08 Oct Circumcision-The Kindest Cut?

Dr Sam Tormey discusses the medical and ethical issues surrounding infant circumcision.

For the majority of males, the presence or absence of the foreskin will make little appreciable difference to health, self-image or sexual function.

On a steaming hot day in the middle of the wet season 10 years ago, an extraordinary scene unfolded in a remote part of the Northern Territory’s Arnhem Land. Two Federal Government ministers, along with reporters and camera crews, witnessed the ritual circumcision of a seven-year-old boy.

Usually a secret ceremony, the public display was an attempt to encourage the process of reconciliation. Instead, subsequent media reports inflamed the latest round of a long and bizarre debate over circumcision in Australia. It also encapsulated in one scene both the ancient history of circumcision in Australia as well as the modern ethical dilemma: what is a good reason to subject boys to this procedure? And it came at something of a tipping point: after a steady decline in the rates of circumcision, the 1990s witnessed a slight reversal of this trend and the emergence of strident voices on both sides of the debate.

The history of male circumcision in Australia is fascinating.

Arguably, this continent has witnessed most facets of the practice on earth: ancient ritual, imperial rubbishing of the practice as savage, then the extraordinary rise of the procedure on the back of some curious Victorian ideas, followed by an equally precipitous decline based on changing medical evidence about the risks and the benefits.

From a peak incidence of about 90 per cent in the 1950s, circumcision rates have fallen to between10 and 15 per cent at present. The year 2000 was about the point when, for the first time in decades, intact males outnumbered those who had been circumcised.

The demographics of circumcision are not only volatile, but they are also strangely different between the States and Territories and have been for some time.

In the last 10 years, rates of circumcision in Queensland, NSW and SA have been around the 15 per cent mark, while rates in the ACT, Victoria and WA have been around five per cent, a genuinely puzzling disparity. The steadily downward overall trend of recent times has provoked the inevitable backlash from proponents of routine circumcision, and today there are vehement polemicists from both sides of the argument.

The media and the internet contain a flood of information from these people, much of it grossly biased and overstated, which I imagine can make for great confusion in the minds of the parents of a new baby boy.

The foreskin or prepuce of the male member has been implicated in a diverse range of human concerns. Indeed, for a small piece of skin, it has a CV that runs to several pages and leaves a wake of politics and passion that beggars belief. From an apparently innocuous role as a protective sheath for the sensitive glans (or head) of the penis, the foreskin has been blamed for the urge to masturbate, various forms of cancer in men and women, as a spiritual impediment to male fertility and status, a facilitator of various infections from syphilis to HIV, and for being a generally unclean and undesirable appendage.

Gods have commanded that it be removed, doctors have by turns vilified and defended it, courts have been asked to punish those who cut it off, passionate defenders of ‘genital integrity’ have railed against equally sincere proponents of the ‘holy cut’.

My parents chose not to circumcise me.

They saw it as an unnecessary and painful procedure that carried significant risks and would be of no foreseeable benefit to me. So my first exposure to circumcision came many years later, as a young doctor on my first attachment to a general surgical team in a busy rural hospital.

On the first morning in the operating theatre, I glanced at the list of procedures planned for the day: operations for bowel cancer, thyroid nodules, hemorrhoids, and a circumcision. The last case stood out starkly from the rest because it involved a perfectly healthy patient who was to have a general anesthetic and then part of his genitals amputated, for no reason other than because his parents wanted this to be done.

It struck me as strange then, and it continues to trouble me, for it goes against the principles of surgery that I learned in medical school: if one is to subject a patient to the risks of anesthesia, hemorrhage, pain, infection, and scarring, you had better have a very good reason as well as the informed consent of the patient. Further to that, my generation of medicos was urged to consider the medico-legal ramifications of all of our actions and omissions to act. Should something have gone wrong with that circumcision, I wondered how the surgeon could possibly have justified his conduct to a jury: there was no medical indication for the procedure, the baby was not unwell in any kind of way and the baby had perfectly normal genitals. ‘Do you mean to say, doctor,’ I imagined a barrister asking, ‘that you anesthetized this baby and removed part of his penis simply because his parents asked you to? Do you think, doctor, that your action was in the best interests of your patient, the child?’

Fortunately, circumcision rarely goes badly wrong.

It is a minor surgical procedure that has been performed without anesthetic by people all over the world for thousands of years. It is usually performed in Australia by general practitioners who use one of two types of clamping device to remove the foreskin after a local anesthetic cream has helped to numb the skin. The circumcision that I witnessed at the rural hospital was a ‘freehand’ circumcision under a general anesthetic, where the foreskin is cut off with scissors and the incision sutured to control the bleeding. Complication rates are up to about three per cent of circumcisions and usually relate to post-operative bleeding and infection, both of which can usually be remedied with simple measures.

Occasionally, too little or too much foreskin can be removed and, as with any surgical procedure, unwanted scarring can occur. Uncommonly, bleeding may be severe and difficult to control or a serious infection may set in. There have been deaths from both haemorrhage and infection following circumcision, however, such dramatic complications are very rare.

There are some genuine medical indications for circumcision that can arise at any stage in life. The most common problem that leads to circumcision is phimosis, where the tip of the foreskin becomes too tight to allow full retraction of the foreskin over the head of the penis. This occurs in about one per cent of males and generally becomes apparent before puberty. It has traditionally been treated by circumcision, however, the use of steroid creams and gentle retraction is often all that is required. It should not be confused with the adhesions between the foreskin and the glans that cause a delay in retraction – this is normal for many uncircumcised boys and results in the great variability of the age at which the foreskin can be fully retracted. Usually, these adhesions will resolve spontaneously with time; if problematic or associated with recurrent infections (balanitis), the adhesions can be divided into a simple procedure. More serious and chronic infections, such as balanoposthitis or balanitis xerotica obliterans, may require circumcision, as can penile cancer (an uncommon cancer that generally develops later in life).

So the vast majority of boys and men will never have a genuine medical reason for circumcision.

This is the joint opinion of the colleges of physicians, pediatricians, surgeons and urologists from Australia and New Zealand. Their statement that “there is no medical indication for routine neonatal circumcision” reflects the opinion of most doctors across the developed world. Their policy statement is perhaps the most useful document that any parent contemplating circumcision for their child could read, as it contains a concise and clear summary not only of the medical perspective of circumcision but also of what we know about foreskins and how we should look after them.

Despite this, some radical voices from a very small minority of the medical profession continue to advocate the routine circumcision of baby boys. Their reasons for doing so now include research suggesting that circumcision may reduce the incidence of urinary tract infection (UTI) in baby boys, of HIV infection in men and of cervical cancer in women. It is important to address these public-health matters, as they certainly may constitute a better reason for circumcision than previous notions have done.

The strongest evidence relates to UTI: it is apparent that circumcised boys have lower rates of these infections, however, most of these infections can be easily detected and treated without complications. Some UTIs will be severe and may result in death despite antibiotic treatment, however, this is uncommon and the risk must be balanced against the complications of circumcision. It has been estimated by Australian doctors, for example, that it would take more than 100 circumcisions to prevent one UTI in the first year of life. For otherwise healthy babies, the statistics would not suggest a net benefit from circumcision as far as UTIs are concerned.

The question of HIV transmission is more controversial, with some studies suggesting that circumcised men are less likely to contract HIV from infected women. Given the demographics of HIV infection in this country, this is not likely to be a factor in decisions about circumcision. It is, of course, more relevant in other countries, however, even if this link is confirmed, it is unlikely to do anything more than distract from the primary public-health message of safe sexual practice.

Of more relevance to Australians is the question of cervical cancer, which is associated with the human papilloma virus (HPV). Again, research about differential rates of HPV infection depending on circumcision, is in its infancy. One large study has suggested that circumcised men may harbour less HPV and thus, presumably, infect fewer women with the virus. This may or may not lead to a lower risk of cervical cancer in women, but certainly, there is a theoretical basis for the claim that circumcised men are less likely to infect their female partners with HPV. If subsequent research does confirm this claim, it should make no difference whatsoever to the necessity for women to have regular pap smears, as HPV certainly is transmitted by circumcised men, although perhaps at a lower rate. Further, it would be an extraordinary and unprecedented idea that one person should have a surgical procedure in infancy in order to prevent another person from potentially contracting a carcinogenic infection at some time in the future. It would seem a bit unfair, for example, to subject a boy to the risks of circumcision on these grounds if he subsequently became a celibate monk or priest. It seems far more reasonable that women should choose whether or not to have unprotected sex with uncircumcised males, or take other measures, such as vaccination against HPV or pap smears, to reduce their risk of cervical cancer. HPV has also been linked to cancer of the penis, however since this is such a rare disease (affecting about one in 100,000 men), and one that occurs in both circumcised and uncircumcised men, no convincing argument can be mounted to justify circumcision as a worthwhile prevention strategy.

Many cultures practise circumcision at various ages and for various reasons.

The Jewish culture of circumcision at eight days of age (the brit milah) is perhaps the best-known ritual, but it was also practised by the ancient Egyptians and by various Indigenous cultures, including some of those in this country, as well as some in parts of Africa and the South Pacific. Christians of the Coptic persuasion and Christians in some parts of Africa are also known to advocate circumcision, as do many Muslims.

In the last few months, I have asked the parents of circumcised boys who I have seen in my practice about their reasons for circumcision. It has surprised me how many parents who are not Jewish, Aboriginal or Muslim feel that circumcision is a strong part of their culture. For men who were circumcised as boys, many feel strongly that their son “is going to look like me”. Many mothers of circumcised boys told me that they did it because “it’s just cleaner, isn’t it?” What is also interesting is how uncomfortable many Australians are with talking about circumcision and, in particular, the ‘ickiness’ factor about general foreskin maintenance.

As attitudes have changed, so has the availability of circumcision.

The question of government rebates for circumcision has always been controversial. In Britain, funding for routine circumcision was not included at the inception of the National Health Service in the late 1940s and rates of circumcision in the UK dropped much faster than in Australia, where routine circumcision has been supported by Medicare. The subsidy for circumcision was removed from Medicare in 1985 but was reinstated shortly afterwards after pressure from various interest groups. State governments in NSW, Victoria, WA, SA and Tasmania have restricted the operation in public hospitals, where circumcision can only be performed as a medical necessity.  This decision is in line with the general philosophy of restricting the funding of cosmetic surgery in the public health system. So in most states, routine circumcision can now only be performed in a GP’s doctor’s surgery or a private hospital. Costs vary greatly so there will usually be a large out-of-pocket expense even after the rebate.

For the majority of males, the presence or absence of the foreskin will make little appreciable difference to health, self-image or sexual function. In the absence of good medical reasons to circumcise boys, perhaps decisions based on culture and religion present the strongest case for the operation. Personally, I would be asking ‘will my son thank me for doing this?’ On this test, I suspect that many Jewish men (or those from other cultures in which circumcision is an integral part of the male journey) probably would be happy that the decision was taken. When things go wrong, however, faith and tradition can be of little comfort. It seems particularly dubious to me that a man injured by circumcision would thank his parents for at least trying to make him look ‘just like dad’.

So think carefully about circumcision, and be aware that if your doctor is advocating it as a routine procedure, he or she is swimming very much against the strong tide of current medical opinion.

Sam Tormey is a doctor who writes on medical issues. His practice is in emergency medicine.

For Further Information:

The Royal Australasian College of Physicians – Paediatrics and Child Health Division, Policy Statement On Circumcision:

Illustrations by Harry Afentoglou