COMMENTS on the 1996 POSITION STATEMENT,
AUSTRALIAN COLLEGE of PEDIATRICS

In 2001 the Australian College of pediatrics (now a division of the Royal Australian College of Physicians) announced that it was reviewing its position statement on circumcision and called for comment from interested people. The following submissions are of interest.

1. Shane Peterson and Dr George Williams for Circumcision Information Australia

2. Dr Robert Darby, Canberra

3. J. Steven Svoboda, Attorneys for the Rights of the Child

Other statements and comments

Position statements from medical organisations in other countries are available at http://www.cirp.org/library/statements

The statement of the American Academy of Paediatrics (http://www.cirp.org/library/statements/aap1999) may also be of interest.

See also the critique of an earlier statement by the AAP (1995) by Dr Robert Van Howe

1. Shane Peterson and Dr George Williams for Circumcision Information Australia

Dr Jill Sewell
Paediatics and Child Health Division
The Royal Australasian College of Physicians
145 Macquarie Street
Sydney NSW 2000

Re: SUBMISSION for POLICY on ROUTINE
NEONATAL CIRCUMCISION

Dear Dr Sewell,

We are aware that the College has created a Taskforce to review the Australian College of Paediatrics/Royal Australian College of Physicians 1996 policy on routine neonatal circumcision of infants and young boys (RNC). We understand that the College has not invited submissions on this topic and we appreciate your approval of our request to make a submission to the review.

Circumcision Information Australia (formerly NOCIRC Australia) was established by the Sydney paediatrician Dr George Williams in 1992 to increase public awareness of the detrimental effects of routine circumcision. We appreciate that ACP disapproval of RNC since 1971,(1) and particularly since 1983,(2) has played an important role in the decline of the practice in Australia.

We are concerned that there has been recent pressure by RNC advocates to revive the procedure as a public health measure,(3, 4, 5) despite legitimate criticism of such advocates' claims in the medical literature.(6, 7, 8, 9, 10, 11) We do not advocate the circumcision of infants or young boys in the absence of definite and health threatening medical indications for three important reasons.

1. The penis is a delicate sensory organ which is permanently damaged by RNC, especially if performed before the natural separation of the glans and foreskin. Circumcision is associated with bodily disfigurement, an unacceptable incidence of complications, and long-term detrimental effects on sexual function which have been under-reported in the medical literature.(12, 13)

2. Circumcision is not an effective method for the prevention of sexually transmitted diseases or exposure to the human papilloma viruses, which are implicated in the development of penile and cervical cancer.(11) Only condoms are an effective method to prevent exposure to infectious pathogens during sexual intercourse. However, with a reduction in sensitivity of the penis and a false belief that they are immune to sexually transmitted infections, circumcised men seem less likely to adopt safer sex practices.(14)

3. Australian and other societies have recognised that parents and other adults do not have the right to use surgery to impose their sexual, cosmetic or religious preferences on children.(15, 16 ,17, 18, 19) Although he is dependent and voiceless, the child is the end consumer or client of RNC. Regardless of the impact on his body, his sexuality, and his personal beliefs, he has no choice but to live with the results of the procedure for the remainder of his life. Children should be given the right to make such decisions about irreversible and non-therapeutic procedures on their bodies after they reach the legal age of consent.

We would appreciate your consideration of the above points and enclosed references. We hope that your revised policy will further strengthen your existing stance on RNC to achieve the following objectives:

1. Provide further protection of the rights of the child in accordance with United Nations(17) and other recommendations;

2. Create a stronger directive for physicians to provide parents with accurate and up-to-date information about the risks of RNC, and its detrimental and irreversible effects on men's health and sexuality.

We draw your attention to action by the College of Physicians and Surgeons of Saskatchewan in their recent memo Caution Against Routine Circumcision of Newborn Male Infants.(20)

Shane Peterson would be pleased to make an oral presentation to your Taskforce and provide a copy of copy of the recent volume Understanding Circumcision(21), should you be so willing.

Yours faithfully

Shane Peterson BSc (Hons)
(Director)

George Williams (MB ChB, FRACP)
(Consultant on Paediatric Health)
Circumcision Information Australia

REFERENCES

1. Australian Pediatric Association, resolution passed a meeting on 24 April 1971, letter to Medical Journal of Australia, 22 May 1971, p. 1148
2. Australian College of Paediatrics (1983) Position Statement on Male Circumcision, Parkville, Victoria. College of Paediatrics (1996) Position Statement: Routine Circumcision of Normal Male Infants and Boys, Parkville, Victoria.
3. Castellsague, X., Bosch, F. X., Munoz, N., Meijer, C. J., Shah, K. V., de Sanjose, S., Eluf-Neto, J., Ngelangel, C. A., Chichareon, S., Smith, J. S., Herrero, R., Moreno, V., and Franceschi, S. (2002) Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners, N Engl J Med, 346(15), 1105-12.
4. Szabo, R., and Short, R. V. (2000) How does male circumcision protect against HIV infection?, BMJ, 320(7249), 1592-1594. (Full text with critical comments at: www.circumstitions.com/Short-HIV.html email responses in BMJ available at http://bmj.com/cgi/eletters/320/7249/1592)
5. Morris, B. (1999) In favour of circumcision, New South Wales University Press, Sydney. (Critique available at: www.circumstitions.com/Morris.html)
6. Milos, M. F. (2002) NEJM Cervical Cancer Study Has Fatal Flaws, BMJ, Electronic Responses.
7. American Cancer Society (2001). Cancer Reference Information: What is Penile Cancer?
8. Bailey, R. C., Plummer, F. A., and Moses, S. (2001) Male circumcision and HIV prevention: current knowledge and future research directions, Lancet Infect Dis, 1(4), 223-31.
9. Bonner, K. (2001) Male circumcision as an HIV control strategy: not a "natural condom", Reprod Health Matters, 9(18), 143-55.
10. Donovan, B. (1999) Review of Morris, In favour of circumcision, Venereology, 12(2), 68-69.
11. Donovan, B., Bassett, I., and Bodsworth, N. J. (1994) Male Circumcision and Common Sexually Transmissible Diseases in a Developed Nation Setting, Genitourinary Medicine, 70(5), 317-320.
12. Peterson, S. E. (2001) Assaulted and Mutilated: A Personal Account of Circumcision Trauma, in Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem, G. C. Denniston, Hodges, F.M., Milos, M.F., (eds), Kluwer Academic / Plenum Publishers, New York, 271-289. (Synopsis available at: www.menstuff.org/books/byissue/circumcision.html)
13. Williams, N., and Kapila, L. (1993) Complications of circumcision, Br J Surg, 80(10), 1231-6.
14. Richters, J., Gerofi, J., and Donovan, B. (1995) Why do condoms break or slip off in use? An exploratory study, Int J STD AIDS, 6(1), 11-8.
15. Family Law Council report to the Attorney-General (1994) Sterilisation and Other Medical Procedures on Children, Commonwealth of Australia.
16. World Medical Association (1993) Statement on Condemnation of Female Genital Mutilation, Budapest, Hungary.
17. United Nations General Assembly (1989) Convention on the Rights of the Child, Document A/RES/44/25 (12 December 1989).
18. Goldman, R. (1998) Questioning Circumcision: A Jewish Perspective, Vanguard Publications, Boston. (Synopsis and review at: www.cirp.org/pages/reviews/goldman/jp.html)
19. Queensland Law Reform Commission (1993) Circumcision of Male Infants: Research Paper, Brisbane.
20. College of Physicians and Surgeons of Saskatchewan (2002) Caution Against Routine Circumcision of Newborn Male Infants, Saskatchewan, Canada.
21. Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem, G. C. Denniston, Hodges, F.M., Milos, M.F., (eds), Kluwer Academic / Plenum Publishers, New York.

2. Dr Robert Darby

Dr Elisabeth Murphy
Paediatrics and Child Health Division
Royal Australian College of Physicians
145 Macquarie Street
Sydney NSW 2000

Dear Dr Murphy

ACP/RACP: Review of policy on routine circumcision of normal male infants and boys

I enclose my submission to the ACP/RACP's current review of the policy on the routine circumcision of normal male infants and boys.

To explain my interest in this issue, I should let you know that I am not a medical doctor but a historian, currently engaged in writing a social history of the rise and decline of routine neonatal (male) circumcision (RNC) in Britain and Australia. My researches over the past few years into the origins and nature of the practice have provided me with a perspective on the issue which, I believe, will be different from that of most paediatricians, but which I hope will be found enlightening and perhaps challenging. My historical knowledge is thus one of the bases on which I feel I am entitled to speak out on this issue.

The second reason for my interest in the matter arises from my personal history as the target of an unwanted routine circumcision. Like most males born in Australia in the 1950s, I was circumcised at birth, and I have no reason to think that I was handled any more severely or traumatically than anybody else at that time. When, at around the age of ten years, I discovered that some boys had a moveable sleeve of soft, ticklish skin covering their penises, and realised what must have been done to mine, I was very upset and bitterly angry with my parents for allowing me to suffer such a loss. It has never been my wish to cultivate a victim mentality, but many discussions with contemporaries over the years have convinced me that, even if most circumcised men accept their status without complaint, the majority would have declined the procedure had they been offered a choice. That, it seems to me, is the strongest argument of all against the continuation of RNC.

My submission takes the form of series of comments on selected paragraphs of the existing Position Statement (1996). I have largely confined my observations to matters on which I feel I have sufficient expertise to make a useful contribution: the history of both ritual and medically rationalised circumcision, and some of the logical and ethical aspects of today's debates on the legitimacy of RNC. I have also included five attachments expanding on some of these points.

I am aware that the most welcome decline in the incidence of RNC in Australia since the 1960s has been largely a consequence of the lead shown by the paediatric community, and in particular a response to the resolution of the Australian Pediatric Association in 1971 that "newborn male infants should not, as a rule, be circumcised", and the rather stronger statement issued by the Australian College of Paediatrics in 1983. I am also conscious that the position statement issued in 1996 represents a slight weakening of the stand adopted then, no doubt in response to the scare over AIDS and UTIs. I hope it is now possible to view those problems in proper perspective, and to see that the alarmist scenarios and dire predictions of circumcision advocates in the USA and Australia have not been fulfilled.

The current review offers the ACP/RACP another opportunity to show leadership on this issue by taking a public stand which will reduce the incidence of such unnecessary and harmful surgery in Australia to an even lower level than it has already attained - for which the boys and girls of the future will thank you.

Yours sincerely

(Dr) Robert Darby
BA (La Trobe), B Litt (ANU), Ph D (UNSW)

Review of policy on
Routine circumcision of normal male infants and boys

Paediatrics and Child Health Division
Royal Australian College of Physicians

Submission by Robert Darby

Comments on the current position statement, 1996

Paragraph 1

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.

1. There is no evidence that ritual or religious circumcision first arose as a hygiene measure. Many ancient and tribal cultures carried out a great variety of mutilating procedures on the genitals of both boys and girls at different ages, but the origins and rationale of these practices are obscure and contested, as are the environmental conditions prevailing at the time when such customs emerged. It is an illusion of Marxist anthropology to assume that ancient religious rituals must have a materialist and rational explanation; modern anthropology recognises that such customs have a ritual origin in the belief structure of the cultures which produced them and do not necessarily have any practical significance. Many conflicting theories have been advanced to account for the rise of ritual operations on the male and female genitals, among which are the following:

• a propitiatory sacrifice, probably a milder form of a ritual which began as outright human sacrifice;
• a mark of tribal identification;
  
• a rite of passage from childhood to adult responsibility;
  
• (in the case of boys circumcised at puberty) the imposition of adult and tribal authority at a time when youthful rebellion might be expected;
  
• a fertility rite, aimed at giving men the power of procreation by making them shed blood from their genitals like women;
  
• an attempt to emphasise feminine or masculine characteristics in girls and boys by removing the parts of the genitals (clitoris and foreskin) believed to resemble the genitals of the other sex;
  
• a punishment for slaves which did not prevent them from reproducing;
  
• a way of humiliating and marking defeated enemies.

The only point of agreement among the proponents of the various theories is that a rational issue like hygiene had nothing to do with it. In the days before aseptic surgery, any cutting of the skin was fraught with risk, and dangerous operations of this kind must have led to many fatal infections and haemorrhage. It is quite wrong to project a 20th century concern with moral and physical cleanliness onto stone age or other ancient cultures which had no such concepts. (See Attachment 1.)

For a summary of current theories on the origin of ritual circumcision, see Gollaher (2000) chs. 1 and 3; see also de Meo (1997); Dunsmuir and Gordon (1999).

2. The opening paragraph as a whole creates a mood favourable to routine circumcision: an ancient practice; promotes hygiene; a valued ritual among respected ethnic groups today. It also gives the impression that there is something inherently unhygienic about the normal penis, or at the very least that it is significantly more difficult to keep clean than the simplified variety. This could be regarded as propaganda rather than an objective assessment of the position. It should also be pointed out that many of the cultures which practise male circumcision also prescribe the circumcision of women (and other forms of female genital mutilation), but that modern societies like Australia do not countenance such rituals, however important they may be to the cultures in question, and have in fact made them illegal.

Paragraph 2

During the last 50-100 years, routine neonatal male circumcision became widespread in English-speaking countries.

1. This is imprecise. Widespread circumcision was introduced in Britain and the USA in the late 19th century for several reasons, prominent among which was the belief that it would discourage masturbation, particularly among boys before puberty. From Britain the practice spread to British colonies like Australia, New Zealand and Canada - but not to Quebec, where the French-speaking inhabitants regarded the idea as an English fad, not a valid medical procedure, and wanted nothing to do with it. Circumcision always remained a controversial procedure in Britain and had critics from the outset, with the result that it remained concentrated among the rich and upper classes and never became as common as in Australia and the USA: at its peak in the 1920s it probably affected no more than a third of British males (Hyam 1990, p. 78). The incidence of the procedure began to decline in the late 1930s and all but disappeared in the early 1950s, following the well known critique by Gairdner (1949). The same pattern was followed in New Zealand. In Australia RNC continued at a considerably higher incidence than ever attained in Britain until the early 1970s, when the practice fell into disfavour, a tendency accelerated in the 1980s. The only countries today where RNC remains common is the USA, where the rate reached almost universal coverage in the 1950s and 60s, but which now stands at between 50 and 60 per cent; and in South Korea, where the procedure was introduced as a consequence of the US occupation following the Korean War.

The inescapable conclusions from this quick survey are:

• routine infant circumcision was a 19th century invention;
  
• it has always been a controversial procedure;
  
• on a world scale it has never been supported by more than minority of the world's medical profession;
  
• its restriction to English-speaking countries, and especially those within the sphere of influence of great powers like Britain and the USA, suggests that it is more like a cultural ritual than a medical procedure with objectively defined and universally agreed therapeutic benefits.

2. The proposition that circumcision, both in girls and boys, was first introduced largely to prevent or discourage masturbation (then regarded as a serious disease in itself and as the cause of many more) is an embarrassment to contemporary advocates of RNC, and one which they attempt to deny (Morris 1999, p. 57). The reality of the connection has, however, been recognised by scholars since the 1950s, and recent research by historians of medicine has proved just how important this link was, even until quite recent times.

3. It is of course true that, merely because circumcision was originally introduced to discourage masturbation, it does not necessarily follow that it has no health benefits today, but this sort of historical background does enable one to view such assertions in perspective. What then becomes apparent is that claims for the health benefits of circumcision have shrunk dramatically over the last hundred years: in the 1890s it was guaranteed to cure, prevent or at least reduce the risk of tuberculosis, rickets, cancer, syphilis, polio, convulsions, epilepsy, bed-wetting, nervousness, brass poisoning (and almost anything you cared to name). Today we are left with no more than some infantile UTIs, usually minor; possibly cancer of the penis (though only a few extremists continue to believe it); and maybe AIDS, which has taken the place of syphilis as the spectre haunting our liberated sex-lives, though the claim is highly controversial and unproven. As scientific understanding of diseases has increased, so the folklore that they could be defeated by sacrificing part of the body has been discredited (though of course that may be necessary in the case of seriously diseased or infected structures); in a century's time the belief that circumcision could protect a man against AIDS is likely to look as ridiculous as the claim that it could save him from TB or "paralysis" does today. The much misunderstood issue of phimosis is covered by Hodges (1999).

Paragraph 3

There have been increasing claims over recent years of health benefits from routine male circumcision.

1. Contrary to the implication of this sentence, there is nothing new in the claim that circumcision may reduce the risk of a man's becoming infected with the AIDS virus - and I note that the alleged benefit is confined to cases where he engages in vaginal intercourse, or takes the active role in anal intercourse, with a HIV-positive partner, without using a condom.

2. The decline of RNC in Australia and the USA has probably been arrested or slowed by the AIDS scare, which has proved as great a boon to long-time advocates of routine circumcision as it has been a godsend to haters of homosexuals. In each case the response has been the same: AIDS is such a serious disease that it demands both the resumption of mass amputation of foreskins and an end to tolerance of sexual deviants whose vile practices spread the virus. As soon as AIDS became a visible problem in the USA, existing enthusiasts for the operation immediately hailed circumcision as a protection (Fink 1986, 1990), a claim which required some gall, considering that the only country with an AIDS epidemic at that time was the very one in which the vast majority of sexually active men were already circumcised. To its great credit, the medical profession in western countries rejected calls to resume persecution of homosexuals as a "strategy" against AIDS, with the result that the disease has been contained in response to the "safe sex" message. The profession should also resist calls to resume persecution of the foreskin as yet another mystical approach to what remains a serious problem. (See Attachment 2.)

3. But the assertion that circumcision could provide protection against AIDS goes back much further than Fink: it is really a revival of discredited claims that it could lower the risk of contracting other STDs. The AIDS of the 19th century was syphilis, a similarly incurable disease with a long incubation period, hideous symptoms, caused by a blood-borne micro-organism, transmitted by sexual contact; it will come as no surprise that one of the major selling points for RNC in the late 19th century was the proposition that it provided significant protection against syphilis. This claim was first put forward by Jonathan Hutchinson (1855) on the basis of his impressions of the Jewish community in east London, and it was repeated in many articles favouring routine circumcision over the next half century (Freeland 1900), some of which added the novel point that the operation also lowered the incidence of gonorrhoea, despite Hutchinson's original observation that Jewish men actually presented a higher incidence of gonorrhoea than his gentile clientele. Only a few extremists today claim that circumcision provides meaningful protection against STDs, and serious doubts have been thrown on their views (van Howe, 1999).

4. From a paediatric perspective, it is hard to see the relevance of any argument for circumcision relating to STDs acquired through sexual contact with another, since children are not sexually active with others. While paediatricians must take account of the long term as well as the immediate health interests of the child, their direct responsibility ends roughly with the onset of puberty; the average age of first intercourse for boys in Australia is about 17, by which time they are old enough to make their own decisions about their health. Even if it were true that circumcision provided a significant degree of protection against AIDS, it does not follow that all boys should be circumcised at birth. The most you could logically and ethically conclude is that if the uncut faced a greater risk, the danger should be explained to them when they are old enough to understand, and advice provided on the options for minimising it. The boy himself is the one who should decide how he wishes to manage that risk; it is not a decision which should be pre-empted by irreversible actions performed by others.

5. Advocates of RNC are fond of likening circumcision to immunisation (Moses et al 1998, p. 372), a comparison which first emerged in the 1890s, but a moment's thought will reveal that it is a false analogy. Successful vaccination does make a person completely resistant to a disease, but merely to reduce the risk of contracting it is not to confer immunity; vaccination boosts the body's natural antibody system, but circumcision removes healthy and normal tissue; immunisation adds to what is already there, but circumcision injures and mutilates a sensitive and psychologically important part of the male body. It could more accurately be characterised as pre-emptive amputation. It is easy enough to protect the body against future diseases by deleting the organs that are expected to suffer: removal of the testicles or prostate will certainly guarantee immunity to testicular or prostate cancer. Most people would not, however, regard it as appropriate for a doctor to do the work of the disease as though on its behalf; and in relation to all body parts except the foreskin this principle is taken for granted.

Paragraph 4

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.

1. The human rights question is broader than this, crucially involving principles of medical ethics and matters of consent: the limits of surrogate consent, the validity of consent where the child cannot know what is going on or give valid consent, the child's right not to be subjected to irreversible procedures that he or she may later regret. Nor is it correct to imply that the issue of human rights can be ignored until the matter is settled by a court: the problem will be there whether it ever comes to court or not. Even so, damages are increasingly being awarded for injury caused by circumcision, and this trend is likely to strengthen as more men become aware of and indignant about the harm that was done to them.

2. But it is just as much a medical ethics as a human rights or legal issue: in the normal course of events, no part of the body is ever amputated except in cases of desperate necessity (gangrene, infection, incurable damage, cancer) and only after all attempts to save it have failed. If a parent asked a doctor to cut off a baby's finger or toe, he or she would not perform the operation because there is obviously no health advantage, and surrogate consent is valid only if the procedure is of proven medical benefit to the child. Many doctors will not perform even such a mild and relatively harmless procedure as an ear-piercing for the same reason: but if they have scruples there, how much more scrupulous and conservative should they be in relation to procedures on a boy's most prized possession? It is hard to see why the rules governing the amputation of the foreskin should be different from the rules governing the amputation of any other non-diseased body part. The ethical issues are complex, involving both the parents' expectations and the child's rights, and the doctor's obligation to act in the best interests of the child.

Paragraph 8

In the majority of cases, parents will decide for or against a routine male circumcision on family, social, aesthetic and religious grounds rather than medical ones. In all cases the medical attendant should avoid exaggeration of either risks or benefits of the procedure.

1. The ACP/RACP may be realistic in acknowledging that family tradition, social pressure, aesthetic taste and religious affiliation may be more important than medical considerations in most parents' decision on this issue. But having recognised that, what is the duty of the medical attendant? I would suggest that his or her overriding priority should be the health and happiness of the child: that he or she should advise the parents as to the boy's best interests from a health point of view, without regard to such considerations. I am sure that most paediatricians feel this way and act so in their practice. But if the decision regarding circumcision is not a medical one at all, but something as subjective as an aesthetic or social preference, it is surely the prerogative of the boy himself (who will have to live with the result for the rest of his life), and not of any other parties, no matter how much power they may have over him at that time, or how little capacity he has to make his will known at that tender age. If so, the appropriate stance is to recommend caution and restraint, pointing out that the decision regarding circumcision should really be made by the one who must carry the consequences.

2. In this context, it is not enough for the medical attendant to exaggerate neither the benefits of circumcision nor the risks of the procedure. There is a third and vital point left out here: the disadvantages of being without a foreskin. Much of the argument as to the health benefits of circumcision has rested on the assumption that the foreskin was useless flap of skin, with the result that the loss of this tissue was never factored into such cost-benefit analyses of the procedure as have been attempted. The negative aspects of having a partially flayed penis have not been properly assessed; indeed, there has been great reluctance to admit that any damage at all is done, let alone anything as severe as a partial flaying or mutilation. If the foreskin performs valuable functions, or even if it is no more than a desirable adornment, the equation changes sharply, and even if circumcision offered real health benefits, they must be set against the disadvantages of losing that part of the body.

3. Before the 19th century nobody doubted that the foreskin was both central to male sexuality and relevant to female sexual pleasure (Hodges 1999, Wolper 1982), and that perspective is now being rediscovered in countries which took up RNC and consequently lost this knowledge (Cold and Taylor 1999, Cold and McGrath 1999, O'Hara 2001, Taylor et al 1996). Another of the obligations of the medical attendant should be to explain to parents, particularly in cases where the father is circumcised, the functions of the foreskin and the many delights of having a normal penis. As the US physician Robert J. Valentine (1974, p. 42), in an article wildly in favour of circumcision, conceded: "If it [the foreskin] does have a function, its routine removal in newborns cannot be justified. Perhaps the foreskin does have a rationale that has been ignored or not recognised."

Or as Thomas Szasz (1996, p. 145) has argued:

"The practice of RNC rests on the absurd premise that the only mammal in creation born in a condition that requires immediate surgical correction is the human male. If the penile foreskin is not merely non-functional but a biological disadvantage so severe as to justify its immediate ablation, then, surely, it might have atrophied by now."

Attachment 1
Rationale for Jewish circumcision

Many fanciful ideas about the origins of Jewish circumcision were proposed in the 19th century as part of the process by which English doctors came to accept and advocate the procedure as a legitimate one on British boys, including the notion that it arose out of concern with cleanliness or to gain other health benefits. These ideas were elaborated at great length in the late nineteenth century by British and American doctors who were keen to get routine circumcision accepted by their own societies, and by Jewish modernisers who wanted to preserve their ancient ritual by finding sanitary justifications for it and thus defending it against the more radical reformers who wanted to abolish it along with many other outdated observances (Glick 2001). The most elaborate presentation of the hygienic value of circumcision was made by the notorious American doctor and snake oil salesman, P.C. Remondino, author of History of circumcision from the earliest times to the present: Moral and physical reasons for its performance (1891), a feverish diatribe against the foreskin. The orthodox position had been put long before by Moses ben Maimon, who insisted that for Jews circumcision was strictly a test of faith, carried out not to correct a defect but to injure and chasten the penis, thus curbing sexual desire. Until this step was abolished in the late nineteenth century, Jewish circumcision also required the Mohel to suck the bleeding penis after he had cut the foreskin the metsitsah phase); far from being a hygienic measure, this operation was a significant vector for the transmission of fatal diseases, including tuberculosis and syphilis, as even Hutchinson and Abraham Wolbarst, both outspoken enthusiasts for universal circumcision, acknowledged.

ben Maimon (12th century) wrote as follows:

With regard to circumcision, one of the reasons for it is, in my opinion, the wish to bring about a decrease in sexual intercourse and a weakening of the organ in question, so that this activity be diminished and the organ be in as quiet a state as possible.

It has been thought that circumcision perfects what is defective congenitally. This gave the possibility for everyone to raise an objection and to say: How can natural things be defective so that they need to be perfected from outside, all the more because we know how useful the foreskin is for the member? In fact this commandment has not been prescribed with a view to perfecting what is defective congenitally, but to perfecting what is defective morally.

The bodily pain caused to that member is the real purpose of circumcision. None of the activities necessary for the preservation of the individual is harmed thereby, nor is procreation rendered impossible, but violent concupiscence and lust that goes beyond what is needed are diminished. The fact that circumcision weakens the faculty of sexual excitement and sometimes perhaps diminishes the pleasure is indubitable. For if at birth this member has been made to bleed and has had its covering taken away from it, it must indubitably be weakened.

Moses ben Maimon, Guide of the perplexed, Part III, Chapter 49

Despite such explicit texts, is interesting to observe how readily some contemporary advocates of RNC still fall for the sort of stories told by Remondino and other propagandists. Brian Morris writes:

"The Bible records that Abraham circumcised himself at age 99, along with his 13 year-old son Ishmael. Not long afterwards his wife Sarah, after many barren years, became pregnant and bore Isaac. Weiss speculates that Abraham had a foreskin problem, possibly exacerbated by the desert environment, and that this problem interfered with his sexual activity. The difficulties were solved by having a circumcision" (Morris 1999, p. 60, citing G.N. Weiss, "Prophylactic neonatal surgery and infectious diseases", Medical Journal, 1997).

It is surprising to see modern scientists treating the Old Testament as though it was literal history. No serious scholars of ancient biblical studies today believes that the books of the Old Testament have any historicity; it is now generally accepted that they are a collection of myths assembled by Jewish religious leaders in the 6th century BCE. It follows that Abraham et al are as much mythical figures as Hercules or Oedipus, and that Weiss's "speculations" are on a par with Archbishop Ussher's calculations of the age of the earth, according to the genealogies of Genesis, back in the 17th century. Recent research also suggests that Jewish ritual circumcision did not become routine and privileged as a sign of the Covenant until the Babylonian exile of the 6th century (at about the same time as the first five books of the Old Testament - the Torah - were compiled), when the rationale would most likely have been the maintenance of cultural identity and racial purity in a hostile social environment by the enforcement of physical distinctiveness, and would have had nothing to do with foreskin problems, protection against disease or the irritation caused by desert sands (Hoffman 1996, Glick 2001). The foreskin was far more likely a protection against such irritation than a source of it, as Valentine and Remondino admit.

Allowing the myth for a moment, if it was Abraham who had the foreskin problem, why did he also circumcise Ishmael? And if this "problem" prevented him from begetting children, how come he already had a son?

Attachment 2
Circumcision and HIV

Robert van Howe and J. Stephen Svoboda
"Circumcision as a preventive for HIV: Reconciling science,
ethics, and human rights"

Paper presented at 14th meeting of the International Society for Sexually Transmitted Diseases Research, Berlin, 24-27 June 2001

Abstract

Circumcision was introduced as a medical therapy in the late nineteenth century as a preventive measure against masturbation. Recently, circumcision advocates, primarily from circumcising first world countries, have promoted circumcision as a preventive for HIV/AIDS. Their recommendation is based on a number of observational studies that suggest an association between the foreskin and an increased risk of HIV infection. These studies compared disparate populations that were distinguishable on other relevant independent variables. The studies also vary significantly between themselves. Any conclusion based on these observational studies, especially in light of their variability, needs to be viewed with skepticism. As a result, any claims of circumcision's effectiveness in thwarting the HIV pandemic are at best speculative and possibly reckless.

A randomized controlled trial involving permanent amputation of a body part, the benefit of which is largely unproven, is clearly fraught with ethical pitfalls. Even if such a study demonstrates a benefit, the decision to recommend universal circumcision would need to take several factors into consideration: (1) How this intervention compares in efficacy, costs, and complications to other interventions. Since the spread of HIV infection is primarily caused by behaviour, behavioural interventions may hold out the most hope in the long term. (2) The surgical complications of the procedure, which are believed to be higher in developing nations. (3) The permanent untoward effects of the amputation. (4) The legal, ethical and human rights considerations surrounding removing healthy tissue from non-consenting minors to allegedly protect them from a disease that may not exist when they reach sexual maturity. (5) The potential for bias in the information transmitted during the informed consent process in older males. (6) The likelihood that such a recommendation would be interpreted as thinly veiled colonialism. (7) The removal of the majority of the male genital mucosa would interfere with the mucosal vaccines that are being developed.

Note: This statement has been slightly updated and edited since its original submission.

References

Cold, C.J. and J.R. Taylor, (1999), "The prepuce", BJU International, Vol. 83, Supplement 1, January, pp. 34-44 Cold, C.J. and K.A. McGrath (1999), "Anatomy and histology of the penile and clitoral prepuce in primates: Evolutionary perspective of specialised sensory tissue of the external genitalia", in George C. Denniston, Frederick Hodges and Marilyn Milos (eds), Male and female circumcision: Medical, legal and ethical considerations in pediatric practice, New York, Kluwer Academic/Plenum Publishers
de Meo, James (1997), "The geography of male and female genital mutilations", in George C. Denniston and Marilyn Fayre Milos (eds), Sexual mutilations: A human tragedy, New York, Plenum Press
Dunsmuir, W.D. and E.M. Gordon (1999), "The history of circumcision", BJU International, Vol. 83, Supplement 1, January, pp. 1-12
Fink, A.J. (1986), "A possible explanation for heterosexual male infection with AIDS", New England Journal of Medicine, Vol. 315, p. 1167
Fink, A.J. (1990), "Newborn circumcision: A long-term strategy for AIDS prevention", Journal of the Royal Society of Medicine, Vol. 83, p. 673
Freeland, E. Harding (1900), "Circumcision as a preventive of syphilis and other disorders", Lancet, Vol. 2, (29 December), pp. 1869-70
Glick, Leonard (2001), "Jewish circumcision: An enigma in historical perspective", in Marilyn Milos, George C. Denniston and Frederick Hodges (eds), Understanding circumcision: A multi-disciplinary approach to a multi-dimensional problem, London and New York, Kluwer Academic and Plenum Press
Gairdner, Douglas (1949), "The fate of the foreskin: A study of circumcision", British Medical Journal, Vol. 2, (24 December), pp. 1433-37
Gollaher, David L. (2000), Circumcision: A history of the world's most controversial surgery, New York, Basic Books
Hodges, Frederick (1997), "A short history of the institutionalization of involuntary sexual mutilation in the United States", in George C. Denniston and Marilyn Fayre Milos (eds), Sexual mutilations: A human tragedy, New York, Plenum Press
Hodges, Frederick (1999), "The history of phimosis from antiquity to the present", in George C. Denniston, Frederick Hodges and Marilyn Milos (eds), Male and female circumcision: Medical, legal and ethical considerations in pediatric practice, New York, Kluwer Academic/Plenum Publishers
Hoffman, Lawrence W. (1996), Covenant of blood: Circumcision and gender in rabbinic Judaism, University of Chicago Press
Hutchinson, Jonathan (1855), "On the influence of circumcision in preventing syphilis", Medical Times and Gazette, Vol. 2, p. 542
Hyam, Ronald (1990), Empire and sexuality: The British experience, Manchester University Press
Morris, Brian (1999), In favour of circumcision, Sydney, New South Wales University Press
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O'Hara, Kristen (2001), Sex as nature intended it, Hudson, Mass., Turning Point Publications
Remondino, P.C. (1891), History of circumcision from the earliest times to the present: Moral and physical reasons for its performance, Philadelphia and London, F.A. Davis
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3. J. Steven Svoboda, Attorneys for the Rights of the Child

27 September 2001

Dr Elizabeth Murphy
Paediatrics & Child Health Division
Royal Australasian College of Physicians
145 Macquarie Street
SYDNEY NSW 2000

Re: Review of Policy on Routine Circumcision of Normal Male Infants and Boys

Dear Dr Murphy

I am a Harvard-educated attorney and Executive Director of Attorneys for the Rights of the Child (ARC), a federally accredited non-profit organization based in the United States but with attorney and non-attorney board members, advisory board members, members and supporters located in many countries throughout the world. My writings have been published by a leading Australian journal, the Journal of Law and Medicine(1). One of the individuals with whom ARC most closely works is Professor Gregory Boyle of Bond University, lead author of the aforementioned article.

I understand that the RACP will be considering the issue of male circumcision at its next Policy Committee Meeting. As I understand things, the Australian College of Paediatrics has been absorbed into the RACP, and the RACP now has adopted and has under review the 1996 Australian College of Paediatrics' (ACP's) Position Statement on Routine Circumcision of Normal Male Infants(2). I am writing to point out a few pertinent principles for your consideration and to provide you with copies of some materials which may be of assistance in your review of this important issue. I have enclosed two articles I co-authored, from the Journal of Law and Medicine and the Journal of Contemporary Health Law and Policy.

The average male circumcision removes at least half of the skin of the penis and also does significant other damage(3). The Australian Association of Paediatric Surgeons has unambiguously rejected the practice, declaring that it "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(4)." The Australian Medical Association has concurred, stating its determination to "discourage circumcision of baby boys in line with the Australian College of Paediatrics' Position Statement on Routine Circumcision of Normal Male Infants and Boys."(5) All national medical associations worldwide which have addressed the issue have uniformly failed to find justification for male circumcision as a routine therapeutic procedure(6). The Queensland Law Reform Commission concluded, "The circumcision procedure is invasive, irreversible and major. It involves the removal of an otherwise healthy organ part. It has serious attendant risks."(7)

Parental consent is invalid except under certain limited circumstances not met by routine infant circumcision.(8) According to the Queensland Law Reform Commission:

"The common law operating in Queensland appears to be that if the young person is unable, through lack of maturity or other disability, to give effective consent to a proposed procedure and if the nature of the proposed treatment is invasive, irreversible and major surgery and for non-therapeutic purposes, then court approval is required before such treatment can proceed. The court will not approve the treatment unless it is necessary and in the young person's best interests. The basis of this attitude is the respect which must be paid to an individual's bodily integrity."(9)

The legal status quo, whereby circumcisions are not punished either criminally or civilly as long as they are done "competently" and with "consent" of the parents, must be unstable. Paragraph 4 of the ACP's 1996 position statement states: "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."(10) Indeed, a number of human rights documents - whether ratified or applicable under principles of customary international law - forbid routine infant male circumcision based on such important principles as the rights of the child, the right to freedom of religion, and the right to the highest attainable standard of health. These include the United Nations Charter, the International Covenant on Civil and Political Rights, the International Covenant on Economic, Social and Cultural Rights, and the Convention on the Rights of the Child, now ratified by all but two of the world's nations.(11) Each of these documents has been ratified by Australia.(12)

The right of freedom of religion does not justify and conflicts with male circumcision. Children bear their own right to freedom of religion, independent of the wishes of their parents or guardians. Under Article 14.1 of the Convention on the Rights of the Child, children have the right to demand that states parties respect their right to freedom of thought, conscience, and religion. No infant is capable of consenting to a surgical procedure based on his own religion. Where the procedure is one based on religion, it is therefore the parents' religion which motivates the procedure and not the religion of the person whose genitals are being surgically altered. A parent's consent is therefore again clearly insufficient.(13)

Precisely due to the necessity of preserving freedom of religion, governments must prevent ritual male circumcision and, for that matter, ritual female genital mutilation. A ritual mutilation permanently takes away the person's right to his bodily integrity and his right to choose whether to permit the alteration of his body under the precepts of a particular religion.

Thank you for your time and attention. If you have any questions regarding any matters raised in this letter or in the attached articles, please feel free to contact me as indicated above.

Very truly yours

J Steven Svoboda
Executive Director

References

1 Boyle GJ, Svoboda JS, Price CP, Turner JN. Circumcision of healthy boys: criminal assault? J Law & Med 2000; 7:301-310.

2 Position Statement: Routine Circumcision of Normal Male Infants and Boys. Parkville, Victoria: Australian College of Paediatrics; 1996.

3 Taylor JR, Lockwood AP and Taylor AJ. The Prepuce: Specialized Mucosa of the Penis and its Loss to Circumcision. British Journal of Urology 1996; 77:291-295.

4 Guidelines for Circumcision. Australasian Association of Paediatric Surgeons. Herston, QLD: 1996.

5 Circumcision Deterred. Australian Medicine 1997 (6-20 January):5.

6 See www.cirp.org/library/statements/, downloaded 26 September 2001.

7 Circumcision of Male Infants Research Paper. Queensland Law Reform Commission. Brisbane 1993, p. 39

8 Svoboda JS, Van Howe RS, Dwyer JG. Informed consent for neonatal circumcision: an ethical and legal conundrum. J Contemp Health Law Policy 2000; 17(1): 60-134.

9 Circumcision of Male Infants Research Paper. Queensland Law Reform Commission. Brisbane 1993, p. 38

10 Position Statement: Routine Circumcision of Normal Male Infants and Boys. Parkville, Victoria: Australian College of Paediatrics; 1996.

11 Boyle GJ, Svoboda JS, Price CP, Turner JN. Circumcision of healthy boys: criminal assault? J Law & Med 2000; 7:301-310.

12 The United Nations. The United Nations and Human Rights, 1945-1995. New York: United Nations Department of Public Information; 1995, p. 504.

13 Svoboda JS, Van Howe RS, Dwyer JG. Informed consent for neonatal circumcision: an ethical and legal conundrum. J Contemp Health Law Policy 2000; 17 (1): 60-134.