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Circumcision specialist fined for improper conduct
Boy dies after plastibell circumcision
Circumcision of male children “a hidden human rights violation”
Tasmanian Children's Commissioner wants circumcision banned
Frankfurt court finds circumcision an unlawful personal injury
Male and female circumcision “not so different”
“Age” op-ed writer calls circumcision male genital mutilation
Korea: Worse sex life after circumcision
United States: Circumcision cuts sensitivity of penis
British Medical Association warns on circumcision
Circumcisions kill 14 African boys in a month
Canada medicare pays for foreskin restoration
Condoms best protection against STDs and HIV-AIDS
Ethics of male circumcision questioned
Australian children healthier with foreskin in place
South African Medical Association rejects circumcision
Mothers' milk the best defence against UTIs
New research: Circumcision bad for health and hip pocket
Circumcision myths: Readers respond
New Canadian policy calls circumcision unnecessary mutilation
Irish surgeon calls for ban on hospital circumcisions
Press Council dismisses complaint by circumcision professor
Man tells of forced childhood circumcision
Circumcision questioned following baby's death
Foreskin is necessary, says top urologist
Hunter Valley hospitals stop circumcision of newborn boys
British Medical Association issues new guidelines on ethics of non-therapeutic circumcision
Vaccine stops cervical cancer
Australia: Too many circumcisions performed, phimosis wrongly diagnosed
Concern at unnecessary circumcision
"No medical reason for circumcision": Canadian doctors
Circumcision: "Unnecessary, damaging and performed without consent"
Aussies warned not to circumcise
New study of reasons why mothers want to circumcise their boys

Circumcision specialist fined for improper conduct

Dr Terry Russell, the ageing Queensland GP who has made a career and a fortune out of amputating the foreskins from baby boys, also seems keen to cut boys' tongues. In 2004 he was fined and censured by the Commonwealth Professional Services Review of Medicare services for falsely diagnosing “tongue tie” when the boys were brought to be circumcised, and cutting their tongue as well as their penis.

The frenulum that tethers the tongue to the floor of the mouth is very similar to the frenulum that tethers the foreskin to the rest of the penis. Perhaps Dr Russell thinks that any body parts resembling the foreskin ought to be removed, “just to be on the safe side”. There was a time, back in the nineteenth century, when many doctors believed that surgery to correct so called “tongue tie” should be as routine as cutting off the foreskin.

The Review reported that Dr Russell had been reprimanded, counselled and ordered to repay the $4 488.88 he had claimed from Medicare.

The Committee noted that there was no clinical indication for cutting the tongue and thus that there was no basis for performing the procedure, nor for claiming the cost of the service under Medicare. Had the Committee looked into the cases of the boys brought in to be circumcised, it would have found that there was no clinical indication for circumcision either, and thus that there was no basis for that procedure to be charged to Medicare. Apparently, the government believes that it is OK to alter the appearance and function of the (highly visible) penis without the consent of the owner, but not to interfere with anybody's (usually concealed) tongue.

The Medicare guidelines state clearly that Medicare does not cover “medical services which are not clinically necessary” or “surgery solely for cosmetic reasons”. Why, then, does it continue to waste taxpayers' money on clinically unnecessary circumcision procedures?

The full text of the report on Dr Russell follows.

Director
Dr John Holmes

The Hon. Tony Abbott MHR
Minister for Health and Ageing
Parliament House
Canberra ACT 2600

Dear Minister

In accordance with subsection 63(1) of the Public Service Act 1999 and section 106ZQ of the Health Insurance Act 1973, I provide you with the 2003-2004 Annual Report of Professional Services Review for your presentation to Parliament.

This report has been prepared in accordance with the Requirements for Annual Reports approved on behalf of the parliament by the joint Committee of Public Accounts and Audit under section 63 of the Public Service Act 1999.

Yours sincerely

John Holmes
5 October 2004

Dr Charles Terence Russell,
General Practitioner, Qld

Dr Russell practiced at Macgregor and Browns Plains in Queensland during the referral period of 1 January 1999 to 31 December 1999 inclusive.

In relation to the rendering of MBS item 30278 (repair of tongue-tie) Dr Russell's conduct was found by the committee to be unacceptable to the general body of general practitioners. In the majority of services examined, the patients had seen Dr Russell for circumcision procedures. He subsequently performed repairs to tongue-ties. Given this pattern, the committee was concerned that while parents consulted with Dr Russell for circumcisions, he opportunistically diagnosed tongue-tie. The committee found there were no clinical indications for the services.

The services were examined in accordance with an approved sampling methodology which resulted in a finding that 90 per cent of MBS item 30278 services rendered by Dr Russell during the referral period were inappropriate. The committee detailed its reasons in a final report to the Determining Authority. Dr Russell did not make a submission on the draft determination. The Authority issued a final determination directing that Dr Russell be reprimanded, counselled and repay $4 488.88. The determination came into effect on 13 February 2004.

Text available on line here.

If the link does not work, search for Russell +tongue tie +Medicare on Google .

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

Circumcision of male children “a hidden human rights violation”

In the April 2007 issue of the Australian Journal of Human Rights , Ranipal Narulla argues that circumcision of male minors should be recognised as a violation of human rights

Synopsis

Male circumcision is an accepted practice within Australian society, despite the fact that female circumcision is widely reviled in the Western developed world. This article will consider why society and the law treat circumcision of males and female differently. Analysis will focus upon the circumcision of male children in Australia, with reference to the United Kingdom and the United States of America. The similar social history of the practice within these jurisdictions is instructive when critically analysing the Australian context. The discussion will encompass the circumcision of all male children, as the issues of lack of consent and the imposition of a parent's religious and cultural norms upon the child are consistent for all minors, with specific focus on neonatal children where such extreme youth creates additional vulnerability. The absence of domestic law in Australia dealing with the circumcision of male children invites analysis of the protection afforded under international human rights instruments to which Australia is legally bound. This article deconstructs the medical myths that surround the circumcision of male children, and in so doing makes a strong argument for the need to recognise circumcision of male minors as a human rights violation.

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

The Australian Journal of Human Rights is published by the Australian Human Rights Centre at the University of New South Wales

On-line issues available from AustLii

Tasmanian Children's Commissioner wants circumcision banned

Tasmania's Children's Commissioner , Paul Mason, wants the State Government to ban the non-medical circumcision of young boys.

Female genital mutilation is illegal in Tasmania.

Mr Mason said it's unfair that boys aren't given the same protection. “We're discriminating against the little baby boys themselves, because they're not safe whereas the little girls are,” he said.

He said circumcision is an abuse of human rights and should be outlawed until the person is old enough to decide for themselves. “It's a permanent procedure. They get no choice. It's painful -- even under anaesthetic.”

Mr Mason has prepared a report on the issue for the Council of Obstetric and Paediatric Mortality and Morbidity. The Council will forward a recommendation to the State Government.

ABC News, 13 August, 2007

Frankfurt court finds circumcision an unlawful personal injury

A regional appeals court in Frankfurt am Main, Germany, found that the circumcision of an 11-year-old Muslim boy without his approval was an unlawful personal injury.

The Sept. 20 decision opened the way toward financial compensation for the boy.

The case may have repercussions for the practice of ritual circumcision in Germany by Muslims and Jews. The court suggested, in part, that it was a punishable offense to subject one's child to teasing by other children for looking different.

The boy, now 14, plans to sue his father for 10,000 Euro (about $14,000), according to a report by the German DDP Press Agency .

Reportedly, the boy, whose parents are divorced, was visiting his father during a vacation when his father forced the ritual circumcision. The boy lives with his mother, who had always rejected circumcision. Muslim boys are traditionally circumcised at elementary school age.

According to the court, circumcision can “be important in individual cases for the cultural-religious and physical self-image,” even if there are no health disadvantages involved. So the decision about whether or not to go through with a circumcision is “a central right of a person to determine his identity and life.”

The court did not give an age minimum at which their parents must seek a child's permission to perform a circumcision . The amount of damages depends, said the court, on the extent to which the boy suffered long-term physical or emotional damage, or “whether his peers would tease him for looking different.”

JTA breaking news, 21 September 2007

Male and female circumcision “not so different”

An article in a leading international journal, Medical Anthropology Quarterly, questions the “quarantining” of male circumcision from female genital mutilation and calls for both less gender discrimination and more respect for the rights of boys.

Abstract

This paper offers a critical examination of the tendency to segregate discussion of surgical alterations to the male and female genitals into separate compartments - the first known as circumcision, the second as genital mutilation. It is argued that this fundamental problem of definition underlies the considerable controversy surrounding these procedures when carried out on minors, and that it hinders objective discussion of the alleged benefits, harms and risks. The variable effects of male and female genital surgeries are explored, and a scale of damage for male circumcision to complement the World Health Organization's categorisation of female genital mutilation is proposed. The origins of the double standard identified are placed in historical perspective, and a brief conclusion makes a plea for greater gender neutrality in the approach to this contentious issue.

Robert Darby and J. Steven Svoboda, “A Rose by any other Name: Rethinking the Similarities and Differences between Male and Female Genital Cutting”, Medical Anthropology Quarterly , Vol. 21, September 2007, pp. 301-323.

A PDF of the article can be downloaded here.

“Age” op-ed writer calls circumcision male genital mutilation

It's child abuse and it's time it was cut out

Catherine Deveny

The Age (Melbourne), October 24, 2007

People give plenty of reasons for circumcising their male children, writes Catherine Deveny. But most of them don't amount to anything.

NO ONE seems to be able to explain to me why the circumcision of baby boys is not considered child abuse. Why in 2007 is it still acceptable for parents to have their babies' foreskins ripped off? How can it be legal, let alone ethical, for any human being to choose for another human being's body to be irreversibly mutilated? No medical reason, no rational thought and in many cases no aesthetic. Just because.

I suggest that we should ban the use of the term “circumcision” and force people to use the term “genital mutilation”. Because that's what it is. It's not “a personal choice”, because that person is not making a choice. It's human rights abuse.

The We Circumcised For Religious Reasons camp justify genital mutilation citing religion. They embrace the parts of religious texts that suit them and dismiss the ones that don't. And when I say “they”, not all of them do. Many believers I know have all applied a little rational thought to the equation and just decided not to inflict unnecessary pain on their child or expose them to avoidable risk. They've decided to file that bit of the Holy Book under the other things that just don't fit; like selling your daughter into slavery or killing your neighbour if they work on the Sabbath.

What kind of God would disapprove of you, stop loving you, or not give you eternal life if you don't mutilate your child's genitals? That doesn't sound like a nice kind of God. And what caring community would shun you, judge you or ostracise you for not inflicting genital mutilation on your child?

Then we have the We Circumcised Our Boys So They Look The Same As Their Father camp. Sure, it's not fair for me to pick on people less fortunate in the brains department than the rest of us, but when they are subjecting innocent children to genital mutilation I'm going in swinging. I'm not going to bother asking the hard question “why do you need them to look like their father?”, because you cannot reason with something that has not come from reason but from mindlessness.

I ask the So They Look The Same As Their Father camp, why stop there? If you want them to look the same as their father, dye their hair, have them undergo cosmetic surgery and if the father has any tattoos or facial hair, sort that out too.

Related to this camp is the We Circumcised Our Boys Because A Circumcised Penis Looks Nicer camp. We are talking the shallow end of the intelligence pool here. How would they feel if they had had their nipples, nose or ears cut off by their parents when they were a child because their parents thought “it looked nicer”? I must say that I do applaud these two camps on their frankness and honesty despite it revealing their stunning stupidity. After all, they could do what others do and make the decision for no rational reason and then rationalise it by joining the We Circumcised Our Boys For Health And Hygiene Despite Looking Closely At The Research camp.

I have read the various studies suggesting that circumcision may reduce the spread of HIV and cervical cancer. I have also read the studies disproving the circumcision-reduces-infection myth. Here in Australia, all of these risks can be effectively and safely managed with condoms and cleanliness. That's right, a bit of frangers and face washers, rubbers and rubbing. Why would you expose a child to an unnecessary medical procedure and all the risks that come with it when you could teach them how to clean themselves and use a condom? Because you can, I suppose. By the same logic, removing all your children's teeth would prevent them getting fillings.

Unless, of course, there is a sound medical reason to circumcise. And when I say sound, I mean sound as in last resort. I don't mean that you walk into a GP with a seven-year-old with a constricted foreskin that is not retracting and walk out with a referral to a surgeon to have your child's genitals mutilated, as a family I know could have.

One of their sons had that very problem. They were offered a referral to a surgeon to have him circumcised. They didn't like the sound of that. Luckily they didn't have private health insurance, because that meant that they were given a referral to the Royal Children's Hospital, where they saw a general pediatric surgeon, or as their son referred to her, a Dick Doctor.

Yes, she said, he could be circumcised, but she was having great success using an ointment available over the counter from the chemist. Three days later, the boy had a retracting foreskin. And two years later, he still does. The wonders of a health service on a budget as opposed to a private business. So if he wants to get himself circumcised as an adult, that's his choice. And he'll have that choice. Because when you circumcise someone, you can't uncircumcise them.

New studies document harm of circumcision

Two careful studies published in the world's leading jounral of urology, BJU International, demonstrate that circumcision damages the penis and cuts sexual capacity and satisfaction.

KOREA: WORSE SEX LIFE AFTER CIRCUMCISION

Two Korean researchers, DaiSik Kim and Myung-Geol Pang, studied 373 sexually active men, of whom 255 were circumcised and 118 were not. They found that circumcision reduced sexual pleasure in most cases and that a significant minority of men reported major injury to their penis, causing bleeding, scarring and chronic pain.

Summarizing their results, the authors write:

There were no significant differences in sexual drive, erection, ejaculation, and ejaculation latency time between circumcised and uncircumcised men. Masturbatory pleasure decreased after circumcision in 48% of the respondents, while 8% reported increased pleasure. Masturbatory difficulty increased after circumcision in 63% of the respondents but was easier in 37%. About 6% answered that their sex lives improved, while 20% reported a worse sex life after circumcision.

Conclusion

There was a decrease in masturbatory pleasure and sexual enjoyment after circumcision, indicating that adult circumcision adversely affects sexual function in many men, possibly because of complications of the surgery and a loss of nerve endings.

DaiSik Kim and Myung-Geol Pang, “The effect of male circumcision on sexuality”, BJU International, Vol. 99 (3), March 2007, pp. 619-22

Download pdf of full article

UNITED STATES: CIRCUMCISION CUTS SENSITIVITY OF PENIS

Meanwhile, researchers in the United States have found that circumcision removes the most sensitive part of the penis.

Researcher Dr Morris Sorrells and others enlisted 159 men from the San Francisco Bay area, 91 of them circumcised, and conducted touch-sensitivity tests, using an instrument that presses with calibrated hairs, on 17-19 different places on their penises. The men could not see where they were being touched.

It was found that the most sensitive part of a circumcised penis was on the scar in the middle underneath. But several places on the foreskin were more sensitive than that while the glans of the uncircumcised penis was more sensitive than in the circumcised.

The paper is summarised here:

Objective

To map the fine-touch pressure thresholds of the adult penis in circumcised and uncircumcised men, and to compare the two populations.

Subjects and methods

Adult male volunteers with no history of penile pathology or diabetes were evaluated with a Semmes-Weinstein monofilament touch-test to map the fine-touch pressure thresholds of the penis. Circumcised and uncircumcised men were compared using mixed models for repeated data, controlling for age, type of underwear worn, time since last ejaculation, ethnicity, country of birth, and level of education.

Results

The glans of the uncircumcised men had significantly lower mean ( SEM ) pressure thresholds than that of the circumcised men, at 0.161 (0.078) g ( P = 0.040) when controlled for age, location of measurement, type of underwear worn, and ethnicity. There were significant differences in pressure thresholds by location on the penis ( P < 0.001). The most sensitive location on the circumcised penis was the circumcision scar on the ventral surface. Five locations on the uncircumcised penis that are routinely removed at circumcision had lower pressure thresholds than the ventral scar of the circumcised penis.

Conclusions

The glans of the circumcised penis is less sensitive to fine touch than the glans of the uncircumcised penis. The transitional region from the external to the internal prepuce is the most sensitive region of the uncircumcised penis and more sensitive than the most sensitive region of the circumcised penis. Circumcision ablates the most sensitive parts of the penis.

Sorrells ML, Snyder JL, Reiss MD, et al.  Fine-touch pressure thresholds in the adult penis. BJU International 2007;99:864-9

Download pdf of full article

Full text of article

Further discussion, with diagrams and illustrations

See also an article by Paul Festa in Nerve magazine, How insensitive: A new study confirms a long-time fear: Circumcised men are missing out

BRITISH MEDICAL ASSOCIATION WARNS ON CIRCUMCISION

The British Medical Association (BMA) has revised their 2003 Guidance on the Law and Ethics of Male Circumcision. The revised guidance dated June 2006 reaffirms the statement “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”.

The guidance confirms that there is rarely any clinical need for circumcision: “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. Doctors should be aware of this and reassure parents accordingly”.

The most significant revision in the new guidance is in respect of the legal situation. The guidance states that, if it was shown that circumcision where there is no clinical need is prejudicial to a child’s health and wellbeing, it is likely that a legal challenge on human rights grounds would be successful. The guidance further states that, if damage to health were proven, there may be obligations on the state to proscribe it. The UN Convention on the Rights of the Child, which has been ratified by the UK, requires ratifying states to “take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children”.

Report from Norm UK

Full text of BMA statement

CIRCUMCISIONS KILL 14 AFRICAN BOYS IN A MONTH

Fourteen boys have died as a result of botched circumcisions in the past month in the Eastern Cape province of South Africa. Hundreds more boys have been maimed and mutilated in the same process which takes place annually at “circumcision schools,” usually conducted in the bush, away from towns and villages. In South Africa, in many groups, boys are circumcised between puberty and adulthood, and it marks the ritualised passing from boyhood to manhood.

In the past few years, however, this “circumcision season” has been marred by untrained and bogus traditional surgeons trying to make money but whose technique lacks expertise and hygiene. The provincial department of health says that 243 deaths and 216 genital amputations from circumcisions were recorded between 1995 and 2004. Last year there were more than 20 deaths. Laws and regulations in the Eastern Cape were passed in the hope of controlling the practice and ensuring hygienic conditions. Traditional surgeons have to be officially recognised and register with the department. Surgeons caught running initiation schools without authority can be sent to prison.

Pat Sidley, Johannesburg
British Medical Journal, Vol. 333, 8 July 2006, p. 62

Further information

South African Medical Association calls for action to “stop the carnage”

Circumcision in South Africa

CANADA MEDICARE PAYS FOR FORESKIN RESTORATION

BC man's foreskin operation a success: Government pays to repair circumcision

By Jennifer Laliberté

In late April Paul Tinari became the first man in Canadian history to have the government pay for surgery to reverse a botched circumcision.

Armed with letters from a urologist and psychiatrist, the Vancouver engineer — who says he's been in pain for years — convinced the BC government to pick up 90% of the $12,000 tab. The final piece fell into place when he located Toronto plastic surgeon Dr Robert H Stubbs, the only doctor in Canada who'd ever performed a foreskin restoration.

"This is not something I went into lightly," says 48-year-old Dr Tinari of the complex, multistage procedure he began at the end of April. "I assessed the risks [of the surgery] and was willing to take them. But I certainly wasn't willing to pay for it."

The BC Ministry of Health says requests for funding for unlisted medical procedures are approved only if the care isn't available in the province and if a medical professional has confirmed there's a serious medical or mental health issue. There were no existing rules to deal with Dr Tinari's unusual case. "Obviously, something like that would be granted coverage only in rare or extenuating circumstances," says ministry spokesperson Sarah Plank. "We certainly don't have a billing code for it."

"He got a big chunk because no one in BC does this and he had his urologist and psychiatrist on his side," observes Dr Stubbs, who specializes in genital cosmetic surgery. "Some provinces are willing to do things like that for their citizens."

"Dr Tinari was a good candidate for the surgery," says Dr Stubbs, who says he doesn't know of any other Canadian physicians doing foreskin restoration. "He had sufficient donor skin and was well aware of what he was getting into. I select my patients very, very carefully," he said. In fact, Dr Tinari is only the third patient he's agreed to take on. "This is like climbing Mount Everest," he says. "It's a huge procedure."

First, the skin is cut along the circumcision scar line and stretched open to create a graft site. Then, two parallel incisions are made on the scrotum — the donor site — leaving a sort of bridge with the two ends attached on either side. "The penis is popped through the hole, with the skin bridge covering the defect you created," Dr Stubbs explains. "Then we let that heal for at least three weeks." In stage two, the two ends of the bridge are cut, separating the penis and scrotum. "You tuck those two pieces that are still dangling to the underside and keep your fingers crossed that enough blood vessels have grown in to ensure survival of the graft." Finally, when the swelling has subsided, the new skin is stretched over the penis with tape and traction weights to form a foreskin.

Personal crusade

Dr Tinari sees this not just as a medical victory but a moral one too. He alleges that his circumcision was forced on him when he was eight years old by priests at his Montreal boarding school as punishment for masturbating. He says the circumcision left him depressed, suicidal and in chronic pain. He says his testicles would pull up onto the shaft of the penis during an erection; a segment of the glans healed to a small amount of remaining shaft skin, forming a skin bridge; stretching of that bridge caused intense pain during erection, occasionally causing tearing and bleeding during sex. He adds that cleaning under the skin bridge was also very difficult, so he suffered from chronic infections for years.

Nowadays, Dr Tinari, who has a PhD in engineering, is the director of an environmental engineering company based in Coquitlam, BC. But he spends a lot of his time campaigning against circumcision and for wider access to foreskin restoration. "People thought that I would go away after the surgery, but that was just the first step," he says. "I did this to restore my own bodily integrity, but also to set a legal precedent."

Given the complexity of the procedure, Dr Stubbs doesn't expect to see a dramatic increase in patients. He's staying out of Dr Tinari's legal pursuits. "I don't ask women why they come in for a breast implant, and I didn't ask him if he had an ulterior motive," says the surgeon. "He may have an agenda that I don't know about, but this isn't something where the success or failure of his surgical procedure should make men consider this an option or not."

Meanwhile, Dr Tinari is still recovering; it's nearly two months since the surgery and his doctor is pleased with the outcome. "We seem to have about an 80-90% graft survival," says Dr Stubbs. "I transferred a strip about 7 cm wide, so he should have plenty for an adequate foreskin." The patient is also very pleased. "I've been working towards this for thirty years," says Dr Tinari. "I'm feeling better every day."

National Review of Medicine (Canada), Vol. 3 No. 12, 30 June 2006

CONDOMS BEST PROTECTION AGAINST STDs and HIV

New evidence that condoms highly effective against STDs and HIV

Writing in the June 22 issue of the New England Journal of Medicine, Markus Steiner and Willard Cates confirm that condoms offer the best protection against the whole range of sexually transmitted infections. After a review of current medical opinion and the various alternatives, they conclude that consistent condom use offers significant protection against most STDS, including syphilis gonorrhoea, chlamydia, herpes and HIV in both women and men, and against HPV (human papilloma virus – the cause of cervical cancer) in women. They recommend that more effort be made to encourage sexually active people (and especially those with multiple partners) to use condoms consistently.

Markus Steiner and Willard Cates, “Condoms and sexually transmitted infections”, New England Journal of Medicine, Vol. 354, 22 June 2006, pp. 2642-43

There is nothing new or surprising in this. It has been well known since at least the 1850s that condoms were an effective barrier against infection by syphilis, and the radical English doctor George Drysdale urged their widespread adoption. Unfortunately, in the prudish atmospheres of the times, his suggestion was regarded as immoral and likely to encourage promiscuity, and most of the medical profession continued to preach against condom use and to recommend chastity instead. As a result, syphilis spread rapidly and reached such epidemic proportions that a Royal Commission had to be established to investigate ways of controlling it.

Further information:

Robert Darby, A surgical temptation: The demonization of the foreskin and the rise of circumcision in Britain (University of Chicago Press, 2005)

Peter Baldwin, Contagion and the state in Europe (Cambridge University Press, 1999)

J. Miriam Benn, Predicaments of love (London: Pluto Press, 1992)
(On the remarkable George Drysdale)

Out of print; you may be able to buy from ABEbooks

Roger Davidson and Lesley Hall (eds) (2001), Sex, sin and suffering: Venereal disease and European society since 1870, (London: Routledge, 2001)

Jane Tolerton, Ettie: A life of Ettie Rout (Penguin 1992)

A biography of the courageous New Zealand woman who provided the diggers in World War I with safe sex advice and free condoms.

Use of condoms, along with regular check-ups, could have contained the syphilis epidemic long before the discovery of penicillin in the 1940s provided a reliable cure.

It may be a long time before we have a cure or vaccine for HIV-AIDS, and in the meantime condoms offer the best and most reliable protection for those who are determined to brave the perils of sexual promiscuity.

Condoms 90 per cent effective against HIV infection

Abstract

The consistent use of latex condoms continues to be advocated for primary prevention of HIV infection despite limited quantitative evidence regarding the effectiveness of condoms in blocking the sexual transmission of HIV. Although recent meta-analyses of condom effectiveness suggest that condoms are 60 to 70% effective when used for HIV prophylaxis, these studies do not isolate consistent condom use, and therefore provide only a lower bound on the true effectiveness of correct and consistent condom use. A reexamination of HIV seroconversion studies suggests that condoms are 90 to 95% effective when used consistently, i.e. consistent condom users are 10 to 20 times less likely to become infected when exposed to the virus than are inconsistent or non-users. Similar results are obtained utilizing model-based estimation techniques, which indicate that condoms decrease the per-contact probability of male-to-female transmission of HIV by about 95%. Though imperfect, condoms provide substantial protection against HIV infection. Condom promotion therefore remains an important international priority in the fight against AIDS.

Steven D. Pinkerton and Paul R. Abramson, “Effectiveness of condoms in preventing HIV transmission”, Social Science and Medicine, Vol. 44, No. 9, 1997, pp. 1303-1312

Further information

Steven Pinkerton and Paul Abramson, “Condoms and the protection of AIDS”, American Scientist, Vol. 85, July-August 1997, pp. 364-73

Roger Short and Malcolm Potts, “Condoms for the prevention of HIV transmission: Cultural dimensions”, AIDS, Vol. 3 1989, Supplement 1, pp. S259-63

This paper urges urging mass distribution of condoms to high risk groups in the Third World, especially areas of Africa with rates of HIV infection. This was before Dr Short got the bright idea that foreskins might be an easier target than the AIDS virus and became a fanatical evangelist for universal routine circumcision. In fact, circumcision may discourage condom use, for two reasons. The first is that circumcised men have less feeling in their penis (because most of the nerves have been removed), and a condom blunts sensation even further. Secondly, Australian researchers have found that normal (uncircumcised) men actually find condoms easier and more comfortable to use:

“Uncircumcised men were found … to be significantly less likely to report condoms slipping off than circumcised men. One possible reason might be that the increased bulk of the distal part of the penis provided by the presence of the foreskin helped to retain the condom.”

Juliet Richters, John Gerofi and Basil Donovan, “Why do condoms break or slip off in use? An exploratory study”, International Journal of STD and AIDS, Vol. 6, 1995, pp. 11-18

A common reason why condoms slip off is because the wearer loses his erection. The most likely reason why this occurs is because he is not getting enough sensation through the latex, and this blunting of feeling will be more severe if he is circumcised and thus deprived of the thousands of nerve endings found in the foreskin.

Further information on condoms and HIV-AIDS

John G. Bartlett, The Johns Hopkins Hospital 2005-06 Guide to Medical Care of Patients with HIV Infection, 12th edition, 2005.

http://www.hopkins-aids.edu

Jeannette Parisot, Johnny come lately: A short history of the condom (London: Journeyman Press, 1987)

And in the Third World, the main reasons for the high rate of HIV infection are poverty, malnutrition, ignorance, oppression of women, sexual promiscuity and low condom use.

Philip Setel, A plague of paradoxes: AIDS, culture and demography in northern Tanzania (University of Chicago Press, 1999)

And see the condom pages of Population Action International

Ethics of male circumcision questioned

In two articles in recent issues of major international journals covering medical ethics and human rights, two British legal experts have questioned the ethics of circumcising male infants, comparing it to female genital mutilation, and have even thrown doubt in whether any such surgery on an individual without his or her consent can be regarded as legal.

Abstracts of the two articles, in the Journal of Medical Ethics and the International Journal of Children's Rights, are given below.

1. "A covenant with the status quo?"

This article offers a critique of the recently revised BMA guidance on routine neonatal male circumcision and seeks to challenge the assumptions underpinning the guidance which construe this procedure as a matter of parental choice. Our aim is to problematise continued professional willingness to tolerate the non-therapeutic, non-consensual excision of healthy tissue, arguing that in this context both professional guidance and law are uncharacteristically tolerant of risks inflicted on young children, given the absence of clear medical benefits. By interrogating historical medical explanations for this practice, which continue to surface in contemporary justifications of non-consensual male circumcision, we demonstrate how circumcision has long existed as a procedure in need of a justification. We conclude that it is ethically inappropriate to subject children – male or female – to the acknowledged risks of circumcision and contend that there is no compelling legal authority for the common view that male circumcision is lawful.

The British Medical Association statement, The law & ethics of male circumcision – guidance for doctors

M. Fox and M. Thomson, "A covenant with the status quo? Male circumcision and the new BMA guidance to doctors"

Journal of Medical Ethics, Vol. 31, 2005, pp. 463-9

Marie Thomson and Michael Fox are at the School of Law, Keele University, Staffordshire, UK.

2.  Short Changed? The Law and Ethics of Male Circumcision

Routine neonatal male circumcision has generally failed to excite medico-legal attention. Notwithstanding recent debates in the ethical literature, notably in special issues or symposia in the Journal of Medical Ethics (2004, 30) and American Journal of Bioethics (2003, 3), the law has yet to engage seriously with this issue. In a forthcoming contribution to an emerging medico-legal debate we have suggested that neglect of this issue is partly attributable to the way in which routine infant male circumcision (and its attendant effects and risks) is typically characterised in opposition to female circumcision for rhetorical and political reasons (Fox and Thomson, 2005). The result is that, while female circumcision is constructed as morally and legally unacceptable within a civilised society, male circumcision is characterised as a standard and benign medical practice. In this article our focus turns to the related failure to engage in a full cost/benefit analysis of the practice and the harm it causes to boy children.

The International Journal of Children's Rights, Vol. 13, 2005, pp. 161–81

Download PDF of whole article here | Download PDF Reader

Further discussion here

Male circumcision and female genital mutilation: Problems of definition

"Victims can sue": Medical ethics expert

Speaking on the BBC on 11 November 2005, the Chair of the British Medical Association Medical Ethics Committee, Dr Michael Wilkes, said that men who resented having been circumcised as children were entitled to compensation.

Interviewer:  I'm here at the British Medical Association to ask Dr. Michael Wilkes about circumcision and in particular whether it's true that unnecessary circumcisions are being carried out.

Dr. Wilkes:  There is hardly a reason to circumcise a little boy for medical reasons because those medical reasons don't exist. We do accept as a by definition of medical reasons and benefit medically that comes from that, that the Jewish Faith have a strong tradition and therefore a strong claim to continue this practice.

Interviewer:  Medically what reason would there be to circumcise either a youngster or an older person.

Dr. Wilkes:  The vast majority of cases for instance of non retractile foreskin, which is a developmental thing, it just takes time, sometimes for the tissue between the foreskin and the glans of the penis, the sensitive part of the penis, to break down so the foreskin can be put back. It's often a question either of time or of very gentle manipulation, certainly not surgery.

Interviewer:  So the people of NORM UK that feel that as if they've been circumcised for the wrong reasons – in the past do you think doctors have circumcised for no good reason maybe.

Dr. Wilkes:  Yes I do, I do, and I suspect that some people from NORM UK, those who are not members of the strong Jewish tradition for instance or maybe slightly less persuasive that – certainly in Muslim tradition – the majority of people who have been circumcised in the past for what was put to them or put to their parents as good medical reasons were probably no such thing and those people certainly have a right to make a claim that what was done to them was an unnecessary and premature intervention at a time when they had no capacity or say in the matter.

Broadcast in Outlook, BBC World Service, 11 November 2005, 12.05 pm.

Further information at Norm-UK

Further information on legal aspects of circumcision

Australian children healthier with foreskin in place

A report on children's health recently issued by the Australian Institute of Health and Welfare is proof that there is no connection between circumcision and health. It also offers good evidence that Australia's anti-circumcision policy has actually improved child health outcomes.

The report, called A picture of Australia's children, shows big improvements in child health over the 20 years from 1983 to 2003, and a halving of infant mortality. These are very significant dates, since 1983 was the start of the huge slide in Australian circumcision incidence, from about 40 per cent of boys in the early 1980s to less than 12 per cent in 2003. It is thus good empirical proof that "lack of circumcision" does not increase child health problems. Even more significantly, it is a decisive refutation of "scientific" predictions by Terry Russell, Brian Morris etc that the fall in the circumcision rate would lead to an explosion of genito-urinary problems in boys. No such problems are identified in this report, which does not even mention any health problems affecting the genito-urinary area.

In fact, if one were to be as unscrupulous in conflating correlation with causation as many of the pro-circumcision zealots, one could reasonably conclude that Australian children have become healthier not just at the same time as the incidence of circumcision has fallen, but because the incidence has fallen. But there is no need to go that far. At the very least the AIHW report is definitive proof that there is zero connection between circumcision and improved health outcomes.

The report can be downloaded from the AIHW website in several pdfs here:

http://www.aihw.gov.au/publications/index.cfm/title/10127

Summary in Sydney Morning Herald

Children fatter but, overall, healthier
By Stephanie Peatling
Sydney Morning Herald
May 3, 2005

Australia's 3.9 million children aged 14 and under are now more likely to be vaccinated and to go to preschool but less likely to die of sudden infant death syndrome or be in a juvenile justice facility, according to a snapshot of children.

The report, by the Australian Institute of Health and Welfare, says obesity, asthma, dental health and the number of women who smoke during pregnancy are of concern. It is the first time the researchers have looked beyond health to other issues affecting children such as homelessness, violence and parental health and disability.

The Minister for Family Services, Kay Patterson, said the report showed "the majority of children are faring well".

"While the report's findings are overall very positive, they do reveal that there are groups of children whose health needs to be improved," she said. "Aboriginal and Torres Strait Islander children have poorer health and wellbeing on the whole."

Children make up 30 per cent of the population, but declining fertility rates and a "greying" population mean they are likely to be only 18 per cent by 2011.

The average life expectancy for today's babies is 77.8 years for males and 82.8 years for females.

In the past two decades the infant mortality rate has halved, from 9.6 per 1000 live births in 1983 to 4.8 in 2003.

Mortality rates also fell by more than half. One of the main reasons for the big decline was the drop in rates of death from sudden infant death syndrome - down by 84 per cent between 1983 and 2003. SIDS still caused 17 per cent of infant deaths.

Vaccination rates were high: 92 per cent of two-year-olds were immunised, although the proportion fell to 84 per cent among six-year-olds.

Most children aged between two and 14 were a healthy weight, with about 20 per cent of boys and girls overweight or obese.

The study found that between 1990 and 2000, the number of decayed teeth in children declined - from 2.1 to 1.7 in a child aged six, and from 1.4 to less than 1 in children aged 12.

"However," the report notes, "in more recent years this decline appears to have ceased, and there are signs of decay experience among children increasing."

The Medical Journal of Australia published an editorial on the report saying it revealed "huge gaps" in knowledge about obesity and mental illnesses.

The best available information on obesity is now 10 years old, the journal says, while the research on child mental health is seven years old.

"A need for up-to-date national data on the social and geographic distribution of childhood obesity and mental disorders stands out as a priority," the journal says. "If current social changes persist, the worsening trends in obesity and mental disorders seem likely to continue, and the children most affected will be those in disadvantaged and disrupted families."

South African Medical Association rejects circumcision

In response to an inquiry from Nocirc of South Africa, the South African Medical Association has formally stated that there is 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 Physicians, which states 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 very significant declaration.

Nocirc-South Africa website

South African Medical Association website

Policy statements by medical associations

Mothers' milk the best defence against UTIs

A recent study from Sweden confirms that breast-milk provides significant protection against urinary tract infections. The study appears to have included both boys and girls, who are, in fact, a lot more prone to UTIs than boys.

"Protective effect of breastfeeding against urinary tract infection", by Marild S, Hansson S, Jodal U, Oden A, Svedberg K., Department of Paediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Goteborg, Sweden. staffan.marild@pediat.gu.se

AIM: To assess the possible protective effect of exclusive breastfeeding against first-time febrile urinary tract infection (UTI) in children.

METHODS: Two children's hospitals and local child health centres in the Goteborg area, Sweden, participated in a prospective case-control study. In total, 200 consecutive cases (89M, 111F), aged 0-6y, presenting with first-time febrile UTI were enrolled. The mean +/- SD age was 0.98 +/- 1.15 y. As control subjects, 336 children (147M, 189F) were recruited from the child health centre of the case, matched for age and gender and included consecutively for each case during the first days after diagnosis. The duration of exclusive breastfeeding was obtained from the case and controls by a standardized procedure.

RESULTS: Ongoing exclusive breastfeeding gave a significantly lower risk of infection. A longer duration of breastfeeding gave a lower risk of infection after weaning, indicating a long-term mechanism. The protective role of breastfeeding was strongest directly after birth, then decreased until 7 mo of age, after which age no effect was demonstrated.

CONCLUSION: A protective role of breastfeeding against UTI was demonstrated. The study provides statistical support to the view that breast milk is a part of the natural defence against UTI.

Acta Paediatr. 2004 Feb;93(2):164-8.

PubMed reference

This study confirms earlier work by Alfredo Pisacane and colleagues.

New research: Circumcision bad for health and hip pocket

A cost-benefit analysis of routine circumcision, just published in the US journal Medical Decision Making, concludes that the practice cannot be justified on either economic or medical grounds. The procedure both adds to health costs and reduces the overall health of the individual.

Abstract A cost-utility analysis, based on published data from multiple observational studies, comparing boys circumcised at birth and those not circumcised was undertaken using the Quality of Well-being Scale, a Markov analysis, the standard reference case, and a societal perspective. Neonatal circumcision increased incremental costs by $828.42 per patient and resulted in an incremental 15.30 well-years lost per 1000 males. If neonatal circumcision was cost-free, pain-free, and had no immediate complications, it was still more costly than not circumcising. Using sensitivity analysis, it was impossible to arrange a scenario that made neonatal circumcision cost-effective. Neonatal circumcision is not good health policy, and support for it as a medical procedure cannot be justified financially or medically.

The article concludes:

The perpetuation of neonatal circumcision cannot be justified financially or medically; therefore, any justification for the practice must be based on religion, culture, or aesthetics. A limitation of cost-utility analysis is the inability to incorporate such factors. Currently in the United States, cultural considerations trump financial and health concerns when deciding to have a newborn male circumcised. Consequently, this cost-utility analysis will have little or no impact on circumcisions performed for cultural reasons. Instead, this cost-utility analysis is aimed at the financial and medical aspects of neonatal circumcision. Should 3rd-party payers pay for the procedure? Based on this analysis, it would be in their financial interests not to. Still, insurance companies take cultural factors into account when marketing their health plans. This justification has been given by members of the insurance industry for providing neonatal circumcision benefits to their customers. It seems odd, however, that other body modifications, such as ear piercing and tattoos, are rarely covered by medical insurance plans.

The medical community faces a different set of issues. Should medical care providers perform a procedure on a newborn knowing that it is more likely to impair health than improve it? Medical ethical standards, such as "do no harm," appear not to condone such a practice. By performing circumcisions on infants, health care providers venture into the realm of being "cultural brokers." The debate whether this is the proper venue for medical services has not taken place. The analysis is clear: Neonatal circumcision cannot be justified on economic or medical grounds. If the medical community is interested in preserving health and saving money, they should refrain from promoting, encouraging, or presenting neonatal circumcision as a medical option. Third-party payers may want to reassess their current reimbursement policies and possibly consider paying physicians or parents not to perform neonatal circumcisions. Either of these options would result in an overall cost savings.

Robert Van Howe, "A cost-utility analysis of neonatal circumcision", Medical Decision Making, Vol. 24, December 2004, pp. 584-601

Full text of the article is available here

New Canadian policy calls circumcision unnecessary mutilation

In their recently released policy on circumcision, the College of Physicians and Surgeons of the Canadian province of British Columbia have called circumcision both unnecessary and a mutilation.

Doctors Fear Circumcision Violates Human Rights

B.C. MDs' governing body says many consider the procedure "unwarranted mutilating surgery"

The Province
Vancouver, B.C.
Wednesday, July 14, 2004
Page A19

by Ethan Baron
Staff Reporter

New British Columbia doctors' guidelines that suggest circumcising male babies may be a human-rights abuse could put a chill on doctors who perform the surgery.

"Routine infant male circumcision is an unnecessary and irreversible procedure," say the B.C. College of Physicians and Surgeons guidelines." Therefore, many consider it to be unwarranted mutilating surgery. "Many adult men are increasingly concerned about whether their parents had the right to give consent for infant male circumcision."

The guidelines refer to an infant's Charter and United Nations rights to security of person and bodily integrity.

"Most physicians reading this are going to feel a certain degree of apprehension about doing or continuing to do circumcisions," said Vancouver pediatrician Dr. David Smith. "No physician wants to be in practice and sued 10 years later for a procedure they did that was acceptable 10 years earlier."

The blood-loss death of one-month-old Ryleigh McWillis two years ago after a circumcision at Penticton Regional Hospital raised a public outcry that led to the new guidelines, said Dr. Peter Seland, in charge of ethics for the college.

"There are no medical benefits when you balance the risks and benefits," Seland said. "People can make their own ethical decisions but they need to be informed."

Provincial health officer Dr. Perry Kendall, speaking as an individual, drew a parallel between routine male circumcision and the much reviled practice of female circumcision in sub-Saharan Africa. "You're mutilating the genitalia," he said.

B.C. college tightens its circumcision recommendations
By Lynn Haley
Medical Post, July 6, 2004

VANCOUVER Opponents of circumcision are applauding a new policy statement issued by the B.C. College of Physicians and Surgeons.

Dr. Peter Seland, deputy registrar (ethics) of the college, said the new statement is intended to help physicians navigate this minefield.

The statement advises that circumcision may be carried out only when it is in the best interests of the child. It also says the procedure has no medical or prophylactic values and that doctors must advise parents of the associated risks including urinary tract infection, urinary retention, meatal stenosis and hemorrhage (as was seen in a recent B.C. case that resulted in the death of a one-month-old boy).

Doctors are under no obligation to circumcise the child at the request of parents, the statement says. "There is a never-ending stream of concerns that we get at the college around this issue," said Dr. Seland. "There is nothing in terms of the intensity of the debate that separates this from abortion. People have very strong views about this issue.

"But when you cut through it all and examine it, it appears there is still a small portion of our society that might have been making the decision without being fully informed as to its implications, making decisions on such flimsy grounds as ‘We want him to be like daddy.' So we really wanted a tool for physicians to look at, and think about where we're at, not just from a medical point of view."

The trump of course, Dr. Seland said, is the cultural and religious aspects of circumcision, unlike female genital mutilation which, Dr. Seland says, is off-the-wall. "Since male circumcision is neutral medically, you can't really say that medical indications trump religious preferences," he noted. "The flames were fanned when that baby died in Penticton. It spurred us on to come out with this guideline."

Such a procedure at birth could conceivably have a traumatic effect in later years, said Dr. Seland. "There is (also) the issue that a decision has been made by the parents to do this on weak grounds, and the result is the adult male is denied erogenous pleasure, though I don't know whether anybody will ever know that for certain," he said.

Dennis Harrison, a spokesman for the Canadian group Association for Genital Integrity, welcomes the changes in policy from the college. He says the focus on bioethics and human rights will help provide physicians with the tools they need to guide parents around the complex issues surrounding the procedure.

"This is very difficult for many parents, because there is often the conflict between the parents' rights and the child's right," said Harrison. "But in a country like Canada, the vast majority of circumcisions are not done for religious reasons. It's true that parents are responsible for making decisions on behalf of their children, but there is no surgical operation a parent can consent to without medical need, and circumcision is not medically necessary. We applaud the college's guidelines, but we think they could have gone further."

The college's statement is available here.

(The Medical Post is a tabloid distributed free of charge to Canadian MDs.)

Irish surgeon calls for ban on hospital circumcisions

A Dublin surgeon and male circumcision expert has said that the procedure should be banned in Irish hospitals.

Describing the procedure as "a mutilation", Dr Matt McHugh said he believed circumcision had no medical justification and exposed patients to various risks. He believed circumcision should "be banned" from all Irish hospitals, despite the cultural requirements of ethnic minorities.

Dr McHugh wrote an influential paper in 1981 in the Irish Medical Journal*, advising against the procedure. Circumcision has previously been carried out for medical purposes to address phimosis, a tightening of the foreskin. However, according to Dr McHugh, a "simple dorsal slit" in the foreskin** is sufficient to cure the problem.

"What I'm saying here and now is that circumcision is a procedure that should never be performed", he said. "Basically, circumcision can be a dangerous procedure, it can have complications," he said. "It involves a general anaesthetic. It's disfiguring and basically you're removing something that shouldn't be removed."

After circumcision he end of the penis "is exposed to all sorts of trauma", according to Dr McHugh. "The foreskin is not useless, it has a function, and the function is to protect the glans of the penis."

He said he believed cultural reasons, such as in those in the Jewish and Islamic faiths where infant boys are circumcised, were not sufficient. "I am a medical man, I am not a religious expert, but I find it absolutely incredible circumcision can be initiated for some obscure religious belief."

He said he would never perform the procedure for non-medical reasons. "That's out of the question. I think most of my colleagues wouldn't either." He said he agreed with the current policy in place in the south-east region, where hospitals refuse to carry out the procedure. "Certainly I am not going to do it, I don't care what they want. I'm not going to mutilate any children. If they come to this country they should be educated about the medical complications associated with circumcision. I feel it is unacceptable that this procedure be carried out for any reason, including religious belief."

Dr McHugh's comments contrast with a 2001 report on pregnancy services for asylum-seekers and refugees. The report, commissioned by the Eastern Regional Health Authority, recommended a review of policy in relation to circumcision at maternity hospitals.

According to one of the authors of the study, Dr Jo Murphy Lawless of the Department of Social Policy in UCD, research carried out for the study found access to the procedure to be one of the areas of concern for many women from ethnic minorities. "We got a strong sense on the ground that there is a demand for it and we needed to put it in place. It was a demand that clearly had to be responded to."

According to Dr Murphy Lawless, there has been no significant change in policy towards circumcision in Irish maternity hospitals. In its ethical guidelines on male circumcision, the British Medical Association said it had no policy on the medical benefits or risks associated with non-medical male circumcision.

* "Circumcision: Is it ever necessary?", Irish Medical Journal, Vol. 74, February 1981, pp. 55-6

** More advanced and effective treatments are now available. See further information on phimosis.

From:ireland.com
23 August, 2003
http://home.eircom.net/content/irelandcom/topstories/1249437?view=Eircomnet
http://www.cirp.org/news/eirecomnet08-23-03/

Press Council dismisses complaint by circumcision professor

The Australian Press Council has dismissed a complaint by Professor Brian Morris against the Good Weekend magazine, published by the Sydney Morning Herald, over a column by Dr Karl Kruszelnicki. Professor Morris's complaint centred on a regular short column, Mythconceptions, in which Dr Kruszelnicki writes about 400 words on many different subjects which fall into the category of "life's myths, curiosities and absurdities".

In particular, Professor Morris complained about a column on circumcision, "May the foreskin be with you", published on 7 January 2004, describing it as "a mischievous anti-circumcision" article and "blatantly biased propaganda".

He said Dr Kruszelnicki was "deliberately deceptive" in not mentioning any of the health benefits of circumcision and criticised one of Dr Kruszelnicki's sources as an "anti-circ activist" and a "hero of the anti movement" who did not have appropriate medical qualifications.

In response, Dr Kruszelnicki, who acknowledged that he is not a urologist,* pointed out that his column did not set out to discuss in detail the pros and cons of circumcision but rather discussed specifically what he saw as "the myth" that circumcision was originally performed for hygiene reasons and how this belief later evolved.

Dr Kruszelnicki named four sources, including the one objected to by Professor Morris. In relation to the latter, Dr Kruszelnicki pointed out he quoted just eight words from that source: the foreskin is "a uniquely specialised, sensitive, functional organ of touch".

The Press Council noted that Good Weekend offered Professor Morris an opportunity to air his views by publishing his letter to the editor on January 31. However, Professor Morris also believed that Good Weekend magazine, in later publishing three letters opposing the views in his letter, demonstrated editorial bias.

Given the nature of the Mythconceptions column and the fact that Good Weekend published Professor Morris's letter, the Press Council said it believed the publication had adequately dealt with the matter.

* Neither is Brian Morris.

Sydney Morning Herald, Tuesday, 13 April 2004

Circumcision myths: Readers respond

Good Weekend, 31 January 2004, Your Say

Dr Karl Kruszelnicki ignores the massive scientific support for the benefits of circumcision (Weekender, January 10) and instead presents only extremist anti-circ nonsense from the likes of Paul Fleiss. Dr K fails to even mention that make circumcision prevents a raft of diseases in both sexes, as well as sexual problems in men. Bacteria abound under the foreskin,* accounting for 11-fold higher urinary tract infections. The foreskin is, moreover, an "HIV magnet". Its removal may reduce the risk of AIDS, penile cancer and cervical cancer.

Professor Brian Morris
University of Sydney

Editor's note: In 2002 the Paediatrics and Child Health Division of the Royal Australasian College of Physicians reaffirmed its position that there is no medical indication for routine male circumcision.

Good Weekend, 21 February 2004, Your Say

The letter from Professor Brian Morris criticising Dr Karl Kruszelnicki's article on circumcision, and Morris's claim that it is "only extremist anti-circ nonsense" would best be consigned to the file for academic twaddle. Male circumcision, per se, does not prevent the raft of diseases he lists. Bacteria under the foreskin or anywhere else thrive only because of lack of personal hygiene. As my medico says, the greatest preventive or infection is lots of soap and water.** As for circumcision preventing "sexual problems in men", what bunkum.

E. Armstrong
Coff's Harbour

There is no "massive scientific support for the benefits of circumcision" as Professor Morris alleges in his letter. The only medical reason for it is to treat phimosis (excessively tight foreskin), which affects about 1 per cent of boys.*** With good hygiene there is no increased incidence of HIV-AIDS, penile cancer, cervical cancer or urinary tract infections. The foreskin protects the sensitive glans of the penis and, rather than causing sexual problems, it increases sexual sensation.

Dr Ian Arthur GP
Sawtell, NSW

I am 37, uncircumcised, and have not in my memory had a urinary tract infection or penis/sexual problem due to my well-designed crumpled end bit. We don't remove the appendix just because it may get infected. Why should circumcision be regarded any differently from the practice of female genital mutilation?

Gary Daly
Mosman

Notes

* A recent scientific study of the foreskin published in the British Journal of Urology found that sub-preputial moisture consisted of water, shed skin cells, secretions from the prostate, seminal vesicle and urethral glands, various sterols and fatty acids which protect skin surfaces in other contexts, and a variety of benign bacteria – i.e. bacteria which are either harmless or beneficial.

** Soap may not be such a good idea, especially in babies and boys, as it can easily irritate the glans and inner foreskin layer. It's often better just to use water. Further information.

*** Most cases of phimosis can now be treated without the need for surgery. Further information.

Man tells of forced childhood circumcision

A Syrian man now living in France has published a horrifying comic strip account of his circumcision when an 8-year old boy

Riad Sattouf: Comics serve as perfect medium
26-year-old writer to release autobiographical bombshell: MyCircumcision
By Olivia Snaije
The Daily Star (Lebanon)
16 April 2004

PARIS France is paradise to the comic book lover. Close to 1,500 new BD books (BD stands for bande dessinee, or comic strips) are produced each year to satisfy the incessant appetite of mainstream and alternative audiences. Each year, the International Bande Dessinee Festival in Angouleme hosts up to 400,000 fans.

Accordingly, if you write and illustrate BDs, France is the place to be. Comics are considered an art form, and cartoonists are worshipped. It's hard to know if Riad Sattouf would have written and illustrated comic books had he grown up somewhere else, but it's clear that this baby-faced 26 year-old has a lot to say, and comics are the perfect medium for him.

Sattouf burst into the world of BD's last year with the publication of the Manuel du Puceau (Handbook for a Virgin) for adolescents, and Les Jolis Pieds de Florence (Florence's Pretty Feet) which won the prestigious 2003 Rene Goscinny prize for best BD writer. His Manuel du Puceau, which does away with any notion of the politically correct, recounts the trials and tribulations of a pimply teenager with a raging libido. Les Jolis Pieds de Florence introduces the adult reader to Jeremie, a Franco-Libyan nerd who creates video games and is hopelessly in love with Florence, a co-worker in his office.

Nothing besides his name and a few vague allusions to the Arab world could prepare the reader for Sattouf's next book, which can be termed a tragi-comic autobiographical bombshell. Ma Circoncision (My Circumcision) came out this year in a collection for teenagers but could very well be for adults. Funny and terrible, it is the gruelling tale of an 8-year-old boy who lives in a Syrian village and is faced with his impending circumcision.

How much of Ma Circoncision is autobiographical? "One hundred percent," said Sattouf.

The son of a French mother and Syrian father, Sattouf was born in Paris but lived until age 11 (except for two years in Libya) in Ter Maaleh, a small village near Homs, in Syria. (Sattouf describes Homs as resembling the spaceport city of Mos Eisley, in Star Wars). In Ma Circoncision, Sattouf recounts how one day his cousins notice that he isn't circumcised. He is immediately accused of being an Israeli, the worst insult the children can think of. Sattouf, who was blond as a child, lies in bed wondering if he is adopted. "Perhaps I really was Israeli?"

"From the very first day my difference was apparent. I was the only foreigner in the village ... I went to the Muslim school and studied the Koran. We travelled to France sometimes so I knew there was another way of life. But the village was a place out of time, in a parallel dimension."

Sattouf, 8, lives in a fantasy world in which he and his cousins are Cimmerian warriors (they've seen a video of Arnold Schwarzenegger in Conan the Barbarian countless times). Corporal punishment at school is common and children are subjected to beatings on the soles of their feet. Their teacher, who looks like a "degenerate James Dean," rants to the children that "France and Europe are friends to the Israelis."

The classroom brutality and ignorance described by Sattouf is such, that the publisher's lawyer strongly recommended at the beginning of the book, a disclaimer which reads: "This book tells a true story, situated in a country in which the totalitarian regime formats children to a single mode of thought. It is against circumcision. It is not an incitement to racial hatred but bears witness to the way a society produces racial hatred."

Sattouf writes that his father decides his son should be circumcised. The next pages are a countdown until the unhappy event. The fateful day rolls around and the circumciser looks like Conan the Barbarian. "How many Syrians look like Arnold Schwarzenegger?" writes Sattouf. "Only one, no doubt, and he was in my living room!" After a long and painful recovery, Sattouf finds out from his father that Israelis are circumcised as well.

Sattouf, who has not seen his father in 14 years, portrays him in Ma Circoncision as a harsh, unfeeling man. " Of course my father was more human than in the book. His moods alternated but there was a certain inflexibility about him, he never doubted his behavior." His father was a university professor with two doctorates from the Sorbonne. He was "very open-minded and totally emancipated. He never prayed, ate pork, but then his past caught up with him." Sattouf's father became deeply religious after a stint of teaching in Saudi Arabia.

"I do have a kind of nostalgia for the village. There was little joy and people were very unhappy. They were conscious of living in misery. I can almost understand why at 50 my father went crazy. The weight of his family's history fell upon him and mowed him down." Sattouf's French mother "didn't speak Arabic and couldn't stand life in the village anymore. She separated from my father and moved back to France."

Sattouf was catapulted from his village in Syria to the city of Rennes, in Brittany. Again, he was considered different. "In secondary school kids called me a dirty Arab. But somehow it didn't affect me as much as when I was called an Israeli in Syria. The biggest difference for me was being in school with girls! Later when I was in art school one of my teachers didn't like Arabs and said that work that wasn't done properly was called Arab work," Sattouf recalled.

As a child Sattouf drew constantly, and avidly read the BDs that his French grandmother sent him to Syria. He says he always knew that he wanted to draw. After art school in Nantes Sattouf attended the Gobelins School for animation in Paris and hasn't left the drawing board since. He began to illustrate BDs while still a student until he broke out on his own and created his character Jeremie, who is in large part autobiographical as well although "all my characters are me, even the girls. It's pretty personal."

Joann Sfar, one of France's star cartoonists, who illustrates and writes mainstream and alternative BDs worked in the same atelier with Sattouf and encouraged him to write Ma Circoncision, among other books. "I'd tell him stuff about my childhood and he couldn't believe it. I realized most people hadn't lived what I had lived. I decided to rid myself of this stuff and make some money, too!"

Sattouf's particular brand of self-mockery in his libidinous anti-hero, Jeremie, (who one French critic termed as having "pathetic grandeur") but also in his childhood character in Ma Circoncision, has allowed him to evacuate many of his painful childhood experiences. In Jeremie the zany humor keeps the BD reading light. In Ma Circoncision, although the same humor is present, there is an undertone of real seriousness. It has also brought Sattouf full face with his feelings of identity. He says he no longer speaks Arabic but that he still reads and writes it.

"I'd like to take up Arabic again to be closer to my past and come to terms with it. People just can't believe that I'm from Syria. But I think I'm much more of an Arab than a kid who is originally from the Maghreb." On the path to stardom in the BD world, Sattouf is juggling several projects at once. He is working on a series of comics for children, more Jeremie adventures, and stories from his Syrian childhood, which he'll publish this time in books for adults. While he doesn't feel "particularly at home in France", it is without a doubt the place for Sattouf to be. No other country would have published a BD as brutally funny and scathingly critical as Ma Circoncision.

Source: The Daily Star (Lebanon)

"Goldorak" is a Superman-type hero popular throughout the French-speaking world, including those portions of the Arab world formerly under French control, such as North Africa, Lebanon, and Syria.

Further information

http://research.cirp.org/news1.html
http://brealbase.prosygma-serveur.com/Circoncision.htm

Circumcision questioned following baby's death

Opposition to circumcision in Canada is growing rapidly following the death of a baby in the province of British Columbia. The boy bled to death after being circumcised in August 2002.

The recently-released report of the BC coroner found 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. A similar case was reported by the Miami Herald in 1993, a case occurred in Ireland in 2003, and cases have also been recorded in Australia.

The Coroner further showed 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 Dr Greg 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.

Canadian news reports

CBC News British Columbia

Circumcision under attack
Feb 11 2004

PENTICTON, B.C. - The report on the death of an infant following a routine circumcision has triggered renewed calls to ban the procedure in B.C.

Ryleigh Roman McWillis was a month old when he bled to death following the operation in Penticton in August, 2002.

A coroner's report released this week makes no recommendations for change, which dismays his parents.

Brent McWillis had hoped the coroner's report into the death of his son Ryleigh would help prevent a similar tragedy in future.

"It was a very unfortunate and nightmarish thing that happened to us," he says. "The only thing I want to see is that it doesn't happen to anyone else's child."

Ryleigh's parents say they'd like all hospitals to adopt better standards to care for infants following a circumcision.

Meanwhile, other groups opposed to circumcision, are calling for an internal review by the B.C. College of Physicians and Surgeons.

"This surgery is not necessary, and if the surgery is not therapeutic, the risk cannot be undertaken," says John Geisheker, the lawyer for the group, Doctors Against Circumcision.

Dr. Eugene Outerbridge of the Canadian Pediatric Society says a study last year, showed male circumcision exposes children to risk, with no real medical benefit.

But Outerbridge says an outright ban would violate the rights of religious minorities.

Source: http://vancouver.cbc.ca/regional/servlet/View?filename=bc_baby20040211

Commentary

From Ottawa journalist Thom Barker, a clear and powerful statement calling for a ban on routine infant circumcision in Canada.

"Commentary" is heard on CBC radio across the country during the breakfast hour.

Introduction

A year and a half ago a baby in British Columbia bled to death after he was circumcised. Last week a coroner's report made no recommendation on the future of the practice. Thom Barker is a freelance writer in Ottawa. On Commentary he has a suggestion.

Thom Barker

Last week we were horrifically reminded that circumcising baby boys is not without the highest risk. It can and occasionally does lead to their deaths. But the articles I've seen on it recently didn't focus on how unnecessary it is; they discussed how circumcision should be done more safely. So with safety in mind here's my advice. Ban it! Stop mutilating infant boys for no good reason.

For nearly 30 years now the Canadian Paediatric Society has officially stated that circumcision is medically unnecessary. Long term statistical evidence has proven that the risks of doing it outweigh the risks of not doing it, and medical ethicists almost universally decry it.

So why do we continue to circumcise about one out of every five boys born in this country? Why do we continue to leave it up to the parents and doctors to decide?

The first reason is familiarity. Circumcision has been and remains such a common practice - to make baby look like daddy - that we're reluctant to recognize it for what it really is: genital mutilation. To do so would be to condemn our parents, our friends, our siblings and possibly ourselves as guilty of criminal assault.

More problematic is the religious justification. Childhood circumcision of boys is an integral aspect of the Jewish and Muslim traditions and cultures. But similar arguments based on tradition did not stop Canada in 1997 from banning female genital mutilation. It did not stop us because it was viewed as a human rights issue. In fact, as a society, we routinely override the rights of parents to protect children from perceived harm. So why doesn't this protection extend to infant boys?

Male circumcision is hardly universal even among practising Jews and Muslims. In fact, there are significant numbers of both, including religious leaders, who advocate discontinuing the practice because it's contrary to more fundamental principles of their faiths, most importantly respect for human life.

So even in the religious context it seems that parents have some freedom of choice.

I was born Catholic. At about the same time that I might have had my foreskin removed, I was baptized instead. When I later renounced my Catholicism I resented having been baptized against my will. But fortunately I didn't have an irreversible physical deformity to forever remind me of it.

Would it be so egregious to make parents wait until their sons can make the decision for themselves? There's no end to the legal protection adults have to damage themselves.

For Commentary, I'm Thom Barker in Ottawa.

Further information

Association for Genital Integrity

Circumcision Information Resource Centre

CIRP News

Foreskins are valuable

The following article by Dr Stan Wisniewski, a professor of urology at the University of Western Australia, was published in the Sydney Morning Herald on 6 November

Foreskins have their purpose - for health and better sex November 6, 2003

There is no scientific evidence in the case being put for circumcision, writes Stan Wisniewski.

A Fertility Society of Australia conference was told on Monday that recent studies showed circumcision protected men against HIV and lowered the risk of cervical cancer in their partners.

However, there is no scientific evidence that circumcision prevents the distribution of sexually transmitted diseases in modern Western societies.

To believe that undertaking circumcision will prevent HIV infection is irresponsible. Boys and their parents need to be taught appropriate hygiene methods of managing the foreskin in childhood and maintain appropriate hygiene measures throughout their lives.

It is alarming that statistics taken from regions where men practise unprotected sex, and may have dubious hygiene information, are being used to support the practice of neonatal circumcision.

The studies on papilloma virus in circumcised men have been conducted in communities where men are usually in monogamous relationships.

It is not circumcision but the number of partners and the practice of unprotected sex that leads to papilloma virus being established and passed on.

I wonder if proponents of circumcision would believe that circumcising the male population of Africa would prophylactically stop the spread of AIDS in that continent without there being a change to public and sexual health strategies?

The motives for circumcision in our culture are difficult to define, but include rites of passage, blood sacrifices and cultural markings. Foreskin, however, is a normal part of the external genitalia and has a special function in protection of the glans penis in childhood and enhancing sexual activity in adult life.

Studies have shown that the skin of the circumcised penis has a greater friction and abrasion within the vagina, and may lead to changes in sexual function and pleasure, in the male and his partner.

Studies have shown that women prefer vaginal intercourse with an anatomically complete penis.

Such studies show circumcision may diminish the female's sexual enjoyment and affect her relationship with the male partner.

In all discussions on circumcision in the newborn child one needs to understand that "informed consent" needs to be considered, and the impact of such consent may not only affect the male but his future sexual partner as well.

In modern Western societies the rate of elective circumcision in newborn males is dropping, and continues to do so.

The rate of circumcision in adult males continues to fall where appropriate hygiene measures are maintained.

There is no scientific evidence that the prophylactic removal of the foreskin sustains any benefit and there is no solid epidemiological evidence to support the theory that circumcision prevents STDs or justifies a policy of involuntary mass circumcision as a public health measure.

(Stan Wisniewski is chairman of the West Australian section of the Urological Society of Australia and a clinical associate professor at the University of WA.)

http://www.smh.com.au/articles/2003/11/05/1068013261631.html

Hunter Valley hospitals stop circumcision of newborn boys

Neonatal procedure suspended
Emma Swain
Maitland Mercury
Wednesday 2 April 2003

Hunter Health has ceased routine neonatal circumcision within its hospitals following a Royal Australasian College of Physicians recommendation.

In its position statement on circumcision, the college stated that it had revised its policy following 'critical literature analysis' by a working party of representatives from a number of professional organisations including paediatricians, paediatric surgeons, general surgeons and urologists from Australia and New Zealand.

The Royal Australasian College of Physicians' division of paediatrics and child health has concluded that where no medical indication for circumcision exists, the procedure is best performed under general anaesthetic after the age of six months to reduce the risks and the discomfort for the child.

Until recently, circumcision of newborn baby boys was available at Cessnock and Belmont hospitals. Hunter Health Area director of child health services professor Trish Davidson said about 250 babies were circumcised in the Hunter each year and the majority of these babies were aged under six months and were performed for social rather than medical reasons.

"Following the College of Physicians' declaration, we have acted quickly and prudently to stop newborn circumcisions in Hunter public hospitals," Professor Davidson said.

"There are some individuals and cultures who favour the circumcision of male babies and the procedure is still available for babies more than six months old. Parents need to ask their GP for a referral to an appropriate surgeon."

While some health benefits have been claimed for circumcision, this review of the literature shows no evidence of benefits outweighing harm for circumcision as a routine procedure. The complication rate of neonatal circumcision is reported to be about one per cent to five per cent and ranges from minor bleeding and infection to damage to the genitalia or, rarely, septicaemia or even death.

Story available on-line here

British Medical Association issues new guidelines on ethics of non-therapeutic circumcision

The British medical Association has released new guidelines on the ethics of non-therapeutic male circumcision - that is, circumcision requested by parents for non-medical reasons and in the absence of any medical need.

The new guidelines throw serious doubt on whether it is ethical to circumcision a boy without medical need and in the absence of his own informed consent. They state that doctors are under no obligation to perform the procedure merely because parents desire it, and stress that they should point out the risks and implications.

If circumcision is to be performed a number of conditions should be met, including:

(1) Consent of both parents

(2) Consent of the boy if he is old enough to express an opinion

(3) Consent is valid only if the persons giving consent have the authority to do so and are fully informed as to what the operation entails, including risks and long term implications. (Doctors thus have an obligation to establish that persons seeking to have a boy circumcised do in fact have the authority to give consent.)

(4) Where parents or guardians disagree, circumcision should not be performed.

Observance of these conditions would have prevented the tragic case in Bundaberg, Queensland, last year, when a Turkish Moslem father abducted his two boys from the care of his separated wife (who had legal custody) and had them circumcised against her wishes and against their own wishes at a local hospital. Further details here

The BMA notes that "Circumcision of male babies and children at the request of their parents is an increasingly controversial area" and that there is no medical benefit in the procedure. The BMA also points out that the prime responsibility of doctors is to the welfare of their child patients and that they must always act in the child's best interests.

The full guidelines are available here

Vaccine stops cervical cancer

Cervical cancer virus vaccine
By Helen Tobler
Australian 12 March 2003

A VACCINE that fights the virus that causes cervical cancer has proven to be successful in an Australian trial. A stage-one trial, involving 30 Brisbane women, found the vaccine either eliminated or significantly reduced levels of human papilloma virus (HPV).

Most cases of cervical cancer, which kills about 250,000 women a year around the world, including 200 in Australia, are caused by the sexually transmitted disease HPV. The women in the Queensland trial already carried HPV, and received either the vaccine or a placebo.

Centre for Immunology and Cancer Research Ian Frazer, from the University of Queensland, said yesterday that the vaccine had triggered an immune response in all 14 women who received it.

"At the end of the study, seven of them had no virus left and the other seven had a significant reduction in the virus," Professor Frazer said. He said once the vaccine was on the market, it would not eliminate the need for Pap smears for several years.

However, if after further trials "the vaccine turns out to be effective, it will put a great deal of pressure on the system to have Pap smears until you're 30, then you won't need Pap smears at all".

The vaccine was shown to be safe and there were no serious adverse side-effects. While a prophylactic vaccine prevents infection, a therapeutic vaccine fights the disease in people who are already infected. A vaccine would be of greatest benefit in the developing world, where most cervical cancer deaths occur, as women do not have access to screening programs.

"This vaccine could be given with the prophylactic vaccine in the parts of the world where nobody screens for the virus," Professor Frazer said. "Ideally you would give the two vaccines together and that would be great."

While it was not clear at this stage how long the vaccine would offer protection, Professor Frazer said the research had suggested it could be effective for 10 years. Professor Frazer, who has presented the findings to a conference in Barcelonam said his results would be published in a scientific journal later this year.

He has developed a vaccine that prevents HPV infection, and in a US trial last year the vaccine was found to be almost 100 per cent successful.

Australia: Too many circumcisions performed, phimosis wrongly diagnosed

Three important articles in Medical Journal of Australia (17 February 2003) argue that too many circumcisions are performed in Australia and that there is inadequate awareness of the value of the foreskin as a normal part of the male genitals.

Dr Katrina Spilsbury and colleagues in Perth show that too many boys under six years old are being circumcised after a diagnosis of phimosis, but that most of these diagnoses must be mistaken or spurious because genuine (pathological) phimosis is very rare at that age. They suggest that parents and doctors need education on the normal development of the foreskin.

This argument is confirmed by an editorial by Dr Paddy Dewan, a leading paediatric surgeon in Melbourne.

In a historical article, "Medical history and medical practice", Dr Robert Darby dispels two persistent myths about the foreskin. He shows that circumcision as practised by tribal peoples did not arise as a health measure; and that it has been recognised since Greek antiquity that the foreskin plays an important role in the body's economy and makes a significant contribution to sexual function.

The three articles are available from the Medical Journal of Australia on-line

Concern at unnecessary circumcision

The Age (Melbourne), Sunday 16 February 2003

Young boys may be undergoing unnecessary circumcisions for a condition that can be effectively treated with creams, according to a study.

The percentage of Australian boys being circumcised has fallen from 95 per cent in the 1930s to only 6.5 per cent 20 years ago.

However, a West Australian report, published in the Medical Journal of Australia on Monday, reveals a high rate of circumcision for phimosis, a condition where the foreskin cannot be retracted, in boys under five. This is despite the condition - which can easily be confused with normal development of the penis - being rare among this age group.

Dr Katrina Spilsbury, of the University of Western Australia's School of Population Health, reviewed the circumcision of boys in the state's hospitals between 1981-1999.

Boys aged five and under had the highest rate of surgery for phimosis, representing about 300 circumcisions each year. More older boys were also being circumcised for phimosis, with a 70 per cent increase in the procedure among boys aged 10-14 during the period studied.

"The past 19 years have seen a steady rise in the rate of medically indicated circumcision," Dr Spilsbury reports. "Most of the increase is the result of an increase in the rates of phimosis." Dr Spilsbury said if the current rate continued, about four per cent of boys would be circumcised for phimosis by the age of 15. This rate was seven times higher than the estimated occurrence of the condition, she said.

"These findings imply a high rate of unnecessary surgery," writes Dr Paddy Dewan of the Royal Children's Hospital in Melbourne in an accompanying editorial. Dr Dewan suggests the high rates might be the result of "manipulation", either by parents who want to circumcise their child for cosmetic reasons or GPs who expect resistance from surgeons unless they give a medical reason for circumcision.

Dr Spilsbury said phimosis could cause pain and urinary tract infections and was associated with sexual dysfunction and cancer in later life. However, there was evidence the use of steroid creams could reverse the situation in around four to six weeks, she said.

"No medical reason for circumcision": Canadian doctors

College of Physicians and Surgeons of British Columbia
College Quarterly
Issue 38, Fall 2002

Infant Male Circumcision

The matter of routine infant male circumcision was a subject of discussion at a recent meeting of the College Council. The College has received repeated requests from special interest groups and individuals to "ban" this procedure. Their objections to routine infant male circumcision are based on a variety of factors including the lack of medical indications, the right of the newborn to make its own long term decisions, immediate risks, long term effects, ethical issues, and so on.

The College's position on routine infant male circumcision is that it is a matter of patients' (or parental) choice, which may be based on traditional, religious, cultural or personal preference. The issue of perceived medical necessity is, in the opinion of most experts, no longer pertinent. Though some studies suggest slightly lower frequencies of urinary tract infection and decreases in HIV transmission in circumcised males, most physicians agree that the procedure should be regarded as a "cosmetic" procedure and in North America should be approached as such. Younger physicians (coming out of training programs) often do not have skill or experience in performing circumcisions and also may have little interest in acquiring such skills or being involved in the procedure.

College Council did not identify any necessity to place restrictions on the availability of routine infant male circumcision, except to remind physicians that when performed routinely, this is a cosmetic surgical procedure which should only be considered after detailed discussion with the parents. This allows parental request and consent to be based on accurate and comprehensive information. Such discussions should include the fact that infant circumcision is not a medical necessity, that many experts including national pediatric associations do not recommend it, that there are risks such as bleeding and infection which can be significant in rare instances, and that currently the majority of male infants are not circumcised. Also, physicians should be aware that they are not required to accept the parents' request for routine circumcision if they are personally unable or unwilling to perform the procedure. Such requests should be referred to others in those situations.

It is Council's opinion that the requests for this procedure will decrease through the natural evolution of public and medical opinion. As a uniquely North American cultural trend in the absence of medical indications, (except for requests based upon religious beliefs) routine infant circumcision will likely become an uncommon procedure.

Further information

Circumcision: "Unnecessary, damaging and performed without consent"

The unkindest of cuts
By Simon Crompton

Times on Line (London), 13 January 2003

THERE IS ONE OPERATION being carried out on thousands of British children by NHS doctors without any clinical need — and without the patient's consent. This procedure has an irreversible physical effect, yet there has been minimal public debate about the extent to which it is being performed.

The procedure is non-religious circumcision, carried out on "therapeutic" grounds on 4 to 6 per cent of boys under 15. Increasingly, the expert consensus is that most non-religious circumcisions are carried out for reasons of family history, medical myth and professional laziness. Some campaigners claim that as many as five in six of these circumcisions are unnecessary and potentially traumatising.

Circumcision has become the subject of bitter debate in the US, where 80 per cent of men are circumcised. Doctors Opposing Circumcision is one of a range of groups challenging the medical orthodoxy of circumcision at birth; their campaign has been buoyed by a statement from the American Medical Association that there is insufficient evidence of benefit to recommend routine neonatal circumcision.

Here, the British Medical Association is reviewing its guidelines and is due to announce its findings in March; current guidance makes it clear that it is unethical to circumcise for therapeutic reasons where research shows that less invasive techniques are available.

Norm-UK, an organisation which campaigns against circumcision, estimates that fewer than 1 per cent of boys require the operation, and that most of those performed on the NHS are unnecessary. Dr John Warren, a consultant physician and founder of Norm-UK, says that the main problem is that GPs and general surgeons are unaware of research indicating when circumcision is medically required. Specialist paediatric urological surgeons are better informed, but not all children are seen by these experts.

Most non-religious circumcisions are performed on children whose parents are concerned about a tight foreskin that will not retract, a condition known as phimosis. "They think there is something wrong, even if it's causing the child no problems," says Warren, who works at the Princess Alexandra Hospital in Harlow, Essex. Yet research published as long ago as 1968 showed that 90 per cent of tight foreskins had resolved themselves by the age of four, and 99 per cent had developed normally by 17. "The message never filtered through, and a lot of people didn't accept it," says Warren.

Family tradition also plays a part. Fathers and grandfathers who were circumcised may want their boys circumcised too (often on the basis that it is "cleaner"), and use the possibility of phimosis to get doctors to perform the procedure. Duncan Wilcox, consultant paediatric urologist at Great Ormond Street Hospital and Guy's Hospital in London, believes that this is the main reason why so many circumcisions are carried out unnecessarily.

"As many as half of the parents who come to see me want their child to have a circumcision," he says. "But when I tell them that there is a risk, as with all operations, the majority are happy to wait and see if the foreskin retracts normally. Doctors are certainly pressurised, and there is always the occasional parent who will get through with pure persistence, or by saying that their child keeps getting infections." The issue would be less important if foreskin removal did not have physical and social implications which carry on into adulthood.

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."

The foreskin contains a rich variety and concentration of specialised nerve receptors. In May 2002, a study in the British Journal of Urology reported that circumcision appears to result in decreased erectile function and penile sensitivity: 38 per cent of men circumcised as adults reported harm to sexual function.

The practice of medical (as distinct from religious) circumcision began in Victorian times as a deterrent to masturbation, then thought to be the cause of insanity, epilepsy, hysteria, tuberculosis, short-sightedness and death. The practice became popular in the 1920s for reasons of hygiene and peaked in the 1940s. In 1949, researchers began to question whether a non-retracting foreskin was abnormal, and numbers have declined.

Norm-UK has received hundreds of calls from men who feel ashamed or mutilated by the procedure. For young boys, the potential embarrassment of having a penis that looks different from those of their friends is obvious. Yet the psychological issues are complex: in a largely Jewish or Islamic community, this argument works as much in favour of circumcision as against it. Dr Lotte Newman, a former president of the Royal College of General Practitioners who chairs the circumcision working party of the Board of Deputies of British Jews, is troubled by developments in Sweden which may lead to a ban on child circumcision there. "The trend against circumcision affects those religions which practise it traditionally," she says.

Such sensitivities may account for the neutral stance of mainstream medical organisations such as the General Medical Council, which states only that its soundings "demonstrated widely conflicting views in society, which neither doctors nor the GMC can resolve".

But perhaps the issue ultimately comes down to one of consent. Adults need to know about the alternatives to have an accurate basis for decision-making. But Norm-UK's concern is that no one should consent to a circumcision on someone else's behalf, even if it is their own child. That means doing everything possible to treat conditions non-invasively until the patient can make an informed choice.

"When I was a kid I had a circumcision and my brother didn't," says Warren. "It made me conscious of the issue as a medical student. Then I had to conduct the operation myself, and was horrified at what I was doing. I thought, one day I will stop this ridiculous practice."

www.timesonline.co.uk/article/0,,589-540977,00.html