1. Medicare guidelines state that benefits are payable only for procedures that are clinically necessary and are not payable for cosmetic procedures.
2. Australian and most world medical authorities have determined that non-therapeutic circumcision is not clinically necessary and is not recommended.
3. Despite this, Medicare pays a benefit for non-therapeutic (clinically unnecessary) circumcision of males at any age.
4. There are strong objections to non-therapeutic circumcision of male minors for medical, bioethical, human rights and financial reasons.
5. In view of Medicare rules and these objections, non-therapeutic circumcision should be deleted from the Medical Benefits Schedule.
6. This objective is most easily and equitably achieved by adding the words “where medically necessary” to each of the circumcision codes.
In 1985, on the recommendation of the National Health and Medical Research Council, circumcision was removed from the Medical Benefits Schedule. For reasons explained below, the decision was soon reversed and the rebate restored. The lesson of the episode is that when Medicare was established in 1984-85 the government’s intention was that it would not cover non-therapeutic circumcision.
A review of Medicare in 2011 found evidence that between 2 and 3 billion dollars are spent inappropriately each year. The review, by Dr Tony Webber, 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”. Among the abuses, 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”.
In a related study, Elshaug et al (2012) identified 150 low value medical procedures whose presence on the MBS demanded scrutiny. Among these (listed in the appendix to their paper) was neonatal circumcision, with the comment “Current evidence fails to recommend widespread neonatal circumcision for the prevention of sexually transmitted infections, urinary tract infections and penile cancer”, citing Perera et al 2010.
At the same time a planned review of specifically paediatric surgery was established by the Department of Health and Ageing (2013) with a view to assessing the justification for Medicare coverage of a range of paediatric surgical procedures, including “the safety, effectiveness, cost effectiveness, and appropriate clinical use of excision of pre-auricular sinus (MBS item 30104), repair of tongue tie (MBS items 30278 and 30281), circumcision (MBS items 30653, 30656 and 30660).”
In May 2012 a poll in the Sydney Morning Herald found that 67 per cent of respondents were in favour of dropping circumcision from the MBS, and in August a survey in Australian Doctor showed that 51 per cent believed that circumcision was child abuse and should not be done at all, while a further 23 per cent believed that it was an individual choice that should neither be available in public hospitals nor funded by Medicare (Hartley 2012).
It is thus evident that there is widespread concern both within the medical community and among the public at large that Medicare continues to subsidise a cosmetic procedure that is increasingly regarded as analogous to designer vaginas, namely, surgery for “designer penises” – that is to say, non-therapeutic (medically unnecessary) circumcision of male infants and boys. This is despite the fact that no medical organisation in the world recommends circumcision as a routine procedure, and that Australian health authorities have consistently recommended against the procedure since 1971.
There is no reason 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.
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 medical validity, appropriateness, ethics and even the lawfulness of this policy have been questioned in recent years. In this submission I argue that for reasons of consistent public policy, financial prudence and respect for established principles of bioethics, human rights, gender equity and law the rebate should be abolished except for cases of proven medical need.
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. I follow the definition of non-therapeutic given by the Tasmania Law Reform Institute (2009, p. 7): “A circumcision is non-therapeutic if it is performed for any reason other than remedying or treating an existing disease, illness or deformity of the body. … A circumcision performed for the purpose of preventing or reducing the likelihood of possible future disease, illness or deformity of the body (a prophylactic circumcision) is a non-therapeutic circumcision.”
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. 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. As the Royal Australasian College of Surgeons (2008) points out, “male non-therapeutic circumcision is not clinically necessary as it does not treat an underlying pathological process.”
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 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 (Cozijn 2013). 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 against routine circumcision have been issued by the British Medical Association (2007), the Canadian Pediatric Society (2015), the Royal Dutch Medical Association (2010), the South African Medical Association, and medical authorities in Germany, Denmark, Finland, Norway and Sweden. Even in the United States, where routine circumcision is deeply entrenched as a medicalised cultural ritual, the American Academy of Pediatrics, although stating in its 2012 policy that the benefits exceed the risks, does not recommend the operation or regard it as medically necessary. Even this moderate position has been heavily criticised by child health experts (Frisch et al 2013) and bioethicists (Svoboda and Van Howe 2013; Darby 2015), and it has been rejected by health authorities in Australia. (Na et al 2015; Forbes 2015). In any case, the opinions of the AAP have no weight in Australia, where the relevant authority is the RACP.
There are six other 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; legal issues; and financial prudence.
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. Studies by Malone and Steinbrecher (2007) and Perera et al (2010) subjected the claims of circumcision advocates to an exhaustive review, and concluded that its value for child health was insignificant. When the medical literature is considered as a whole 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.
As Perera et al comment, however, 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 in 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 risk of infection – unless 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 (2007) has stated that circumcision has no relevance to Australia’s HIV problem, and their conclusion has been endorsed in a paper by Darby and Van Howe (2011) which argues that circumcision is not a surgical vaccine and is not appropriate as an HIV control tactic in developed countries such as Australia. These conclusions have been confirmed by Bossio et al (2014), which points out that the evidence for circumcision having a protective effect against heterosexually transmitted HIV is not applicable to developed countries such as the United States or Australia.
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.
• In Britain the National Health Service has never included routine circumcision among its free procedures, and covers it only as a therapeutic procedure in cases of medical necessity. The same is true of New Zealand.
• In Canada, where medical insurance is the responsibility of the provinces, the only province to include circumcision in its cover is Manitoba; and even there many doctors refuse to charge the state but bill the parents.
• In the United States, the federal government provides the funds for public health insurance to the states, which make their own decisions as to which services they cover. When the program was introduced in 1965 all states covered circumcision, but since then 18 of the 50 states have ceased to fund it, and more are likely to do so as budgetary constraints intensify (Craig and Bollinger 2006).
• 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.
• Circumcision is not funded by the Israeli government, but remains the responsibility of and a charge to each Jewish family.
• 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.
Further details and references are provided in Darby (2011).
For a surgical intervention to be ethically permissible the fundamental requirement is that the person must give informed consent. An adult male can consent to having himself circumcised, 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 and uncontroversially 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 competent. 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, and most importantly circumcision fails to respect the boy’s autonomy and preserve his future options as an adult individual (Sarajlic 2014).
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. The ethical status of non-therapeutic circumcision of minors has been under a cloud for the last couple of decades (Svoboda et al 2000) and has been the subject of so many critiques that it must now be regarded as highly controversial; while there is no consensus on the issue, it is clear that the majority view from the bioethical and human rights community is that the procedure is not significantly different from female genital mutilation and should be subject to similar restrictions (Earp 2015). For a summary of current opinion, see the special issue of the Journal of Medical Ethics, July 2013.
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 (2007) 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 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.
In recent times it is not merely the ethics but even the legality of circumcision that has been questioned. In 1993 the Queensland Law Reform Commission observed that non-therapeutic circumcision of minors was probably unlawful under the common law of assault, as well as specific provisions of the Queensland criminal code covering assault, injury and sexual assault. More recently an exhaustive review of the ethical and legal status of non-therapeutic circumcision by the the Tasmania Law Reform Institute (2012) concluded that there was no medical justification for the operation, that it was dangerously unregulated, and recommended a range of legal reforms, including partial prohibition in the case of incompetent minors.
Given the controversial status of non-therapeutic circumcision of minors and the lack of proof as to medical need or even significant benefit, doubts have been raised as to the legality of health insurance payments. A study by a United States legal expert (Adler 2011) argues that payments for non-therapeutic (medically unnecessary) circumcision by the US health insurance scheme Medicaid violate the protocols for benefits under this program and are thus unlawful. The article 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.
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 (2003) 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 (2004) 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 may 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. If the rebate had been abolished in 1985 as intended, the accumulated savings would have been quite significant. And there are other reasons to predict that if the subsidy is retained expenditure will rise.
1. The high birthrate in Australia’s increasing Muslim community. Muslims traditionally circumcise boys and tend to prefer a clinical operation by a doctor rather than a traditional circumciser, unlike the Jewish people’s use of a mohel. Muslim doctors in Sydney are distributing advertising material which ignores the recommendations of the RACP and instead stresses the “medical benefits” of circumcision, suggesting that they seek to attract paying customers not merely from their co-religionists, but from the public at large. The presence of a financial rebate will make the procedure more attractive to parents and is likely to increase demand.
2. Irresponsible media commentary on the role of circumcision in controlling HIV and other STIs, as well as the efforts of circumcision promoters such as the “Circumcision Academy of Australia” and entrepreneurial circumcision practitioners, aim to generate a mood of alarm. The demand for circumcision could increase if parents are misled by their advocacy 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.
Economists have shown that price signals are the most effective means of encouraging or discouraging consumer behaviour. This is highly relevant to subsidies for circumcision, as Craig and Bollinger (2006) found that the single most important factor governing the incidence of circumcision in the United States was whether the state provided a rebate under Medicaid. 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.
The main argument for dropping non-therapeutic circumcision from the MBS is not the cost-saving, however, 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 cultural/religious rites and practices should be funded by the Australian taxpayer through the health budget.
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 my study of the incident, published in the international journal Hygiea (Darby 2011). My 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. The lesson of 1985 is that a controversial procedure such as circumcision must be approached with tact and sensitivity to cultural sensibilities. It may be necessary to consult with Jewish and Muslim community organisations, and it is vital not to repeat the mistakes made in 1985, and especially the deadly mistake of limiting removal of the rebate to a specific age-group. Nobody likes having to pay more for a good or service, but so long as all age groups and cultural identities are treated equally there should be no valid grounds for complaint.
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.
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.
Adler, Peter. 2011. Is it lawful to use Medicaid to pay for circumcision? Journal of Law and Medicine, Vol. 19, December 2011: 335-353.
Australian Federation of AIDS Organisations. 2007. Male circumcision has no role in the Australian HIV epidemic. Briefing paper, 23 July 2007.
Beauchamp TL, Childress JF. 2009 Principles of Biomedical Ethics (6th edn). Oxford University Press: 2009.
Bossio JA, Pukall CF, Steele S. 2014. A review of the current state of the male circumcision literature. J Sex Med. 2014 Dec;11(12):2847-64. doi: 10.1111/jsm.12703
British Medical Association. 2007. The Law and Ethics of Male Circumcision: Guidance for Doctors (November 2007).
Cozijn. J. 2013. Incidence and prevalence of circumcision in Australia.
Craig A. and Bollinger D. 2006. Of waste and want: A nationwide survey of Medicaid funding for medically unnecessary, non-therapeutic circumcision. In George C. Denniston et al (eds.), Bodily Integrity and the Politics of Circumcision: Culture, Controversy and Change (New York, Springer, 2006).
Darby, Robert. 2011. “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 Dr Darby's Academia.edu page.
Darby, Robert and Robert Van Howe. 2011. 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.
Darby, Robert. 2015. Risks, benefits, complications and harms: Neglected factors in the current debate on non-therapeutic circumcision. Kennedy Institute of Ethics Journal, Vol. 25 (1), March 2015: 1-34.
Department of Health and Ageing. 2013. MBS Reviews, Paediatric Surgery – Scope. Discussion paper draft (February).
Earp, Brian. 2015. Female genital mutilation and male circumcision: Toward an autonomy-based ethical framework. MedicoLegal and Bioethics 2015; 5 (3 Oct): 89-104.
Elshaug AG, Watt AM, Mundy L, Willis CD. 2012. Over 150 potentially low-value health care practices: an Australian study. Med J Aust 2012; 197: 556-560. doi: 10.5694/mja12.11083.
Forbes, David. 2009. No evidence to support routine circumcision. Sydney Morning Herald, 12 September 2009.
Forbes D. 2015. Circumcision and the best interests of the child. J Paediatr Child Health. 2015 Mar;51(3):263-5. doi: 10.1111/jpc.12853.
Frisch, Morten, et al. 2013. Cultural bias in the AAP’s 2012 Technical Report and Policy Statement on male circumcision. Pediatrics 131 (4): 796-800.
Hartley, Jo. 2012. Strong opposition to newborn circumcision, Australian Doctor, 9 August 2012.
See also: Morris, Wodak circumcision campaign falls flat
Aussies give thumbs down to circumcision
Malone, Padraig, and Steinbrecher H. 2007. Medical aspects of male circumcision. British Medical Journal 2007; 335: 1206-1209.
Na AF, Tanny SP, Hutson JM. 2015. Circumcision: Is it worth it for 21st-century Australian boys? J Paediatr Child Health. 2015 Jun;51(6):580-3. doi: 10.1111/jpc.12825.
Narulla, Ranipal. 2007. Circumscribing circumcision: Traversing the moral and legal ground around a hidden human rights violation. Australian Journal of Human Rights, Vol. 12, 2007, 89-118.
Perera, C.L, F.H. Bridgewater, et al. 2010. Safety and efficacy of nontherapeutic male circumcision: a systematic review. Ann Fam Med 8(1): 64-72.
Royal Australasian College of Physicians. Circumcision of Infant Males [Policy statement]. Sydney: October 2010. Available at
Royal Australasian College of Surgeons. 2008. Australian Safety and Efficacy Registry of New Interventional Procedures – Surgical. Report No. 65: Male non-therapeutic circumcision. Adelaide: RACS, 2008.
Royal Dutch Medical Association. 2010. Non-therapeutic Circumcision of Male Minors (May 2010).
Sarajlic, Eldar. 2014. Can Culture Justify Infant Circumcision? Res Publica 20 (4). November 2014, 327-343. DOI 10.1007/s11158-014-9254-x
Spilsbury K, Semmons JB, Wisniewski ZS, Holman CD. 2003. Routine circumcision practice in Western Australia 1981–1999. ANZ Journal of Surgery 2003;73(8):610-4.
Svoboda JS, Van Howe RS, Dwyer JG. 2000. Informed consent for neonatal circumcision: An ethical and legal conundrum. Journal of Contemporary Health Law and Policy 2000;17:61-133.
Svoboda, J. Steven and Robert Van Howe. 2013. Out of step: Fatal flaws in the latest AAP policy report on neonatal circumcision. Journal of Medical Ethics 39 (7): 434-41.
Sydney Morning Herald 12 May 2012, The Question: Should elective circumcision continue to be covered by Medicare?
Tasmania Law Reform Institute. 2009: Non-therapeutic Male Circumcision. Issues Paper No. 14.
Tasmania Law Reform Institute. 2012. Non-Therapeutic Male Circumcision. Report No 17, August. University of Tasmania.
Van Howe RS. 2004. A cost-utility analysis of neonatal circumcision. Medical Decision Making 2004;24:584-601.
Webber, T. 2012. What is wrong with Medicare?. Medical Journal of Australia 2012; 196 (1): 18-19.
NOTE: This submission was prepared by Dr Robert Darby, Canberra. Australia. Also available at his Academia.edu page.