Response to RACP's 2002 circumcision policy statement

New policy statement by Australian and New Zealand doctors rejects circumcision

The new policy statement on routine male circumcision issued by the Paediatric and Child Health Division of the Royal Australasian College of Physicians should be welcomed by all those concerned with the welfare and happiness of Australian and New Zealand boys. Although it does not go as far as it could towards discouraging this unnecessary and harmful surgery, it has many positive features. Its message is clearly that boys should be left as nature made them.

The new statement is one of the most authoritative policies on circumcision ever issued by a medical organisation. It has been endorsed by six Australian and New Zealand medical bodies. After a thorough review of the medical literature, including recent claims about the supposed protective effect of circumcision against STDs, AIDS, penile cancer, urinary tract infections and cervical cancer in female partners, the working party concluded that there was "no medical indication for routine male circumcision" and that there was "no evidence of benefit outweighing harm for circumcision as a routine procedure".

The statement, which includes links to many of the articles in medical and other journals cited by the statement, accompanied by some critical comment is available here. Another copy of the statement with a critical commentary and evaluation, and links to further information and many of the articles cited, is available at Circumstitions.

MEDIA RELEASE by Circumcision Information Australia, 28 September 2002

Human Rights Groups Welcome Statement on Male Circumcision

Australasian human rights groups welcome the release of the new Position Statement on Circumcision by the Paediatric and Child Health Division of the Royal Australasian College of Physicians. "This is a victory for good sense and the spirit of Anzac cooperation" said Shane Peterson for Circumcision Information Australia and NORM New Zealand.

The new policy states: "there is no medical indication for routine male circumcision." It also warns against risks and complications more strongly than previous statements, and raises serious legal and ethical issues. "The new statement sends a clear message to doctors that they should warn parents against choosing circumcision for their sons. The few old GPs and cranky professors who get up in the media to preach the medical benefits of circumcision are now exposed as quacks."

The new statement has been endorsed by six Australian and New Zealand medical bodies.

After a thorough review of the medical literature, including recent claims that circumcision is protective against STDs, AIDS, urinary tract infections and cervical cancer in female partners, the working party concluded that there is "no evidence of benefit outweighing harm for circumcision as a routine procedure".

The new policy is based on a narrow evaluation of the medical benefit and harm of circumcision. Mr Peterson said, that despite this narrow view, the College still concluded that the risks of harm and injury outweigh the claimed benefits. "When additional factors are considered, the case against routine circumcision becomes overwhelming."

A surprising omission from the statement is a discussion of the sensory and mechanical roles of the foreskin in male sexual function, and its contribution to sexual pleasure and self-esteem for both the man and his partner. "The penis is a fragile sensory organ. Removal of the foreskin and frenulum by circumcision is similar in effect to surgically injuring the retina of the eye in a way that causes tunnel vision and colour-blindness."

The working party also paid little attention to important issues in human rights and medical ethics. A person has the right to an intact body and to refuse unnecessary medical treatment. It is doubtful if it can ever be ethical to amputate healthy tissue from a non-consenting minor in the absence of acute medical necessity.

Mr Peterson said it is now time to address the disturbingly high rate of infant circumcision in some states compared to others. In 2001-2002, Medicare funded the circumcision of approximately 14% of male infants born in South Australia and New South Wales, and over 20% of male infants born in Queensland. During this same period, about 5% of male infants were circumcised in Victoria, Western Australia, Tasmania and the ACT. The incidence of circumcision in New Zealand has been less than 5% for over a decade.

"Doctors now insist that medical interventions must be based on evidence of benefit exceeding the risk of harm. There is no evidence based rationale for this significant difference in the incidence of circumcision between states and countries", said Mr Peterson. "It is now time to remove routine circumcision from the Medical Benefits Schedule."

In his ground breaking article "The fate of the foreskin" in 1949, Douglas Gairdner, consultant paediatrician to United Cambridge Hospitals, advised that routine circumcision was harmful and recommended against it. As a result of Gairdner's research and the policy of the National Health Service, the rate of routine circumcision in Britain fell from about 30% in the 1940s to less than 5% in the 1950s.

Gairdner debunked the myth of phimosis and showed that it was normal for the foreskin not to be retractable in early childhood. He also concluded that circumcision did not provide meaningful protection against STDs or cancer. He documented injuries and side effects, including the death of around 16 boys under five each year in the UK from 1942 to 1947.

Deaths still occur regularly from circumcision. The recent death of an infant following circumcision in British Columbia during August made national news. In response, several Canadian state medical bodies have cautioned doctors against performing unnecessary circumcisions. For further information .

Mr Peterson said the new RACP statement is a very positive step towards protecting children. "Doctors should be required to give a copy of the new statement to all parents who enquire about circumcision. Parents should then have a week's cooling off period to think about it. The written consent of both parents should also be mandatory."

Review of RACP policy 2002 by Circumcision Information Australia

The recent policy statement on routine male circumcision issued by the Paediatric and Child Health Division of the Royal Australasian College of Physicians should be welcomed by all those concerned with the welfare and happiness of Australian and New Zealand boys. Although it does not go as far as it could towards discouraging this unnecessary and harmful surgery, it has many positive features. Its message is clearly that boys should be left as nature intended.

In reaffirming earlier statements against routine circumcision dating back to 1971, the RACP has issued strong advice to parents that circumcision of their baby boys is neither necessary nor desirable. It has also sent an unmistakeable message to doctors that they should warn parents against the operation.

The statement is one of the most authoritative policies on circumcision ever issued by a medical organisation. It has been endorsed by six Australian and New Zealand medical bodies. After a thorough review of the medical literature, including recent claims about the supposed protective effect of circumcision against STDs, AIDS, penile cancer, urinary tract infections and cervical cancer in female partners, the working party concluded that there was "no medical indication for routine male circumcision" and that there was "no evidence of benefit outweighing harm for circumcision as a routine procedure".

This is a significant victory for good sense. The working party has carefully considered the clamour of those urging universal circumcision as a strategy against problem diseases and has rejected their scenarios as alarmist and their prescriptions as scientifically unsound. Doctors are now obliged to tell parents seeking advice about circumcision that there is no medical benefit from the operation and a significant risk of harm. In other words, the Australian and New Zealand medical profession is saying "Don't do it".

Perhaps the greatest value of the new statement is that it reaches its conclusions on the basis of a narrow calculus of medical benefit and harm, and still finds that the risk of harm outweighs the possibility of benefit. The working party did not pay much attention to the important areas of human rights (e.g. a person's right to a non-disfigured body and to refuse unwanted medical treatment), or to medical ethics (e.g. whether it can ever be ethical for a doctor to amputate healthy tissue from a non-consenting minor in the absence of acute medical necessity). But the statement did acknowledge that even if it were true that circumcision reduced the incidence of UTIs, "this should not be the only consideration": in other words, retention of the foreskin for whatever reason could in itself be more important than reducing the risk of disease.

The most serious omission from the statement is any discussion or acknowledgement of the value of the foreskin as a natural and prominent part of the male genitals and a significant contributor to normal sexual function, partners' pleasure and a person's happiness and self-esteem. When these and similar factors are added to the equation, the case against routine circumcision becomes overwhelming.

There is now no basis for claims made by maverick GPs and misguided professors that there are sound scientific reasons to circumcise male infants. The medical aspect of the long-running debate has now been settled. The few old GPs and cranky professors who get up in the media to preach the medical benefits of circumcision no longer have a leg to stand on. They are now exposed as the quacks they have been all along, more reminiscent of a top-hatted Victorian, issuing dire warnings against the perils of masturbation, than a modern medical practitioner concerned about the quality of life of those under his care.

The statement opens the way for a consideration of whether routine circumcision should be deleted from the Medicare benefits schedule. Now that male circumcision has authoritatively been declared an unnecessary and non-therapeutic procedure, there is no reason why taxpayers should fund it through the health care budget. In the rare instances where circumcision is medically required it should of course be publicly funded, but where it is performed for non-medical reasons it should be categorised as a cosmetic procedure and paid for by the individuals who want it done.

The weaknesses of the position statement may be summarised under eight headings:

1. The statement does not recognise that the foreskin itself is a normal part of the body and a prominent part of the penis, with value in its own right, and which makes a significant contribution to sexual functioning, self-esteem, body image and personal happiness. There is a vast medical literature on the significance of the foreskin, from Hippocrates, Galen and the classical Greeks, who devised procedures to lengthen inadequate prepuces, right down to the modern Canadian researchers who have investigated the unique innervation of the penis and identified the ridged bands and frenular delta. Further details.
   
2. It does not recognise that the removal of an excessive quantity of tissue, resulting in a tight circumcision and uncomfortable erections, is very common. Tearing and bleeding of the penile skin after puberty is less common, but not rare.
3. It does not discuss the risks of general anaesthesia, nor indicate that sucrose and EMLA are not effective analgesics, when used separately or together.
4. It does not consider less invasive surgical methods to treat pathological phimosis which retain the foreskin, such as the dorsal slit.
   
5. It does not propose a method to ensure that each state/territory health department prints an accurate and up-to-date information booklet, based on the recommendations of this statement, to be distributed to all parents expecting a child. Doctors should be required to give parents requesting circumcision a copy of the leaflet (and ideally the full statement) before they can perform the procedure.
   
6. The statement does not warn doctors that there is a real and increasing danger of litigation on the part of individuals who, without necessarily suffering complications or serous injury, grow up and wish that they had not been circumcised. (See comments on Canadian situation below.)
   
7. It does not pay sufficient attention to human rights and ethical issues. It has long been accepted than an individual has the right to refuse medical treatment, and it is increasingly argued by legal and ethics experts that male circumcision is little different from female genital mutilation and should be governed by similar rules. More people are asking whether it can ever be ethical for a doctor to amputate healthy tissue from a non-consenting minor in the absence of acute medical necessity.
   
8. It does not adequately address the issue of parental consent for medically unnecessary circumcision. (See comments below.)

In a recent case in Bundaberg, Queensland, a non-practising Moslem father, who did not have legal custody of children by his former partner, arranged for the circumcision of his two sons during an access visit, against the mother's express wishes and in breach of a specific order by the Family Court. (See details on this site). Stricter rules governing consent for non-therapeutic circumcision could have prevented this sad and all too common occurrence. A high proportion of marriages in Australia are between men and women of different ethnic/cultural backgrounds, and the children of such unions cannot be said to belong strictly to one or the other group; this is all the more true in the many cases where marriages end in separation while the children are still young.

Children in such situations will eventually decide which (if any) of the parental cultures they wish to identify with, or whether they wish to choose a cultural identity of their own, and we recognize their right to make a free choice. In a multicultural society , freedom of religion means that each individual must have the freedom to adopt his or her own religion and not have it imposed on them. In order to ensure that this right is real, their bodies must be protected from tell-tale alterations as much as their minds from indoctrination. Individual determination has a physical as well as a mental dimension.

In the United Kingdom and Sweden the judicial systems have intervened in instances where Moslem fathers have sought or arranged for the circumcision of boys without maternal consent. In two cases the fathers were convicted, and in one of these cases the father was gaoled for three months. The practitioner who performed the circumcision was also charged with an offence, though acquitted, by the National Board of Health and Welfare.

The rights of mothers and boys would have better protection if the following conditions had to be met before a practitioner agreed to perform medically unnecessary circumcision:

1. Check bona fides: The medical practitioner should establish that the persons requesting the circumcision do in fact have legal custody of the children. In the Queensland case the father was separated from the mother and was not the legal guardian of the children. The mother had sole custody; his consent was probably invalid in law.
   

2. Written consent of both parents: Where circumcision has been requested in the absence of medical indications or for cultural reasons, doctors should obtain the written consent of both parents before performing the procedure. If the written consent of both parents or guardians cannot be obtained, the practitioner should advise that he cannot perform the circumcision. Physicians should provide a complete copy of the new RACP statement to all parents who inquire about the procedure. Parents should then have a "cooling off" period of a week to consider their decision.
   

3. Check that the boys do not object: If the boys are old enough (e.g. over 5 years old), before proceeding the practitioner should explain honestly to the boys what he is going to do to them and ascertain that they are willing to go through with it. If they do not understand what is proposed or if they show hesitation or objection, the practitioner should decline to carry out the surgery.

Legal risk

In Canada, where the recent death of a baby after circumcision in British Columbia has made national news, several state medical bodies have cautioned doctors against performing unnecessary circumcisions. The College of Physicians and Surgeons of Saskatchewan has asked doctors to consider the physical risk to the patient and the legal risk to the physician before becoming involved in the routine circumcision of infants. It warns that circumcision poses a greater risk of harm than benefit and could form the basis of lawsuits by circumcised adults. The college registrar, Dr Dennis Kendel, says the threat of litigation is now producing "a great deal of sober second thought" among physicians. "It could have what we call 'long-tail liability' if this societal movement takes on more steam and more men become angry because they think they ought not to have been circumcised". Link to full details here

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