Statements on circumcision from medical organisations
Australian Pediatric Association, 24 April 1971
The Australian Pediatric Association recommends that newborn male
infants should not, as a routine, be circumcised.
Medical Journal of Australia, 22 May 1971, p. 1148
Australian College of Paediatrics
Official statement, 1983
1. The ACP should continue to discourage the practice of circumcision
in the newborn male infant.
2. Educational material on the topic of circumcision should be
available to parents before the birth of their baby and also in
maternity hospitals. This will facilitate informed discussion with
their medical attendant.
3. Some parents after considering medical, social, religious and
family factors will opt for circumcision of their infant. It is
then the responsibility of the medical attendant to recommend that
this circumcision be performed at an age and under medical circumstances
that reduce the hazards to a minimum.
This statement was reviewed and reissued by the ACP on 28 May 1991.
Australian College of Paediatrics
Position Statement, 1996
The Australian College of Paediatrics has prepared the following
statement on routine circumcision of infants and boys to assist
parents who are considering having this procedure undertaken in
their male children and for doctors who are asked to advise on or
undertake it.
Routine circumcision of normal male infants and boys
Circumcision of males has been undertaken for religious and cultural
reasons for many thousands of years. It probably originated as a
hygiene measure in communities living in hot and dry environments.
It remains a very important ritual in some religious/cultural groups.
During the last 50-100 years, neonatal male circumcision became
widespread in English-speaking countries. Until the late 1960s or
early 1970s, it was generally performed without any form of anaesthesia.
In Australia, the circumcision rate has fallen very considerably
in recent years and it is estimated that currently only 10 percent
of male infants are routinely circumcised. It is now generally performed
with some form of local or general anesthesia.
There have been increasing claims of health benefits from routine
male circumcision. There are, however, also risks associated with
the procedure from infection, bleeding and damage to the glans penis.
The College has recently reviewed evidence in relation to risks
and benefits and has concluded that it is not possible to be dogmatic
on the exact risk/benefit ratio. There are suggestions of reductions
in the risk of urinary tract infections, of local inflammatory conditions
of the penis and later cancer of the penis. It has also been claimed
that there is a reduction in the risk of sexually transmitted disease
(especially HIV) and of cancer of the cervix in partners of circumcised
males. However, studies claiming these benefits do have methodological
problems which could influence findings and these problems will
be difficult to overcome. Therefore, at the present time it would
be wrong either to claim that there are definite health benefits
or to deny that they exist.
The possibility that routine circumcision may contravene human
rights has been raised because circumcision is performed on a minor
and is without proven medical benefit. Whether these legal concerns
are valid will probably only be known if the matter is determined
in a court of law.
The Australasian Association of Paediatric Surgeons has informed
the College that it is its view that routine male circumcision should
not be performed prior to the age of 6 months. It considers that
"Neonatal male circumcision has no medical indication. It is
a traumatic procedure performed without anaesthesia to remove a
normal and healthy prepuce."
The College believes informed discussion with parents regarding
the possible health benefits of routine male circumcision and the
risks associated with the operation are essential. Up-to-date, unbiased
written material summarising the evidence in plain English should
be widely available to parents.
If the operation is to be performed, the medical attendant should
ensure this is done by a competent operator, using appropriate anaesthetic
techniques and under medical conditions that minimise the hazards.
In the majority of cases, parents will decide for or against a
routine male circumcision on family, social, aesthetic and religious
grounds rather than on medical ones. In all cases the medical attendant
should avoid exaggeration of either benefits or risks of this procedure.
Issued 27 May 1996
The Australasian Association of Paediatric Surgeons
Position statement, 1996
Guidelines for circumcision
Preamble
The Australasian Association of Paediatric Surgeons does not support
the routine circumcision of male neonates, infants or children in
Australia. It is considered to be inappropriate and unnecessary
as a routine to remove the prepuce, based on the current evidence
available.
Due to religious beliefs, Jewish children are circumcised by the
seventh day of life, as a mark of dedication to God. Children born
into the Muslim faith will likewise be circumcised for religious
reasons, although the timing for the procedure is less clearly defined.
There are Christian groups in other parts of the world, who insist
on ritual religious circumcision, as well as tribal or cultural
customs promoting male circumcision.
We do not support the removal of a normal part of the body, unless
there are definite indications to justify the complications and
risks which may arise. In particular, we are opposed to male children
being subjected to a procedure, which had they been old enough to
consider the advantages and disadvantages, may well have opted to
reject the operation and retain their prepuce.
Indications for male circumcision
Balanitis Xerotica Obliterans
Recurrent Balanoposthitis
Phimosis resistant to steroid cream
Contraindications to male circumcision
Hypospadias and other congenital anomalies of the penis, e.g. epispadias,
chordee
Sick and unstable infants
Family history of a bleeding disorder or an actual bleeding disorder
Timing of surgery
Neonatal male circumcision has no medical indication. It is a traumatic
procedure performed without anaesthesia to remove a normal functional
and protective prepuce. At birth, the prepuce has not separated
from the underlying glans and must be forcibly torn apart to deliver
the glans, prior to removal of the prepuce distal to the coronal
groove.
Balanitis Xerotica Obliterans, when diagnosed, should be treated
by circumcision.
Timing of circumcision for recurrent balanoposthitis is difficult
to define. Many infants and children will have an episode of preputial
inflammation. If successive occurrences of dysuria with associated
redness and purulent discharge from beneath the prepuce have been
treated and the previously fully or partially retractable prepuce
is less readily retractable after the subsidence of the inflammation,
circumcision should be considered.
The physiological phimosis will normally resolve by the age of
3-4 years. If it fails to respond to steroid cream/ointment applied
several times daily for 4-6 weeks, there is a reasonable probability
that these boys will have problems in the future.
Infants and children who have a proven urinary tract infection
and, on investigation, are found to have a significant urinary tract
anomaly, e.g. posterior urethral valves or significant vesico-ureteric
reflux, may benefit from circumcision. This will reduce the normal
bacterial flora resident under the prepuce, which in the presence
of a urinary tract anomaly may be associated with an increased risk
of further upper tract infections with possible local and systemic
damage.
The risk of carcinoma of the penis developing in the uncircumcised
is very low. Lifetime penile hygiene is the key to penile health
and a reduction in the incidence of carcinoma of the penis.
Personal sexual behaviour patterns will determine whether sexually
transmitted infections with human papilloma virus, herpes simplex
virus and the human immune deficiency virus are contracted. Routine
or infant male circumcision is not justified in Australia to protect
males from contracting diseases that some may acquire through their
ignoring the recognized precautions to be taken during their sexually
active life.
Consent for surgery
Parents requesting circumcision of their male children should have
the complications both general and local, explained to them. These
complications are usually minor but can be severe and may result
in the death of the child. Time should also be spent discussing
the advantages and disadvantages of the operation, both in the short
and long term, as is currently applicable in Australia. There are
many adults in the community who hold a very strong opinion as to
the place of circumcision. This may be for religious reasons or
for family "custom" or a claim of "cleanliness"
or other reasons. In this event the procedure should be performed
electively after six months of age.
When performed, it should be carried out by a surgeon performing
circumcisions on children on a regular basis with an anaesthetist
using appropriate techniques. This would imply that the anaesthetist
is fully trained in the art of paediatric anaesthesia, including
the ability to perform caudal and penile regional or local anaesthesia.
The operation should be carried out in a paediatrically orientated
environment, designed to reduce the risk to the child and providing
support to the parents or caregivers.
Points of interest
Marshall in 1960, reporting to the Society of Pediatric Urologists
in Philadelphia and quoted by John Duckett, a distinguished pediatric
urologist in Philadelphia, calculated that 140 boys a week for 24
weeks would need to be circumcised to prevent one case of carcinoma
of the penis.
The Jewish Talmud stated that "the third child was excused
from circumcision if the first two had died as a result of the circumcision".
Dr. Derek Llewellyn Jones in his book Everywoman (1971), stated:
"Mothers
demand it, doctors profit by it and babies cannot complain about
it".
The 1989 United Nations Convention on the Rights of the Child states:
"State parties should take all effective and appropriate measures
with a view to abolishing traditional practices prejudical to the
health of children."
Circumcision of male infants was addressed in a research paper
published by the Queensland
Law Reform Commission in December 1993. The preface addresses
the problem when it states:
"From the Commission's research to date, it is apparent that
there are two quite vocal sides of the debate on routine male circumcision.
One side advocates the practice, primarily on a preventative health
basis or on religious grounds. The other side opposes the practice,
primarily on human rights and preservation of bodily integrity grounds.
Both sides rely on medical evidence and opinion to support their
respective views".
Having considered all the information the paper concludes with
"The Commission has yet to decide what, if any reform of the
law should be recommended in relation to infant male circumcision."
Australian Medical Association, 1997
The AMA will discourage circumcision of baby boys in line with
the Australian College of Paediatrics "Position Statement on
Routine Circumcision of Normal Male Infants and Boys".
The statement, released in June and supported by the AMA's November
Federal Council meeting, includes:
- The Australian College of Paediatrics should continue to discourage
the practice of circumcision in newborns.
- Educational material should be available to parents before the
birth of their baby and in maternity hospitals.
- Some parents after considering medical, social, religious and
family factors will opt for circumcision. It is then the responsibility
of the doctor to recommend this is performed at an age and under
circumstances which reduce hazards to a minimum.
Australian Medicine, 6-20 January 1997, p. 5
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