News about circumcision from Australia and around the world : 2011

In a hard hitting editorial that raises the spectre of neocolonialism, the South African Medical Journal has condemned the push for mass circumcision of African men as the solution to the nation’s HIV-AIDS problem. The editorial, by the journal editor Professor Daniel Ncayiyana, reviews the evidence for the claim that circumcision reduces the risk of female-to-male infection, and finds it less conclusive than assumed (and far less significant than regularly proclaimed in sensationalist newspaper headlines). Instead of taking the risky and expensive surgical road, the editorial urges South Africa to follow the recommendation of the Australian Federation of AIDS Organisations, which has rejected circumcision and reiterated that “correct and consistent condom use … is the most effective means of reducing female-to-male transmission, and vice-versa.”

For a full report, see the Africa page.

USA: Medical benefits for circumcision may be unlawful

Payments for non-therapeutic (medically unnecessary) circumcision by the United States health insurance scheme Medicaid violate the protocols for payments under this program and may thus be unlawful. This is the startling conclusion of an article by US legal expert Peter Adler in a leading law journal in December 2011. The article shows that the federal and state Medicaid acts stipulate that physicians and patients can use Medicaid to pay for medical services only when they are clinically necessary. This provision clearly excludes non-essential medical services, such as cosmetic surgery, and some states expressly exclude cosmetic surgery from the list of covered treatments. In addition, federal and state Medicaid law require diagnosis of a medical condition and recommendation of an effective treatment before any benefit is payable. Even then, surgery is permitted only as a last resort.

Since the vast majority of circumcision procedures subsidized by Medicare are of normal male infants and boys who are not suffering from any sort of pathological condition that requires surgery or any other medical treatment, it follows that most circumcision procedures violate the Medicaid guidelines and hence that the resulting payments are unlawful. American medical associations have concede that circumcision is not merely unnecessary, but that it is usually performed for religious, cultural, personal, or even cosmetic reasons (so that the boy “looks like his father”). It is estimated that between 50 and 100 million boys have been circumcised in the United States since the introduction of Medicaid in 1965, at a cost of several billion dollars. Although 18 of the 50 states have dropped circumcision from their schedule of covered treatments, it follows that a high proportion of this money has been expended unlawfully.

The article concludes that it is not within the discretion of the US federal government or the other 32 states to continue Medicaid coverage of circumcision merely because they wish to do so or because they think that circumcision is a matter of parental choice. The law is clear: Medicaid payments for non-therapeutic circumcision must cease.

Source: Peter Adler, “Is it lawful to use Medicaid to pay for circumcision? Journal of Law and Medicine”, Vol. 19, December 2011: 335-353. The abstract of the paper may be viewed, and the full paper purchased, from the Journal of Law and Medicine home page.

Circumcision and HIV prevention: New study slams flaws in African clinical trials

A new review of those three famous Randomised Controlled Trials (RCT) of circumcision in Africa slams the claim that they prove that circumcision significantly reduces the risk of men contracting HIV/AIDS during unprotected sexual intercourse with an infected female partner. While the risk reduction achieved by circumcision has commonly been reported as “60 per cent”, the paper points out that this is merely relative risk, and that the absolute risk reduction is much lower - a miserable 1.3 per cent. Even the relative risk reduction (49 per cent) appears to have been exaggerated. Just as seriously, there appears to have been a 60 per cent relative increase in the risk of male to female HIV transmission when the male partner is circumcised. The authors of the paper argue that circumcision is still unproven as an effective means of HIV prevention, and that - given the expense, the risk of complications, the damage to sexual function and the danger of human rights and ethical abuses - it should not be deployed on the massive scale that we are witnessing.

The review, in the December 2011 edition of the Journal of Law and Medicine, is by independent research consultant, Dr Gregory J Boyle, PhD, DSc, and George Hill, a consultant with the American ethical medicine group, Doctors Opposing Circumcision.

For full details, see the Africa page.

Infant male circumcision is genital mutilation

An article in the British newspaper, The Guardian, argues that men should have the right to choose circumcision, not have the choice forced upon them:

There are still many people who like to pretend that infant circumcision and genital mutilation are not the same thing. Some of them apparently work at Indonesia’s health ministry, the Departemen Kesehatan, who recently issued guidelines for “safe” female circumcision and wheeled out a spokeswoman to dispense the following words of wisdom: “I would like to stress that female circumcision is not genital mutilation, which is indeed dangerous. They are two things that are very different.”

The same attitude is widespread in Britain. Thousands of people believe, against all logic and reason, that male infant circumcision is somehow not genital mutilation. Mutilation is a loaded term, so let me be clear what I mean. I don’t mean that circumcision is mutilation. If consenting adults want to modify their bodies by snipping a bit off here or adding a bit there, then that's their right, and beauty is very much in the eye of the beholder. Infant circumcision is a completely different matter. Infant circumcision involves performing surgery without consent to permanently alter an individual’s genitals. … Just as we call sex without consent “rape”, circumcision without consent or reasonable justification should be called “mutilation”.

Circumcision of infants or children without an immediate medical requirement is an unjustified violation of basic human rights.

For full text, see Martin Robbins, Infant male circumcision is genital mutilation, The Guardian, 6 December 2001

Not a surgical vaccine: Circumcision not appropriate for HIV control in Australia

A paper in the Australian and New Zealand Journal of Public Health argues that circumcision of baby boys has no place among HIV control measures in Australia. Researchers Robert Darby and Robert Van Howe said that there was nothing in the results of the African circumcision trials to justify circumcision as an HIV control measure in developed countries, nor to warrant circumcision of infants rather than adult men. “Quite apart from the ethical problem, today’s infants would not be at risk of any sexually transmitted infection until they become sexually active in 16-20 years time. By then both prevention and treatment options, as well as the virus itself, may well have changed beyond recognition”, Dr Darby said.

In their paper the authors reviewed recent suggestions that widespread circumcision of male infants be introduced in Australia as a means of combating heterosexually transmitted HIV infection. They found them flawed in several crucial areas. These include doubts about the African trials themselves, their relevance to Australia, the risks and harm of circumcision, and issues relating to informed consent and human rights. They also criticised the notion of circumcision as a “surgical vaccine” as unscientific and irresponsible from a public health point of view. “Such an exaggerated claim is likely to encourage high-risk behaviour”, Dr Darby said.

The proposals under review were largely inspired by three clinical trials in Africa. But Dr Darby said the public health situation is dramatically different in a wealthy, developed nation such as Australia. “There is no heterosexual HIV epidemic in Australia that would justify a costly, authoritarian program on the scale suggested,” he said. “On the contrary, our analysis supports the conclusion of the Royal Australasian College of Physicians, in its policy statement on circumcision, that routine circumcision is not appropriate in the Australian and New Zealand context.”

Read full report on this site.

Conference report: Law, human rights, and non-therapeutic interventions on children

A conference titled, “Law, Human Rights, and Non-Therapeutic Interventions on Children,” was held on 31 August – 1 September at the University of Keele, UK. Speakers from the United States, Britain, the Netherlands and Australia covered all aspects of non-therapeutic surgery on children’s genitals, including male circumcision, female genital cutting (mutilation), and intersex children (i.e. babies born with ambiguous genitalia). The conference organizers, including David Smith of Genital Autonomy Eu and Michael Thomson, professor of Law at the University of Keele, took a very creative approach, bringing together grass-roots anti-circumcision and child protection activists with academics and officials not necessarily associated with direct advocacy. All participants felt that the event was "a smashing success", marking a new phase in the struggle for recognition of the rights of children to bodily integrity.

Read detailed report on the conference here.

Economists slam African circumcision programs

In recent months the African circumcision programs have come under strong attack from leading economists, who warn that the programs are not cost effective and are distorting the health budgets of recipient countries. The circumcision programs were introduced after three clinical trials appeared to show that circumcision could reduce a male’s risk of acquiring HIV through unprotected sexual intercourse with an infected female partner. The degree of risk reduction is estimated by the authoritative Cochrane Review as somewhere between 38% and 66% – which has not prevented circumcision advocates and an uncritical media from bandying a mythical “60 per cent protection” as though it was the same thing as immunity. The excessive stress on HIV control, and within this on circumcision as the best tactic, is criticised in a paper by Michael Grimm and Deena Cass, published by the German Development Bank; while Bjorn Lomborg and economists at the Copenhagen Consensus Center have criticised the African circumcision programs as too expensive, and far less effective than cheaper interventions that have the additional advantages of being both less risky and less controversial.

Read full account on Circumcision and AIDS control page

Men circumcised as children at greater risk of HIV

A study in Mozambique has found that men circumcised as children are 2 or 3 time more likely to be infected with HIV than uncircumcised men. The study, by Dr D.D. Brewer, confirms earlier research in Kenya, Lesotho and Tanzania that young people without sexual experience were more likely to be HIV-positive if they had been circumcised or if they had gone through traditional cutting rituals such as scarification. The results confirm the argument of David Gisselquist and others that a significant number of African AIDS cases are not the result of heterosexual intercourse, but of non-sterile medical procedures. The increasing evidence of non-sexual transmission of HIV casts further doubt on the value of mass circumcision campaigns as the magic bullet against AIDS.

Read details of study on Circumcision and AIDS control page

Zambia: Another study fails to find that foreskins increase risk of HIV

A study of the possible link between genital herpes and increased risk of HIV in Zambia did find that men with herpes were more likely to be HIV-positive, but also found that lack of circumcision did not increase the risk of HIV infection. Quite the contrary, the study found that uncircumcised men were less likely to contract HIV. In their discussion of the results, however, the authors of the study failed to mention this vital fact, and concluded by recommending that circumcision be promoted as an AIDS control strategy – thus violating the most basic principles of evidence-based medicine.

Read full story on AIDS News page

Cutting through the myths of circumcision

Further evidence that intelligent Americans are rejecting and abandoning circumcision is provided in a September issue of the on-line journal Psychology Today, which has published a series of articles tackling common myths about the foreskin and circumcision. In one of these articles Dr Darcia Narverez considers the perennial issues of hygiene, cleanliness and sexually transmitted diseases.

Read the article on USA News page here.

Australia: Rising demand for female circumcision

An article in the February edition the Medical Journal of Australia warns against the rising demand for female circumcision. The article, by law professor Dr Ben Mathews, calls for increased protection of girls and women from this danger. The demand is generated by recent immigrants from Middle Eastern and African countries where circumcision of girls and boys is a common customary or cultural practice. As more immigrants arrive from these places, the demand for circumcision of young girls is rising along with the demand for circumcision of young boys. Female circumcision (also known as Female Genital Mutilation (FGM) or female genital cutting) refers to a wide range of procedures in which parts of the external female genitalia are cut off to satisfy culturally determined requirements of chastity, cleanliness, and aesthetics. FGM is often practiced in poor sanitary conditions, leading to significant complications

Read full article on female circumcision page

Melbourne: Sailor sues over circumcision injury

A FORMER sailor who was circumcised without consent and against his will by a ship's doctor and suffered ridicule from his shipmates is seeking compensation almost 40 years after the operation. He woke during the operation and had to be physically restrained while it was completed, according to evidence to a tribunal. The attendant holding him down then joked his foreskin would make good fish bait.

The Melbourne man, 56, is seeking a $28,600 a year defence force pension because he claims his severe depression that emerged after the circumcision was caused by his defence service. The Repatriation Commission rejected his claim, despite its own expert diagnosing the man, known only as DZLG, as suffering a "generalised anxiety disorder" because of the ridicule after the operation. But the Administrative Appeals Tribunal ruled the commission was wrong and recommended the man be given a pension.

The man was 19 when he was posted on HMAS Sydney in 1973 and attended sick bay with a sore penis, the tribunal was told. He had expected to receive an antiseptic cream but instead was circumcised and he told the tribunal the operation "just happened" and he had no time to object. A medical attendant "held the removed foreskin in tongs and joked about using it for fishing", he said. The man fainted and spent four days in sick bay, then his shipmates started taunting him. “Jokes were made referring to the size of his penis . . . he was called names,” the tribunal found. When he transferred to another ship the taunts continued and he became depressed, alienated and lonely, the tribunal found.

His lawyer, Greg Isolani of KCI Lawyers, said the bullying affected the sailor for the rest of his life, leaving him a "shattered man". He said it was "extremely disappointing" that the Department of Veterans' Affairs forced him to appeal to a tribunal.

Source: Herald Sun (Melbourne), 4 September 2011

Circumcision of male infants and boys: The rising tide of doubt

In recent months there has been a spate of articles in the United States, British and even Australian media on the pros and cons of circumcising non-consenting male infants and boys, but the predominant sentiment in these essays has been doubt and rejection. No matter what "health benefits" circumcision may provide in later life, it is increasingly recognised that such a radical surgical operation is not necessary for the well-being of children, and is not ethically permissible if performed on a person without his informed consent.

Is there such a thing as male circumcision?

It is common to hear the phrase male circumcision (abbreviated to MC by those who do not really want to think about the realities of surgery on the most sensitive part of the male body), but the truth is that there is no such thing as male circumcision. People also speak of circumcision as a "valid procedure" - but what on earth could such an absurd expression mean? It's like saying that sexual intercourse is a valid procedure. I suppose it means that circumcision is a justified or justifiable operation, but the truth of that claim will depend on context: it may be justifiable to perform the operation on adults who have given informed consent, and even on children who cannot give consent in situations of therapeutic necessity (i.e. to correct a pathology that has not responded to conservative treatment); and it is arguable that it is justifiable where the parents are devout, conscientious, practising adherents of a religion that holds that children must be circumcised. Like sexual intercourse, it all depends on the context: with the consent of a person above the legal age of consent, sexual intercourse is justifiable; without consent, or if the person is below the statutory age, it is sexual assault or rape. There is no reason why the rules for permanent bodily alterations, particularly in such a physically and psychologically sensitive area should be less strict than the rules for sexual activity. In fact, the expression "male circumcision" is meaningless: there is no such thing as male circumcision, only circumcision of males in a variety of contexts, some of which are justifiable, some of which may be justifiable, and some of which are definitely not justifiable. Without specifying the context you cannot say whether the operation is "valid" or not.

On a new page we reprint a range of recent critiques of "male circumcision" as commonly understood - that is, medically unnecessary circumcision of male infants or boys. These are humans with inherent human rights, who have not given their consent to such a dramatic alteration of their body. Read the articles here.

Circumcised men at equal risk of HPV infection

A large-scale study at the University of Washington has found no difference in the incidence of HPV infection between circumcised and uncircumcised male college students. HPV (Human Papilloma Virus) is a large group of viruses that may cause genital warts, and are implicated in the genesis of genital cancers. HPV is very common among the sexually active population. but most people never show any symptoms. The risk factors for the development of cancer have been shown to be numerous different sexual partners and smoking. The new study confirmed previous research which showed that the location of the virus differed between circumcised and uncircumcised men: circumcised men tend to carry the virus on the shaft skin of the penis, while intact men are more likely to carry it on the glans. The study also also found that circumcised men have more sexual partners. In a previous study the researchers found found that for college females the circumcision status of their partner was NOT a risk factor for HPV infection in women. The authors comment that the African Random Clinical Trials, which seemed to show that uncircumcised men were more likely to carry the HPV virus, were seriously flawed because they took samples only from the glans (not from the shaft skin, where the virus is concentrated in the circumcised).

ABSTRACT

Background: The role of circumcision in male HPV acquisition is not clear.

Methods: Male university students (aged 18–20 years) were recruited from 2003 to 2009 and followed up triannually. Shaft/scrotum, glans, and urine samples were tested for 37 human papillomavirus (HPV) genotypes. Cox proportional hazards methods were used to evaluate the association between circumcision and HPV acquisition. Logistic regression was used to assess whether the number of genital sites infected at incident HPV detection or site of incident detection varied by circumcision status.

Results: In 477 men, rates of acquiring clinically relevant HPV types (high-risk types plus types 6 and 11) did not differ significantly by circumcision status (hazard ratio for uncircumcised relative to circumcised subjects: 0.9 [95% confidence interval{CI}: 0.7–1.2]). However, compared with circumcised men, uncircumcised men were 10.1 (95% CI: 2.9 –35.6) times more likely to have the same HPV type detected in all 3 genital specimens than in a single genital specimen and were 2.7 (95% CI: 1.6–4.5) times more likely to have an HPV-positive urine or glans specimen at first detection.

Conclusion: We found no differences by circumcision status in overall HPV acquisition or in number of HPV types acquired. Findings held for all clinically relevant HPV types, as well as for the subgroups of high-risk types, high-risk -9 types, and HPV-16. This observation is consistent with findings from other longitudinal studies.

Bottom line: Circumcision does not lower the risk of infection with Human Papilloma Virus. People who claim that uncircumcised men are more likely to develop or communicate genital cancers are ignoring the facts and spreading misleading information.

Source: Kelley Van Buskirk et al, Circumcision and Acquisition of Human Papillomavirus Infection in Young Men, Sexually Transmitted Diseases 38 (12), December 2011.

Journal homepage: http://journals.lww.com/stdjournal/pages/default.aspx

Abstract available at journal - Published ahead of print: http://journals.lww.com/stdjournal/toc/publishahead

Further information male genital cancers

Further information on cervical cancer

Foreskin restoration: New regenerative medical technologies offer hope to circumcised men

For men deprived of and missing their foreskin - either because it was taken without their consent when they were babies, or because they made a big mistake as an adult - there have been only two ways to cope with the loss: grin and bear it (and maybe not admit that there was a loss, like the fox who lost his tail), or attempt restoration by slowly stretching the remnant foreskin tissue. In the early years A.D. this method was used by young Jewish men who wanted to appear uncircumcised and thus take a greater part in Hellenic social life; but the method was slow, and would work well only if there was a fairly large quantity of foreskin tissue left to stretch. Men who had suffered a really tight circumcision had a far more difficult and often impossible task.

But recent advances in regenerative medical techniques are now offering hope that it may be possible to regrow the foreskin, nerves and all, and restore it to something like what it would have been naturally. It is only an idea as yet, but similar techniques using stem cells have been successfully used to regrow some internal organs, and there are reports of successful vaginal reconstructions using similar methods. For the present the organisation behind the initiative, Foregen, is seeking to raise funds for further research and a pilot program. Where is the Gates Foundation when you need it? After providing hundreds of millions of dollars to circumcise Africans, the least it could do is offer a few hundred thousand to repair the damage. After all, when the HIV crisis is over and AIDS can be prevented or cured, many of those men may want their foreskins back.

IntactNews recently interviewed Vincenzo Aiello, the founder of Foregen, a non-profit organization raising funds for foreskin regeneration using the latest regenerative medicine technologies. Foregen’s ambition is to provide foreskin regeneration surgeries for men who were circumcised without their consent. Read the full interview here.

Australia: Circumcision rate continues its slow decline

Contrary to recent, ignorant, media reports, the incidence of infant circumcision in Australia is not increasing, but, on the contrary, is static nationally and actually declining in most states and territories. This is the conclusion of an analysis of circumcision figures for the period 2000-2010, published in the August issue of the Australian and New Zealand Journal of Public Health. The article compared the Medicare rebate for circumcision of boys under 6 months with male birth statistics, concluding that the incidence of circumcision had stayed pretty steady at 12 per cent across the nation, but with big falls in some states, offset by small rises in others.

The most striking feature of the figures is wide variation among the states – from a low of 1.5 per cent in Tasmania to a high of 17.3 per cent in New South Wales for 2010. In between are the Australian Capital Territory and Western Australia on 6 per cent and 6.8 per cent respectively, and South Australia and Queensland on 15.1 and 14 per cent. Another feature of the figures are the sharp falls in Tasmania, from 9.3 per cent in 2000 to 1.5 per cent in 2010; in the Northern Territory from 7.6 to 2.7 per cent; and in Queensland from 20.3 per cent to 14 per cent. There have been small rises over the same period in Victoria (5.3% to 8%) and New South Wales (14.3% to 17%), though these may well be a product of changes in hospital policy rather than evidence of increased demand for the operation.

The article suggests that the rises in NSW and Victoria may be related to the decision by state governments (NSW in 2006, Vic and SA in 2007) to cease providing non-therapeutic (medically unnecessary) circumcision as a service in their public hospitals. This may have resulted in a shift in the provider of the service from hospitals (where no Medicare rebate is payable or recorded) to GPs and specialist clinics, where the procedure shows up in the Medicare statistics. The rise may thus be more apparent than real. The article wonders why Medicare is providing a rebate for circumcision, considering that the latest statement by the Royal Australasian College of Physicians does not recommend it or regard it as necessary, and the Medicare guidelines state that rebates are not available for “medical services which are not clinically necessary”. The article concludes that there is no evidence for recent assertions that “circumcision is back in favour”, and points out that, on the contrary, it is continuing its slow decline from the high-point of the mid-1950s, and is close to its lowest level for nearly a century.

Source: Robert Darby, Infant circumcision in Australia: A preliminary estimate, 2000-10, Australian and New Zealand Journal of Public Health 35 (4), August 2011.

New leaflet on foreskin care wins applause

Several viewers of this website have written in to commend the new leaflet, Circumcision and foreskin care: Guide for parents, saying it is the most sensible and thorough outline of the subject they have seen. One letter is from David Priestly*, a man in his late 60s, father of three sons, none of whom was circumcised, who received advice on how to care for his own foreskin from his father, who in turn was taught by his father ... and so on. The letter displays a wealth of experience and good sense on the habits of the foreskin and the sort of care that will keep it happy, problem free and in good working order, as well as advice on how to handle the minor problems that may arise from time to time, not to mention a lively sense of the importance of the foreskin for body image and sexual pleasure. There is a lost world of secret men's business here, where knowledge of the body was passed down the family from father to son. (*Name changed for privacy reasons.)

Read the full letter here.

Boy awarded $4.6 million for circumcision injury

Los Angeles, USA: A boy has been awarded damages of $4.6 million for injuries suffered during a routine circumcision procedure when he was a week old. The boy will need yearly visits to a pediatric urologist and will continue to obtain psychiatric care to deal with the trauma of this incident and resultant surgeries. In addition, future surgery may be required as he grows older. The lawyer for the family said that the case was “one of the most extraordinary” in which he had been involved, and that the victory offered benefits for society and other families: “In the process of this litigation, we also have exposed a danger to children which we hope to eradicate by the effects of this litigation and settlement.” The boy’s mother, a single parent with one other son, said she hoped this case would help to prevent this sort of tragedy from happening to anyone else and that that warnings would be given to people about what could happen.

Read full story at Daily Breeze.

“Unethical and illegal”: South African Medical association rejects circumcision of infants

In a letter dated 23 June 2011, the South African Medical Association has stated that it does not support the practice of circumcision of infants as a means of preventing HIV transmission and that it considers circumcision of infants to be both unethical and illegal. The letter was signed by Ms Ulundi Behrtel, Chairperson of the Human Rights, Law and Ethics Committee. The full text of the letter follows:

23 June 2011
Mr Dean Ferris, Co-Director
National Organisation of Circumcision Information Resource Centre, South Africa

Dear Mr Ferris

CIRCUMCISION OF BABIES FOR PROPOSED HIV PREVENTION

We refer to the above matter and your email correspondence of 16 February 2011. The matter was discussed by the members of the Human Rights, Law & Ethics Committee at their previous meeting and they agreed with the content of the letter by NOCIRC SA. The Committee stated that it was unethical and illegal to perform circumcision on infant boys in this instance. In particular, the Committee expressed serious concern that not enough scientifically-based evidence was available to confirm that circumcisions prevented HIV contraction and that the public at large was influenced by incorrect and misrepresented information. The Committee reiterated its view that it did not support circumcision to prevent HIV transmission. We trust that you will find this in order.

Yours faithfully
Ms Ulundi Behrtel
Head: Human Rights, Law & Ethics unit
Obo Chairperson: Human Rights, Law & Ethics Committee
SA Medical Association

A pdf of the letter is available on request through the contact form.

“Human rights violation”: Blood, Sweat and Tears singer Jason Paige condemns circumcision

Hot on the heels of Russell Crowe calling circumcision “stupid and barbaric”, another celebrity has spoken out against the practice. This time it’s Jason Paige, lead singer for the rock group Blood, Sweat and Tears, who has devised a one-man show to highlight the physical damage that circumcision can cause and to show people that doing it to babies, children or anybody who has not given informed consent is a serious human rights violation. He told his story in an interview with Rebecca Wald, founder of the blog Beyond the Bris.

“Los Angeles performer Jason Paige wants the audience of his one-man comedy show to realize his song about his botched bris isn’t a joke. So he calls a few audience members to the stage and has them face him. The rest of the audience can’t see Jason as he pulls down his pants to reveal what he calls his “piercing,” a small hole in his penis through which he can--and does, for performances--dangle an earring. Proof to the crowd of his circumcision gone wrong comes as the audience participants return to their seats, stunned looks on their faces.

“Jason has a circumcision complication known as a skin bridge. A remanent of his foreskin became fused to the head of his penis as an infant during the healing process. Sometimes skin bridges can result in painful erections and severe disfigurement. In Jason’s case, it prompted him to learn more about "what goes down" during a circumcision procedure, and ultimately to oppose the practice. It also inspired him to record a music video titled “Circumcision” and sung to the tune of Stevie Wonder’s “Superstitious.” In the parody, Jason wears a black tee-shirt with white letters that ask: Guess Where I’m Pierced?”

[Note: Skin bridges are a very common complication of circumcision. The high risk of such an adverse result is yet another reason why circumcision, if it must be performed, should not be done until the foreskin has separated naturally from the glans and become fully retractable.]

Read the full story at Beyond the Bris.

Another U.S. state drops circumcision from its medical benefits schedule

Colorado has become the 18th American state to drop medically unnecessary circumcision from the schedule of medical benefits under the Medicaid program. The decision comes as a result of a campaign by human rights and child protection advocates to protect baby boys from genital cutting, and in response to the budgetary crisis affecting so many American public authorities. When there is little enough funds available for necessary medical procedures, it makes no sense to waste valuable health dollars on unnecessary and harmful operations that the recipients do not want.

Read full details of decision on this site

More circumcision deaths in South Africa

So far this month (June 2011) seven boys have died from circumcision wounds in South Africa’s Eastern Cape province. Winter is the traditional time for teenage boys from the Xhosa people to be circumcised in accordance with a customary tribal rite by which they are initiated into adult status. The operation has always had a high casualty rate, so much so that in 2003 the South African Medical Journal called for action to “stop the carnage”. Last year 62 boys died from the operation and a further 23 lost all of their genitals, so it does not appear that this appeal has had much impact.

According to the South African newspaper New Age, the deaths occurred “despite large-scale intervention from the departments of health and local government and traditional affairs as well as traditional leaders to stop the deaths of initiates.” Nkosi Xolile Ndevu, provincial secretary of the Congress of Traditional Leaders of South Africa said the deaths initiates was attributed to profit-driven traditional surgeons who did not perform the ritual properly. “Some of them have no knowledge on how to carry out the custom, leaving these young boys in the hands of inexperienced young men,” said Ndevu. Health spokesperson Sizwe Kupelo agreed and shared Ndevu’s sentiments. “These killings are attributed to assault and poor coordination of the custom in some parts of the province,” said Kupelo. Supporters of the circumcision rite say that because it is a traditional custom it should not be interfered with and must be allowed to continue.

We are struck by the difference between the deafening silence of Western medical and human rights agencies when it comes to the death of boys from traditional circumcision and the loud noise of their zealous efforts to eradicate far milder and less harmful forms of female genital cutting. Apparently, harm to boys does not matter. One fact is clear: in South Africa, more teenage boys die from circumcision than from heterosexually-transmitted HIV-AIDS.

Source: Sithandiwe Velaphi, Seven initiates die, The New Age (South Africa), 24 June 2011

New study: Circumcision cuts sexual satisfaction in men and partners

A study by Danish researchers has found that circumcision not only reduces sexual satisfaction in circumcised men, but also in their female partners. The study, reported at 20th World Congress for Sexual Health, Glasgow, in June 2011, and published in the International Journal of Epidemiology, examined the association of male circumcision with a range of sexual measures in both sexes. The conclusion was that male circumcision was “associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in women, notably orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment.”

The authors comment that more study of these issue is warranted, especially in regions where circumcision is more common than in Denmark (where it is, of course, extremely rare). The authors do not specify these places, but they are most likely referring to the United States, where circumcision is still extremely common, and to the African countries, where circumcision is being introduced on a mass scale as a tactic against heterosexually-transmitted HIV infection. An implication of their study is that if African men are not being informed as to the possible adverse effects of circumcision on sexual function and satisfaction, their consent to the operation may not be legally valid.

Source: Morten Frisch, Morten Lindholm and Morten Grønbæk, Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark, International Journal of Epidemiology, advance access 2011;1–15.

Read more on the Controversy page of this site, Circumcision and sexual satisfaction.

If you would like a PDF of the complete article, please contact Circumcision Information Australia via the Contact form.

Guardian: Time to ban all genital cutting of minors?

Boys, as well as girls, are entitled to legal protection against genital cutting, according to a recent article in the British Guardian newspaper. The authors, Neil Howard and Rebecca Steinfeld, make a forceful case that it is discriminatory and unfair for girls to be protected from genital mutilation while millions of boys continue to be subjected to circumcision, usually without any kind of regulation or supervision.

Commenting on the Californian proposal to make it illegal to perform any medically-unnecessary cutting of the genitals of male minors (under 18 years), the authors point out that the medical arguments in favour of circumcision (claims of reduced susceptibility to sexually transmitted infections) do not apply to children, and that the religious/cultural arguments are debatable. “Certainly, the ability to freely practise one's religion remains a vital component of any liberal democracy”, they write. “But should this trump an individual's right to their bodily integrity? And shouldn't such a principle be extended to all those who, by virtue of their age, are too young to decide on which body parts they would or would not like to keep?” Fundamentally, the issue comes down to whether males and females have equal rights, or whether, when it comes to bodily integrity, males are second class citizens.

Read article in full on News in Depth page

"Barbaric and stupid": Actor Russell Crowe condemns circumcision

New Zealand born movie star Russell Crowe recently added weight to the U.S. campaign against involuntary circumcision of infant boys by calling it “stupid and barbaric”. Expressing his thoughts through his Twitter account on 2 June, he added “Who are you to correct nature? Babies are perfect?”

As with all comments on Twitter, especially from famous people, his comments ignited a firestorm of responses, some critical, many in agreement, and of course the usual red herring that to criticise circumcision was somehow an expression of anti-semitism. Crowe defended himself by pointing out that he was not in the least anti-Semitic and had many Jewish friends, and that he was taking a stand for the “perfection of babies”.

Despite claims that Crowe apologised for his remarks (e.g. in the New York Times report, which mistakenly referred to him as Australian-born and began with ill-mannered speculations about his own children), it is clear that Crowe stands by his comments. His only apology was to regret that his remarks had caused offence in some quarters. "I have a deep and abiding love for all people of all nationalities. I'm very sorry that I have said things on here that have caused distress." He did not intend to mock the rituals of other religions etc, but added: "I can't apologize for my heartfelt belief.”

We see no reason for Crowe to apologise to anybody. The old canard that to criticise circumcision is to attack the Jews (and presumably any other culture that practises circumcision, though these are rarely mentioned) is nothing more than an attempt to suppress discussion of the subject - in other words, blatant censorship and denial of free speech. If to criticise circumcision is to be anti-semitic it is obviously impossible to criticise circumcision at all - which result is, of course, is the purpose of the allegation. In fact, Jewish people have always been prominent in the American anti-circumcision movement, and an increasing number of Jewish voices are supporting the campaign in California to give male minors the same level of legal protection against genital cutting that girls already enjoy.

There is no reason to suppose when he made his remark that Crowe was thinking of Jews at all. Living in the USA he must be aware that the majority of American parents circumcise their sons; Jews are only a tiny fraction of this number. In all likelihood he was thinking of circumcision as a stupid American practice. Nobody has jumped up and down and complained that his remarks were anti-American.

For all that, Crowe is right: circumcision first emerged as an initiatory blood rite among barbaric tribes, and it is stupid for civilised people to maintain such a cruel practice in this modern age.

Uganda: Circumcision campaign increases HIV infections

Recent news reports from Africa reveal that circumcision as a tactic for stopping the spread of HIV is having the opposite effect, as men who have consented to be circumcised believe that they are now completely immune to infection and can have as much unsafe sex as they like, with as many partners as they can find, and don’t need to use condoms. In Uganda a report has found that “new HIV/AIDS messages meant to reduce the prevalence of the disease are instead facilitating its spread”, while in Swaziland a poster campaign is generally interpreted by men as meaning “that after circumcision, they would be safe from sexually transmitted illnesses”. This is exactly the result that critics of the circumcision solution have consistently predicted and warned against from the start. Suggesting that circumcision is a “surgical vaccine” against HIV, as many irresponsible researchers, circumcision promoters and journalists have done, gives people a false sense of security and encourages them to engage in unsafe sex - with inevitably tragic results.

Full details on the AIDS news page

Circumcision: Let the owner of the foreskin decide

An article in the Canadian Medical Association Journal suggests that it is wrong to circumcise male infants, but that the operation could reasonably “be offered” to boys just before puberty. This is the opinion of Dr Noni Macdonald, a professor of pediatrics at Dalhouisie University, who writes that since the “potential benefits” of circumcision kick in only after males become sexually active, it would make more sense to offer circumcision to 11-year olds than to do it to babies. “The [infant] isn’t at risk of HIV and sexually transmitted diseases, because they’re not sexually active, so why are we rushing to do it at that time?” She wonders why people are more likely to accept circumcision of a baby, who cannot give any kind of consent, and for whom the operation is of no benefit at all, than of a pre-teen, who might have at least some chance of understanding his options.

Good questions, but we do not feel that Professor Macdonald has come up with the right answers. She is correct to say that it is unethical to circumcise anybody without informed consent, and also that infants cannot possibly derive any benefit from such an operation, but we cannot agree that it would be acceptable to routinely “offer” to circumcise boys at 11 or 12 years of age. If boys at that age are not considered capable of consenting to sexual relations with other people, they are certainly not competent to consent to having part of their genitals surgically removed – an irreversible step, far more radical than mere sexual activity.

Another objection is that the average 11 year old does not have sufficient maturity, independence or knowledge to agree to such an operation, and is too subject to pressure from parents, relatives and peers to be able to make a free and informed choice. If circumcision provides some degree of protection against sexually transmitted infections (a contentious point), the only logical age at which a male can legally consent to circumcision would be the same as the age of consent for sexual purposes – that is, from 16 to 21 years, depending on the jurisdiction. In other words, if it is wrong to perform circumcision in infancy, it is equally wrong to perform it at any time before legal adulthood.

Read full details of the proposal and further commentary on this site.

Circumcision may increase HIV risk

An article in the Journal of Public Health in Africa warns that mass circumcision programs in Africa will not only fail to lower the incidence of HIV, but may actually increase the risk of HIV infection. The authors point out that the only evidence for circumcision having any protective effect (and even then only for men during unprotected intercourse with an infected female partner) is found in three clinical trials, but that the trials are riddled with methodological flaws. Among other problems, there was no way of telling whether the men who became HIV positive did so through sexual contact or through non-sexual means (such as non-sterile medical treatment); and the protective effect of circumcision has been exaggerated (a risk reduction of somewhere between 38 and 64 per cent, not the “60 per cent” trumpeted by the media). On top of this there is no evidence that even this level of protection will be replicated in the real world, outside the artificial conditions of the trials, in which the men received an intensive level of counselling not likely to be repeated elsewhere.

As well these flaws the authors point out that we still lack a plausible biological explanation of how the foreskin increases the risk of HIV infection (if it does); that men who have been circumcised are more likely to engage in unsafe sex (and that many men actually submit to circumcision because they think it means that they do not need to use a condom); and that the massive sums being poured into once-off circumcision programs (literally billions of dollars) consumes resources that could be used for more effective and less harmful tactics.

Abstract: The World Health Organization and UNAIDS have supported circumcision as a preventive for HIV infections in regions with high rates of heterosexually transmitted HIV; however, the circumcision solution has several fundamental flaws that undermine its potential for success. This article explores, in detail, the data on which this recommendation is based, the difficulty in translating results from high risk adults in a research setting to the general public, the impact of risk compensation, and how circumcision compares to existing alternatives. Based on our analysis it is concluded that the circumcision solution is a wasteful distraction that takes resources away from more effective, less expensive, less invasive alternatives. By diverting attention away from more effective interventions, circumcision programs will likely increase the number of HIV infections.

Robert S. Van Howe, Michelle R. Storms, How the circumcision solution in Africa will increase HIV infections, Journal of Public Health in Africa, Vol 2, 2011, e4.

New South Wales doctor found guilty of genital mutilation

A former New South Wales doctor who excised a woman’s external genitals during an operation to remove a small patch of discoloured tissue on her labia has been found guilty of assault occasioning grievous bodily harm. His victim, aged 58 at the time of the operation, told the court that the doctor had informed her that he was going to remove a lesion, but never mentioned removing anything else. If he had, she said “I would never have walked through that hospital door to start with”. The doctor’s defence, that the complete removal of the woman’s external genitalia was necessary to stop a cancerous growth from spreading, was rejected as spurious. The doctor’s name has been suppressed by the court, though will presumably be revealed when he comes up for sentencing at a later date.

Read full report and commentary here

Circumcision insignificant protection against cancer virus

An American study of of 4000 men in Brazil, Mexico and Florida (USA) has found that around half the population carries strains of the human papilloma virus (HPV) implicated in the generation of cervical and prostate cancer, but that the main risk factor for developing cancer is having a large number of sexual partners. Circumcision was found to have little protective effect against infection with the virus. Instead, the researchers recommend that vaccination with one of the new HPV vaccines that are already being given to women also be made available to men.

Read full details of report on cervical cancer page

Anaesthetic risk to infants

A semi-editorial in the New England Journal of Medicine has called for more research into the effects of anaesthetics on infants and young children. The authors are concerned at emerging evidence that exposure to anaesthetics can have unpredictable effects on behaviour and learning ability and may cause brain damage. They write:

"A retrospective cohort analysis followed a birth cohort of 383 children who underwent inguinal hernia repair during the first 3 years of life and compared them with 5050 children in a control sample who had undergone no hernia repair before the age of 3.4 The children who underwent hernia repair were twice as likely as those who did not to be given a diagnosis of a developmental or behavioral disorder . A population-based, retrospective, birth-cohort study examined the educational and medical records of children who were exposed to a single anesthetic, two anesthetics, or more. In contrast to the hernia-repair study, this study reported no increased risk of learning disabilities with a single anesthetic . However, an increasing risk of learning disabilities was associated with two or more anesthetics . The risk of learning disabilities also increased with greater cumulative exposure to anaesthesia."

Although the authors point out that no firm conclusions can be drawn from these studies, there is cause for concern and justification for further research. If it is found that anaesthesia does harm the infant brain it will pose a severe dilemma for circumcision promoters. It is now agreed that circumcision without anaesthesia is totally unacceptable, and indeed circumcision has been described by the Professor of Surgery at Royal Children’s Hospital, Melbourne as “close to the legal definition of assault if no consent was given and no anaesthetic or analgesia was used”. [1] But if it is not possible to give an effective anaesthetic or to get informed consent from an infant or child, it would appear that it is also impossible to circumcise him, and the operation must be delayed until he is old enough to tolerate the one and understand the other.

Source: Bob Rappaport, R. Daniel Mellon, Arthur Simone, Janet Woodcock, Defining Safe Use of Anesthesia in Children, New England Journal of Medicine, 9 March 2011

[1] J M Hutson, Circumcision: A surgeon’s perspective. J Med Ethics 2004;30:238–240

United States losing faith in circumcision

Although the United States remains the last bastion of routine circumcision as a “health precaution”, the incidence of circumcision in there has been declining slowly since the 1970s, and more rapidly since the turn of the century: one recent estimate claims that it has fallen as low as 33 per cent, though this figure is not accepted by everybody. A feature of the US situation is the growing gulf between the official opinion of bodies such as the Centers for Disease Control and the circumcision policy committees of the American Academy of Pediatrics, which are stacked with believers in circumcision and wish to see the practice continue, and a growing community groundswell against the practice, led by women, and especially mothers. One expression of this movement is a proposal in California for a new law to treat medically unnecessary circumcision of a male minor on the same basis as female genital cutting, that is, as a criminal offence. Whether or not the law is passed, it is stimulating debate on the issue, and for the first time in many years the circumcision advocates find themselves in a defensive position, and rather on the back foot, as an increasing number of critical articles in mainstream newspapers and magazines suggest.

“Bizarre mutilation”: Child health journal dismisses circumcision

An editorial in the January edition of the (Australian) Journal of Paediatrics and Child Health calls circumcision a “bizarre mutilation” and dismisses claims that it contributes to hygiene or improves child health. The editorial, by the editor in chief, David Isaacs, covers several aspects of both ritual and “health” circumcision, runs through the origins of circumcision as a religious/cultural rite in the region bordering the Red Sea, and comments that “there seem to be insufficient health benefits for circumcision to have evolved through natural selection”. He also devotes some attention to the rise of medically-rationalised circumcision of infants in nineteenth century Britain and the USA, and although the discussion is brief, he correctly notes that at that time the principle selling point for the operation was that it would discourage masturbation in infants and boys. Professor Isaacs concludes with a question that deserves greater debate – “Should the autonomy of an infant to choose when he is older outweigh his parents’ right to choose to have their infant son circumcised?” – but does not explore this issue. His remark that circumcision is no laughing matter seems undermined by the rather flippant style in which the editorial is written. Overall its message is that circumcision is primarily a cultural ritual and from a medical point of view too trivial a matter to be discussed in medical journals.

Read full editorial and CIA comments here

Circumcision in boys and girls: British Medical Journal criticises the double standard

An article in the "Viewpoint" section of the British Medical Journal by Dr Mihail Evans mounts a reasoned and powerful critique of the prevailing double standard on male and female genital cutting, encoded as it is in the terms commonly used: male circumcision but female genital mutilation. Dr Evans writes: "New legislation in France has led to more debate on whether wearing the veil amounts to the sexual repression of Muslim women. Islam’s treatment of women is a regular topic in the Western press, yet few jump to the defence of Muslim and other little boys subjected to childhood circumcision. Indeed, the circumcision of the grandson of President Sarkozy, ironically a proponent of the veil ban, made only the gossip pages in France. As a permanent surgical genital alteration, circumcision is arguably a much more serious matter. After all, a Muslim woman has, at least in theory, the option to throw away her veil. The circumcised man’s foreskin has been thrown away already."

Read full article and comments from readers

Medical Journal of Australia: The case against circumcision as HIV preventive

In September last year the Medical Journal of Australia published an article in which David Cooper, Alex Wodak and Brian Morris called for a dramatic scaling up of neonatal circumcision in Australia as a response to an alleged rising incidence of heterosexually trasnsmitted HIV infection. The suggestion raised many eyebrows at the time, and was roundly rejected by the Royal Australasian College of Physicians, which had just finalised its own policy statement on circumcision, having found that there was no medical justification for the practice in Australia, and specifically denying that HIV-AIDS in adults was a valid reason to circumcise children. The MJA was slow to publish criticism of the Cooper, Wodak, Morris call, but at last, on 17 January, they published no fewer than eight letters rebutting their arguments. As an editorial note introducing the letters comments, "An article in the 20 September issue of the Journal that suggested circumcision of infant boys could be considered a “surgical vaccine” against future heterosexually transmitted HIV has attracted strong criticism from many of our readers." Covering a wide range of issues, from law, ethics and human rights to the principles of evidence-based medicine, the letters amount to a comprehensive rebuttal of the Cooper et al position.

Read the letters in full here

World AIDS Day editorial endorses behavioural change as the great hope for AIDS control

Also in the Medical Journal of Australia, an editorial for World AIDS Day (1 December) argues that behavioral change is still the tip of the spear for effective HIV prevention. Entitled, "HIV will only be defeated when behavioural means of prevention become the basis of the global response," William D. Bowtell writes, "We can contain HIV by improving access to treatments and providing care to people with the disease. But HIV will only be defeated and eradicated when the lessons of behavioural prevention that we developed and applied in Australia two decades ago become the basis of the global response." There is no mention of the C word because circumcision has no place in effective prevention efforts.

Another reason not to circumcise:

Australia faces big MRSA problem

The 17 January edition of MJA Insight reports that Australia has a serious and increasing problem with a variety of Staphylococcus aureus that has become resistant to most antibiotics. MRSA stands for methicillin-resistant Staphylococcus aureus. Staph bacteria are commonly found on the skin and in the nasal cavity, and are the cause of many serious infections, ranging from boils and carbuncles to septicaemia (gangrene), osteomyelitis, pneumonia and abscesses in almost any part of the body. They commonly infect surgical wounds, particularly in clinical settings (such as surgeries) where many operations are performed and it is almost impossible to ensure a sterile environment. This is yet another reason why unnecessary surgeries such as non-therapeutic circumcision should be avoided.

A summary of the report is available at News in Depth.

Study finds no association between HPV risk and lack of circumcision

A large-scale study has found no association between circumcision status and susceptibility to infections with human papilloma virus (HPV), a group of wart viruses responsible for genital herpes and implicated in the generation of cervical and other genital cancers. The study involved 3463 heterosexual men from 71 sites in 18 countries in Africa, Asia-Pacific, Europe, Latin America, and North America. Although there have been claims that circumcision may reduce the risk of infection with HPV, this study was unable to confirm such findings.

Abstract

Background. We examined the baseline prevalence of penile, scrotal, and perineal/perianal human papillomavirus (HPV) in heterosexual men (HM). We also evaluated baseline characteristics of HM to assess factors associated with prevalent HPV detection.

Methods. We tested serum samples from 3463 HM aged 16–24 years with 1–5 lifetime female sexual partners for antibodies to HPV 6, 11, 16, and 18. We collected baseline swab specimens for the detection of DNA of HPV 6, 11, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59 from 3 areas: penile, scrotal, and perineal/perianal. Risk factors for prevalent HPV DNA detection were evaluated.

Results. The prevalence of any tested HPV type was 18.7% at the penis, 13.1% at the scrotum, 7.9% at the perineal/perianal region, and 21.0% at any site. Having >3 lifetime female sexual partners had the greatest impact on HPV prevalence: odds ratio (OR) 3.2 (95% confidence interval (CI) 2.1–4.9) for HPV 6, 11, 16, and 18; and OR 4.5 (95% CI 3.3–6.1) for all HPV types tested. HPV DNA detection was highest in Africa. Neither condom usage nor circumcision was associated with HPV DNA prevalence.

Conclusion. Genital-HPV DNA detection is common in young, sexually active HM. We found HPV to be most prevalent in African men and least prevalent in men from the Asia-Pacific region. Increased numbers of sexual partners was an important risk factor for HPV DNA prevalence.

Source: Eftyhia Vardas et al. External Genital Human Papillomavirus Prevalence and Associated Factors Among Heterosexual Men on 5 Continents. Journal of Infectious Diseases 2011:203 (January 2011) 58-65

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