A recent study (yet another one) in Kenya has found no association between being uncircumcised and being at greater risk of infection with HIV. To put it another way, the study found that circumcision had no protective effect against HIV-AIDS. The study, by Matthew Westercamp et al and published by PlosOne, examined “the behaviors, beliefs, and HIV/HSV-2 serostatus of men and women in the traditionally non-circumcising community of Kisumu, Kenya prior to establishment of voluntary medical male circumcision services. A total of 749 men and 906 women participated. Circumcision status was not associated with HIV/HSV-2 infection nor increased high risk sexual behaviors. In males, preference for being or becoming circumcised was associated with inconsistent condom use and increased lifetime number of sexual partners. Preference for circumcision was increased with understanding that circumcised men are less likely to become infected with HIV.”
Several recent articles by prominent scholars have added to the growing chorus of doubt as to the effectiveness, cost, ethics and general propriety of male circumcision as a solution to Africa’s AIDS problem.
Writing in the American Journal of Preventive Medicine, Dr Laurence Greene and colleagues argue that the three clinical trials that provide on which the circumcision programs are based do not provide sufficient evidence for the effectiveness of circumcision as an HIV preventive. Even more seriously, there is no evidence that a protective effect observed in the artificial or “laboratory” conditions of supervised trial will be replicated in the real world – neither in Africa and certainly not in the developed world.
In the Journal of Medical Ethics, Marie Fox and Michael Thomson argue that on the evidence so far it is premature to promote circumcision as a reliable strategy for combating HIV. They point out that both the sponsors and the media, both popular and scientific, have exaggerated the protective effect of circumcision suggested by the clinical trials, and that questions of medical ethics, human rights and personal choice have been swept aside in the rush to roll out circumcision programs.
Meanwhile, several new papers by British and American researchers have confirmed the conclusions of many other studies that circumcision would have little or no protective effect on sexual transmission of HIV among men who have sex with men. It has further been well established that male circumcision does not protect women against HIV transmission.
For many years the struggle against HIV-AIDS, particularly in poor countries, has been weakened by the stance of the Catholic Church against the use of condoms. The basis for the ban is that they are a form of birth control, prohibited since the 13th Century on the word of the theologian Thomas Aquinas. Since condoms are about 95 per cent effective as a preventive of HIV and many other sexually transmitted infections, the prohibition has had much the same effect as would a ban on, say, smallpox vaccination or the use of penicillin as an antibiotic. The obstinacy with which the Vatican maintained this dogma has dismayed many compassionate people, including Catholics, who have reasonably pointed out that even if using a condom was a sin, it could not be a worse sin than infecting another person with a fatal and incurable disease.
It now appears that the current Pope, Benedict XVI, has at last seen the cogency of this argument, and agreed that Catholics are entitled to use condoms if their purpose is not to prevent conception, but to prevent the spread of HIV.
There is further evidence from Africa that the circumcision programs intended to reduce the risk of HIV infection are leading to reduced condom use. This is exactly what the critics of circumcision as an AIDS prevention strategy warned would be likely to happen, and events are proving the sceptics correct.
In Zambia, a school headmistress complains that media campaigns are driving teenage boys into agreeing to circumcision without any explanation of the risks or likely effects, and that the boys believe being circumcised means that it is now safe for them to indulge in unprotected sex.
In Swaziland, there are increasing fears that the aggressive circumcision programs there are discouraging men from using condoms, leading to an epidemic of unsafe sex. Men have realised that while the presence of the foreskin makes forms of safe sex such as masturbation highly enjoyable and satisfying, circumcision takes away most of the pleasure. Once circumcised, they find the only way to get satisfaction is by engaging in “bareback” sex with a partner.
Melbourne, 12 November 2010: A Melbourne doctor has been suspended for inflicting severe injuries on a 2-year old boy during a “routine” circumcision operation. The boy was circumcised by Dr Mohammed Mateen Ui Jabbar, using the plastibell device on 29 January 2008, as a result of which he suffered gross swelling and severe scarring of his penis. The boy was unable to urinate after the operation and was taken to the Royal Children’s Hospital, where he required surgery to remove the plastibell device and six further operations on his penis, including plastic surgery.
According to the Melbourne Herald-Sun, the hearing at the Victorian Civil and Administrative Tribunal was held on 11-12 October 2010, and the decision handed down on 5 November. The full details of the determination can be found at the Australasian Legal Information Institute (Austlii).
This was the fourth time that Dr Jabbar had been reprimanded by the Victorian Medical Board, despite which he has been permitted to continue practising until his 3-month suspension takes effect on 22 November 2010. On previous occasions the doctor had been reprimanded for improperly touching a woman’s breasts and for prescribing testosterone for a male client without medical need.
In an article published in the scholarly journal Ethnicities, Matthew Johnson criticises the double standard commonly applied to male and female genital cutting and argues that if male circumcision were examined objectively and with the same criteria that are applied to female genital mutilation it would be seen as another “traditional practice prejudicial to the health of children” and thus a violation of human rights.
Parents can safely stop agonising over whether their baby boys need to be circumcised, thanks to a new medical policy statement.
According to Australian and New Zealand child protection advocates, the revised policy on circumcision recently released by the Royal Australasian College of Physicians means that parents can simply forget about the idea of circumcising. “The circumcision decision is actually a fake dilemma”, said Sydney paediatrician and child heath specialist Dr George Williams. “No normal baby needs to be circumcised. Thanks to the new policy, parents can stop worrying about surgery and focus instead on the important things that a new baby needs – love, warm clothes and breast milk.”
After a lengthy review of the medical evidence, the RACP concludes that routine infant circumcision is not warranted in Australia and New Zealand. This is because the diseases from which circumcision may give some protection are too rare or not a threat to children; because it does not protect enough; and because the resulting harm is too great and the complication rates are too high.
“The authors of the policy have gone into great detail about those diseases and the levels of protection they may offer, but that’s the bottom line,” said Dr Williams “Circumcision is not medically necessary or even desirable, and is not recommended as a health precaution.”
“They’ve gone into less detail about the harm, complications and risks of circumcision, but these go all the way up to death – for example, from unnoticed bleeding, or infection with diseases such as meningitis. That’s an unacceptable risk for a surgical operation that the RACP says is unnecessary.”
Tasmania’s Children’s Commissioner, Paul Mason, praised the RACP for recognising the importance of ethical and human rights issues in the circumcision decision; for recognising that the foreskin has significant sexual functions and is actually the most sensitive part of the penis; and for pointing out that the operation is non-therapeutic (i.e. does not fix anything) and that the infant is unable to give consent. For these reasons it acknowledges that circumcision of minors has been under heavy fire from bioethics and human rights advocates for many years.
“This is an untested area, but we believe it cannot be ethical for parents to decide to remove a healthy, functional body part from a baby, or for a doctor to perform a medically unnecessary surgery on a patient who has not given his consent. We doubt the law will continue to hold a parent’s consent to be valid”, Mr Mason said.
The RACP also deserved praise for recognising that many men bitterly resent having being circumcised. “Thousands of men in previously circumcising countries (Australia, USA, Canada, UK) are using DIY methods to restore a semblance of their foreskins. Although some men might wish they had been circumcised as a baby, they are far fewer and have an easy remedy – to get circumcised now. It is not so simple for a man whose foreskin was surgically removed when he was too young to protest.”
With fewer than one baby in five circumcised anywhere in Australia these days, and fewer than one in 20 in several states, and virtually no Pakeha or Maori babies circumcised in New Zealand, circumcising for conformity’s sake is a dead issue. “Indeed”, said Ken McGrath, Senior Lecturer in Pathology at Auckland University of Technology, “if parents are worried about peer acceptance, their best plan is to leave the boy’s penis alone.”
Mr McGrath commended the RACP for rejecting the aggressive lobbying of a small pro-circumcision faction, who have been pushing hard for the introduction of near universal circumcision in Australia, supposedly as a public health measure. “Some of the reasons they give for circumcising – such as to prevent splashes on the toilet seat or to avoid zipper injuries – are simply absurd.
“The fact is that the medical arguments for routine (medically unnecessary) circumcision are dead as a doornail.”
Commissioner for Children
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Policies of other medical authorities
Australian and New Zealand doctors have decisively rejected a proposal that near-universal circumcision of baby boys be introduced as a strategy against heterosexually transmitted HIV infection. The call, published in the Medical Journal of Australia, came from a small group of well-known circumcision enthusiasts who based their suggestion on evidence from three clinical trials in Africa that circumcision of adult men can reduce the risk of a male’s acquiring HIV during unprotected sexual intercourse with an infected female partner.
But this suggestion has been firmly knocked back by the Royal Australasian College of Physicians, which points out that Australia is not Africa, that infants and children are not at risk of sexually transmitted diseases, and that more circumcision would do nothing to reduce or contain the risk of HIV infection in the Australian and New Zealand context. They also point out that the recommendation by the World Health Organisation, that circumcision be offered as an option for AIDS control in areas of high HIV prevalence, applied to sexually active adult men, not to infants or children, and was not intended to apply to the developed world.
Dr Gervase Chaney, President of the Paediatric and Child Health Division of the RACP, said that he and his colleagues did not agree with the new proposal. Speaking on the ABC’s “World Today” program on 20 September, Dr Chaney said: “We believe that the evidence currently would not support that in Australia. It might be supported in other countries, particularly in Africa where there are much higher rates of HIV transmitted heterosexually. But at this stage that is not something that we would support; we disagree with that group.”
Also commenting was the President of the Australian Medical Association, Dr Andrew Pesce, who said that he found it “difficult to believe that a foreskin, evolved over billions of years of human evolution, needed to be chopped off as soon as the baby was born.”
“What we are talking about”, Dr Pesce continued, “is that otherwise healthy boys have an operation because of a feeling that it’s good for them in the future, even though there is nothing wrong now. That requires a lot of rigorous data collection, a really good understanding of what the potential benefits over the lifetime of the operation are, and balancing them up against the immediate surgical risks of a procedure which can have a low but a measurable complication rate of bleeding, infection, scarring things like that.”
The RACP’s new policy on routine circumcision of male infants and boys, released a fortnight later, states firmly that it does not recommend circumcision as a “routine” or medically unnecessary procedure: “After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.”
The policy also points out that routine circumcision is under strong attack from bioethics and human rights advocates, “because it is recognised that the foreskin has a functional role, the operation is non-therapeutic and the infant is unable to consent.”
Summing up the pros and cons, the statement continues: “The decision to circumcise or not to circumcise involves weighing up potential harms and potential benefits. The potential benefits include connectedness for particular socio-cultural groups and decreased risk of some diseases. The potential harms include contravention of individual rights, loss of choice, loss of function, procedural and psychological complications.”
That being the case, it would appear that the potential harms outweigh the potential benefits, meaning that the circumcision decision is one that can properly be made only by the person who must bear the consequences. The new statement leaves this issue open, but does point out that leaving the circumcision decision to be made by the boy when he is old enough to understand the issues and make an informed choice has the merit of respecting individual autonomy and preserving all the options:
“The option of leaving circumcision until later, when the boy is old enough to make a decision for himself does need to be raised with parents and considered. This option has recently been recommended by the Royal Dutch Medical Association. The ethical merit of this option is that it seeks to respect the child’s physical integrity, and capacity for autonomy by leaving the options open for him to make his own autonomous choice in the future.”
That would surely also be the attitude of all parents who genuinely respected the body and mind of their children.
The policy concludes by noting that its recommendation not to cut is consistent with policies on circumcision released by the British Medical Association, the Canada Pediatric Society, the American Academy of Pediatrics, the Royal College of Surgeons of England and the Royal Dutch Medical Association.
The RACP's full policy statement is available at their website.
Despite the hype about circumcision as the magic bullet against HIV infection, new figures from Africa show that AIDS is more common among circumcised men.
Australian circumcision promoters are hitting the headlines with demands for mass circumcision of baby boys in Australia as a precaution against HIV acquired from unprotected heterosexual intercourse. In support of this proposal they refer to old evidence from Africa as to the protective effect of circumcision against heterosexually acquired HIV infection, as shown in three clinical trials. While the World Health Organisation rolled out circumcision programs with funds provided by Bill Gates and President Bush, sceptics warned that the trials were riddled with scientific flaws and that it was far too early to tell whether circumcision would have a significant protective effect in the real world - quite part from the vast cost and serious ethnical doubts. Recent news from Africa is proving the sceptics correct, as the incidence of AIDS in many Africa countries continues to rise among circumcised populations.
In Swaziland, a small nation in south central Africa, where the government is planning particularly ambitious programs, it was recently revealed that the incidence of HIV infection was significantly higher among circumcised men. According to government figures, the incidence of HIV among circumcised men is currently at 22 per cent, but among uncircumcised men at only 20 percent. These are both astronomical figures (nothing like the situation in Australia), but they do not show any evidence of circumcision having a protective effect against HIV; on the contrary, looking at these figures, you would have to conclude that circumcision increased the risk of infection with AIDS.
What is even more scandalous is that the Swaziland government was perfectly aware of these figures when it decided to roll out the circumcision programs. Makes you wonder how some of the Gates/Bush billions have been spent.
The Ethics Committee of the Norwegian Medical Association has called for legal restrictions and possibly an outright ban on the circumcision of male minors. Although circumcision is almost unheard of among the native population, it is common among the Jewish and Muslim minorities, and often performed without anaesthetic. The leader of the Ethics Committee, Trond Markested, says that circumcision exposes baby boys to unnecessary pain and risk of complications, both during the surgery itself and in the post-operative period. “Haemorrhages and infections are common. Speaking of my own experience, I have seen serious cases where too much skin was removed. Such cases result in a tilted penis. Lasting scars may cause additional problems,” he says.
Violation of principles of medical ethics
Boys are frequently circumcised without anaesthetics, but even when anaesthetics are used, circumcising healthy children is simply wrong. “There are no medical reasons for it, and it violates central principles of medical ethics,” says Markested. Meanwhile in Sweden, a spokesman for the Society of Paediatric Surgery, chief surgeon Gunnar Göthberg, recommends an outright ban on circumcision of minors, which he characterizes as genital mutilation of boys. “In my work as a paediatrician and a paediatric surgeon, I always look to the UN Convention on the Rights of the Child. There are no medical arguments for circumcising boys,” he says. “Strictly speaking, the removal of a small part of the body amounts to an amputation, for which reason circumcision is wrong.” Jan Helge Solbakk, professor of medical ethics at the universities of Oslo and Bergen, is also in favour of a ban. “This is a matter of abuse. Circumcising boys is abusive, as is circumcising girls. In both cases, a ban is necessary,” says Solbakk.
These criticisms are rejected by Rolf Kirschner, chief physician at the gynaecological department of the National Hospital and formerly leader of the Jewish synagogue of Oslo. “Firstly, I want to be clear that I am talking about male, not female, circumcision,” he says. “Secondly, I find it hard to understand why this particular issue is brought up over and over again, considering the fact that the rights of children are brutally violated in many other circumstances. Finally, I claim that many of my fellow physicians are criticizing something they are not capable of fully understanding.” He thinks that ancient traditions that have been around for thousands of years should be respected.
Trond Markestad is well informed on the circumcision of boys, however, as he has worked as a paediatrician in the United States, where neonatal circumcision is very common. “Indeed, I have performed several circumcisions myself, and have observed serious complications following the surgery”, he says. “In the U.S.A. the practice was to circumcise without an anaesthetic, but to give the babies a mixture of sugar and cognac. The pain they suffered was obvious, and so was the pain following the surgery. I would never do this again.” says Markestad.
Circumcising Little Boys is Abusive and Should be Banned
by Tonje Grimstad
A study of American men presented at the AIDS conference in Vienna (July 2010)has concluded that circumcision would have little or no impact in reducing the impact of AIDS in the United States. This is partly because most sexually active men in America are already circumcised, and partly because those who are not circumcised would not be willing to get circumcised.
The study was based on surveys of 521 gay and bisexual men in San Francisco. Findings indicated that 115 men (21 percent) were HIV-positive and 327 (63 percent) had been circumcised. Of the remaining 69 men (13 percent), only three (0.5 percent) said they would be willing to participate in a clinical trial of circumcision and HIV prevention, and only four (0.7 percent) were willing to get circumcised if it was proven safe and effective in preventing HIV.
The results of this study are likely to be relevant to other developed countries, where AIDS is not a heterosexual epidemic, as in some African countries, but a relatively uncommon disease confined to specific sub-cultures - homosexual men and intravenous drug users. The most striking finding of the study was that, even if it were proved that circumcision significantly reduced their risk of contracting AIDS through unsafe sex, only 0.7 per cent of adult men would be willing to get circumcised. If virtually no adult male is willing get himself circumcised as a “health precaution”, it would be grossly unethical, wasteful and inappropriate to force circumcision on sexually inactive (and thus not at risk) minors.
In May 2010 the American Academy of Pediatrics astonished the world by announcing a policy on female circumcision that accepted the right of parents to impose mild forms of genital cutting on girls, such as a “ritual nick” to the clitoris. The suggestion was dropped after massive protests, but the first groups to raise objections were the American and British anti-circumcision organisations (Nocirc, Attorneys’ for the Rights of the Child, Intact America, Norm-UK, etc). These bodies are critical of any genital mutilation of children, both male and female, but are generally regarded as being more concerned with male circumcision. It was only after they had taken the lead that the mainstream organisations concerned specifically with female genital mutilation (FGM) and the obstetrical colleges spoke up, as a result of which outcry the policy change was soon reversed.
Another positive effect of the affair has been to provoke a variety of new voices to speak up for gender equity and to argue that boys should also be given protection against genital mutilation. In recent weeks British midwives, Australian Greens, a British columnist and an American mother have all argued that boys are entitled to protection from circumcision, just as much as girls from FGM.
In a hard-hitting statement issued on 27 May 2010, the Royal Dutch Medical Association (KNMG) has condemned non-therapeutic circumcision of male minors and urged its members to discourage the practice. The statement points out that prophylactic or preventive circumcision of normal male infants and boys confers no health benefit; carries many risks of harm and damage; has an adverse effect on sexual function and bodily appearance; and is a violation of the child’s right to physical integrity. They also argue that it is inconsistent and discriminatory to prohibit any form of genital cutting of girls while refusing to offer boys any protection at all.
The KNMG urges doctors to inform parents considering the procedure as to the absence of medical benefits and the danger of complications. “The rule is: do not operate on healthy children”, says Arie Nieuwenhuijzen Kruseman, chairman of the KNMG. “It is an unfortunate fact that any surgical procedure can cause complications. Doctors accept this to a certain extent because there are medical reasons for the procedure. However, no complications can be justified that occur as the result of an operation that is medically unnecessary.”
The statement is notable for acknowledging that it is impossible to draw a sharp distinction between male circumcision and female genital mutilation and includes an incisive discussion of the many similarities between the two sets of procedures, both as to physical effects, cultural justifications and ethical status. The statement argues that it is impossible to mount a credible campaign against female genital mutilation unless it is part of a wider campaign against all forms of genital mutilation of children, both male and female.
Their position contrasts with that of many United States commentators, who regard even the slightest interference with the genitals of girls as violation of their human rights, while ignoring or even advocating far more violent and intrusive surgery on the genitals of boys.
Each year in the United States more than 100 newborn baby boys die as a result of circumcision and circumcision complications. This is the alarming conclusion of a study, published in the journal Thymos, which examined hospital discharge and mortality statistics in order to answer two questions: (1) How many baby boys dies as a result of circumcision in the neonatal period (within 28 days of birth)? (2) Why are so few of these deaths officially recorded as due to circumcision?
The study, by researcher Dan Bollinger, concluded that approximately 117 neonatal deaths due directly or indirectly to circumcision occur annually in the United States, or one out of every 77 male neonatal deaths. This compares with 44 neonatal deaths from suffocation, 8 in automobile accidents and 115 from Sudden Infant Death Syndrome, all of which losses have aroused deep concern among child health authorities and stimulated special programs to reduce mortality. Why, the study asks, has the even greater number of deaths from circumcision not aroused the same response?
With the proclamation of the South African Children’s Act in April 2010, South African boys now have a significant level of legal protection against unwanted circumcision. The act gives children the right not to be subjected to social, cultural and religious practices detrimental to their well-being, and prohibits circumcision of male children under the age of sixteen except in cases where there is a valid religious reason, or if the operation is medically necessary for therapeutic purposes. Although these are significant loopholes, the act still gives South African boys considerably greater legal protection than is enjoyed by boys in Australia or in most other countries.
A study of almost 4300 men carried out by researchers from La Trobe University, Victoria, and the University of NSW has found that circumcision does not reduce the risk of contracting most sexually transmitted infections (STI), but significantly increases the risk of non-specific urethritis (the clap) and slightly reduces the risk of penile candidiasis (an easily cured fungal infection). The observed incidences of HIV and syphilis were so low that it was not possible to conclude that circumcision had any protective against these STIs.
The authors of the study, published in the Australian and New Zealand Journal of Public Health, comment that findings from an earlier Australian survey showing slightly higher rates of sexual performance difficulties among older uncircumcised men had been used to support the procedure. It had previously been thought that uncircumcised men found greater difficulty maintaining an erection and were more likely to experience pain during intercourse. The new study found that on these measures there was no difference between circumcised and uncircumcised men in the over-50s age group.
The conclusion of the study is that that “circumcision appears to have minimal protective effects on sexual health in the Australian context.” It is thus no longer possible to argue for circumcision in Australia on the basis that it will reduce a man’s later risk of getting infected with venereal disease.
Reports from the United States and several African countries show that, despite the WHO push for circumcision as the key strategy against AIDS, HIV infection rates are increasing rapidly among circumcised populations. In America the New England Journal of Medicine reveals an HIV epidemic in pockets of the (largely circumcised) USA that rivals the problem in (largely circumcised) regions of Africa.
In Britain we find that 6 out of 10 new HIV cases in British Africans are among Muslims (almost all circumcised), and that in Uganda “confused” young Muslim men are having to be reminded that circumcision is not an adequate protection against sexual diseases. In Kenya, where mass circumcision of young men has been funded by the WHO and touted as the solution to the AIDS problem, it has been revealed that in two areas of almost universal male circumcision, HIV infections are rising rapidly. On top of that, women are complaining that circumcision is giving promiscuous men a false sense of security, and discouraging condom use.
Most recently, a study of 4,889 men published in the journal AIDS has shown that circumcised gay men are not less likely to become infected with HIV. Headlined in the press as “Circumcision may not cut HIV spread among gay men”, the study in fact showed that HIV infection was higher among circumcised men than among the uncut. After controlling for sexual behaviours and demographic factors the report concluded there was no difference between the two groups.
And in Malawi local authorities are sceptical of claims by UNAIDS and the World Health Organisation that circumcision is the magic bullet against AIDS, point out that in their country the incidence of HIV is higher among circumcised men, and are refusing to carry out the WHO’s recommendations.
In Fresno, California, a father is facing the serious charge of mayhem for imposing a small tattoo on his 7-year-old son. Mayhem is an old offence, referring to any sort of serious maiming or mutilation of the body, and usually attracts a stiff sentence - as much as life imprisonment in California. But if a small mark on the skin, without cutting or loss of tissue, is mutilation, how would you describe the removal of the foreskin from the penis, and what sort of penalty should that attract when performed without need or consent on a minor?
A judge in Fresno, California (United States) recently raised the stakes in a case that has drawn widespread attention -- reinstating aggravated mayhem charges against two Bulldog gang members accused of inking a gang tattoo on a 7-year-old boy. Judge Gary Orozco's ruling means that the two men -- the boy's father and his friend -- could face life in prison rather than a maximum term of 16 years. The case also opens the door to a broader definition for child-abuse cases, according to the defense attorneys. Even Orozco acknowledged that the case raises the question of whether a parent ever has a right to subject children to potentially painful procedures such as getting pierced ears or being circumcised.
The Australian Broadcasting Corporation reported on 6 February 2010 that health authorities are concerned that there is a growing incidence of female genital mutilation (FGM) in Australia. Although any form medically unnecessary genital surgery on women has been criminalised in most states, Dr Ted Weaver, from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists states that "there is some evidence to suggest that it does happen in certain parts of Australia."
Various forms of male and female genital cutting are practised by a number of African, Middle Eastern and Muslim communities, who naturally wish to retain their traditional rites and customs when they immmigrate to Australia. This creates a ticklish problem in which the ideology of multiculturalism, the desires of parents, the principles of universal human rights, medical ethics and the rights of the child come into collision.
A recent study by medical researchers in Adelaide has concluded that the health benefit from routine (preventive) circumcision is close to zero. The following summary was published in the Toronto newspaper, Globe and Mail.
Little evidence that world's most common surgical procedure can prevent sexually transmitted infections, urinary tract infections and penile cancer
by André Picard, Public Health Reporter
Globe and Mail, Tuesday, Jan. 12, 2010
While it is the most common surgical procedure in the world, there is virtually no demonstrable health benefit derived from circumcision of either newborns or adults, a new study concludes. The sole exception seems to be using circumcision to reduce the risk of transmission of HIV-AIDS in adult males in sub-Saharan Africa, though it is unlikely that benefit carries over to other parts of the world where rates of HIV-AIDS are much lower.
The research, published in Tuesday’s edition of the Annals of Family Medicine, shows that, despite claims, there is little evidence that circumcision can prevent sexually transmitted infections, urinary tract infections and penile cancer. There are also risks to the surgery that, while rare, range from sexual dissatisfaction through to penile loss.
“Patients who request circumcision in the belief that it bestows clinical benefits must be made aware of the lack of consensus and robust evidence, as well as the potential medical and psychosocial harms of the procedure,” said Guy Maddern, of the department of surgery at the Queen Elizabeth Hospital in Adelaide, Australia, and lead author of the study.
In newborns, he said, the surgery is “inappropriate” because it offers no therapeutic benefit.
About one-third of males worldwide undergo circumcision, the surgical removal of the prepuce (or foreskin). The procedure is done principally for religious, cultural and social reasons. Religious male circumcision is practised under both Jewish and Islamic law, and it is an integral part of some aboriginal and African cultural practices. The main social reasons the practice has continued is a widespread desire that boys resemble their fathers, and a belief that boys who undergo circumcision have fewer health problems. The new study, a systematic review (a compilation and analysis of previously published research), looked only at the latter point.
Dr. Maddern and his research team found no evidence that uncircumcised men have higher rates of penile cancer. In fact, they noted penile cancer is extremely rare and seemingly unrelated to the presence of a prepuce. The belief that urinary tract infections are more common in uncircumcised males is not backed up by research. Dr. Maddern noted the fewer than 2 per cent of boys suffer urinary tract infections which “makes it unlikely that preventive circumcision of normal boys would outweigh the adverse events associated with the procedure.”
Finally, there was no evidence at all that there are fewer sexually-transmitted infections among circumcised males. The exception was a study in sub-Saharan Africa that showed doing the surgery on adult males reduced their risk of contracting HIV-AIDS. (However, rates of HIV-AIDS were not reduced in their female partners.) Rather, Dr. Maddern said, the prepuce seems to act as a barrier against contamination and, by helping maintain a moist environment, enhances sexual pleasure.
According to the study, the only medical justification for circumcision is to treat boys or men with penile abnormalities.
Circumcision health benefit virtually nil, study finds
Globe and Mail (Toronto, Canada)
Tuesday, Jan. 12, 2010
THREE teenage Aboriginal boys turned up in the grounds of the bush hospital on December 30. They stood outside with blood pouring down their legs. They were too embarrassed to go inside, fearing they would encounter a female nurse or doctor. They had just been through a circumcision ceremony in a camp outside Tennant Creek, 500km north of Alice Springs.
It had gone badly wrong. The boys, who had received no anaesthetic, were left mutilated by elders who it is suspected were drinking when they performed the initiation ritual. The Northern Territory Health Department confirmed the boys had presented with severe lacerations but refused to give the ages of the teenagers. News Ltd understands the boys were 16 or under, which should have prompted the hospital to report the incident to police as a possible case of child abuse. Police were not told. The three boys were hospitalised for three nights before being released back into the community.
The bungled circumcisions have only now come to light because a woman - the wife of a cattle station manager - had been at the hospital with a sick child. The woman had let her two children play just outside the hospital's doors while awaiting a doctor. The kids started throwing pebbles at each other. Then it was noticed the rocks were covered in congealed blood. Hospital staff cleaned up the children, destroyed one of their sets of clothing, and tested the blood on the children for disease. The children will continue to be monitored.
"There are two issues here," said the woman, who asked not be named in order to protect her children's identity, while demanding a Territory Health Department investigation. "One is the nature of these circumcisions, which seem brutal, the other is the health of my children. "The blood was right outside the hospital door, near a cement pad where the ambulance pulls up. They should have cleaned it up."
In the right circumstances, circumcision ceremonies are carefully controlled. Women sing goodbye to their boys throughout the night and then depart to let the men perform the cutting, after which the boys emerge as men. But Tennant Creek, a largely indigenous town, is awash with alcohol. There are concerns as well that young men are being snatched by elders and forced to go through the procedure against their will. One witness who declined to be named said on the morning the three boys presented in hospital, he had seen a young man running for his life through the streets of Tennant Creek. The boy had been picked up by elders and was in the queue for the cut. "This young fella escaped and took off and was running through town," said the witness. "This painted-up bloke was racing after him and a Toyota was cruising around looking for the boy as well. I think they grabbed him. "I'm not sure if he was one of the three (who were mutilated)."
Jeff Warner, director of Tennant Creek's Anyinginyi Health Aboriginal Corporation, said the circumcisions took place in a makeshift bush camp out of Tennant Creek. "Speaking to people around town, they're saying its common knowledge that there was alcohol in the camp at the time," he said. He asked an elder who had attended the ceremony, who denied it.
Circumcision ceremony goes horribly wrong
Northern Territory News, January 11th, 2010
ABORIGINAL ceremonies should be preserved, says the Territory Government, despite concerns ritual circumcisions are being botched.
Three Aboriginal boys arrived at Tennant Creek Hospital last month after a manhood ceremony in a camp left them mutilated. The trio stood outside the hospital bleeding, authorities have confirmed. It was reported earlier this week that elders performed the ritual without anaesthetic and were drinking alcohol at the time. NT Government Minister Gerry McCarthy said the cultural ceremony was "to be preserved". "The horrible situation ... in Tennant Creek lends itself to some really open and honest dialogue about how Government can support the traditional elders with their cultural practices in a supportive, but not an invasive way."
Mutilation 'not to stop' tradition
Northern Territory News, January 13th, 2010
Before the Northern Territory government rushes to display its cultural sensitivity, it should recall that Australia is signatory to the United Nations Convention on the Rights of the Child. Article 24 (3) of this treaty commits parties "to take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children." If this sort of thing is not prejudicial to children's health, it is hard to know what is. Blaming alcohol rather than the circumcision procedure itself is completely missing the point.
New research confirms earlier claims that up to one in five HIV cases in Africa are infected during medial and surgical procedures by medical staff using dirty needles and non-sterile clinical equipment. According to the authors of a series of papers in a publication backed by the Royal Society of Medicine, nearly five million new cases of HIV are caused each year by erratic health practices. The findings raise serious questions about the international effort to combat HIV and AIDS, which focuses largely on trying to stop virus transmission through unsafe sex or from mothers to their unborn children.
Researchers accused governments of ignoring and covering up the problem so as not to undermine existing health schemes. John Potterat, an epidemiologist and one of the editors of the International Journal of STD and AIDS, said that “Governments and international health agencies have deliberately chosen to ignore the evidence.”
In the same issue of the journal, David Gisselquist argues that the main factors behind Africa’s AIDS epidemic are double standards in research ethics, health-care safety, and scientific rigour. Dr Gissselquist is also the author of a recent book which presents these arguments in detail.
Christchurch, New Zealand: A boy was rushed to hospital after the doctor attempting to circumcise him at a private clinic severed a major artery in another part of his penis while trying to hold him down. The operation was performed at an unnamed medical centre last January by a general practitioner, assisted by an unqualified practitioner and his wife. The case has been referred to the Health and Disability Commissioner for a decision as to whether the doctor should face criminal or other charges.
According to the report released by the Commission, when the parents and the boy arrived at the clinic they were directed to the waiting room while the doctor finished performing a circumcision on a 14-year-old boy. The family were alarmed when they heard the older boy’s screams. The clinic manager (wife of the operating doctor) told them that, although the 14-year-old boy had been given the maximum dose of morphine, he was “too sensitive and could not handle the pain”.
The boy's mother told the commissioner that the child was taken into the operating room and given an injection, but that the doctor starting cutting into his penis before the painkiller had time to take effect. Seeing her son in agony caused the mother to start crying, at which point the doctor ordered her out of the room, accusing her of transmitting her anxiety onto the child and disturbing him. About 10 minutes later, the boy's father was also ejected from the room. “We could hear our son crying for help and begging us not to leave him there by himself. He kept asking them to let us in, but they wouldn't listen,” she said.
After about an hour, the boy's father walked in to the operating room and found the doctor talking to another doctor on the phone, apparently seeking advice on circumcision procedures. He saw the clinic manager and the unlicensed doctor holding the struggling boy down “as if they were holding a wild animal,” the report said. About an hour-and-a-half after the boy went into the operating room, the doctors called an ambulance because they were unable to stop his bleeding.
Source: The Press (Christchurch, New Zealand), 8 December 2009
A recent article by David Shaw in the British journal, Clinical Ethics, suggests that medically unnecessary or non-therapeutic circumcision of male minors (NTC) is not only ethically dubious, but may be illegal in that it breaches the UK’s Human Rights Act. Although the article focuses on Britain and the various guidances on circumcision issued by the General Medical Council and the British Medical Association, the arguments of the paper are relevant to any country that professes adherence to human rights principles yet still permits unregulated NTC of minors to occur. Equally, although the paper takes its examples from religiously motivated circumcision (that is, situations where parents profess adherence to the Jewish or Muslim faith), the principles it discusses are applicable to any situation where parents want to get a boy circumcised without medical need. The author considers various examples where the interests of the child have been held to take precedence over the religious or other beliefs of the parents, such as cases where Jehovahs’ Witnesses have tried to prevent a child from receiving a life-saving blood transfusion.
The paper lays particular stress on guidance issued by the British Medical Association, particularly its suggestion that medically unnecessary surgery should be deferred until the child reaches the age of consent. It points out that consent obtained from a child before this time is unlikely to be fully informed and likely to be subject to adult pressure. The author argues that any decisions by doctors and courts should aim to protect the autonomy of the child and to keep his options open: “Not performing NTC will increase future options: an uncircumcised man can easily be circumcised, but a circumcised man would only have the option of attempting a clinically difficult circumcision reversal.”
In conclusion the author addresses the argument that if doctors refuse to perform medically unnecessary circumcisions, parents will turn to back-street operators who are likely to perform the operations incompetently and with more additional damage. Highlighting the anomalous situation of circumcision in the surgical repertoire, he asks to imagine “a situation where two adherents of a minority religion ask their doctor to pull off their son’s thumbnails, as this is part of the religion in which they want to bring up their son. The pain will be transient, and the nails will grow back, but the parents claim that it is an important rite of passage. I think it is reasonable to say that the doctor would send them packing, without recourse to conscientious objection or fear of backstreet nailpulling. In the case of NTC, the foreskin will not grow back; why should this procedure be treated differently?”
Source: David Shaw, Cutting through red tape: Non-therapeutic circumcision and unethical guidelines, Clinical Ethics, Vol. 4, 2009, 181-186
A recent commentary in the (Australian) Journal of Paediatrics and Child Health offers a refreshing perspective on female genital cutting (FGC) that does not try to quarantine it from male circumcision but, on the contrary, recognizes that they are comparably harmful and ethically questionable procedures. The commentary, by Sonia Grover, begins by acknowledging that the decline in the incidence of circumcision of boys (from 90 per cent in the 1950s to around 10 per cent today) was the result of “a shift in community attitudes and of recognition that there are health risks associated with the procedure and no health advantages.” She further points out that the severity of the consequences of FGC tend to be exaggerated by activists and that they do not necessarily lead to a total loss of sexual sensation. Risks such as haemorrhage, infection and death also apply to circumcision of boys.
Grover reports that there is no evidence of any FGC occurring in Australia. Whether this is the result of laws in most states that prohibit the practice or simply lack of demand is unclear, but the latter explanation is the more likely – in which case the law would be more an expression of society’s disapproval than a measure intended prevent a widespread practice. Very different is the situation of boys, thousands of whom are circumcised in Australia each year, usually because a parent or guardian prefers them to be that way. In a society that prides itself on treating the sexes equally, this is an anomaly that demands explanation and reform.
In conclusion, Grover notes that there is a rising incidence of teenage girls and young women seeking labioplasties – that is, surgical reductions in the tissue of the labia majora and minora. This trend would appear to be a cosmetic fashion. Although adult women are competent to consent to such surgeries for themselves, it is ironic that the result would fall within the World Health Organisation definition of female genital mutilation.
Source: Sonia Grover, Female genital mutilation, Journal of Paediatrics and Child Health, Vol. 45, November 2009, 614-615
Most Canadian health authorities have already issued policies that reject circumcision, including the College of Physicians and Surgeons of British Columbia, which released a revised policy in September 2009. The following points are highlights of the statement.
“Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western counties. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention.”
The new policy states clearly that “routine removal of normal tissue in a healthy infant is not recommended.” It also points out that:
The policy recommends that doctors should:
It has been a bad year for circumcisers and their unfortunate subjects in the USA. In recent news, juries have awarded substantial damages for infant circumcisions that resulted in serious injury to the child, and yet another boy died following his circumcision procedure. In California, $429,000 was awarded to an infant who lost the tip of his penis during a “routine” operation. In Georgia a jury awarded $2.3 million to a boy whose penis was severed. In South Dakota a baby boy bled to death after having been circumcised at a local hospital.
A medical trial in Thailand has raised hopes of a major breakthrough in the fight against Aids after scientists said an experimental vaccine had reduced the risk of HIV infection by a third. The world's largest HIV/AIDS vaccine trial of more than 16,000 volunteers was the first in which infection has been prevented, according to the US army, which sponsored the trial with the National Institute of Allergy and Infectious Diseases.
A combination of two vaccines was tested on HIV-negative Thai men and women aged 18 to 30 at average risk of becoming infected. All the volunteers were given counselling and condoms to help them avoid HIV. Then half were randomly picked to receive the vaccine, while the other half got dummy shots. Until the trial ended, nobody knew who had been given the genuine vaccine and who had not.
In a recent survey of child health outcomes, the United States scored so badly that on many indicators it was ranked near the bottom with countries such as Turkey and Mexico. The study of all thirty countries in the Organisation for Economic Cooperation and Development ranked the USA 24th in overall child health and safety and 23rd in material well being.
Under health and safety the OECD measured the incidence of low birth weight, infant mortality, breast-feeding, vaccination for pertussis (whooping cough) and measles, mortality in children 0-19 years and suicide. In addition, it measured the number of births to teenage girls (15-19 years). On all these indicators except suicide the USA scored very badly, and its high rate of teen births placed it right off the scale and up with Mexico and Turkey.
The really interesting thing about these figures is that it throws doubt on the claim that circumcision improves child health outcomes. On the basis of these OECD figures it is clear that the countries with the lowest incidence of circumcision have the healthiest children and those with the highest incidence (Turkey and the USA) have the least healthy.
A national charity has called for wider awareness of the risks of circumcision, as the inquest is held into the death of a 16-day-old baby following a religious ritual two years ago. Amitai Moshe died in 2007 following a ritual circumcision in North London and the inquest into his death began at Hornsey Coroner's Court on Monday. The inquest follows one in Windsor earlier this year which concluded that baby Celian Noumbiwe had bled to death within hours of a circumcision at a doctor's surgery in Reading.
Many parents who consider circumcision necessary for ritual reasons believe that the operation is harmless in early infancy, and that it will bring benefit to the child. However, men's health charity Norm-UK believes that this position is not supported by experts. Gordon Muir, a consultant urological surgeon at King's College Hospital, who spoke out about circumcision at Norm-UK's conference last year, said: "There is no evidence that circumcising children has lower risk than carrying out the same procedure in adults, and no medical benefit can be shown for baby boys in the UK having this procedure unless there are significant abnormalities of the foreskin. While the risk of major tragedies such as this is very low, I see many men who have suffered years of trauma and anxiety due to badly performed circumcisions they never needed for medical reasons, and never consented to."
Jack Cohen a reproductive biologist who is to become Norm-UK's third patron, said: "Jewish law contains an exemption for families who have suffered deaths from the surgery, so it has long been known that circumcision can kill. "Why should we continue to put boy's lives at risk for an ancient tradition of tribal marking and social control?"
Dr John Warren, founder of Norm-UK said: "Circumcision-related deaths in the West are rare but not as rare as the public think... as well as the two deaths investigated in England this year and another in 2006, two baby boys bled to death in Italy in summer 2008, and one in Ireland in 2003. We believe there are other cases which have passed under the radar due to the political sensitivity of the issue."
An analysis of national census religious data reveals that at least 19,000 boys could be circumcised each year in the UK. In 1993 (when circumcision rates would have been much lower) The Independent newspaper, reporting the death of baby Boma Oruitemeka, stated that more than 100 boys from babies to teenagers were treated each year for life-threatening circumcision complications.
In an attempt to find out the current picture, this year Norm-UK made freedom of information requests to hospitals across England. To date only a few have supplied the data requested. Norm-UK said that London's Great Ormond Street hospital was one of the hospitals that initially seemed reluctant to provide the information requested. However, when the charity escalated its request the hospital revealed that over the past five years it had treated, an average of almost two boys each week for complications of circumcision in the community. Yet no child protection reports are on record since 2005.
Child protection experts now also recognise male circumcision as a potential source of harm to a child and the London Safeguarding Children Board's child protection procedures state that "Poorly performed circumcisions have legal implications for the doctor responsible". The guidelines add: "If a professional in any agency becomes aware, through something a child discloses or other means, that the child has been or may be harmed by circumcision, a referral must be made to [local authority] children's social care".
Norm-UK is a registered charity, founded in 1995, dedicated to the education of the public and the medical profession about the foreskin. For more information, go to www.norm-uk.org.
Charity warns of circumcision risks
By Lorraine Connolly, Community Newswire, 8 September 2009
The following letter was sent to the Sydney Morning Herald by Professor David Forbes, Chair of the Paediatrics & Child Health Policy & Advocacy Committee, Royal Australasian College of Physicians. He is commenting on a disgraceful article in the SMH about the RACP’s recently released circumcision policy – an article that is not really a news item at all, but an editorial defending routine circumcision of innocent babies, criticising the RACP for rejecting the practice, and giving sympathetic coverage to the maverick views of the notorious circumcision fanatic, Professor Brian Morris. The article is quite in keeping with the SMH’s decrepit pro-circumcision policy and expresses its complete failure to keep up with developments in science, medicine, medical ethics, human rights and law. Wake up, granny!
Please find copied below a letter sent to the SMH today in response to this article from the RACP.
Your Friday 11 article “Doctors circumspect on circumcision” warrants clarification on a number of issues.
The key point of the recently released RACP statement on circumcision is that the RACP believes that at the present time there is not evidence to support routine circumcision of newborn and infant males.
Your article sends a dangerous public health message that circumcision prevents HIV transmission. It is vital that everyone engage in safe sexual practices such as condom use, whether circumcised or not. Recent reports of circumcision offering some protection against HIV infection in Africa relate to circumcision of adult males, not of infants. Further the stated benefits of protection against urinary tract infection are marginal, and do not justify mass circumcision. Our changing understanding of the relationship between urinary tract infection and chronic renal disease further weakens the case for routine circumcision.
There is evidence that circumcision does result in memory of painful experiences, and is not quite as simple and low risk as your report states.
The Colleges’ recent statement is not anti-circumcision, but clearly states that parents should be informed of risks and benefits, and then supported in their decision. When circumcision is undertaken it should be with appropriate anaesthesia, and by a skilled operator who can minimise the risks of side effects. The option of delaying the decision to circumcise is one way of dealing with the ethical and potential legal issues of undertaking an elective procedure on a minor. The procedure is not to be equated with vaccination, either in its delivery or in its effectiveness.
It should be noted that Professor Morris, quoted in your report, is not a member of the RACP and is not and has not been engaged as a reviewer for the College.
Chair, Paediatrics & Child Health Policy & Advocacy Committee
Royal Australasian College of Physicians.
11 September 2009
A prominent reproductive biologist has thrown his weight behind NORM-UK, the charity concerned with the male foreskin and campaigning for personal choice in circumcision. Professor Jack Cohen, who has an academic career spanning 55 years, has co-authored books with Terry Pratchett and worked as a consultant on science fiction productions, joins actor Alan Cumming and art critic Brian Sewell as a patron of the charity. Speaking as an honoured guest at the charity's annual general meeting in Staffordshire, Professor Cohen said. "I'm delighted to join NORM-UK, to help to raise public awareness of the very real issues around male circumcision." As a tissue researcher in Boston in 1963-4 I became known as the prepuce man, collecting 400 infant foreskins for experimentation in one year (sometimes from parents who had fainted after watching the surgery on their son). Now it seems this poacher has turned gamekeeper!"
"Although I circumcised my first two sons", he added, "I have increasingly questioned the practice, and its origins. I support the principle that every man and woman has the right to veto alterations of their body. Unfortunately in its early historical form circumcision was designed to weed out and ostracise those who resisted authority – denying them the right to reproduce. Thus the harm has become deeply entrenched with questioning seen as an aberration. I’m happy to see this is beginning to change."
Asked whether the African circumcision experiments should sway parents who are questioning circumcision, Professor Cohen said, "There are still no good grounds for believing that circumcision will protect a boy from HIV in the future. The small numbers who were apparently protected by surgery in the trials don't justify the policy conclusions drawn, particularly when they stand in contrast to population evidence, in Africa and elsewhere."
Dr John Warren, Chairman of NORM-UK commented, "We are delighted to have Professor Cohen as a supporter of our work, and we concur with his view of the African HIV experiments. Parents who think circumcising might reduce their child’s risk of HIV should ask, why should Israel have the same HIV rate as Sweden when one is almost entirely circumcised and one almost entirely not circumcised? They should also ask whether they can be sure of his future sexuality. There is no evidence that circumcision protects gay men at all and in fact in Britain a circumcised gay man is 20% more likely to report having been diagnosed HIV+ than a gay man who has not been circumcised."
The most recent statement on circumcision from the Royal Australasian College of Physicians states clearly:
"the RACP does not recommend that routine circumcision in infancy be performed".
The statement was issued on 27 August 2009 and represents the considered opinion of the Australasian Association of Paediatric Surgeons, the New Zealand Society of Paediatric Surgeons, the Urological Society of Australasia, the Royal Australasian College of Surgeons and the Paediatric Society of New Zealand. The new policy warns that
serious ethical, human rights and legal problems hang over medically unnecessary circumcision of minors;
many adult men are resentful at having been circumcised in infancy;
in most cases there is no net benefit to the child;
the foreskin is functional tissue whose removal affects sexuality;
evidence as the value of circumcision as a tactic against AIDS is from Africa and is not relevant to Australia;
health arguments for circumcision are not strong enough to justify the loss and risk.
Most importantly, the policy considers circumcision to be an intimate alteration of the body and that the decision should properly be left up to the boy to make when he is old enough to understand the issues.
The health of Australia’s children continues to improve, according to the latest report on child health from the Australian Institute of Health and Welfare, A Picture of Australia's Children 2009. During the period 1986-2006 there was a dramatic decline in infant and child deaths (which fell by half), improved survival in cases of cancer, and a reduction in the incidence of asthma.
These are significant findings, given that the period 1986 to 2006 witnessed a huge decline in the incidence of circumcision, from about 40 per cent of boys in the early 1980s to about 10 per cent in 2006. 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 and other diehard promoters of routine circumcision that the fall in the circumcision rate would lead to an explosion of genito-urinary problems in boys and an ever-increasing death toll from urinary tract and bladder infections. No such problems are identified in this report, which does not even mention any health problems affecting the genito-urinary area.
On the contrary, the halving of the death rate among infants and children suggests that leaving the foreskin in place could even have significantly improved child health outcomes and contributed to the decline in infant and child mortality. It is, after all, quite illogical to claim that a boy with wound on his penis is somehow healthier than a boy who has not been injured there. As the British child health expert N.R.C. Roberton points out, “it is fundamentally illogical that mutilating someone might be beneficial.” *
Problems identified by the AIHW report include an increasing incidence or diabetes and obesity, more, tooth decay, too much television, not enough vegetables, and persistent poor health among indigenous Australians. It is hard to see how even a fanatic like Brian Morris could blame “lack of circumcision” for children not eating their vegetables.
The Australian Institute of Health and Welfare is the Australian Government’s premier health research foundation.
N.R.C. Roberton, “Care of the Normal Term Newborn Baby,” in Textbook of Neonatology, eds. Janet M. Rennie, N.R.C. Roberton, 3rd edn. (Edinburgh: Churchill Livingston, 1999), 378-379.
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.
The Hon. Tony Abbott MHR
Minister for Health and Ageing
Canberra ACT 2600
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.
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.
The report can be found by searching Russell +tongue tie +medicare on Google.
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 place 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
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
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 .
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.”
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