True accounts of personal tragedy

Advocates of routine circumcision say it is a safe procedure, with a negligible rate of mistakes and things that go wrong, and in a relative sense (compared with brain or heart surgery) this may be true. Even so, the rate of immediate complications in the USA is between 3 and 9 per cent, meaning (tens of thousands of boys each year), with a further 5 per cent experiencing problems later. Outside the sterile wards of US hospitals, in tribal initiation settings as in Africa, circumcision may infect boys with tuberculosis, tetanus and possibly AIDS, as well as causing crippling injury to the penis. Between 60 and 80 boys die each year in southern Africa alone.

Even if the rate of complications in western countries is low in a statistical sense, the result for the unlucky few can be a personal disaster, as the tragic cases recorded on this page show.

Further Information
Deaths
Complications
Dissatisfaction

Boy dies after plastibell circumcision
Baby boy dies after circumcision
Death of Ryleigh McWillis, British Colombia, Canada, from bleeding following circumcision
British men seek compensation for circumcision injury
Neil Peterson (USA)
Australian parents
An English mother
An English man
Shane Peterson (Australia)
Dr David Nunn (Australia)
Photos show how to identify circumcision damage

Boy dies after plastibell circumcision

OTTAWA — A one-week-old Ontario infant died from complications after undergoing a circumcision in a provincial hospital.

Information about the case was published in the April 2007 edition of Paediatric Child Health.

The baby, whose name has been withheld by the parents, passed away after his kidneys [no, bladder] became enlarged to seven times their [its] normal size.

The child was born at an unidentified Ontario hospital “sometime in the last three years,” said Dr. Jim Cairns, Ontario's deputy chief coroner. “The family wants to keep this anonymous.”

No charges were ever laid and no legal action was ever taken in the case.

According to the Paediatric Child Health article, the boy was “bottlefed and was reported to be doing well when he was circum[cis]ed.”

Five hours later, the parents returned to their family doctor with the infant, who had become “irritable and had blue discolouration” below the belly button.

Doctors noticed the discolouration and slight swelling of the penis, but sent the child home.

Fourteen hours after the circumcision, according to Cairns, the child was brought to another hospital where doctors noted he was extremely irritable with marked swelling of the penis and bruising to the scrotum.

The child was then transferred to a paediatric centre, where his bladder was diagnosed, Cairns said, to “seven or eight times its normal size.”

The PlastiBell ring, which is used to hold back the foreskin after circumcision, was removed and drained and the child went into shock.

“If the PlastiBell had been taken off five hours after he got there, he would be alive,” said Cairns. [Perhaps. If the PlastiBell had never been used in the first he would certainly be alive.]

The child's death was attributed to septic shock — “an overwhelming infection, leading to multi-organ failure,” Cairns said.

“Death is rare after circumcision,” said Cairns. “But complications can happen.”

The case was brought to Cairns' attention because the circumstances of every death of an Ontario child under five years of age must be reviewed by the provincial coroner's office.

Mark Brennae, CanWest News Service
Published: Wednesday, June 13, 2007

canada.com, June 13, 2007

Further details and links

Paediatrics and Child Health, Vol 12, No. 4, April 2007

7-Day-old died after circumcision

The Mirror (London), 15 February 2007

Exclusive by Stephen Moyes

DETECTIVES are investigating the death of a seven-day-old baby after he was circumcised. Stunned relatives at the Jewish ceremony saw the toddler experience breathing difficulties. He was taken to hospital but died eight days later. A post mortem found the infant died from cardiac arrest and oxygen starvation.

Police are to interview family members and the senior rabbi who performed the operation at Golders Green Synagogue in North London. Concerns raised by doctors treating the baby have led to the probe being led by Scotland Yard’s child abuse investigators.

Police and Home Office sources said the investigation was “highly unusual”.  A Scotland Yard spokesman stated: “The death is being treated as unexplained at this early stage.”

The baby died two weeks ago at University College Hospital, Central London.

Circumcision of boys is an operation in which the foreskin is removed from the penis. With small babies, local anaesthetic is often sufficient and avoids the risks of a general anaesthetic. Some people believe the skin is redundant and gets in the way of hygiene.  Others say it is a vital part of the male anatomy and should not be removed.  Judaism considers circumcision to be an important ritual. The operation is usually performed by a mohel - a specialist in the procedure and its rituals. Many British mohels are doctors, rabbis or both. All have received appropriate medical and religious training.

A spokesman for The United Synagogue, a membership of 35 orthodox synagogues in Greater London, said: “We are awaiting the results of the police enquiry and until then it would not be appropriate for us to comment further.”

http://tinyurl.com/2db9x5

Death of Ryleigh McWillis, British Colombia, Canada, from bleeding following circumcision

The following letter was sent to the medical board in each state and territory in Australia, and to state health departments in South Australia, New South Wales and Queensland in March 2004.

Risks associated with circumcision of male infants and children

A recent Coroner's report from the province of British Columbia in Canada indicates that the risks inherent in the circumcision of male infants are greater than commonly appreciated. We enclose a copy of the Coroner's report for your information.

The report shows that the baby, Ryleigh Roman Bryan McWillis, aged one month, was circumcised in the Penticton Regional Hospital on 20 August 2002. He was released from the hospital into the care of his parents; suffered extensive bleeding from the wound; was returned to Penticton Hospital; and was subsequently transferred to the B.C. Children's Hospital, where he died less than 48 hours after the operation. The Coroner concluded that the death was due to "multiorgan hypoxic/ischemic injury due to hypovolemic shock as a result of massive hemorrhage from a circumcision site." Tragic though it is, there is nothing extraordinary in this outcome: bleeding and death are well-known complications of circumcision. [1-3] A similar case was reported by the Miami Herald in 1993, [4] a case occurred in Ireland in 2003, [5] and cases have also been recorded in Australia. (See below and Attachment 1.)

Since the prepuce is highly vascularized, it is likely to haemorrhage when cut, and severing of the frenular artery is also possible during circumcision procedures. [6] Infants have a very small volume of blood in their bodies, and they can tolerate only about a 20 per cent blood loss before hypovolemia and hypovolemic shock set in, followed quickly by death. A 4000 gram male newborn has only 11.5 oz (340 ml) of total blood volume at birth, 85 ml per kilogram of weight. [7] Blood loss of only 2.3 oz (68 ml) - about a quarter of a cup - represents 20 per cent of total blood volume at birth, and is sufficient to cause hypovolemia. [8] The quantity of blood loss that might kill an infant - 85 ml - is easily concealed in today's highly absorbent diapers: Ryleigh's parents were quoted by the Canadian Broadcasting Corporation as stating that they had no way to know that their baby boy was bleeding to death. [9] Circumcision of infants, even in optimum conditions, thus carries an inherent danger of hypovolemic shock and death.

The Coroner further shows that the doctor at Penticton Hospital performed the circumcision in the absence of any medical indication or need, but at the request of his parents. This practice - needless circumcision at parental request - is thus shown to be hazardous to children's lives. As Watters and Carroll have shown in their study of parental attitudes in rural New South Wales, parents rarely appreciate the risks associated with the excision of an infant's prepuce, and are ill-equipped to make decisions that should properly be made after expert paediatric advice or left to the boy himself. [10]

It is a widely accepted principle that the primary duty of doctors is to consider the well-being of their patient above all else. [11] Medically unnecessary circumcisions at parental request are inconsistent with that paramount duty. Doctors must comply with ethical guidelines issued by the Australian Medical Association to "practise the science and art of medicine to the best of your ability." [12] Circumcision of male infants in the absence of any medical indication or need carries serious risks, offers no significant therapeutic benefit, and is inconsistent with those duties.

Parents have a duty to protect their children and to act in their best interests. [13] Non-therapeutic circumcision of children infringes children's legal right to bodily integrity and their rights as human beings to life and security of person. [14] Election of medically unnecessary circumcision is inconsistent with parents' responsibilities to the child; indeed, it is debatable whether it is legally possible for them to give valid consent to the non-therapeutic circumcision of an incompetent minor. [15]

We do not suggest that deaths or serious complications from circumcision are common in developed countries: Australia has an enviable record with respect to deaths from circumcision, none having been reported since 1993. There is, however, no room for complacency. As well as good medical practice, the absence of such reports is as much a consequence of the declining and now low incidence of infant circumcision (see Attachment 2) and the difficulty of attributing deaths to circumcision when they are the result of later complications, such as infection, or of long term sequelae, such as suicide. Several authorities agree that there is no reliable record of mortality (see Attachment 1), and the Australian Institute of Health and Welfare has admitted that their statistics cannot identify deaths due indirectly to circumcision:

We have information on circumcision and there are external cause codes for complications of medical and surgical care. However, it is not possible to tell if the complication was a result of the circumcision. For example, the circumcision may have been undertaken in a previous admission, and the patient readmitted with a complication. If this was the case, we couldn't tell that it was the same patient and we wouldn't know for sure that the complication was due to the circumcision. [16]

It is a similar picture with respect to complications, the incidence of which is the subject of wide disagreement. In 1970 Leitch suggested a rate of 15.5 per cent, [17] while more recently the Royal Australasian College of Physicians cites estimates ranging from an implausible 0.06 per cent to an equally unlikely 55 per cent, depending on definition. It seems to regard a likely incidence as falling within the range of 2 to 10 per cent, and it warns that "serious complications, such as bleeding, septicaemia and meningitis may occasionally cause death". [18] If the rate of complications is 15, 10 or even only 2 per cent, it is apparent that the small number of cases that get publicly reported represent only the tip of the iceberg; this understatement contributes to the impression that circumcision is a safe operation.

Whatever the figure - and it seems unlikely that definitive statistics will ever emerge - it will readily be agreed that there must be a lower threshold of tolerance for adverse outcomes from unnecessary or cosmetic surgical procedures than from those which are required for a person's health. This principle is all the more important when the person does not choose the surgery for himself. Although the incidence of circumcision in Australia is low by historic standards (around 12 per cent, compared with about 50 per cent in the early 1970s), there has been a gradual increase since 1993, and it is still disturbingly prevalent in New South Wales, South Australia and Queensland. If the frequency of the operation continues to increase, complications and adverse outcomes will become more common. It is clear that the surest way to avoid both complications and death from circumcision is by not performing the operation in the first place.

Your attention is particularly drawn to the disturbingly high and increasing incidence of circumcision in New South Wales. Its frequency has risen by about 30 per cent over the past ten years and is now double that found in Victoria, the ACT, Tasmania, Western Australia and the Northern Territory.

We suggest that the Canadian tragedy makes it timely to remind medical practitioners of the unavoidable risks of surgery and of their duty to protect infants and children from procedures that are not needed for, and which may well harm, their health and happiness. By ratifying the United Nations Convention on the Rights of the Child, Australia has pledged itself to protect children from "traditional procedures prejudicial to the health of children", [19] and it is hard to see how non-therapeutic male circumcision would not fall into that category.

We seek your advice on how you propose to ensure that tragedies like the McWillis case do not occur in your state. We also ask you to advise us on whether you would be willing to adopt measures in order to:

· alert health care providers to this incident;
· ensure that they follow the recommendations of the RACP's Policy statement on circumcision (2002) in warning parents who seek the operation of the real risks of the procedure;
· remind them that is their duty to act in the best interests of the child;
· point out that circumcision should be performed only when there is a compelling and immediate medical indication, and only after conservative treatments of foreskin problems have failed. (Medical ethics dictate conservative treatment prior to radical surgery involving amputation of tissue. [20])

We believe that such reminders would go far towards minimising the danger of exsanguination, hypovolemic shock and death as a consequence of non- therapeutic circumcision and greatly reduce the risk of adverse outcomes from therapeutically or otherwise justified circumcision. We urge that you take appropriate action and thereby continue to fulfil your board's obligation to protect the public, [21] especially its smallest and weakest members.

Yours sincerely

Shane Peterson
22 March 2004

References

A pdf copy of the Coroner's report is available here.
http://www.cirp.org/library/death/

Williams N, Kapila L. Complications of circumcision. Brit J Surg 1993; 80: 1231-6
http://www.cirp.org/library/complications/williams-kapila/

1. Fetus and Newborn Committee, Canadian Paediatric Society (CPS). Neonatal circumcision revisited. Can Med Assoc J 1996; 154(6):769-80.
http://www.cps.ca/english/statements/FN/fn96-01.htm

2. Beasley S, Darlow B, Craig J, et al. Position statement on circumcision. Sydney: Royal Australasian College of Physicians, 2002
http://www.racp.edu.au/hpu/paed/circumcision/

3. Baby bleeds to death after circumcision. Miami Herald, June 26, 1993.
http://www.cirp.org/news/1993.06.21_death/

4. Neans McSweeney. Baby dies after botched circumcision. Irish Examiner, Cork, Thursday, 21 August 2003
http://www.cirporg/news/irishexaminer08-21-03b/

5. Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 Suppl. 1:34-44.
http://www.cirporg/library/anatomy/cold-taylor/

6. Paediatric Handbook, editors J Smart, T Nolan, Sixth Edition, Blackwell Science Asia, Carlton South, Victoria, Australia, 2000, page 82.

7. Glancy GL. Shock in children warrants special considerations. Ski Patrol Magazine 1997, Summer

8. Canadian Broadcasting Corporation, Wednesday, 11 February 2004. Circumcision under attack.
http://www.cirp.org/news/cbc02-11-04a/

9. Greg Watters and John Carroll, "Just like dad: Maternal attitudes to neonatal circumcision in an Anglo-Celtic society", paper given to Urological Society of Australasia, Scientific Meeting, Queenstown, NZ, 6 March 2003
http://www.circinfo.org/news.html

10. Australian Medical Association. Code of Ethics (1996).
http://www.ama.comau/web.nsf/doc/WEEN-5WW598

11. Ibid.

12. Beasley S, Darlow B, Craig J, et al. Position statement on circumcision. Sydney: Royal Australasian College of Physicians, 2002.
http://www.racp.edu.au/hpu/paed/circumcision/

13. Articles 3 and 5. Universal Declaration of Human Rights, G.A. res. 217A (III), U.N. Doc A/810 at 71 (1948).
http://www1.umn.edu/humanrts/instree/b1udhr.htm

14. Gregory J Boyle, J Steven Svoboda, Christopher P Price, J Neville Turner. Circumcision of Healthy Boys: Criminal Assault? 7 J Law Med 301 (2000).
http://www.cirp.org/library/legal/boyle1/

15. Narelle Grayson, Hospitals and Mental Health Services Unit, AIHW, email message to Shane Peterson, 14 January 2004

16. I.O.W. Leitch, "Circumcision: A continuing enigma", Australian Paediatric Journal, Vol. 6,1970, 60
http://www.cirp.org/library/general/leitch1/

17. RACP Policy statement on circumcision, 2002
http://www.racp.edu.au/hpu/paed/circumcision/

18. Article 24.3, U.N. Convention on the Rights of the Child (1989). UN General Assembly Document A/RES/44/25.
http://www1.umn.edu/humanrts/instree/k2crc.htm

19. Committee on Medical Ethics. The law & ethics of male circumcision - guidance for doctors. London: British Medical Association, 2003.
http://www.cirp.org/library/statements/bma2003/

20. New South Wales, Medical Practice Act 1992. Section 2A (1)

British men seek compensation for circumcision injury

The British Guardian recently (29 October 2005) ran a major feature article, “Sore Point”, on the resentment felt by men who had been circumcised as children:

Circumcision – beloved by the Victorians … can be a cause of great anguish. Richard Johnson meets men finding ways to reverse a cut they wish they’d never had.

Guardian, Saturday October 29, 2005

See text of full article here.

In response to a letter agreeing that circumcision was immoral but questioning the comparison with female genital mutilation, the Guardian published the following letter from John Dalton.

As a victim of male circumcision and a subject of Richard Johnson’s article (Sore Point, October 29), I have no wish to belittle the suffering of circumcised girls. I would, however, like to respond to Catherine Long’s objection to male circumcision being compared to female genital mutilation (Letters, November 5). Male and female circumcision both remove normal tissue from normal children without therapeutic need or personal consent. The time has come for children to be protected from non-therapeutic circumcision without prejudice in respect of race, religion or gender.

John D Dalton
Frizington, Cumbria

Guardian Weekend Magazine, 12 November 2005

Not new complaint

The following letter signed by twenty English men was published in the British Medical Journal in 1996.

Circumcision of children

EDITOR,  We are all adult men who believe that we have been harmed by circumcision carried out in childhood by doctors in Britain. We are concerned about the ethics of this surgery on children and that it is commonly carried out when it is not essential. We have read the BMA’s ethical guidelines, which give no guidance to practitioners who are faced with a boy who has been referred for circumcision. [1] The possible future wishes of the patient should be considered.

Although it was shown 28 years ago that preputial development continues to the age of 17 and that only three of 1968 boys needed surgery, [2] many British doctors still seem to be ignorant of this research. [3] The European charter for children in hospital states that every child must be protected from unnecessary medical treatment. The United Nations Convention on the Rights of the Child states that children have rights to self determination, dignity, respect, integrity, and non-interference and the right to make informed personal decisions. Unnecessary circumcision of boys violates these rights.

A non-retractile foreskin in a boy can be managed conservatively. [4, 5] Circumcision should therefore rarely be necessary. It would be helpful if paediatric urologists could produce guidelines to advise doctors how foreskin problems in boys can be managed. Preferably, circumcision should not be done until the patient is adult or at least old enough to understand what is intended; then he has a right to a full, illustrated explanation of the nature of the operation and the reasons for it in advance, with the opportunity to ask questions, and help in coming to terms with the alteration of his anatomy afterwards. If the patient is not satisfied with the explanations his views should be taken into consideration.

It cannot be ethical for a doctor to amputate normal tissue from a normal child. In the case of disease, circumcision should be used only when there is evidence that conservative treatment is unlikely to be effective or when it has failed. Avoiding surgery may even be cheaper for purchasers of health care. Doctors should approach the child's foreskin with a combination of good ethics, a recognition of the rights of children, and advice based on evidence.

Norm UK, PO Box 71, Stone, Staffordshire ST15 0SF

John P Warren, P David Smith, John D Dalton, Graham R Edwards, Marc Foden, Robert Preston, Philip Stewart, Adam Roberts, Philip C Cookson, Joseph Elliott, J S Phillips, James Williams, Matthew Mallinson-Read, Ian Morris, John Bowring, Rob Warburton, James Blazeby, Tony Peters, John Moore, John Stevens

1. BMA. Medical ethics today: its practice and philosophy. London: BMJ Publishing Group, 1993.

[Note: This has now been superseded by British Medical Association, Medical Ethics Committee, The law & ethics of male circumcision: Guidance for doctors, 4 April 2003]

2. Oster J. Further fate of the foreskin. Arch Dis Child 1968;43:200-3.

3. Griffiths D, Frank JD. Inappropriate circumcision referrals by GPs. J R Soc Med 1992;85:324-5.

4. Wright JE. The treatment of childhood phimosis with topical steroid. Aust NZ J Surg 1994;64:327-8.

5. Cuckow PM, Rix G, Mouriquand PDE. Preputial plasty: a good alternative to circumcision. J Pediatr Surg 1994;29:561-3.

British Medical Journal, Vol. 312, 10 February 1996, p. 377

Neil Peterson: Constant pain from infant circumcision

UI [University of Iowa] freshman Neil Peterson grew up convinced that he was no different from other boys even though he spent much of those years in excruciating pain.

The Missouri native experienced uncomfortable erections from early childhood until two years ago, when the 24-year-old anthropology student discovered that he suffered from a rare complication after being circumcised too tightly. Since then, he's spoken out about the procedure and formed a local chapter of Students for Genital Integrity, a nationwide support group.

"I had to recognize that I was unhappy the way I was," he said. "[Forming the group] was a very un-American thing for me to do, because society normalcy calls for circumcision in men. It has healed me to talk about it."

Peterson said his complication was healed after he learned to stretch his foreskin out to alleviate his condition. Although he no longer experiences pain, he is dedicated to speaking out against genital mutilation.

Circumcision and other types of bodily mutilation are crimes against human rights, Peterson said. His group contends that children should not be forcibly circumcised, as they now are as infants at their parents' request. The group is dedicated to educating the public and doctors that circumcision is not necessary, in addition to highlighting the dangers of sex-reassignment surgery to distinguish hermaphrodites as male or female.

The group will be formally recognized as a UI student organization next week, Peterson said.

Peterson is planning to hold fund-raisers and host speakers at the university and write to representatives, expressing the need for a law barring circumcision in the United States.

The Circumcision Information and Resource Pages reports that approximately 60 percent of American males are circumcised, down from nearly 90 percent in the 1960s.

Edward Bell, a UI professor of pediatrics, said complications such as Peterson's are rare. The American Academy of Pediatrics says 0.2 to 0.6 percent of circumcisions end with complications. Bleeding and infection are two problems that can occur when a boy is circumcised, as well as scarring if the doctor removes too much foreskin.

Bell said that circumcision has become an unnecessary procedure for most males. "Circumcision is more of a cultural issue than a medical one," he said. "It would be nice if parents didn't insist upon having their boys circumcised." Many parents don't want their boys to look different from their brothers, peers, or fathers, Bell said.

"Circumcision has become cosmetic surgery, and it's really just a matter of personal preference," Bell said.

By Paula Mavroudis - The Daily Iowan 12/5/02
http://www.dailyiowan.com/news/337674.html
pauletta-mavroudis@uiowa.edu

Australian parents, 2002

"Yes, we had it done"

"We decided to have our son, Jonas, circumcised, because my husband, Conrad, wanted to. He's circumcised, so it's a case of like father like son. We researched it before we had it done, and nothing really bothered me for or against it. However, Conrad's family are doctors and nurses, and they all encouraged us to have it done.

"If I had another boy, I would have to have him circumcised too, because you can't have one boy done and not the other. But it was a horrible experience. Jonas was three weeks old when we took him to a doctor's surgery for the procedure. Apparently that's all this doctor does and all you could hear in the surgery was babies screaming. Now, I hear that doctors are doing it later, but I wouldn't have it done that way. At three weeks, Jonas screamed for about 20 minutes -- if they're older, they're more aware that it's hurting. I would recommend having it done earlier.

"After the circumcision, his penis was wrapped in gauze while it healed, and it was just so painful for me. We had to bath him in salt water to help the healing process and slowly pull the gauze away. As we were unwrapping it, some of the gauze was stuck to the skin and it was just horrible - hard and heartbreaking. Unless you've got the guts for it, I wouldn't do it. But I don't regret it.

"There are a lot of people saying to me now that less children are now being circumcised, so I don't know how that's going to effect Jonas as he's growing up. It's starting to worry me that he won't be like everybody else."

-- Juliette Van Outen

"No, we didn't have it done"

"I always thought I would circumcise any sons I had, because I think a circumcised penis looks nicer, and because my husband, Anton, is circumcised. But when I had Saxon, I realised there was no way I was going to inflict unnecessary pain on my little boy.

"Every time I thought about the actual procedure, I'd feel physically sick. When my husband brought up the subject -- he wanted Saxon to be done -- I'd say let's wait until he's six months, which is when babies can be anaesthetised. It was my way of buying time.

"Saxon turned six months and the subject was casually broached again. I said I didn't want to do it; that I couldn't see the pros outweighing the cons. Anton still said he wanted it done. We left it at that. Just before Saxon turned one, I read an article that confirmed my feelings against getting it done. The article described the pain of the procedure and the fact that uncircumcised men experience greater pleasure during sex. I told my husband that now I was adamantly against circumcision. He just said 'Well, I figured out pretty quickly that, when we didn't do it straight away, we wouldn't do it at all.' It wasn't a big issue between us, thankfully."

-- Vicky Redlich

"I said no, but doctors changed my mind."

"Jon was circumcised when he was four. I deliberately chose not to have him (and my other boys) done as babies, but then when he was nearly four, Jon started to scream when he went to the toilet and I knew something was wrong. It turned out that his foreskin wouldn't retract and this was causing him pain when he did a wee. Our doctor convinced me that circumcision was the best option.

Jon had a general anaesthetic for the operation and came out of it quite quickly, but he was in lots of pain for weeks after. He screamed whenever he did a wee and he screamed the first time I put him in the bath after the operation. After that he wouldn't go near the bath for two weeks. His penis got infected and he needed antibiotics to clear it up.

He kept crying and saying, "I wish I had my old willy back". It was really rough on Jon and created several weeks, if not a couple of months, of crying and pain, but we've had no problems since."

- Ginny Anderson

"Circumcision: Fore(skin) and against"
Practical Parenting, June 2002, pages 48-50

[NOTE: It is not unusual for boys to go through a phase during which the foreskin balloons out when they urinate. This is nothing to worry about: it can actually help gently stretch the foreskin and detach it from the glans. Phimosis can now nearly always be successfully treated with steroid cream.]

An English mother

"I am an English atheist and my husband is an Egyptian Muslim. My son was born with undescended testicles and at the age of two and a half had an operation to bring them down permanently. Even though I was completely against it as a form of mutilation, my husband was adamant that our son would be circumcised one day - definitely in Egypt when he was older and without anaesthetic. As I thought it would be safer for him in England, under anaesthetic, and to avoid any further family conflict in the future, I thought it better to get it over and done with while he was having his other operation.

Not a day has passed since (it's been five years now) that I have not regretted giving in to my dominant husband. The pain my little boy went through with his penis weeping and covered in stitches for days afterwards, the thoughts of how it would affect him psychologically, how he would feel about being different from other boys, how it would affect his sexual pleasure when he grows up, how he might hate me one day for agreeing to this barbaric mutilation, and all these thoughts and more haunt me every day since. To have it done when there was no medical reason, no reason whatsoever for it having to be done - I just cannot live with my conscience without knowing there is any advantage whatsoever. If only I had said no, wait until he's older and can decide for himself - of course he never would have decided 'yes', who would agree to having the most sensitive part of their body mutilated? "

Source: http://www.norm-uk.org/circumcision_unhappy.html

An English man

Alex was circumcised at 25 during an operation to correct a bend in his penis. The surgeon decided - without Alex's consent - to remove the foreskin, an action that other surgeons have subsequently confirmed as unnecessary. "There was a huge reduction in erogenous tissue," says Alex, now 29, a systems analyst from Oxfordshire. "The feeling of pleasure has changed so much that I haven't been able to achieve orgasm since the operation. It had a disastrous effect on my relationship: my partner wondered whether it was her fault, and that contributed to the end of our relationship. Since then I've found it hard to get into a new relationship. I am conscious of how I look, and girlfriends have given me quizzical looks. They are not used to seeing circumcised men. I haven't had the confidence to go into a public changing room since the operation."

Source: Simon Crompton, "The unkindest of cuts", Times (London), 13 January 2003

Assaulted and mutilated: Shane Peterson's account of circumcision trauma

Summary

The excessive removal of skin and mucosa is one of the most common complications of neonatal circumcision, yet the true frequency of this complication and its adverse effects on physical and psychological development has not been adequately documented. A personal account is presented of the lifelong trauma associated with a routine neonatal circumcision in which almost all penile shaft skin was removed in addition to the preputial skin and mucosa. The trauma of this iatrogenic injury exerted a negative effect on physical and psychological development, including sexuality, perceived place in society, and career. Reconstructive surgery to resolve the physical injury yielded disappointing results. Partial resolution of the psychological trauma has been achieved through a combination of ongoing counseling, successful litigation, and an emphasis by the victim on public education in regard to the detrimental effects of routine neonatal circumcision.

Introduction
Overview
Major life events
Birth and circumcision
Adolescent years
Young adult years
Life options
Reconstructive surgery
Short term results
Long term results
Suicide attempt
Legal action
Current status
What I would like to see happen in Australia
References

Introduction

I am a 27-year-old postgraduate student (doing PhD) who was badly injured by a routine neonatal circumcision performed within days of my birth. For the last nine years, I have struggled to cope with this injury and seek legal redress for my suffering, while at the same time I have successfully pursued a career in medical science. I recently achieved a precedent-setting legal victory in Australia with an admission of liability and AU $360,000 in damages for my injury. I view routine circumcision as an act of assault and a breach of human rights, and I am dedicated to the eradication of this unnecessary and potentially disastrous procedure.

Overview

This article is an account of my experience of the possible, and largely unpublicized, complications that can arise from routine neonatal circumcision. Circumcision and other forms of male and female genital mutilation originated in primitive societies and have been practiced for several thousand years. Despite this long tradition of mutilation, the resulting complications, injuries and deaths have been consistently unreported.

Ironically, many contemporary advocates of male circumcision claim that the historic development of this practice in primitive societies is evidence that male circumcision is beneficial to health. For example, circumcision advocates Szabo and Short1 claim that male circumcision is depicted in a controversial relief from the Old Kingdom tomb of Ankhmahor at Saqqara, Egypt. This relief may be one of the oldest records of male genital mutilation in the ancient world, and dates from around 2400 BC.2-3 A number of trained Egyptologists, however, doubt this claim. A number of alternative interpretations have been offered by experts in the field. Some Egyptologists argue that this is a scene of a ritual shaving,4 while others suggest that it might be a scene of emergency dorsal slit surgery to relieve a case of paraphimosis.5 Even if genital mutilation is depicted in this relief, controversy exists over the similarity of this practice to circumcision, and its cultural significance to the Ancient Egyptians.6

Regardless of the type of genital mutilation depicted in the Ankhmahor tomb relief, it is apparent that one man has been forcibly restrained. This can be interpreted as involuntary genital mutilation. The relief provides evidence that, since ancient times, it has been normal for individuals to be very unhappy and distressed when forcibly subjected to an act of mutilation. All forms and degrees of genital alteration, including circumcision, have always been a phenomenon that should be a matter of personal choice.

Major life events

I was born and circumcised in Western Australia in 1973, but was unaware of any genital abnormality as a young child. Because I was circumcised as an infant and not informed of this fact, I was not aware that my body had undergone any surgery. I had no reason to suspect that I had a penile problem until puberty. At the age of 18, in 1992, I underwent reconstructive surgery. The outcome of this surgery was exceedingly disappointing, and I attempted suicide six months later. In 1993, six months after the suicide attempt, I underwent further surgery.

Between 1993 and 1997, I concentrated on pursuing my academic career and resolving the emotional and ethical issues associated with my injury. I first sought legal advice in 1994, then commenced a legal claim for medical negligence with a Writ of Summons issued in October of 1997. This claim was finalized in 1999 with an admission of liability and payment of damages. I have since had several interviews with the media and am now dedicated to promoting public awareness of the detrimental affects of routine circumcision.

Birth and circumcision

My early childhood was happy. I had many interests, most especially in science. I was unaware of any complications with my circumcision. The circumcision scar was at the extremity of the penis, just below the corona glandis. Having no conception of what my penis looked like prior to circumcision, I was completely unaware that the family doctor who circumcised me had removed not only the foreskin but also most of the penile shaft skin. He then pulled up the scrotal skin and stitched it just under the corona. As an infant and young child, the excessive removal of skin was less obvious because of the lack of pubic hair.

There were two reasons why my parents decided to have me circumcised. First, my father had been circumcised shortly after birth, and was unaware he had lost tissue of any value. Second, my father's younger brother was spared circumcised as an infant but was subsequently circumcised at the age of eight, allegedly due to painful adhesions, bleeding, and repeated infections. My father remembered how traumatic this experience was, and my parents wanted to spare me from suffering similar problems. From information provided later by my grandmother, it appears likely that my uncle's "problems" were actually the result of repeated, forcible premature retraction of the foreskin for cleaning during infancy.

My mother had concerns about circumcision. She was a young mother of 17 years and knew nothing about how circumcision was performed, what risks were involved, and what the expected result should be. When family members suggested that she should have her unborn child circumcised if it was a boy, she sought advice from her family doctor during a prenatal check up. She was advised not to worry: "Just one little snip and it would all be over." The doctor assured her there were no risks and that it was such a simple procedure that Jewish mohels, with no medical qualifications, could perform circumcisions. Consequently, I was circumcised by this family doctor. My parents did not notice that anything was amiss during my early childhood. My mother does recall the penile skin appearing very tight during erections when I was a baby. She thought little of this, as my father's penile skin was similar.

Adolescent years (1986-1990)

With the onset of puberty between the ages of 12 and 13, I became aware of pubic hair growth and penile erections. These erections were very tight and painful, with the hair-bearing scrotal skin pulled up onto the penile shaft. With the onset of this pain, I suspected that my penis might be abnormal. There was, and still is, however, a lack of available, accurate information about the normal anatomy and function of the penis. Instructors for the sex education classes at school advised that it was normal for adolescents to feel concerned that the changes taking place in their bodies during puberty might not be normal. We were taught that these doubts are a normal part of growing up and there was no need for concern.

Although I took this advice and tried not to worry, I still suspected that I had been born deformed. The severity of the problems increased as I progressed through my teenage years at high school. As the penis grew, the skin became tighter and more painful, and the bending of the penis to the left became more apparent. This physical deformity had a major impact on my confidence and self esteem. I was reluctant to use public change rooms after physical recreation classes and tried to avoid sporting activities. I became very shy, self-conscious, and found it difficult to interact spontaneously with other teenagers my age. Because of these difficulties, I withdrew socially and made less of an effort to make friends.

Because I often appeared quiet and shy, I was susceptible to victimization. I was bullied and bashed on a regular basis. Because I did not make my interest in the opposite sex obvious in a chauvinist manner, I was, occasionally, labeled as 'gay.' This experience indicates to me that I live in a prudish society that is unable to deal competently with sexual issues.

Young adult years

In 1991, at the age of 17, I was relieved to escape the bullying environment of high school and commence university studies. At that time, I believed I could achieve my life ambitions by succeeding at university. Unfortunately, by this time, the severity of the erectile deformity, tightness, and pain had increased to the extent that I could no longer achieve a full erection. As a university student, I was exposed to relationship and sexual issues. Although I met people I felt attracted too, I was unable to deal with these issues because of my belief that I had been born deformed and would be rejected. At this time, I was still unaware that my deformity was due to a circumcision injury.

I felt very ashamed of my deformity and was unable to seek help. This situation led to anxiety and depression, and I failed courses at university. The depression and anxiety, combined with the lack of success at university, eventually overwhelmed me. I did not know what do and regularly contemplated suicide. Although I had previously been sexually attracted to the opposite sex, at this point in my life I began to consider alternative options. During my second year at university, in 1992, I reached a crisis point. I felt compelled to confide in someone, so I told my mother. My mother was shocked and immediately suspected the deformity could be related to my circumcision. This was the first occasion that either one of my parents had ever mentioned that I had been circumcised.

I made an appointment with my family doctor on 11 April 1992. This appointment was not with the doctor who had delivered and circumcised me. I had seen my family doctor regularly from the age of six months. During the examination, the physician took one look at my penis and said that whoever circumcised me had not known what he was doing. The doctor informed me that I had suffered an aggressive circumcision, and that far too much skin had been amputated. He then referred me to a urological surgeon, whom I saw on 23 April.

The urological surgeon examined me more closely, but appeared reluctant to admit that my penis had been damaged. He commented that if anything was wrong, it was not obvious. After I insisted that a problem definitely existed, the urologist conceded that any potential problems would be more apparent upon an artificial erection. When I asked if the problem could be repaired, the urologist informed me that the tissue removed by the circumcision could never be replaced. I was told that I might just have to put up with the situation. This scenario was intolerable to me, so the urologist referred me to a plastic and reconstructive surgeon. I was examined by the plastic surgeon on 7 May 1992. This surgeon specialized in the treatment of severe burn victims, especially small children. Upon examination, the plastic surgeon advised that my injury would be very difficult to treat, but she believed that she might be able to improve my situation.

My reaction

It was difficult for me to cope with the above events, all of which took place within the space of only one month during the first university semester of 1992. I was shocked and angered to learn that I had not been born deformed, but was injured because my body had been interfered with by another person. I hated the family doctor who circumcised me, and I hated my parents for allowing it to be done. I began to feel disgust towards Australian society, which has historically maintained that routine neonatal circumcision is a beneficial practice. I also resented members of my extended family who were reluctant to believe that I was seriously injured by a simple procedure that, in their minds, removed only "the useless piece of skin on the end of a man's dick."

Research findings

As a university student, I was trained in research skills and had access to medical libraries. I began to research the topic of circumcision intensively in order to explore possible treatment options. The results of my research were dismaying. I was angered to find that my circumcision had been completely unnecessary from a medical standpoint.7 I was horrified to find that, in addition to excessive skin removal, circumcision results in a range of injuries referred to as "complications."8-11 I suspect that this sort of ruse serves to dissociate the blame of the injuries from the surgery that caused them. Such injuries include:

1. Haemorrhage12
2. Urinary retention13
3. Meatitis, meatal ulcer and meatal stenosis14
4. Adhesions or skin bridges15-16
5. Infection: including gangrene,17 septicemia and meningitis18
6. Chordee19
7. Cysts20
8. Urethral injury and fistula21-23
9. Hypospadias and epispadias24-25
10. Impotence26-27
11. Psycho-social issues, such as schizophrenia28-29
12. Amputation or necrosis of the glans30-32
13. Total necrosis, ablation or amputation of the penis33-35
14. Death36-37

I was stunned to learn that in cases of penile amputation during routine neonatal circumcision, infants have been surgically reassigned to the female gender.38-40 There are many ways by which an unnecessary routine circumcision can destroy a man's life, and not all of them are listed as complications. Many of the most frequent complications, as in my case, are seldom listed as such. All complications, both major and minor, can exert a negative impact on the quality of a man's life. This is especially true when circumcision is imposed on an individual without his permission, as is always the case with routine neonatal circumcision.

I also learned from my research that the quantity of skin removed during neonatal circumcision is highly variable between patients.41 It is evident that excessive skin removal is one of the most common injuries.42 Indeed, one contemporary urological textbook includes a subheading under circumcision:

Disasters: Too much skin removed
Take the excised foreskin (pick it up off the floor, if necessary!) and stitch it back in place. Often, it will take as a free graft. If it does not, graft the penis with skin taken from a hairless area.43

If a victim's skin is not picked up off the floor and reattached, a far less satisfactory option is reconstructive surgery involving skin grafts to the penis in an attempt to replace the excess removed during circumcision. I also learned that the penile skin, mucosa, and nerves that are removed by circumcision can never be replaced,44 and skin-graft recipients can be very dissatisfied with the results of such surgery. Grafted skin is not a satisfactory surrogate for the penile skin and mucosa and lacks the necessary innervation, elasticity, and suppleness. It is interesting that the highly unique characteristics of preputial tissue make it an excellent candidate for grafting to repair dermal trauma of other areas of the body, such as severe lacerations or burn injuries.45

Life options

My options in early 1992 were to endure my circumcision injury for the rest of my life, commit suicide, or try surgery. By this time, I had seriously considered suicide for more than a year. Rather than enduring the circumcision injury for the rest of my life, suicide represented an attractive option, as it would free me from my physical pain and psychological trauma. First, however, I chose reconstructive surgery as the only available option before the final resort of suicide. While reviewing the medical literature, I was interested in function more than cosmetics, and took an evidence-based approach. If a sex-change operation would yield the most functional end result, I might even have pursued that option. After assessing the medical literature, however, I was satisfied that penile reconstruction with skin grafts was more likely to achieve a functional result than a gender reassignment.

The option of non-surgical skin stretching requires special consideration. Although it is likely that I lacked sufficient remaining skin to stretch, I am disappointed that I was not made aware of this alternative in 1992. Unfortunately, non-surgical options were not presented in the literature that I surveyed nor offered by my surgeons. I have observed that medical practitioners are generally immersed in a surgical paradigm and often fail to advise patients of less invasive alternatives to surgery. Surgery is one of the most invasive and high-risk forms of medical intervention. As such, surgery should always be the absolute last resort for the treatment of a condition, to be employed only after all other less invasive options have failed.

Reconstructive surgery

I underwent reconstructive surgery on 30 June 1992. A full-thickness skin autograft of 12 by 14 cm was harvested from my left thigh for grafting to the penis. The thigh was the only prospective donor site that was large enough to supply a graft of the appropriate dimensions. A split-thickness graft was then harvested from my right thigh and applied to cover the exposed subcutaneous tissue at the left thigh donor site. Overall, the reconstructive procedure resulted in two large wounds to my thighs.

A full-thickness skin graft is composed of the full thickness of skin (dermis and epidermis), with the dermal surface of the graft trimmed of the underlying fat or subcutaneous tissues.46 A split-thickness graft contains only the epidermis and a portion of the dermis. Although a split-thickness skin graft involves less trauma to the donor site, these grafts tend to be brittle and often contract when placed on unsupported tissue. My surgeons grafted a full-thickness of skin to the penis out of concern that a split-thickness graft might contract and erectile function would again be restricted.

Description of penis before reconstruction

Prior to reconstruction, the circumcision scar was very prominent and had migrated towards the base of the penis, due to the tethering and tension. The remnant inner preputial mucosa was stretched and distorted, with pitting and scarring evident. The shape of the glans was also distorted by the tension. The circumcision scar was highly irregular, as excision of the preputial tissue was asymmetrical, with more skin removed from the left side of the penis, than the right side. This created tethering and deviation of the penis towards the left upon erection. During erection, due to the extreme skin deficit and tension, the scrotal skin migrated more than two thirds of the distance along the penile shaft towards the glans.

A damaged remnant of the frenulum remained, which was particularly sensitive. As occurs in all circumcisions, the normally moist glans mucosa underwent keratinization and has been covered by a dry layer of dead epithelium. This represents a further reduction in sexual sensitivity of the penis, in addition to that caused by excision of the preputial mucosa and erogenous nerve endings.

Operative procedure

An artificial erection was produced by placement of a tourniquet around the base of the penis and injection of normal saline solution into the left corpus cavernosum. The chordee (deviation) of the penis to the left was made quite evident through this procedure. Next, an incision was made along the circumcision scar. Upon release of the tension, the hair-bearing scrotal skin retreated to the base of the penis. The underlying connective tissue (Buck's fascia) was completely exposed, illustrating the severe skin deficit due to the removal of almost all the shaft skin by the neonatal circumcision.

Another critical observation made at this stage of the operation was the complete absence of the dartos fascia. This abnormal situation, caused by the original circumcision, was not detected until this stage of the surgery. The dartos fascia is a delicate layer of areolar tissue that assists with the mobility of preputial tissue over the penis.47 It should not be completely removed during circumcision, and its removal in my case resulted in painful adhesions between the remnant preputial mucosa and underlying Buck's fascia. These adhesions caused further tethering of the penis. In conjunction with the excessive and asymmetrical excision of preputial tissue, the absence of the dartos fascia and resultant adhesions would have rendered non-surgical techniques of skin stretching ineffective.

The remnant preputial mucosa was subsequently excised due to adhesions to the Buck's fascia. With excision and the release of tension, the preputial mucosa contracted to one fifth of its pre-operative size. Post-operatively, I discovered that removal of this mucosa had resulted in a dramatic loss of sexual sensitivity. I could not have appreciated the significance of this loss had I not experienced it myself. This loss is made all the more significant when combined with the sensitivity lost as a result of the large amount of preputial tissue removed during the original circumcision. Therefore, having experienced a "second circumcision", I can attest from experience that circumcision dramatically reduces sexual pleasure.

The full thickness skin graft from the left thigh was placed around the penis. The skin graft was attached to the penis with Histoacryl tissue adhesive (Braun) with the suture line along the underside of penis in the position of the raphe. Surgery concluded with the application of a compression bandage to secure the skin graft to the penis and facilitate the establishment of a blood supply. The thigh donor sites were also bandaged. Postoperative pain was acute, and pethidine injections were given at the base of the penis at two or three hourly intervals for one week. Similar pain was also experienced in the donor sites.

Short-term results

The end result of the surgery was more aesthetically pleasing than the appearance when the bandages were removed, one week post-operatively. A large amount of swelling was evident, and I was surprised that any part of my body could swell to such a large size. The skin graft had an unpleasant consistency of thick, dried leather. With the topical application of vitamin E oil twice daily, the graft gradually became more supple over a period of several weeks, and the swelling subsided. Unfortunately, as the suppleness and elasticity of the graft increased, the graft contracted as it does not express the genes and hormones that instruct natural penile skin to remain loose. A series of ridges formed, which later developed into red hypertrophic scarring. The graft also developed hair due to follicles inadvertently transplanted with the graft from the thigh.

The donor site wounds were very similar to burn injuries, and were treated as such. DuoDERM E, a semipermeable polyurethane wound dressing, was worn for several weeks post-operatively to facilitate re-epithelialization and reduce pain.48 After wound closure was complete, the thigh donor sites also developed prominent red hypertrophic scarring during the healing process over subsequent weeks.

To reduce the hypertrophic scarring of the penile graft and thigh donor sites, I was advised by the surgeon to massage twice daily with vitamin E oil, and wear compression bandages on the donor sites as much as possible. Although very inconvenient and uncomfortable, I disciplined myself to massage with vitamin E oil and wear the compression bandages as directed. Although not directed to do so, I also wore condoms to compress and assist in scar reduction of the penile skin graft. Compression bandages and condoms were worn for over two years postoperatively.

Electrolysis

In June 1993, electrolysis was performed to destroy the hair follicles transferred with the graft from the thigh to the penis. A steroid injection was also given to assist in scar reduction for the penile skin graft. Unfortunately, the outcome of electrolysis was horrific, with extreme swelling and pain. Due to the fragility of the penile skin graft, necrosis and atrophy of tissue occurred in a radius of several millimeters around each electrolyzed hair follicle. Although these wounds have healed, dark scars and pitting remain.

Long-term results

The penile skin graft reduced tethering and enabled fuller erections. Upon erection, the penis became longer and the deviation to the left less severe. The remaining deviation is due to the restricted growth of the left corpus cavernosum - a permanent result of the tethering during puberty. This deformity demonstrates that penile growth and development are severely restricted when the penis is denuded by circumcision. The prominent scarring of the thigh donor sites is an unpleasant outcome of the surgery, as the damage caused by the neonatal circumcision has disfigured other areas of my body. These bright red scars were prominent while I was naked in change rooms or wearing shorts in summer. The scars have attracted attention and caused embarrassment on a number of occasions, including in the workplace.

The prominent redness of the donor sites faded after approximately three years, and the raised edges of the scars were reduced by the bandages and vitamin E massage oil. The graft sites, however, are now conspicuously pale, with ridging of the skin and an absence of hair. They still attract unwelcome curiosity. Despite the application of vitamin E oil and compression with condoms, the reduction of the scarring on the penis has been much less successful than for the donor sites.

Pain persisted in the graft and donor sites for many years after the surgery, but the intensity and frequency subsided with time. I now experience aches and pains only occasionally. However, since the surgery I have also experienced unpleasant or altered sensations, such as itching or tingling, and numbness. These still persist. Apart from this sensory disturbance in the underlying tissue, I have no sensation in the penile skin graft and also large areas of the donor sites. Due to the absence of the dartos fascia, the graft has adhered to the underlying buck's fascia and is not mobile like natural penile skin. The graft has also contracted and is approximately six to eight times thicker than normal penile skin.

Suicide attempt

There was no way that I could have been psychologically prepared for the highly invasive and extreme nature of the reconstructive surgery, and the resulting pain, trauma, and embarrassment. Members of my extended family were still reluctant to believe that I had been injured, as were a number of psychiatrists whom I consulted. A number of these professionals appeared to be biased in favor of circumcision due to their medical training, and told me that my problems were "all in my head." They advised that I should "just get over" my perceived problems and get on with my life. I felt alone and isolated. I also began to view my injury as a result of assault, and I felt that I had been mutilated. These feelings first emerged before the reconstructive surgery, and increased in intensity with the trauma of surgery.

Six months after the surgery, I attempted suicide on 7 January 1993. I had concluded that the impact of the circumcision injury on my life was insoluble. With the exception of my parents and close friends, few people were willing to acknowledge the severity of my injury and trauma, and even fewer people wanted to help. I felt as though I was living in a society where circumcision was still beyond criticism and few people were willing to accept the reality that routine circumcision is a harmful and destructive practice. I could not allow myself to be a hypocrite and live silently in a society where unnecessary circumcision was still condoned and practiced.

Legal action

After surviving a suicide attempt, I experienced a fuller appreciation that the cause of my horrendous experiences is unethical and completely unacceptable. I realized that I could not live with myself if I did nothing to prevent the practice of unnecessary circumcision and spare others from enduring what I had suffered. I decided that I was unwilling to remain yet another victim whose silence was taken by society as an affirmation that circumcision is harmless.

For several subsequent years, I concentrated on my university studies and tried to resolve the psychological trauma. This was most difficult. Overall, my Bachelor degree was delayed by four years due to the reconstructive surgery and associated trauma. During this time, I also considered the possibility of taking legal action to gain recognition of my injury and provide proof to Australian society that male circumcision is a highly destructive practice. I first sought legal advice from Dwyer Durack in 1994, but felt overwhelmed by the potential emotional trauma and financial expense of my case. Consequently, I did not proceed with an action at that time.

In October of 1997, I was finally approaching the final examinations for my degree. Unfortunately, I was also approaching my 24th birthday. This birthday represented the expiry date for the Statute of Limitations for issue of a Writ of Summons against the doctor who circumcised me. I was not psychologically prepared to commence legal action in 1997, but I was determined not to miss any potential opportunity for justice with expiry of the Statute of Limitations. A Writ was issued against Dr. Michael Morley in October 1997, based on the failure of Morley to fulfill his duty of care. The Statement of Claim included loss of quality of life, pain and suffering, and special damages that included a psychological component. My solicitor at Slater and Gordon estimated that I might receive between AU $50,000 to $100,000 in compensation. I replied that, after my horrendous experiences, I would accept no less than AU $500,000 and would prefer in excess of AU $1,000,000.

The legal action was difficult due to a lack of similar claims and precedents in Australia. An additional disadvantage was that civil cases in Western Australia are determined by a judge only, in contrast to a judge and jury in other Australian states. Western Australia is also the most conservative state with respect to the treatment of sexual issues by the judicial system. For these reasons, I tried to avoid proceeding to trial. My solicitors found my case difficult to research, prepare, and discuss. It was necessary for me to maintain constant communication and an assertive attitude to ensure the progress of my case. I also completed as much of the research and photocopying as possible to assist my solicitors and to minimize costs.

In August 1999, my claim proceeded to a pre-trial conference. I interrupted my doctoral studies at Australian National University and returned to Perth for the first conference on 30 August. As the solicitors for the Defendant requested further evidence, two more pre-trial conference sessions were held on 27 September and 2 November. My psychological health and studies suffered due to the time required for gathering additional evidence, the financial cost, emotional drain, and the associated stress and depression. I felt that I was in danger of losing my PhD candidature.

A settlement was still not reached at the final pre-trial conference. Not satisfied that the Defendant's solicitors gave my injury due recognition, I directed my solicitor to issue a 24A offer. This offer gave the Defendant one final opportunity to settle before the claim proceeded directly to trial. The terms of my offer were:

1. The Defendant pay the Plaintiff the sum of AU$360,000 plus repayment to the Health Insurance Commission of AU$5,070.40.

2. The Defendant pay the Plaintiff's costs and disbursements of the action up to and including the date of acceptance of this offer, to be taxed if not agreed.

3. The Defendant admit liability.

The Defendant accepted this offer in late November 1999. Although my private health insurance fund paid approximately AU$5,000 of my medical expenses, the Defendant refused to recognize or refund this money. Despite the Defendant's agreement to pay costs, I was required to pay approximately half of the legal costs involved.

The admission of liability was vital to my sense of victory and vindication. I wanted public acknowledgement that I had been injured by routine neonatal circumcision. This injury was inflicted on me and has deprived me of freedom, liberty, and a normal life. For this reason, I refused to forego my freedom of speech and agree to a settlement that included a confidentiality clause, or a clause denying the medical practitioner's responsibility for my injury.

Current status

I am still in a state of shock from my experiences. I am unhappy to have endured such severe injury and trauma due to a surgical procedure that was completely unnecessary. I would never have consented to circumcision if I had received an opportunity to make the choice that was rightfully mine. Since 1999, I have focused on public awareness to help prospective parents be aware that routine circumcision is completely unnecessary and very destructive. My parents would never have consented to my circumcision if this information had been made available to them. Public awareness was most successfully achieved by an article published in Woman's Day, which included an interview with Dr David Brand, the current head of the Australian Medical Association. Woman's Day obtained an unprecedented statement:

The Australian Medical Association doesn't advise circumcision for many reasons. They claim the practice can lead to scarring, deformity, severe blood loss, as well as infection.49

The Australian Medical Association had never previously acknowledged to the public that circumcision could lead to scarring and deformity.

What I would like to see happen in Australia

Routine circumcision is a controversial issue, with no easy solution. I believe that no person has the right to surgically inflict their religious, sexual, or cosmetic preferences on another person. I contend that no parent or adult has the right to inflict medically unnecessary and irreversible surgery on a child. The Australian legal system must address this issue, as it has done for the issue of sterilization of intellectually disabled females (Family Law Council, 1994), for which Court permission is now required by a new division in the Family Law Act.50 Likewise, Court permission should be required to perform circumcision on a child under the age of 18, or an adult incapable of giving informed consent, unless there is documented proof of the absolute medical necessity for the health of the individual to support the decision to operate without consent.

Many people respect an individual's right to engage in unprotected sex with multiple sexual partners, yet maintain a mistaken belief that the risk of disease transmission may be reduced through the forcible removal of a normal and healthy body part from non-consenting babies. This view fails to recognize or acknowledge that it is solely my right to choose the sexual practices that I will engage in, and solely my right to choose which body parts I will retain or discard.

It is also solely my right to choose the religious beliefs and cultural traditions I will subscribe to, and again, solely my right to choose which body parts I will retain or discard. Members of some ethnic groups claim that they have a right to dictate the cultural and religious beliefs that their children will adopt. Such views fail to recognize that children are not the property or the chattel of their parents. I contend that children require an opportunity to learn about their cultural heritage and exercise freedom of choice over the beliefs and traditional practices they will adopt. Parents have a duty to protect their children from harmful practices, and no tradition should be enforced by the permanent alteration or disfigurement of the body of an individual who is legally incapable of providing informed consent.

As with many issues concerning human rights, it is difficult to convey these messages to society. The public needs to be accurately informed and educated about circumcision and its associated risks and disadvantages. My mother was shocked to learn that the "useless bit of skin" removed from me was actually rich in sensory nerve endings.51 She now considers male circumcision the equivalent of female circumcision - a cultural practice that the majority of parents in western societies would never contemplate inflicting on their daughters. It would be beneficial to promote public awareness of the similarities in cultural origins and destructive consequences of male and female genital mutilation.

I would like also like to see it become unlawful for family doctors and other inadequately qualified individuals to perform circumcision. Only a pediatric surgeon has the necessary expertise and experience to perform surgery on small children and deal with the possible injuries and complications that circumcision can cause. A step in this direction was recently taken in Israel, following the heavily publicized case of glans amputation during a ritual circumcision.52 The Israeli Health Ministry has agreed to issue a directive to Israeli hospitals, for the first time allowing them to certify doctors to perform circumcisions.53

It should also be unlawful for surgery of any kind to be practiced without adequate pain relief. Several ethnic groups and a number of medical practitioners have disseminated a primitive, self-serving belief that infants do not experience pain when subjected to circumcision.54 The extreme pain and distress experienced by infants who undergo circumcision, however, is well documented.55-56 For the less than 1% of the male population who may require circumcision for genuine medical reasons,57 adequate pain relief should be provided, both during the procedure and postoperatively. As a means of discouraging the current widespread practice of circumcision without adequate pain relief, laws should be passed to imprison any individual who is guilty of such conduct for inflicting torture and grievous bodily harm.

Rebates for circumcision should be limited on the Medicare Benefits Schedule. Rebates should not be given for routine circumcision or any other unnecessary medical intervention. The Australian public health system is currently in financial crisis. Patients with life-threatening conditions are being denied prompt and essential treatment. Public awareness of the human and economic costs of medically unwarranted circumcision, and the resulting injuries and trauma, may assist in changing attitudes towards this unnecessary and harmful practice.

Acknowledgements

I thank Mrs. Kerry Peterson and Dr. George Williams for their assistance with the preparation of my symposium presentation and this manuscript. I also thank all those who were present at the Sixth International Symposium on Genital Integrity (Sydney 2000), where this paper was first given . Their encouragement and support helped me to deliver this most difficult account of my experiences.

References

1. Szabo R, Short RV. How does male circumcision protect against HIV infection? BMJ 2000;320(7249):1592-4.

2. Kanawati N, Hassan A. The Teti Cemetery at Saqqara. vol. II. The Tomb of Ankhmahor. The Australian Centre for Egyptology: Reports 9. Warminster: Aris & Phillips Ltd. 1997. pp. 49-50.

3. Bailey E. Circumcision in ancient Egypt. The Bulletin of the Australian Centre for Egyptology. 1996;7:15-28.

4. Roth AM. Egyptian Phyles in the Old Kingdom: The Evolution of a System of Social Organization. Chicago: Oriental Institute of the University of Chicago; 1991. pp. 62-75.

5. Spiegelman M. The circumcision scene in the tomb of Ankhmahor: the first record of emergency surgery. The Bulletin of the Australian Centre for Egyptology 1997;8:91-100.

6. See the discussion in: Hodges FM. The ideal prepuce in ancient Greece and Rome: male genital aesthetics and their relation to lipodermos, circumcision, foreskin restoration, and the kynodesme. Bulletin of the History of Medicine 2001;75:375-405.

7. Duckett JW. The neonatal circumcision debate. In: King LR, editor. Urologic Surgery in Neonates & Young Infants. Philadelphia: Saunders; 1988. pp. 291-9.

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Dr David Nunn, Australia

I was circumcised when I was 19 because I wanted to be "normal" like other young men. I am now many years down the track from 19 and I consider it to be the biggest and worst mistake of my whole life. The first time I masturbated after being circumcised it was an absolute let-down because the feeling was about one third the intensity of my pre-circumcision and has been ever since. By removal of the prepuce (foreskin) quite a large amount of nerve tissue is destroyed, and hence the wonderful feeling associated with the glans moving in and out of the prepuce. All doctors should be compelled to explain to the parents of innocent baby boys and to adults seeking circumcision the destructive effects of such a mutilation.

Sent to Canadian site offering special underwear to help protect penis and restore sensitivity in circumcised men:
http://www.manhood.mb.ca/nunn.jpg

Graphic pictures tell a sad tale

http://www.noharmm.org/IDcirc.htm

http://www.circumstitions.com/Botched1.html