Even though routine neonatal circumcision is almost unknown in Britain and rare in Australia, New Zealand and Canada, too many boys between the ages of 4 and 10 are still circumcised because of "phimosis" - that is, because their foreskin cannot be fully drawn back. Many parents (and too many doctors) do not understand that it is quite common for the foreskin not to become fully retractable until the boy reaches puberty or even later, and that there is no need for any action unless he is suffering pain or discomfort. If he is and medical treatment is needed, the preferred treatment these days is application of steroid cream. A premature or (even worse) a fraudulent diagnosis of phimosis should not be used as an excuse to circumcise an otherwise healthy boy.
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
Comments in the media
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.
The Age (Melbourne), Sunday 16 February 2003
DOCTORS have been advised to tell parents there is no medical reason to routinely circumcise boys. The policy statement developed by the paediatric and child health division of the Royal Australasian College of Physicians raises the prospect of future legal action if the surgery is performed. Parents who have their child circumcised and doctors who perform the surgery could face legal action when the child grows up.
The stance follows a major review of existing information and reaffirms the position of the College of Paediatrics and the Australasian Association of Paediatric Surgeons.
"Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure," the RACP says. "There is no medical indication for routine male circumcision." In Australia the circumcision rate has fallen in recent years to about 10 per cent of male infants. The rate of complications from neo-natal circumcision is between 1 and 5 per cent.
The Advertiser (Adelaide) and Courier Mail (Brisbane), 19 May 2003
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."
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.
College of Physicians and Surgeons of British Columbia
College Quarterly, Issue 38, Fall 2002
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