On a world scale circumcision is a minority practice. Medically-rationalised or "health" circumcision became common in the late Victorian period in Britain and the USA, then spread to other English-speaking countries – Australia, New Zealand and Canada. It never became established anywhere else, except in South Korea, as a consequence of the American occupation following the Korean War in 1953. Britain abandoned circumcision in the 1940s-50s, followed by New Zealand in the 1960s, Australia in the 1970s and Canada in the 1980s.
Since the 1970s medical authorities in all these countries have been faced with the problem of stopping a harmful tradition that their colleagues in an earlier and poorly-informed age initiated so thoughtlessly. Accordingly, they have issued a succession of official statements and policies that recommend against routine (i.e. medically unnecessary) circumcision of normal male infants and boys. Like the sorcerer's apprentice, they have found it more difficult to halt the madness than to get it going.
Circumcision is not appropriate for 21st Century Aussie boys. A definitive article in Australia’s leading child health journal confirms the judgement of Australian paediatricians since 1971 that boys should not be routinely circumcised as a health precaution. In a rebuff to the American Academy of Pediatrics (and by extension the Centers for Disease Control, which repeats its errors) the article endorses the conclusion of the circumcision policy statement issued by the Royal Australasian College of Physicians in 2010, namely, that there is no medical warrant for routine circumcision in the Australian and New Zealand context.
The paper, by leading Australian child health authorities, runs through the reasons traditionally cited for non-therapeutic circumcision of infants and finds none of them convincing or sufficient. They particularly reject the common argument that circumcision should be performed in order to reduce the risk of HIV infection. Although there is evidence that circumcision can reduce the risk of disease transmission during unprotected intercourse with an infected female partner, all of it comes from studies of adult circumcision in under-developed African countries with both very high HIV prevalence and social and epidemiological conditions quite different from those in Australia. As the authors point out “Although most of the research on circumcision have sound scientific basis, its findings are usually only applicable to the specific socio-cultural context in which the study was conducted”, and they warn that too many authors “tend to prematurely extrapolate the data in an attempt to set national and international standards.” (Brian Morris: are you listening?)
The authors also raise important questions of bioethics and human rights, pointing out that while adult males can give autonomous consent to circumcision for any reason, “it is difficult to argue the same ethical principles for infants.” While parents have “legal rights to consent for a medical procedure if it is in the child’s best interest,” it is difficult to justify circumcision “as being in the best interest of the infant when most uncircumcised Australian adult males themselves … are reluctant to undergo adult circumcision?” In other words, circumcision fails the imputed judgement test and violates the child’s right to a open future.
The upshot is that paedatricians should seek to discourage parents from having their boys circumcised, as was the case back in the 1980s. Very few boys are circumcised these days, and the incidence is declining, meaning that the old, silly argument about “looking like his father” is no longer relevant. Quite the contrary: “as fewer children are being circumcised, parents’ priorities might have changed from making the boy to look like his father to allowing the boy to look more like the other uncircumcised boys at school.”
The authors conclude that “although there is a benefit of circumcision in those with urogenital tract anomalies, in a healthy newborn, the disease in the foreskin is non-existent.” Taking into account the lack of significant medical benefits, risk of complications, the harms of foreskin loss, and the financial cost, routine circumcision in Australia “cannot be justified. From medical point of view, the ‘price’ is still too high.”
Source: Angelika F. Na, Sharman P.T. Tanny and John M. Hutson. Circumcision: Is it worth it for 21st-century Australian boys? Journal of Paediatrics and Child Health. Advance access, 12 February 2015.
A guide for parents on the vexed question of circumcision has been released by the Paediatrics and Child Health Division of the Royal Australasian College of physicians – Australia’s premier medical authority. The leaflet points out that only a small minority of Australian boys are circumcised these days, nearly all for cultural and religious reasons, not for reasons of health. In simple language, the leaflet outlines the functions of the foreskin, the risks and harms of the operation, the possible (slight) benefits in later life, and some of the bioethical and human rights issues relevant to making an irreversible decision about an important part of another person’s body – a decision that he will have to live with for the rest of his life. The doctors responsible for the advice state clearly that “newborn baby boys do not need to be circumcised unless there is a medical reason” – that is, unless there is a genuine, diagnosed medical problem that must be treated surgically. Even in these cases, it is good medical practice to give conservative treatments a fair trial before resorting to surgery.
The leaflet warns that the risks and harms of circumcision include pain, bleeding, infections, permanent additional damage to the penis, later psychological problems and “violation of individual rights” because infants and children are not able to give informed consent to an operation they may not want and may later resent. There is certainly evidence that circumcision may reduce the functionality of the penis and lessen sexual responsiveness and pleasure in maturity. The leaflet also points out that “routine” (i.e. medically unnecessary or non-therapeutic) circumcision has been the focus of increasingly critical attention from experts in medical ethics, human rights and law, who warn that the foreskin has functions, belongs to the individual as much as any other body part, is removed without informed consent (usually without medical need) and that circumcision of a minor therefore denies a person control over his own body. An increasing number of men appear to be unhappy at having been circumcised in infancy, and many are either seeking to restore their foreskins or turning to the law to seek damages.
The leaflet provides basic tips on penis care in infancy, and points out that the foreskin needs no special attention and should be left alone. The foreskin is nearly always fused to the rest of the penis in early infancy, but gradually loosens and becomes possible to pull back as the boy grows. This process should not be hurried, and the foreskin should never be forcibly pulled back. Persistent tightness that becomes a problem (phimosis) can usually be successfully treated by appropriate medications, such as steroid ointment.
The RACP experts also point out that while there is some evidence from underdeveloped countries, especially in Africa, that circumcision may reduce the risk of sexually transmitted infections, such as HIV and syphilis, there is no evidence that circumcision has any such protective effect in a developed country such as Australia. In any case, circumcision is no substitute for safe sex.
The leaflet points out that many uncircumcised boys these days have circumcised fathers, and that neither the fathers nor the sons seem to be upset by this small difference. It concludes by pointing out that circumcision can safely be put off until the boy is old enough to understand the risks, consequences and possible benefits of circumcision, and make an informed decision for himself.
The most recent and authoritative statement was issued by the Royal Australasian College of Physicians in October 2010. This document 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.”
The policy also points out that routine circumcision is under strong attack from bioethics and human rights advocates, “because it is recognised that the foreskin has a functional role, the operation is non-therapeutic and the infant is unable to consent.”
Summing up the pros and cons, the statement continues: “The decision to circumcise or not to circumcise involves weighing up potential harms and potential benefits. The potential benefits include connectedness for particular socio-cultural groups and decreased risk of some diseases. The potential harms include contravention of individual rights, loss of choice, loss of function, procedural and psychological complications.”
That being the case, it would appear that the potential harms outweigh the potential benefits, meaning that the circumcision decision is one that can properly be made only by the person who must bear the consequences. The new statement leaves this issue open, but does point out that leaving the circumcision decision to be made by the boy when he is old enough to understand the issues and make an informed choice has the merit of respecting individual autonomy and preserving all the options:
“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. This option has recently been recommended by the Royal Dutch Medical Association. 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.”
The policy concludes by noting that its recommendation not to cut is consistent with policies on circumcision released by the British Medical Association, the Canada Pediatric Society, the American Academy of Pediatrics, the Royal College of Surgeons of England and the Royal Dutch Medical Association.
The Australian Pediatric Association recommends that newborn male infants should not, as a routine, be circumcised.
— Australian Pediatric Association, 24 April 1971
The ACP should continue to discourage the practice of circumcision in the newborn male infant.
— Australian College of Paediatrics, Official statement, 1983
The Australasian Association of Paediatric Surgeons does not support the routine circumcision of male neonates, infants or children in Australia. It is considered to be inappropriate and unnecessary as a routine to remove the prepuce, based on the current evidence available. We do not support the removal of a normal part of the body, unless there are definite indications to justify the complications and risks which may arise. In particular, we are opposed to male children being subjected to a procedure, which had they been old enough to consider the advantages and disadvantages, may well have opted to reject the operation and retain their prepuce.
— The Australasian Association of Paediatric Surgeons, “Guidelines for circumcision”, 1996
A more detailed statement was issued by the Royal Australasian College of Physicians in 2002 an reissued 2004. The document summary states:
The Division of Paediatrics and Child Health, Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of infants and boys assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that there is no medical indication for routine male circumcision. Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure.
The policy statement represents the consensus position of the Australasian Association of Paediatric Surgeons, the New Zealand Society of Paediatric Surgeons, the Urological Society of Australasia, the Royal Australasian College of Surgeons and the Paediatric Society of New Zealand.
Royal Australasian College of Physicians, 2002 and 2004
A further statement, reiterating these points, was issued in August 2009
When considering routine infant circumcision, ethical concerns have focused on recognition of the functional role of the foreskin, the non-therapeutic nature of the operation, and the psychological distress felt by some adult males circumcised as infants. The possibility that routine circumcision contravenes human rights has been raised because circumcision is performed on a minor for non-clinical reasons, and is potentially without net clinical benefit for the child.
Recently there has been renewed debate regarding both the possible health benefits and the ethical concerns relating to routine male circumcision. The most important conditions where some benefit may result from circumcision are urinary tract infections, and in adults HIV infection and cancer of the penis. The frequency of these conditions, the level of protection offered by circumcision and complication rate of circumcision do not warrant a recommendation of universal circumcision for newborn and infant males in an Australian and New Zealand context.
After extensive review of the literature the RACP does not recommend that routine circumcision in infancy be performed, but accepts that parents should be able to make this decision with their doctors. One reasonable option is for routine circumcision to be delayed until males are old enough to make an informed choice. In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarising the evidence should be widely available to parents. In the absence of evidence of substantial harm, parental choice should be respected.
Royal Australasian College of Physicians, August 2009
In its guidelines on circumcision, the British Medical Association takes a stronger and more critical line against unnecessary surgical interventions in children. It lays down the following principles of good practice:
The BMA also advises that where a problem exists, circumcision should be the last resort, employed only after non-surgical treatments have been tried and failed:
"Unnecessarily invasive procedures should not be used where alternative, less invasive techniques, are equally efficient and available. It is important that doctors keep up to date and ensure that any decisions to undertake an invasive procedure are based on the best available evidence. Therefore, to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate.
"Male circumcision in cases where there is a clear clinical need is not normally controversial. Nevertheless, normal anatomical and physiological characteristics of the infant foreskin have in the past been misinterpreted as being abnormal. The British Association of Paediatric Surgeons advises that there is rarely a clinical indication for circumcision. [Go to reference 5] Doctors should be aware of this and reassure parents accordingly."
On the question of consent, the BMA insists that in the case of children, both parents must give their consent, and that it must be in writing. Further, if the child is old enough to express an opinion, his wishes and preferences must be taken into account:
"The BMA and GMC have long recommended that consent should be sought from both parents. Although parents who have parental responsibility are usually allowed to take decisions for their children alone, non-therapeutic circumcision has been described by the courts as an “important and irreversible” decision that should not be taken against the wishes of a parent. [Go to reference 15] It follows that where a child has two parents with parental responsibility, doctors considering circumcising a child must satisfy themselves that both have given valid consent. If a child presents with only one parent, the doctor must make every effort to contact the other parent in order to seek consent."
Summary of consent issues
Health benefits of circumcision doubted
In relation to circumcision as a prophylactic measure (to reduce the supposed risk of diseases that may be contracted in the future), the BMA warns that there are no agreed "health benefits" in circumcision of children and that doctors must warn parents that medical opinion is divided.
"There is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research. Doctors performing circumcisions must ensure that those giving consent are aware of the issues, including the risks associated with any surgical procedure: pain, bleeding, surgical mishap and complications of anaesthesia. All appropriate steps must be taken to minimise these risks. It may be appropriate to screen patients for conditions that would substantially increase the risks of circumcision, for example haemophilia.
"Doctors should ensure that any parents seeking circumcision for their son in the belief that it confers health benefits are fully informed of the lack of consensus amongst the profession over such benefits, and how great any potential benefits and harms are. The BMA considers that the evidence concerning health benefit from non-therapeutic circumcision is insufficient for this alone to be a justification for doing it."
The full text of the BMA statement is available from the BMA website.
Or download as PDF document here: BMA-Circ.
Other countries where medical authorities have issued policies and guidelines on circumcision include Canada, the United States, Finland, Sweden and Denmark. As you might expect, it is the Scandinavian countries that are most critical of the practice and the United States that is most ambivalent, reflecting the extent to which circumcision has become embedded as a medical ritual there. Getting rid of an outdated medical procedure is easy; getting rid of an entrenched social custom is a different matter.
Interestingly enough, the South African Medical Association does not consider the AIDS crisis a sufficient justification for routine circumcision of male infants or other normal male minors. In response to an inquiry from Nocirc of South Africa, the South African Medical Association stated that there was no justification for routine circumcision of infants or children. In letter to Nocirc SA, dated 4 February 2005, and signed by Professor Ed Coetzee, Chairperson of the SAMA Education, Science and Technology Committee, the Association states:
“After lengthy DISCUSSION on the matter, the Committee RESOLVED that it be conveyed to NOCIRC-SA that, from a medical point of view, there was no medical justification for routine circumcision in males and children.”
In this conclusion, SAMA joins medical authorities in Britain, Canada, the USA, Australia and New Zealand in agreeing that there is no medical case for routine circumcision. In fact, it goes slightly further than the Royal Australian College of Physician in 2002s, which stated that there is “no medical indication”; SAMA says there is “no medical justification”, an even stronger rejection.
Coming from a country with an extremely high incidence of HIV infection (and also a high incidence of male circumcision), this is a significant declaration. South Africa is also one of the very few countries to have passed legislation regulating and to some extent restricting circumcision of male minors.
In a statement released on 9 September the Canadian Pediatric Society confirmed its long-standing opposition to routine circumcision of male infants and boys. The new policy states clearly that the recommendation of the CPS is against circumcision because the benefits are small and outweighed by the risks. This outcome has surprised some observers, who were expecting the CPS to follow the American Academy of Pediatrics to conclude, while not recommending circumcision, that the benefits exceeded the risks, and that circumcision was a matter of “parental preference”. In rejecting this assessment as scientifically unsound, the new CPS policy aligns itself with those of the Royal Australasian College of Physicians and child health experts in Britain and all European countries. Their position leaves the Americans more isolated than ever as the only medical organisation in the world to think that there is anything worthwhile in routine circumcision. Scholars have criticised the risk/benefit calculus as inadequate for the “circumcision decision”, as it fails to consider the value of the foreskin and the likely future wishes of the boy, or to give adequate weight to bioethical and human rights principles. It is nonetheless significant that the CPS could recommend against circumcision after a narrow calculation of the strictly medical issues considered pretty much on their own. Once you add the functions of the foreskin and bioethical issues to the equation, the case against circumcision becomes overwhelming.
Earlier policies and policies issued by the various provincial medical bodies and the Canadian Pediatric Society are available from CIRP.
In a statement issued on 27 May 2010, the Royal Dutch Medical Association (KNMG) has condemned non-therapeutic circumcision of male minors and urged its members to discourage the practice. The statement points out that prophylactic or preventive circumcision of normal male infants and boys confers no health benefit; carries many risks of harm and damage; has an adverse effect on sexual function and bodily appearance; and is a violation of the child’s right to physical integrity. They also argue that it is inconsistent and discriminatory to prohibit any form of genital cutting of girls while refusing to offer boys any protection at all.
The KNMG urges doctors to inform parents considering the procedure as to the absence of medical benefits and the danger of complications. “The rule is: do not operate on healthy children”, says Arie Nieuwenhuijzen Kruseman, chairman of the KNMG. “It is an unfortunate fact that any surgical procedure can cause complications. Doctors accept this to a certain extent because there are medical reasons for the procedure. However, no complications can be justified that occur as the result of an operation that is medically unnecessary.”
The statement is notable for acknowledging that it is impossible to draw a sharp distinction between male circumcision and female genital mutilation and includes an incisive discussion of the many similarities between the two sets of procedures, both as to physical effects, cultural justifications and ethical status. The statement argues that it is impossible to mount a credible campaign against female genital mutilation unless it is part of a wider campaign against all forms of genital mutilation of children, both male and female. Their position contrasts with that of many United States commentators, who regard even the slightest interference with the genitals of girls as violation of their human rights, while ignoring or even advocating far more violent and intrusive surgery on the genitals of boys.
The German Paediatric Association (Berufsverband der Kinder- und Jugendärtze [BVKG]) has condemned the AAP’s recent circumcision policy as culturally biased, medically inaccurate or irrelevant, and inattentive to the best interests of the child. The observations were made in the course of a submission to the German parliament (Bundestag), urging that it not pass a law authorising circumcision of minors, but that boys under the age of 14 be protected from circumcision, in accordance with the Cologne court ruling. The document points out that the principal pressure for circumcision of male infants and boys is cultural/religious, not health-related, and that advocates of circumcision for ritual/religious reasons make cynical and one-sided use of the medical literature for their own purposes. The English abstract of the document follows:
The American Academy of Pediatrics (AAP) recently released its new technical report and policy statement on male circumcision, concluding that current evidence indicates that the health benefits of newborn male circumcision outweigh the risks. The technical report is based on the scrutiny of a large number of complex scientific articles. Therefore, while striving for objectivity, the conclusions drawn by the eight task force members reflect what these individual doctors perceived as trustworthy evidence. Seen from the outside, cultural bias reflecting the normality of non-therapeutic male circumcision in the US seems obvious, and the report’s conclusions are different from those reached by doctors in other parts of the Western world, including Europe, Canada, and Australia. In this commentary, a quite different view is presented by non-US-based doctors and representatives of general medical associations and societies for pediatrics, pediatric surgery and pediatric urology in Northern Europe. To these authors, there is but one of the arguments put forward by the AAP that has some theoretical relevance in relation to infant male circumcision, namely the possible protection against urinary tract infections in infant boys, which can be easily treated with antibiotics without tissue loss. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts and penile cancer, are questionable, weak and likely to have little public health relevance in a Western context, and do not represent compelling reasons for surgery before boys are old enough to decide for themselves.”
Dr. med. Wolfram Hartmann
President, German Paediatric Association (BVKJ)
Berufsverband der Kinder- und Jugendärzte (BVKJ. e.V.)
Mielenforster Str. 2, 51069 Köln
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