It is interesting to trace the evolution of the statements and policies on circumcision issued by Australian medical authorities, from the one-line announcement in 1971 that circumcision was not recommended to the 100-page thesis published in 2002. Interestingly, the need to elaborate on the policy was not felt until the mid-1990s, when medical conservatives and others committed to circumcision as a cultural practice became alarmed that the United Nations Convention on the Rights of the Child (1989) threatened to make circumcision a recognised human rights violation and hence impossible in countries that professed respect for human rights. Their response was to revive the most credible of the old rationalisations for circumcision (prevention of phimosis, cancer, syphilis and other sexually transmitted infections, and to look for new ones. HIV-AIDS seemed tailor-made for this purpose. As a consequence of the agitation of this committed band of circumcision promoters in the medical research industry (mainly in the U.S.A.), circumcision has today become a controversial question, and not a forgotten medical fad like mercury or frontal lobotomy
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
This statement was reviewed and reissued by the ACP on 28 May 1991.
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
NOTE: There are many problems and dubious claims in this policy statement. These were the subject of critical comment in 2001-02, when the Royal Australasian College of Physicians was reviewing the policy and a number of individuals sent comments and submissions in.
Guidelines for circumcision
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
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."
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
Routine Circumcision Of Normal Male Infants And Boys - Summary Statement
The Paediatrics & Child Health Division, Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of infants and boys assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that there is no medical indication for routine male circumcision.
Circumcision of males has been undertaken for religious and cultural reasons for many thousands of years. It remains an important ritual in some religious and cultural groups. In Australia and New Zealand, the circumcision rate has fallen 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 anaesthesia, and usually outside the neonatal period. The best recognised indication for circumcision is phimosis.
There have been increasing claims over recent years of health benefits from routine male circumcision. The most important other conditions where some benefit may result from circumcision are urinary tract infections, HIV and later cancer of the penis.
The complication rate of neonatal circumcision is reported to be around 1% to 5% and includes local infection, bleeding and damage to the penis. Serious complications such as bleeding, septicaemia and meningitis may occasionally cause death.
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 be known only if the matter is determined in a court of law.
If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment.
In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarising the evidence should be widely available to parents.
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.
While this statement is clearly an improvement on that of 1996 it nonetheless falls short in several important areas: (1) It fails to consider the anatomy and physiology of the foreskin itself and its functions as a sexual organ. (2) It confuses ethical and human rights issues with legal issues; whether circumcision without consent is a violation of human rights or medical ethics is independent of the question as to whether it is legal. (3) It fails to acknowledge the right of the individual to choose whether he prefers to have a foreskin or not. (4) It accepts the conclusions of a number of flawed or questionable studies.
For further analysis on this site, see
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