cost to the government will be considerably higher, given that this figure does not include the cost of treating complications and long-term adverse effects, which may not become apparent until adolescence. A cost-utility analysis of neonatal circumcision by American researcher Robert Van Howe found that even if the extreme claims of circumcision advocates were true, the associated complications and adverse outcomes would cancel out and exceed the benefit to health by a considerable margin. On top of this there may be losses to revenue arising from tax rebates that parents are able to claim under the Medicare safety net for expenses related to child-bearing.

These are not substantial sums in the context of today’s billion-dollar budgets, but when every effort is being made to rein in public expenditure, especially the ever-expanding health budget, every million saved can help to make a difference. Not only this: given the irresponsible media commentary on the role of circumcision in HIV control and the efforts of scaremongering evangelists and entrepreneurial circumcision practitioners to generate a mood of panic, the demand for circumcision could increase if parents are misled by their propaganda and become fearful of the alleged risks of not getting it done. It is thus possible that the cost of the circumcision subsidy will increase unless entitlement is restricted. Removal of non-therapeutic circumcision from the MBS will send a clear signal to Australian parents that routine circumcision is not a medically recommended procedure and is not necessary for the health and well-being of their child.

Parental right to circumcise for religious reasons not affected

The main argument for dropping non-therapeutic circumcision from the MBS is not the cost-saving, but the principles of prudent and targeted assistance to those in need; of adherence to stated entitlement guidelines and lawful program administration; of respecting current expert medical advice; of observing accepted principles of ethics and human rights; and of avoiding discrimination on the basis of sex. Allowing Medicare to provide a rebate for non-therapeutic circumcision sends the wrong signals to parents, suggesting that it is a socially and medically approved procedure, and thereby encouraging the practice.

There is nothing in this proposal that will limit the right of parents to circumcise their children if they feel they have a compelling cultural or religious reason, merely that they will not receive a public subsidy for doing so. There is no intent to restrict the right of Jewish, Aboriginal or Muslim parents to circumcise their children in accordance with their respective traditions; but equally there is no reason why such rites and practices should be funded by the Australian taxpayer through the health budget.

The Hawke government’s thwarted attempt to drop circumcision from the MBS in 1985

It is true that when the Hawke government dropped circumcision from the MBS in 1985 it faced protests from Jewish community leaders and soon backed down, leading to the development of the myth that there was a “community backlash” and discouraging further attempts. This myth has been disproved in a detailed study of the incident by Dr Robert Darby, published in Hygiea, an international journal for the history of public health. His conclusions are that the decision was justified on medical and public policy grounds; that there was no wide public outcry and, indeed, that the decision was widely approved; and that the rapid reversal of the decision was the result of inept implementation, failure to consult, and a fortuitous combination of subsequent factors, including, vigorous lobbying by the groups who felt most deeply affected. The main objection of Jewish community leaders was not to the dropping of the rebate in itself, but the fact that it was dropped only from the code for circumcision of boys under 6 months, leaving the rebate in place for operations at later ages. Since Jewish people traditionally circumcise at 8 days, they justifiably felt that this was unreasonable discrimination.

It is not clear why the government, rather than abjectly restoring the rebate, did not resolve the problem by requiring a medical indication at all ages, as would have been the simplest, most economical and most equitable course of action. The government now has the opportunity to rectify this mistake. If a proven medical requirement is attached to each of the codes for circumcision, there is no reason why the sensibilities of the Moslem and Jewish communities should be affronted, since the new rules would apply to everybody in the community, without discrimination.

Conclusion

There is no reason why Medicare, and thus the Australian taxpayer, should continue to fund operations that medical authorities have defined as unnecessary and potentially harmful, and which many people regard as an violation of the rights of the child, or even genital mutilation. The government must face up to its responsibilities, bite the bullet, rectify the mistakes it made in 1985, and delete non-therapeutic circumcision from the Medical Benefits Schedule.

Appendix:  Relevant MBS codes and payments (as at 1 January 2012)

30653: Circumcision of a male under 6 months of age
Scheduled fee: $45.65; Benefit: $34.25 (75%); $38.85 (85%)

30656: Circumcision of a male under 10 years of age but not less than 6 months of age
Scheduled fee: $106.15; Benefit: $79.65 (75%); $90.25 (85%)

30659: Circumcision of a male 10 years of age or over by a GP
Scheduled fee: $146.95; Benefit $110.25 (75%); $124.95 (85%)

30660: Circumcision of a male 10 years of age or over by a specialist
Scheduled fee: $182.15; Benefit $136.65 (75%); $154.85 (85%)

30663: Haemorrhage, arrest of, following circumcision requiring general anaesthesia
Scheduled fee: $141.65; Benefit $106.25 (75%); $120.45 (85%)

Until 1995 these codes were unisex and read “circumcision of a person”, thus authorising a benefit for circumcision of females as well as of males. In order to protect girls from genital mutilation as part of the general development of laws and policies against FGM that followed the passage of the UN Convention on the Rights of the Child, “person” was changed to “male”, thus introducing two elements of discrimination: females were denied a service that remained available to males; but males were denied the protection that was accorded to females.

The deletion of non-therapeutic circumcision from the schedule can be effected by simply by adding the phrase “where medically indicated” to each of the codes above. “Medically indicated” means a case where (1) there is a medical problem that has not responded to conservative (non-surgical) treatment after reasonable efforts; and (2) this is certified by two qualified medical practitioners, one of whom must be an appropriate specialist, and neither of whom may be the surgeon or other operator who is to perform the surgery.

Selected references

Adler, Peter. “Is it lawful to use Medicaid to pay for circumcision?” Journal of Law and Medicine, Vol. 19, December 2011: 335-353.

Australian Safety and Efficacy Registry of New Interventional Procedures – Surgical. Report No. 65: Male non-therapeutic circumcision. Adelaide: Royal Australasian College of Surgeons, 2008.

Australian Federation of AIDS Organisations. Male circumcision has no role in the Australian HIV epidemic. Briefing paper, 23 July 2007.

Beauchamp TL, Childress JF. Principles of Biomedical Ethics (6th edn). Oxford University Press: 2009.

British Medical Association, The Law and Ethics of Male Circumcision: Guidance for Doctors (November 2007). Available at http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp

Darby, Robert. “Infant circumcision in Australia: A preliminary estimate, 2000-2010”. Australian and New Zealand Journal of Public Health, Vol. 35, August 2011

Darby, Robert and Robert Van Howe. “Not a surgical vaccine: There is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia.” Australian And New Zealand Journal of Public Health, Vol. 35, October 2011: 459-465. Available at http://onlinelibrary.wiley.com/doi/10.1111/j.1753-6405.2011.00761.x/full

Darby, Robert. “Scientific advice, traditional practices and the politics of health-care: The Australian debate over public funding of non-therapeutic circumcision, 1985.” Hygiea Internationalis: An Interdisciplinary Journal for the History of Public Health, Vol. 10, December 2011. Available at http://www.ep.liu.se/ej/hygiea/

Forbes, David. “No evidence to support routine circumcision.” Sydney Morning Herald, 12 September 2009. On-line at: http://www.smh.com.au/national/letters/no-evidence-to-support-routine-circumcision-20090911-fkna.html

Malone, Padraig and Henrik Steinbrecher. “Medical aspects of male circumcision.” British Medical Journal 335 (8 December 2007): 1206-1209.

Narulla, Ranipal. “Circumscribing circumcision: Traversing the moral and legal ground around a hidden human rights violation”. Australian Journal of Human Rights, Vol. 12, 2007, 89-118

Royal Australasian College of Physicians. Circumcision of Infant Males [Policy statement]. Sydney: October 2010. Available at http://www.racp.edu.au/page/policy-and-advocacy/paediatrics-and-child-health

Royal Dutch Medical Association. Non-therapeutic Circumcision of Male Minors (May 2010). Available at http://knmg.artsennet.nl/Diensten/knmgpublicaties/KNMGpublicatie/Nontherapeutic-circumcision-of-male-minors-2010.htm

Spilsbury K, Semmons JB, Wisniewski ZS, Holman CD. “Routine circumcision practice in Western Australia 1981–1999”. ANZ Journal of Surgery 2003;73(8):610-4. Available at http://www.cirp.org/library/procedure/spilsbury1/

Svoboda JS, Van Howe RS, Dwyer JG. “Informed consent for neonatal circumcision: An ethical and legal conundrum.” Journal of Contemporary Health Law and Policy 2000;17:61-133. Available at http://www.cirp.org/library/legal/conundrum/

Van Howe RS. “A cost-utility analysis of neonatal circumcision.” Medical Decision Making 2004;24:584-601. Available at http://www.cirp.org/library/procedure/vanhowe2004/

A comparable case in Colorado

In the United States of America, where even the most minor local issues tends to be politicised, insurance coverage of non-therapeutic circumcision tends to become a political football. Last year Colorado dropped payments for circumcision from Medicaid (the USA equivalent of Medicare), but this year politicians in the state legislature who had been misled by the usual scaremongering propaganda put out by the usual suspects tried to restore it. Their arguments - for example, that the foreskin caused spina bifida, or that circumcision was good because it deadened the penis and discouraged teenage sexual activity - demonstrate why politicians should not get involved in these questions unless they have done some research.**

Colorado drops circumcision from Medicaid

A bill that would have restored Medicaid funding for circumcisions in Colorado died Friday. The measure squeaked through a hearing in the House Health and Environment Committee on Thursday, then died in Appropriations Friday morning. Opponents, who included health professionals, budget hawks and anti-circumcision activists told health committee members on Thursday that circumcision is cosmetic and potentially harmful, and taxpayers should not fund it. Proponents for the bill argued that funding for circumcision for babies on Medicaid is a social justice issue. In general, insurance companies pay for the procedure for insured Colorado babies even though the American Academy of Pediatrics does not deem circumcisions to be “medically necessary.” Meanwhile, low-income parents who want their babies circumcised are being put on waiting lists for the procedure until parents can prove they’ve paid in advance.

Sen. Irene Aguilar, D-Denver, an internal medicine doctor for Denver Health, testified on behalf of restoring public funding for circumcision. Last year, Colorado lawmakers decided to save money and cut funding for Medicaid circumcisions. They were following the lead of 17 other states. Proponents wanted taxpayers to once again pay for the procedures for parents who choose to have their infants circumcised. Fiscal analysts estimated that covering the procedures again would cost the state about $195,000 next year and $230,000 the year after that.

“As a physician, I don’t try to influence parents one way or the other,” Aguilar said. “People make this decision based on religious and cultural reasons.” She said that there is some evidence that infant boys who don’t get circumcised have higher rates of urinary tract infections and that adult men who are uncircumcised and live in poverty tend to have increased rates of HPV, which can lead to higher rates of cervical cancer in female partners. [What business does a medical doctor have performing unnecessary surgery based on religious or cultural reasons?]

Only one other doctor testified on behalf of circumcision. The rest of the witnesses opposed public funding for the procedure for a variety of reasons. They included Dr. Jennifer Johnson, a family physician who works with Medicaid and uninsured patients at Clinica Family Health Services. “I’ve done at least 100 circumcisions and just recently decided to stop,” Johnson testified. She said she and her husband, who is Jewish, decided not to circumcise their own son, who is now 4. She said she was concerned when she researched the issue and found that removing the foreskin from a boy’s penis damages numerous nerve endings. While circumcision is traditional in the Jewish community, Johnson said her husband was open to new research about the potential harms from circumcision.

If boys or men decide to remove the foreskin as adults, then they can make that decision, Johnson said. But she decided that as a physician, she should no longer do a procedure that is potentially harmful. “This is not a necessary procedure,” Johnson said. “It’s a healthy, normal body part. There are a lot of medical needs in our population. We have no business using limited health care dollars on a medically unnecessary cosmetic procedure.”

One lawmaker, Rep. Sue Schafer, D-Wheat Ridge, elicited laughter in the hearing room when she asked Dr. Johnson if circumcision might help reduce teen pregnancy rates and teen sexual activity by reducing nerve sensation in boys’ penises. “I’m wondering if there’s a risk of more sexual activity, more male irresponsibility” for uncircumcised boys, Schafer asked. Johnson answered that teen pregnancy is certainly a problem, but said circumcision won’t halt teen sexual activity. “Circumcision is not a cure for behavior. That’s about education,” she said.

While circumcision is an ancient tradition in some religions, circumcision opponents said it became popular in the U.S. as a method to prevent masturbation among boys. Later, fathers wanted their sons to look like them. “Frankly that’s cosmetic surgery…and I strongly urge you to vote against it,” said Dr. Matt Mason, a physician from Telluride. He was skeptical about cost estimates and said circumcision is now rare in Western Europe, Canada and New Zealand. [He might have added Australia; circumcision has always been rare to vanishing point in all Europe, not just the west.]

Source: Katie Kerwin McCrimmon, Circumcision bill dies in Colorado House, Health Policy Solutions, 5 May 2012

** Take the example of a local senator, who claimed in an email to constituents that “Reliable studies prove that male circumcision reduces instances of infectious disease, some congenital obstructive urinary tract anomalies, neurogenic bladder, spina bifida and urinary tract infections.” He continued to dispense this fiction despite having been challenged previously by a competent physician, Dr. Mat Masem, who stated, “There are rare therapeutic indications for male circumcision, which generally relate to pathologic conditions of the foreskin. However, a number of the conditions you mentioned as being positively affected by circumcision have absolutely nothing to do with the foreskin. Spina bifida is an anomaly of the spine; congenital obstructive urinary tract anomalies are related to urethral strictures or other abnormalities of the urinary tract; and neurogenic bladder is a neurological condition. ”

Source: Jere DeBacker, Opinion: Lawmakers clueless about circumcision research, Health Policy Solutions, 1 May 2012.

Social disadvantage vs anatomical/physiological disadvantage

As for the argument that Medicaid/Medicare should cover circumcision because otherwise poor people cannot afford it (“Circumcision a health right of the poor”, as Brian Morris and Jake Waskett have claimed) - surely it’s bad enough to be poor. Why should poor people be deprived of their foreskins as well? That is merely adding injury to insult.

4. The Hawke government's unsuccessful attempt to drop circumcision from the MBS

Robert Darby, Scientific Advice, Traditional Practices and the Politics of Health-Care: The Australian Debate over Public Funding of Non-Therapeutic Circumcision, 1985. Hygiea Internationalis: An Interdisciplinary Journal for the History of Public Health, Vol. 10, December 2011.

ABSTRACT In 1985 the Australian Government sought to delete circumcision of infants from the benefits payable under its newly established universal health scheme, Medicare. Although the decision had been recommended by the government’s health advisers and was welcomed by medical authorities, it was soon reversed after protests from Jewish community leaders. I present a detailed narrative of this affair and explain why a decision based on sound medical knowledge advice was rescinded after quite mild objections. The answer is found to lie partly in contingent factors, such as the details of the policy change, the personalities of the government figures involved, and problems with implementation and communication; and partly in the sensibilities of the ethnic/religious communities most directly affected. I dispel the misconception that the original decision aroused widespread opposition and show, on the contrary, that it was based on good advice, represented sound public policy, and was widely supported. I conclude that the episode may have useful lessons for other governments seeking to implement or resist policy changes that affect the sensitivities of cultural minorities.

Download full text from Hygiea as PDF here

5. Sydney Morning Herald, The Question - Should elective circumcision continue to be covered by Medicare?

Medicare should not cover non-therapeutic circumcision

(a) Medical historian, Dr Robert Darby

The Australian government is under pressure to balance budgets, give more recognition to individual human rights, promote gender equity and protect children from harm. One simple way to make progress on all these fronts is to drop non-therapeutic circumcision from the Medical Benefits Schedule.

Medicare currently provides a no-questions-asked rebate for circumcision, despite the fact that most of these operations have no medical indication, and in defiance of Medicare’s own guidelines. These state that benefits are not payable for “medical services which are not clinically necessary”, nor “surgery for cosmetic reasons”. A medical procedure is clinically necessary only if it is essential to correct a diagnosed disease, injury, deformity or other pathological condition. Surgery for cultural or social reasons is essentially cosmetic surgery, intended to alter the appearance of the body. According to the Royal Australasian College of Surgeons, “male non-therapeutic circumcision is not clinically necessary as it does not treat an underlying pathological process.” Medicare should not, therefore, cover such procedures.

There are five further reasons.

1. No health case for routine circumcision. All the medical authorities that have issued policies on routine circumcision have rejected the operation as unwarranted and potentially harmful, most recently the Royal Australasian College of Physicians in a lengthy statement of October 2010.

2. Consistency with international practice. Australia is the only country in the world that provides an automatic rebate for medically unnecessary circumcision. Even in the United States, 18 states have dropped circumcision from the list of benefits, and more are considering the question.

3. Ethics and human rights. The vast majority of circumcision procedures funded by Medicare are on infants and other minors, few of whom present any pathology requiring surgery. Since minors cannot give consent and may prefer to keep their foreskins, payments for such operations are questionable from a bioethical and human rights perspective, and may even be unlawful.

4. Avoiding sex discrimination. Girls are legally protected from any mutilation of their genitals; the least we can do for boys is not provide a public subsidy for needlessly modifying theirs.

5. Economy and financial prudence. Government welfare programs should be targeted at genuine need and be administered with prudence and economy. An open-slather approach to funding a medically unnecessary procedure is wasteful and invites over-servicing. For reasons of consistent public policy, financial prudence and respect for established principles of bioethics and gender equity, the rebate for circumcision should be abolished except for cases of proven medical need.

NOTEThis is the original text of Robert Darby’s contribution to the Question of the Week, Sydney Morning Herald, Saturday 12 May 2012. The text as published was slightly edited. Dr Darby is an independent scholar who has written extensively on the history and ethics of male and female circumcision. His publications include A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain (University of Chicago Press, 2005) and, most recently, “Scientific advice, traditional practices and the politics of health-care: The Australian debate over public funding of non-therapeutic circumcision, 1985.” Hygiea Internationalis: An Interdisciplinary Journal for the History of Public Health, Vol. 10, December 2011. Available at http://www.ep.liu.se/ej/hygiea/

(b) Urologist Dr Stan Wisniewski

Male circumcision is performed for religious, medical and social reasons. Religious circumcision is performed outside the ambit of the public health purse and is cost neutral, as long as no complications occur. Advocates of universal circumcision in newborn infants believe the procedure is a prophylaxis against future disease and that the phallus looks better and somehow functions better. Circumcision for infection, poor skin retraction or neoplastic changes is required in 5 to 10 per cent of males in the West. This means more than 90 per cent would not need the procedure in their lifetime.

Infections in the foreskin or urinary tract are rare in infancy. The foreskin becomes retractile between 5-10 years of age and teaching hygiene should be intrinsic to healthcare. Contraction and transmission of sexually contracted diseases cannot be prevented by circumcision. The argument that AIDS is not transmitted by circumcised males is not factual. Penile skin cancer is rare and seen in situations of neglect and poor hygiene. One would need to perform 100,000 circumcisions to prevent one case of penile cancer.

The idea that circumcision improves virility or sexual prowess is not scientifically validated. The foreskin has many sensory receptors important for sensual pleasure, and the mechanics of intercourse change when foreskin mobility is removed.

The reason for performing surgery on neonates is a matter of expediency rather than scientific dictum. The operation is often performed without appropriate analgesia and screams and wriggling are ignored. Studies show many boys carry psychological scars afterwards, leaving them agitated and irritable for long periods, sometimes into adulthood. Physical consequences such as excessive skin removal, penile shortening, disfigurement and complications with bleeding and death are all reported. Many circumcised men express anger at parents for their decisions which they now regret, to the point of parents being sued. This is not a benign procedure free of problems. Rates of neonatal circumcision in educated, sophisticated societies continue to fall.

A Medicare rebate for prophylactic neonatal circumcision would allow crusaders to continue to perpetuate a practice that is not substantiated. Nature, honed by millennia of evolution, decrees the foreskin is part of the perfection of humans. Until the time that other changes transmute, why do we think we can do better?

Dr Stan Wisniewski is past president of the Urological Society of Australia & New Zealand.

Source: Should elective circumcision continue to be covered by Medicare, Sydney Morning Herald, 12 May 2012

6.  ANU law student writes on why Medicare should not continue to pay for non-therapeutic circumcision

The following paper was written in 2009 by a third year Law student at the Australian National University, as an assignment for a medical law and ethics unit. The author wishes to remain anonymous.

It’s time for Medicare Australia to stop providing rebates for infant male circumcision

ABSTRACT Infant male circumcision is a controversial procedure that has been debated for years. The overwhelming body of Australian medical opinion is firmly against the procedure and clearly classes it as non-therapeutic, yet the procedure is still covered by Medicare, despite their own guidelines stating they do not cover non-therapeutic procedures. This means the Australian government is indirectly authorising a non-recommended procedure. With the medical opinion firm, and in light of recent debates about the ethics and legality of male circumcision, now is the time for Medicare to stop covering this procedure.

* * * * * *

For years the potential benefits, disadvantages and ethical issues surrounding male infant circumcision have been debated in Australia and overseas. While male infant circumcision used to be common, even routine, in Western nations including Australia, it has dropped significantly in popularity as doctors and parents have become aware that it is not medically necessary or even recommended. Currently, it is estimated that around 10% of newborn baby boys are circumcised in Australia each year, at parental choice. As Medicare provides a rebate for circumcision of a boy under 6 months old, this unnecessary procedure costs Medicare, and therefore the Australian taxpayers, roughly $2 million each year. This is despite Medicare’s own statements that they do not provide rebates for clinically unnecessary procedures. Recent policies, reviews and cases relating to the medical, ethical and legal aspects of infant circumcision – such as the Tasmanian Law Reform Institute review, the Royal Australian College of Physicians new policy statement, and a case from the Oregon Supreme Court – highlight the importance of there being a swift policy change in Australia so that Medicare and the Australian Government come in line with current medical opinion and no longer indirectly endorse a non-therapeutic, non-recommended procedure fraught with legal and ethical uncertainties.

To read full text, download document as PDF here


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