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Advice from Australian health authorities
NEW SOUTH WALES
NSW Health Department statement
Children's Hospital, Westmead
Circumcision Fact Sheet
Urinary Tract Infections (UTIs)
VICTORIA
Royal Children's Hospital
Clinical Practice Guidelines: The penis and foreskin
Kids' health: Info for Parents: Penis and foreskin care
SOUTH AUSTRALIA
Children, Youth and Women's Health Service
Guide to circumcision
RACP policy statement on male circumcision:
Response by Circumcision Information Australia
Media release, 28 September
Statement on new policy by Circumcision Information Australia
Most Doctors Say "Don't do it!"
New policy statement by Australian and New Zealand
doctors rejects circumcision
The new policy statement on routine male circumcision issued by
the Paediatric and Child Health Division of the Royal Australasian
College of Physicians should be welcomed by all those concerned
with the welfare and happiness of Australian and New Zealand boys.
Although it does not go as far as it could towards discouraging
this unnecessary and harmful surgery, it has many positive features.
Its message is clearly that boys should be left as nature made them.
The new statement is one of the most authoritative policies on
circumcision ever issued by a medical organisation. It has been
endorsed by six Australian and New Zealand medical bodies. After
a thorough review of the medical literature, including recent claims
about the supposed protective effect of circumcision against STDs,
AIDS, penile cancer, urinary tract infections and cervical cancer
in female partners, the working party concluded that there was "no
medical indication for routine male circumcision" and that
there was "no evidence of benefit outweighing harm for circumcision
as a routine procedure".
The full text of the statement is on the RACP
website.
Another source for the statement, which includes links to many
of the articles in medical and other journals cited by the statement,
is available here.
The copy of the statement with a critical commentary and evaluation,
and links to further information and many of the articles cited,
is available here.
Previous statements on circumcision
by Australian medical bodies
MEDIA RELEASE
Human Rights Groups Welcome Statement on Male Circumcision
Australasian human rights groups welcome the release of the new
Position Statement on Circumcision by the Paediatric and Child Health
Division of the Royal Australasian College of Physicians.
"This is a victory for good sense and the spirit of Anzac
cooperation" said Shane Peterson for Circumcision Information
Australia and NORM New Zealand.
The new policy states: "there is no medical indication for
routine male circumcision." It also warns against risks and
complications more strongly than previous statements, and raises
serious legal and ethical issues.
"The new statement sends a clear message to doctors that they
should warn parents against choosing circumcision for their sons.
The few old GPs and cranky professors who get up in the media to
preach the medical benefits of circumcision are now exposed as quacks."
The new statement has been endorsed by six Australian and New Zealand
medical bodies.
After a thorough review of the medical literature, including recent
claims that circumcision is protective against STDs, AIDS, urinary
tract infections and cervical cancer in female partners, the working
party concluded that there is "no evidence of benefit outweighing
harm for circumcision as a routine procedure".
The new policy is based on a narrow evaluation of the medical benefit
and harm of circumcision. Mr Peterson said, that despite this narrow
view, the College still concluded that the risks of harm and injury
outweigh the claimed benefits.
"When additional factors are considered, the case against
routine circumcision becomes overwhelming."
A surprising omission from the statement is a discussion of the
sensory and mechanical roles of the foreskin in male sexual function,
and its contribution to sexual pleasure and self-esteem for both
the man and his partner.
"The penis is a fragile sensory organ. Removal of the foreskin
and frenulum by circumcision is similar in effect to surgically
injuring the retina of the eye in a way that causes tunnel vision
and colour-blindness."
The working party also paid little attention to important issues
in human rights and medical ethics. A person has the right to an
intact body and to refuse unnecessary medical treatment. It is doubtful
if it can ever be ethical to amputate healthy tissue from a non-consenting
minor in the absence of acute medical necessity.
Mr Peterson said it is now time to address the disturbingly high
rate of infant circumcision in some states compared to others. In
2001-2002, Medicare funded the circumcision of approximately 14%
of male infants born in South Australia and New South Wales, and
over 20% of male infants born in Queensland. During this same period,
about 5% of male infants were circumcised in Victoria, Western Australia,
Tasmania and the ACT. The incidence of circumcision in New Zealand
has been less than 5% for over a decade.
"Doctors now insist that medical interventions must be based
on evidence of benefit exceeding the risk of harm. There is no evidence
based rationale for this significant difference in the incidence
of circumcision between states and countries", said Mr Peterson.
"It is now time to remove routine circumcision from the Medicare
benefits schedule."
In his ground breaking article "The
fate of the foreskin" in 1949, Douglas Gairdner, consultant
paediatrician to United Cambridge Hospitals, advised that routine
circumcision was harmful and recommended against it. As a result
of Gairdner's research and the policy of the National Health Service,
the rate of routine circumcision in Britain fell from about 30%
in the 1940s to less than 5% in the 1950s.
Gairdner debunked the myth of phimosis and showed that it was normal
for the foreskin not to be retractable in early childhood. He also
concluded that circumcision did not provide meaningful protection
against STDs or cancer. He documented injuries and side effects,
including the death of around 16 boys under five each year in the
UK from 1942 to 1947.
Deaths still occur regularly from circumcision. The recent death
of an infant following circumcision in British Columbia during August
made national news. In response, several Canadian state medical
bodies have cautioned doctors against performing unnecessary circumcisions.
For further information
Mr Peterson said the new RACP statement is a very positive step
towards protecting children. "Doctors should be required to
give a copy of the new statement to all parents who enquire about
circumcision. Parents should then have a week's cooling off period
to think about it. The written consent of both parents should also
be mandatory."
The new Policy Statement on Circumcision is available at the RACP
website.
Statement by Circumcision Information Australia
The recent policy statement on routine male circumcision issued
by the Paediatric and Child Health Division of the Royal Australasian
College of Physicians should be welcomed by all those concerned
with the welfare and happiness of Australian and New Zealand boys.
Although it does not go as far as it could towards discouraging
this unnecessary and harmful surgery, it has many positive features.
Its message is clearly that boys should be left as nature intended.
In reaffirming earlier statements against routine circumcision
dating back to 1971, the RACP has issued strong advice to parents
that circumcision of their baby boys is neither necessary nor desirable.
It has also sent an unmistakeable message to doctors that they should
warn parents against the operation.
The statement is one of the most authoritative policies on circumcision
ever issued by a medical organisation. It has been endorsed by six
Australian and New Zealand medical bodies. After a thorough review
of the medical literature, including recent claims about the supposed
protective effect of circumcision against STDs, AIDS, penile cancer,
urinary tract infections and cervical cancer in female partners,
the working party concluded that there was "no medical indication
for routine male circumcision" and that there was "no
evidence of benefit outweighing harm for circumcision as a routine
procedure".
This is a significant victory for good sense. The working party
has carefully considered the clamour of those urging universal circumcision
as a strategy against problem diseases and has rejected their scenarios
as alarmist and their prescriptions as scientifically unsound. Doctors
are now obliged to tell parents seeking advice about circumcision
that there is no medical benefit from the operation and a significant
risk of harm. In other words, the Australian and New Zealand medical
profession is saying "Don't do it".
Perhaps the greatest value of the new statement is that it reaches
its conclusions on the basis of a narrow calculus of medical benefit
and harm, and still finds that the risk of harm outweighs the possibility
of benefit. The working party did not pay much attention to the
important areas of human rights (e.g. a person's right to a non-disfigured
body and to refuse unwanted medical treatment), or to medical ethics
(e.g. whether it can ever be ethical for a doctor to amputate healthy
tissue from a non-consenting minor in the absence of acute medical
necessity). But the statement did acknowledge that even if it were
true that circumcision reduced the incidence of UTIs, "this
should not be the only consideration": in other words, retention
of the foreskin for whatever reason could in itself be more important
than reducing the risk of disease.
The most serious omission from the statement is any discussion
or acknowledgement of the value of the foreskin as a natural and
prominent part of the male genitals and a significant contributor
to normal sexual function, partners' pleasure and a person's happiness
and self-esteem. When these and similar factors are added to the
equation, the case against routine circumcision becomes overwhelming.
There is now no basis for claims made by maverick GPs and misguided
professors that there are sound scientific reasons to circumcise
male infants. The medical aspect of the long-running debate has
now been settled. The few old GPs and cranky professors who get
up in the media to preach the medical benefits of circumcision no
longer have a leg to stand on. They are now exposed as the quacks
they have been all along, more reminiscent of a top-hatted Victorian,
issuing dire warnings against the perils of masturbation, than a
modern medical practitioner concerned about the quality of life
of those under his care.
The statement opens the way for a consideration of whether routine
circumcision should be deleted from the Medicare benefits schedule.
Now that male circumcision has authoritatively been declared an
unnecessary and non-therapeutic procedure, there is no reason why
taxpayers should fund it through the health care budget. In the
rare instances where circumcision is medically required it should
of course be publicly funded, but where it is performed for non-medical
reasons it should be categorised as a cosmetic procedure and paid
for by the individuals who want it done.
The weaknesses of the position statement may be summarised under
eight headings:
- The statement does not recognise that the foreskin itself is
a normal part of the body and a prominent part of the penis, with
value in its own right, and which makes a significant contribution
to sexual functioning, self-esteem, body image and personal happiness.
There is a vast medical literature on the significance of the
foreskin, from Hippocrates, Galen and the classical Greeks, who
devised procedures to lengthen inadequate prepuces, right down
to the modern Canadian researchers who have investigated the unique
innervation of the penis and identified the ridged bands and frenular
delta. Further details.
- It does not recognise that the removal of an excessive quantity
of tissue, resulting in a tight circumcision and uncomfortable
erections, is very common. Tearing and bleeding of the penile
skin after puberty is less common, but not rare.
- It does not discuss the risks of general anaesthesia, nor indicate
that sucrose and EMLA are not effective analgesics, when used
separately or together.
- It does not consider less invasive surgical methods to treat
pathological phimosis which retain the foreskin, such as the dorsal
slit.
- It does not propose a method to ensure that each state/territory
health department prints an accurate and up-to-date information
booklet, based on the recommendations of this statement, to be
distributed to all parents expecting a child. Doctors should be
required to give parents requesting circumcision a copy of the
leaflet (and ideally the full statement) before they can perform
the procedure.
- The statement does not warn doctors that there is a real and
increasing danger of litigation on the part of individuals who,
without necessarily suffering complications, grow up and wish
that they had not been circumcised. (See comments
on Canadian situation below.)
- It does not pay sufficient attention to human rights and ethical
issues. It has long been accepted than an individual has the right
to refuse medical treatment, and it is increasingly argued by
legal and ethics experts that male circumcision is little different
from female genital mutilation and should be governed by similar
rules. More people are asking whether it can ever be ethical for
a doctor to amputate healthy tissue from a non-consenting minor
in the absence of acute medical necessity.
- It does not adequately address the issue of parental consent
for medically unnecessary circumcision. (See
comments below.)
In a recent case in Bundaberg, Queensland, a non-practising Moslem
father, who did not have legal custody of children by his former
partner, arranged for the circumcision of his two sons during an
access visit, against the mother's express wishes and in breach
of a specific order by the Family Court. (See
details on this site). Stricter rules governing consent for
non-therapeutic circumcision could have prevented this sad and all
too common occurrence. A high proportion of marriages in Australia
are between men and women of different ethnic/cultural backgrounds,
and the children of such unions cannot be said to belong strictly
to one or the other group; this is all the more true in the many
cases where marriages end in separation while the children are still
young.
Children in such situations will eventually decide which (if any)
of the parental cultures they wish to identify with, or whether
they wish to choose a cultural identity of their own, and we recognize
their right to make a free choice. In a multicultural society ,
freedom of religion means that each individual must have the freedom
to adopt his or her own religion and not have it imposed on them.
In order to ensure that this right is real, their bodies must be
protected from tell-tale alterations as much as their minds from
indoctrination. Individual determination has a physical as well
as a mental dimension.
In the United
Kingdom and Sweden
the judicial systems have intervened in instances where Moslem fathers
have sought or arranged for the circumcision of boys without maternal
consent. In two cases the fathers were convicted, and in one of
these cases the father was gaoled for three months. The practitioner
who performed the circumcision was also charged with an offence,
though acquitted, by the National Board of Health and Welfare.
The rights of mothers and boys would have
better protection if the following conditions had to be met before
a practitioner agreed to perform medically unnecessary circumcision:
- Check bona fides: The medical practitioner should establish
that the persons requesting the circumcision do in fact have legal
custody of the children. In the Queensland case the father was
separated from the mother and was not the legal guardian of the
children. The mother had sole custody; his consent was probably
invalid in law.
- Written consent of both parents: Where circumcision
has been requested in the absence of medical indications or for
cultural reasons, doctors should obtain the written consent of
both parents before performing the procedure. If the written consent
of both parents or guardians cannot be obtained, the practitioner
should advise that he cannot perform the circumcision. Physicians
should provide a complete copy of the new RACP statement to all
parents who inquire about the procedure. Parents should then have
a "cooling off" period of a week to consider their decision.
- Check that the boys do not object: If the boys are old
enough (e.g. over 5 years old), before proceeding the practitioner
should explain honestly to the boys what he is going to do to
them and ascertain that they are willing to go through with it.
If they do not understand what is proposed or if they show hesitation
or objection, the practitioner should decline to carry out the
surgery.
Legal risk
In Canada, where the recent death of a baby after circumcision
in British Columbia has made national news, several state medical
bodies have cautioned doctors against performing unnecessary circumcisions.
The College of Physicians and Surgeons of Saskatchewan has asked
doctors to consider the physical risk to the patient and the legal
risk to the physician before becoming involved in the routine circumcision
of infants. It warns that circumcision poses a greater risk of harm
than benefit and could form the basis of lawsuits by circumcised
adults. The college registrar, Dr Dennis Kendel, says the threat
of litigation is now producing "a great deal of sober second
thought" among physicians. "It could have what we call
'long-tail liability' if this societal movement takes on more steam
and more men become angry because they think they ought not to have
been circumcised". Link to full details here
OPINIONS FROM OTHER COUNTRIES
American doctors now say: Don't cut boys
Deciding whether or not to circumcise your baby boy?
A good discussion by a sensible doctor about the value of the foreskin and the harm of circumcision.
Sound advice from Dr Sears.com
Dr Roxanne Allegretti
In the USA, where circumcision is still common, more doctors are coming out against the practice. In a recent newspaper article, Dr Roxanne Allegretti, of Fredericksburg, Virginia, writes that there is no need to circumcise boys. She writes:
I hear fathers say they worry that if their son does not have it done, he'll wonder why he doesn't look like his dad. Well, that is just as easy to explain as questions like, “Dad, why do you have hair there and I don't?” Or, “Dad, why do you have blue eyes and I have brown eyes?”
Read full text of article
GREAT BRITAIN
Net Doctor, Great Britain
Meanwhile, in Britain, Dr John Dean says: “The best advice is ‘if it isn't absolutely necessary, don't circumcise'."
Read full text of article.
A British paediatrics textbook:
Routine circumcision of the newborn as commonly practiced in the USA is to be condemned, the incidence of complications, including death, far outweighing the supposed advantage of avoiding such problems as carcinoma of the penis. ... The fact that it is “more hygienic” is often used as an excuse for circumcision but one does not chop off the ears to save washing them, or the feet because they may smell! ... The only valid reason is a fibrous phimosis. This may be due to inappropriate attempts at retraction at an early age, causing splitting and scarring of the preputial meatus ... Circumcision is thus performed either for religious or tribal reasons, for fibrous phimosis or, perhaps most frequently, for remuneration!
Forfar and Arneil's Textbook of Paediatrics. Edited by A.G.M. Campbell and N. McIntosh, 5th edn, 1998, Churchill Livingston
IRELAND Sensible advice from Irish doctors:
What are the myths about circumcision?
Contrary to the claims of scaremongers:
Circumcision does not prevent sexually transmitted diseases.
Circumcision does not prevent HIV infection.
Circumcision does not prevent urinary infections.
Circumcision does not prevent cancer of the penis.
http://www.irishhealth.com/index.html?level=4&id=1907
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