2 25 240 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> The Conversation (Australia) 17 August 2011 by Ryan McAllister, Research Assistant Professor of Physics and Oncology at Georgetown University and John W. Travis, Adjunct Professor of Wellbeing at RMIT University The foreskin is the most sensitive part of the penis. For centuries, children have been subjected to cultural and medicalised practices that were ultimately proven harmful and a violation of basic bodily integrity. Such practices have included foot binding, forehead flattening, scarification and genital cutting. In English-speaking countries, the practice of cutting the genitals of male children was gradually medicalised over a period of 150 years with the benign-sounding label “circumcision.” Today, there is increasing awareness that infant male circumcision – once deemed a “parental choice” – is really an unnecessary, irreversible and harmful bodily modification. With the recently discovered functions of the foreskin and a growth in awareness, we’re fortunately beginning to see the rights and experience of the child become the paramount consideration in discussions about circumcision. <h3>The foreskin: The most alive and sensitive part of the penis</h3> The human foreskin is a contiguous part of the skin system of the clitoris or penis. In infant males, the foreskin is attached to the head of the penis (glans). The outer foreskin protects the more sensitive inner foreskin and the glans from abrasion and injury. The moveable skin facilitates sexual pleasure. In fact, the foreskin is typically the most sensitive area of the penis. When circumcised males lose sensitivity and skin mobility, it’s likely to significantly alter their sexual experience. One <a href="https://www.circinfo.org/news_2011.html#frisch">recent Danish study</a> concluded that male circumcision was associated with sexual difficulties for men and their female partners. <h3>Bioethics of medically unnecessary (cosmetic) surgery on minors</h3> Surgery without consent is ethical only in cases of: (1) incapacitated patients, in order to save their life; (2) minors, with proxy consent from a parent or guardian, but only for surgery that addresses an underlying pathological condition that has not responded to conservative treatment. Excision of an infant’s foreskin for dubious medical or cultural purposes is an anomaly. Because it removes healthy, typically-developed tissue, the procedure fails to meet either of the above conditions. Circumcision of minors also stands in contradiction to other medical ethics principles, including: <ul> <li>avoiding causing needless harm;</li> <li>promoting the patient’s medical well-being;</li> <li>providing information on a procedure that a reasonable person would deem significant.</li> </ul> <h3>Complications and harm</h3> Circumcision can cause skin bridges, haemorrhaging, infection, as well as major penile damage. Dozens of case studies describe severe complications, including penile amputations and death; several infant deaths have been reported in the past few years. A Canadian Coroner’s report, issued in 2007 following the death of a baby in Ontario, recommended the Canadian Paediatric Society conduct a surveillance study on complications. The most detailed assessment of circumcision complications cites meatitis (affecting 8% to 31% of those circumcised), infection (affecting between 0.4% and 10%, age varying) and many other severe complications. A more recent British literature survey estimates complications, including infection and hemorrhage, at rates as high as 10%. Paediatric urologist David M. Gibbons, <a href="http://www.circumstitions.com/Complic.html#urol">commented on MensHealth.com</a>: “in a two year period, I was referred [more than] 275 newborns and toddlers with complications of neonatal circumcision … 45% required corrective surgery (minor as well as major, especially for amputative injury) …” Another urologist reported repairing over 1,600 botched circumcisions over a three-year period. Official rates of complications are likely to be under reported. But regardless of the actual complication rate, it is unethical to subject a child to these risks. <h3>Insignificant benefits</h3> While some use medical benefits to justify male circumcision, those gains rarely materialise in the real world, and the damage outweighs any gain. For example, there is evidence from some African countries with very high levels of heterosexual HIV prevalence that circumcion may reduce the risk of female-to-male HIV transmission in unprotected sexual intercourse by somewhere between 38% and 66%. But studies of the general population have failed to find any decrease in HIV infection rates among circumcised men compared with uncircumcised men. HIV rates are three to four times higher in American men (mostly circumcised) than in Europe (rarely circumcised). But factors far more significant than circumcision status determine HIV transmission. While proponents claim circumcision reduces other sexually-transmitted infections (STIs), many other studies, including a 2008 New Zealand birth cohort study, failed to find any such evidence. <h3>Misleading portrayal</h3> Despite potentially severe complications, hospital websites generally portray circumcision as values-neutral and safe. Because most hospitals don’t give parents adequate information on the risks of circumcision to allow for true informed consent, few parents understand the effects their choice will have on their child and the adult he will become. <h3>Parental regret and survivor perspectives</h3> In blogs, vlogs and other online forums, many parents have shared concerns about their child’s circumcision. Experiences range from “If I knew what I know now, I wouldn’t have done it,” to “I will die hearing my baby’s screams”. Many men have also expressed dissatisfaction with their circumcision, including a sense of “being violated,” “being sexually maimed,” and having feelings of anger toward parents or the medico who performed their circumcision. On thousands of websites, Facebook groups and blogs, circumcised men go to share their experiences and support one another. <h3>Society’s role</h3> A cultural framework that considers circumcision ethically neutral and the foreskin “a useless flap of skin” omits important considerations. Before debating supposed benefits, we need to ask why would we ever even consider cutting our children’s genitals. The medical benefits of male circumcision are insignificant: no evidence to date justifies irreversible surgery on children unable to give consent. Society has recognised the inherent right of minor females to be free from unnecessary genital cutting. In the twenty-first century it is time to recognise the same rights of male children. For more of Ryan McAllister’s research in infant male circumcision, watch his recent university lecture <a href="https://www.youtube.com/watch?v=Ceht-3xu84I">Circumcision, an Elephant in the Hospital</a>. Watch John W. Travis' video on <a href="https://www.youtube.com/watch?v=kN0rxo8y6WM">infant wellness and circumcision</a>. <a href="http://theconversation.edu.au/unethical-and-harmful-the-case-against-circumcising-baby-boys-1543" rel="noopener" target="_blank">Click here for original source of article, with links to further information and comments</a>. One of the links is to an article by Brian Morris which describes circumcision of infants as "safe, convenient, cheap and fast". All that could be true, but it would not mean that the operation was necessary, desirable, beneficial, or without harmful effects. In a modern surgical setting the same could be said of nearly any operation on children: clitoridectomy, for example, or cutting off toes, fingers or earlobes. The fact that an operation is cheap and can be done "conveniently" (meaning on a person who lacks the power to resist) is not a reason for doing it. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Conversation: circumcision unethical and harmful darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> Recent calls by Brian Morris and friends for the introduction of routine circumcision have been dismissed by health experts as nothing more than the “blinkered ideology” that Morris has been “peddling for years.” These were the words of paediatric surgeon Dr Neil Price, commenting on a recent article that collected a pile of pro-circumcision studies in order to attack the recently-released policy of the Royal Australasian College of Physicians. Meanwhile in Sydney the head of the AIDS Council of New South Wales, Nicolas Parkhill, condemned Morris’s call for mass circumcision as a response to Australia’s HIV problem, pointing out that in Australia (unlike Africa) HIV was largely confined to homosexual men and injecting drug users, neither of whom could derive any risk reduction from circumcision. “ACON does not support the implementation of male circumcision as a HIV prevention strategy in Australia,” Mr Parkhill said. Other child health experts in New Zealand were equally dismissive. The president of the NZ Paediatric Society, Dr Rosemary Marks, said while there might be “some small benefits” arising from circumcision, they were not enough to warrant funding the procedure. “I think that’s a very long bow to draw.” Compared to the other priorities for health care, this would be very low on the list. Auckland paediatric surgeon James Hamill referred to the policy of the Royal Australasian College of Physicians, that routine circumcision was not warranted in Australia or New Zealand, as the consensus among child health authorities. The benefits of circumcision (if any) had to be viewed in context, he said, remembering that Australia and New Zealand do not have the problems faced by so many impoverished and underdeveloped African countries, and that children do not run the risks encountered by sexually promiscuous adults: “We don’t live in a desert, or in a country with a high rate of HIV, so in different cultural or geographical context it may be different.” The article by Morris and friends was published in an on-line journal called Open Journal of Preventive Medicine – an obscure, low-status publication that nobody had ever heard of until now. The article itself contains little or nothing new, but is merely a rehash of the same material that circumcision promoters have been peddling for the last decade, including totally exploded claims about lack of circumcision being a risk factor for prostate cancer. What next: circumcision as a preventive of epilepsy and a cure for brass poisoning? As one sceptic was heard to remark, just because you call an opinion “an evidence-based policy” does not mean that it is a fair-minded survey of all the relevant evidence, or that it is anything more than the personal opinion of the true believers who put their names to it. References: <a href="http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10791087">New Zealand Herald, 10 March 2012</a>; <a href="http://gaynewsnetwork.com.au/news/northern-territory/5273-circumcision-not-cure-all-for-public-health-acon-says.html" rel="noopener" target="_blank">Gay News Network, 8 March 2012</a>; <a href="http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10790330" rel="noopener" target="_blank">New Zealand Herald, 7 March 2012</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Child health experts slam circumcision proposal darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>Sexism and double standards alive and well, as girls get full protection</h3> <h3>while boys are thrown to the wolves</h3> The new policy on female genital mutilation released by the Royal Australasian College of Physician in April 2012 takes a firm stand in defence of the bodily integrity and human rights of girls and women. According to the policy, FGM is an injury to the external genitals; it is usually performed on girls between infancy and 15 years of age; it causes harm; it violates the human rights of the victims; it is wrong because it is performed on minors without consent; it is illegal in all Australian states; and, although it is a practice authorized and recommended by some cultural and religious minorities, it is unacceptable in Australia. Doctors should vigorously oppose any form of FGM and become advocates for girls who are threatened with it, even against their parents and culture of origin. These are very fine sentiments, and one wonders why the same principles have not been adopted in the RACP’s policy on circumcision of boys. Every one of the above objections to FGM also applies to male genital mutilation: circumcision is also an injury to the external genitals (usually more severe than mild forms of FGM, such as a nick); it is usually performed between infancy and 15 years of age; it causes harm; it violates the human rights of the victims; and it is performed on minors without consent. But at this point some striking differences emerge: despite injuring the genitals, causing bodily harm and violating a boy’s human rights, circumcision is apparently OK if a boy’s parents prefer him to be circumcised; the practice is not illegal or even regulated anywhere in Australia; and doctors are not urged to oppose the practice and become advocates for the victims. One can only feels that the RACP is suffering from a certain schizophrenia. If any form of female genital mutilation is a violation of a girl’s human rights, it follows that the right must also apply to boys. A human right is a right that applies to all humans, regardless of gender or age, simply by virtue of their humanity; it has nothing to do with the culture of their parents. For the RACP’s position to be logically consistent there are only two possibilities here: either a girl’s right not to have any part of her genitals injured by FGM is a not a human right at all, but gender-specific right, applicable only to females; or boys are not human. Neither possibility seems very likely, and the shabby truth appears simply to be that the RACP is in the grip of the usual sexist double standard on genital mutilation, whereby the slightest nick to the female genitals is an outrage that must be abhorred and opposed, while the most ruthless and brutal circumcision of a boy is a harmless snip that must be allowed and may be applauded. The RACP’s full policy on female genital mutilation is reproduced below, preceded by the media release that announced it. We urge readers to add the words and male or and boys or and men whenever they see the word female, girls or women. The result will be a non-discriminatory policy statement that shows equal respect for the bodily integrity and human rights of all children, not merely those fortunate enough to have been born without a penis. Why isn’t circumcision also “a child protection issue”? <h2>Media release: Female genital mutilation an unacceptable practice in Australia and New Zealand</h2> Physicians (RACP) today launched the Female Genital Mutilation/Cutting (FGMC) Policy. With increasing numbers of immigrants arriving in Australia and New Zealand, paediatricians may encounter in their practice, girls or women who have undergone FGMC, or are at risk of it, according to Professor David Forbes, Chair of the Policy and Advocacy Committee of the Paediatric and Child Health Division (P&HCD). FGMC is defined as an injury of the external female genitalia undertaken for cultural or non-therapeutic reasons. FGMC is usually carried out on young girls between infancy and 15 years of age. With cultural migration, the practice has moved to Western countries. “FGMC is recognised internationally as a violation of the human rights of girls and women,” Professor Forbes said. “FGMC exposes children and women to significant health risks and has no measurable health benefit. The RACP believes that it is not an acceptable practice.” The P&CHD, through the launch of the policy, is calling for all paediatricians to be aware of the practice and the associated risks, and to seek opportunities for prevention and child protection. “It is important for paediatricians practising in Australia and New Zealand to understand both the cultural context in which FGMC occurs and the clinical implications for patients who have undergone the procedure. Girls and adolescent women may be exposed to the risk of FGMC either in Australia or New Zealand or on return visits to their country of origin. Girls and adolescent women migrating to Australia and New Zealand may already have undergone FGMC or may be at risk of undergoing FGMC on return visits to their country of origin.” All forms of FGMC are condemned by leading health professional organisations. It is illegal in Australia and New Zealand for cosmetic genital surgery of any form to be undertaken on minors. FGMC causes significant short and long-term health risks for girls and women, including acute and chronic infection, infertility, childbirth difficulties, sexual relationship difficulties and significant short and long-term psychological trauma. United Nations organisations report that 140,000,000 women have undergone FGMC and 3,000,000 girls are at risk of the procedure every year. “Paediatricians need to develop the skills to be able to recognise families where FGMC may be practiced and girls are at highest risk, and to discuss FGMC with these families,” according to Professor Forbes. Children and adolescent girls who have experienced FGMC may require long-term care that that necessitates the involvement of a range of different services including mental health and gynecological services. Royal Australasian College of Physicians, 24 April 2012 The full RACP policy on female genital mutilation follows <h2>FEMALE GENITAL MUTILATION/CUTTING</h2> Definition Female genital mutilation/cutting (FGMC) is defined as an injury of the external female genitalia undertaken for cultural or non-therapeutic reasons. The term FGMC is now in use by UNICEF and some other international agencies [1]. FGMC comprises all procedures that involve partial or total removal of the external female genitalia, or other deliberate injury to the female genital organs for non-medical reasons[1]. This includes so-called “nicking” of the external genitalia. Key Points <ul> <li>FGMC is recognised internationally as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women.</li> <li>All forms of FGMC including so-called “nicking” of the clitoral hood are condemned by leading health professional organisations [11, 12]. It is illegal in Australia and New Zealand for cosmetic genital surgery of any form to be undertaken on minors.</li> <li>FGMC violates basic human rights, exposes children and women to significant health risks and has no measurable health benefit. The RACP believes that it is not an acceptable practice.</li> </ul> Background FGMC is a cultural, but not religious, practice of groups from Saharan Africa, parts of East Africa, Asia and South America. It is believed to have arisen in Africa and to pre-date Islam. It is not restricted to Islamic populations, is not supported by Islamic doctrine and has been condemned as an unacceptable practice by Islamic groups [1, 14]. United Nations organisations report that 140,000,000 women have undergone FGMC, and 3,000,000 girls are at risk of the procedure every year [1]. Traditionally FGMC was performed to safeguard family honour and social position, and to prevent female promiscuity and rape [3]. FGMC is sustained by the belief that it is in the best interest of the child and that failure to participate may place the child at risk [1, 4], although this justification is no longer considered valid. FGMC is usually carried out on young girls between infancy and 15 years of age [2]. It is typically carried out by traditional circumcisers, but is now performed by health care providers in some countries. With cultural migration the practice has moved to Western countries and has been documented in North America and a number of European countries [5, 6]. It is not clear that FGMC is practiced in Australia and New Zealand [7], although press and legal reports suggest that it is being undertaken in these countries. [8] FGMC causes significant short and long-term health risks for girls and women, including acute and chronic infection, infertility, childbirth difficulties, sexual relationship difficulties and significant short and long term psychological trauma. There are higher rates of Caesarean section for women who have undergone FGMC, and increased infant death rates [9], 10]. FGMC is illegal in Australia and New Zealand and in most other western countries. [8] It is also illegal to send girls and young women overseas for the purpose of genital surgery. In some Australian and New Zealand jurisdictions it is a requirement that children who are perceived to be at risk of FGMC or have ever experienced FGMC are to be notified to child protection services. Western custom and practice appears inconsistent in relation to genital surgery, by tolerating and even facilitating cosmetic genital surgery that includes piercing and labioplasty. Key differences are that genital cosmetic surgery is usually performed on consenting adults, while FGMC is performed without consent on minors. Paediatricians and FGMC FGMC is relevant to paediatricians in Australian and New Zealand, and it is important that paediatricians are aware of the practice and the risks associated with it, and the opportunities for prevention and child protection: Girls may be exposed to the risk of FGMC either in Australia and New Zealand or on return visits to their country of origin. Girls immigrating to Australia and New Zealand may already have undergone FGMC or may be at risk of undergoing FGMC on return visits to their country of origin. Paediatricians need to develop the skills to be able to recognise families where FGMC may be practiced and girls are at highest risk, and to discuss FGMC with these families (See Royal College of Nursing educational resource [13]). The RACP has a role in ensuring trainees and practising paediatricians have access to training regarding cultural awareness and specific aspects of recognition and management of FGMC. In clinical settings with potential high prevalence of FGMC this should be routinely, but respectfully, inquired about in order to avoid missing girls at risk. Care must be taken to avoid stigmatizing particular ethnic groups. Paediatricians working with communities that traditionally practice FGMC should seek opportunities, in conjunction with other health and child protection services to raise awareness that FGMC is not an acceptable practice in Australia, and to educate community leaders regarding healthy attitudes to female sexuality and to the dangers of FGMC. FGMC is a child protection issue, and paediatricians need to be prepared to advocate for girls and young women with their families and communities, and if necessary with the agencies charged with child protection. Paediatricians may be required to collaborate with other health and non-health professionals to advocate for and protect girls at risk. Service providers need to be aware that in protecting girls from FGMC they may expose them to risk of becoming ostracized within their families and communities through not participating in cultural rituals, and they may need special intervention to minimise this risk. Children and adolescent girls who have experienced FGMC are at risk of a range of serious, long-term physical and psychological problems. They will require long-term care that may require the involvement of a range of different services including mental health and gynaecological services. Royal Australasian College of Physicians, April 2012 References 1. OHCR, et al., Eliminating female genital mutilation: An interagency statement, 2008, World Health Organization: Geneva. 2. World Health Organisation, Female Genital Mutilation: Fact Sheet, 2012, World Health Organisation: Geneva. 3. Shell-Duncan, B., et al., Dynamics of change in the practice of female genital cutting in Senegambia: Testing predictions of social convention theory. Social Science & Medicine, 2011. 73: p. 1275-83. 4. Alo, O.A. and B. Gbadebo, Intergenerational Attitude Change Regarding Female Genital Cutting in a Yoruba-Speaking Ethnic Group of Southwest Nigeria. J Womens Health (Larchmt), 2011. 20: p. 1655-61. 5. Davis, D.S., Ritual genital cutting of female minors. Pediatrics, 2010. 125(5): p. 1088-93. 6. Jaeger, F., M. Caflisch, and P. Hohlfeld, Female genital mutilation and its prevention: a challenge for paediatricians. Eur J Pediatr, 2009. 168(1): p. 27-33. 7. Grover, S., Female genital mutilation. J Paediatr Child Health, 2009. 45(10): p. 614-5. 8. Matthews, B., Female genital mutilation: Australian law policy and practice challenges for doctors. Med J Aust, 2011. 194: p. 139-41. 9. Chibber, R., E. El-Saleh, and J. El Harmi, Female circumcision: obstetrical and psychological sequelae continues unabated in the 21st century. J Matern Fetal Neonatal Med, 2011. 24(6): p. 833-6. 10. Merritt, D.F., Genital trauma in children and adolescents. Clin Obstet Gynecol, 2008. 51(2): p. 237-48. 11. American Academy of Pediatrics, Policy Statement- Ritual cutting of female minors. Pediatrics, 2010. 12. Royal College of Obstetricians and Gynaecologists Joint RCOG/RCPCH statement on the AAP policy statement on FGM. 2010. 13. Royal College of Nursing, Female genital mutilation. An RCN educational resource for nursing and midwifery staff, 2006, Royal College of Nursing,: London. 14. WISE Muslim Women’s Shura Council, Female Genital Cutting: Harmful and Un-Islamic. 2010. Accessed 5 March 2012: http://www.wisemuslimwomen.org/images/uploads/WISE_Shura_Council_FGC_DigestStatement.pdf_.pdf </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource RACP's policy on female genital mutilation darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> A report by the Tasmanian Law Reform Institute has condemned the open slather approach to non-therapeutic circumcision of male minors and recommended much tighter regulation of the practice. The report analyses the borderline legal status of circumcision in Australia and the risks this uncertainty creates for both boys and circumcision practitioners, and makes fourteen recommendations for reform. These include a proposal for the outright prohibition of medically unnecessary circumcision of “incapable minors” (infants and young boys), with an exception for recognized religious and ethnic groups who traditionally practise circumcision (Jewish, Muslim and some Aboriginal communities). The report also recommends that circumcision always require the authorization of both parents, and that if parents disagree about whether a boy should be circumcised the operation may not be performed unless authorized by a court. It also proposes uniform standards of competence, disclosure and operational procedure for providers of circumcision services. The report has been hailed by child health and human rights experts as an impressive first step towards giving boys some degree of protection against needless destruction of their foreskins. Dr Robert Darby told Circumcision Information Australia that the report was a trailblazing effort that raised the discussion of non-therapeutic circumcision of minors to a new level. “For its scientific precision, its comprehensiveness, its human rights and bioethical awareness, and the good sense and practicality of its recommendations, the report could hardly have been bettered”, Dr Darby said. “Even though the recommendations apply only to Tasmania, any reforms there will set a new benchmark that other states will have to consider, and by which their own efforts at child protection will be judged. Coming on top of <a href="https://www.circinfo.org/Circumcision_and_law.html">the Cologne decision</a> that non-therapeutic circumcision is bodily harm, the TLRI report further revolutionizes the debate: the issue is no longer whether circumcision has so called “health benefits”, but whether it is legally and morally permissible.” Dr Darby said that a particularly valuable recommendation was to extend the time allowed for an individual who believes he has been harmed by circumcision to bring a legal action for damages against his circumciser. "This proposal recognises the sad (but often suppressed) truth that many men resent having been circumcised and would have preferred to go through life with an entire penis, or at least to make their own decision on such a personal matter. Existing legal rules, however, make it very difficult for them to seek legal redress, leaving the false impression that most men "don't mind" one way or the other. You can be pretty sure that if the playing field is made a little bit more level, the lawsuits will start to flow thick and fast." <h2>Non-therapeutic male circumcision: Recommendations for reform</h2> The recommendations of the Tasmania Law Reform Institute report on circumcision are as follows. 1. The Institute supports the enactment of legislation to reform the law governing circumcision. 2. The Institute recommends reform to provide a clear legislative basis for the legality of circumcision performed at the request of an adult or capable minor. 3. The Institute recommends the enactment of a new and separate offence generally prohibiting the circumcision of incapable minors in Tasmania. The new legislation ought to create an exception for the performance of some well-established religious or ethnicity motivated circumcision on incapable minors. 4. The Institute recommends the enactment of legislation to require joint parental authorisation for the circumcision of an incapable minor. 5. The Institute recommends the enactment of a law to require court authorisation for a circumcision whenever parents disagree about the desirability of performing a circumcision. 6. The Institute does not recommend the enactment of legislation mandating court authorisation for the circumcision of minors. 7. The Institute recommends the enactment of a law to require that all circumcisers provide accurate information as to: <ul> <li>the financial cost of the procedure;</li> <li>the non-therapeutic nature of the operation;</li> <li>the purpose and function of the foreskin;</li> <li>the procedure itself;</li> <li>the procedure’s effect on the functioning of the penis;</li> <li>the risks of the procedure;</li> <li>the nature and significance of the evidenced prophylactic benefits of circumcision in an Australian context;</li> <li>the potential for children to grow up into adults who resent their circumcision (this may include a discussion of the common rationales and prevalence of circumcision);</li> </ul> <ul> <li>the availability of the procedure in adulthood;</li> <li>the legality of the procedure.</li> </ul> 8. The Institute recommends that health policy, community and industry leaders use non-legislative avenues of reform to improve the dissemination of accurate information on the known and potential effects and significance of circumcision. 9. The Institute recommends the enactment of a criminal law that sets general principles against which to judge the acceptability of a circumciser’s practice. These principles should set minimum standards that all circumcisers of incapable minors must meet in the provision of their service. Parliament should give an existing health regulatory body the responsibility of formulating regulations to qualify the general standards set in statute. The Institute recommends the setting of standards as to matters such as: <ul> <li>the pain relief provided;</li> <li>the instruments used;</li> <li>the skill of the person performing the operation;</li> <li>the skill with which the procedure is performed;</li> <li>the adequacy of the wound care and post-procedure monitoring.</li> </ul> The standards set by statute and in regulations ought to reflect the minimum standards the community would expect circumcisers to meet at the time of the operation in the circumstance in which they are operating. In particular, the standards should ensure that no minor be put at a needlessly high risk of pain or complication from a circumcision. 10. The Institute recommends further investigation into whether the law governing the use and sale of human tissue would benefit from reform. 11. The Institute does not recommend reform to the law regulating the commercial aspects of a circumciser’s service. 12. The Institute recommends the enactment of reform to create a uniform period in which individuals harmed by a circumcision as a minor may bring an action against their circumciser. This period should extend for an appropriate time after the harmed person has reached the age of majority. This new limitation period should be enacted in a provision in a new Circumcision Act. 13. The Institute recommends the enactment of legislation to require circumcisers to transmit information relevant to actions that may be brought for harm they cause to a minor to an appropriate government authority. 14. The Institute does not recommend the enactment of a no-fault compensation scheme for harm caused by a circumcision performed upon an incapable minor. <a href="http://www.utas.edu.au/law-reform/publications" rel="noopener" target="_blank">The full report is available from the TLRI website</a> <a href="https://theconversation.edu.au/tasmanian-report-calls-for-groundbreaking-reform-of-circumcision-law-9105" rel="noopener" target="_blank">Warwick Marshall summarises the TLRI report at The Conversation</a> <a href="http://eprints.utas.edu.au/11729/" rel="noopener" target="_blank">Warwick Marshall, Master of Laws thesis on legal status of circumcision in Australia</a> <a href="http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2276538" rel="noopener" target="_blank">Dr Robert's Darby's submission to the TLRI circumcision inquiry at SSRN network</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Tasmanian law report recommends regulation of circumcision darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> A Canberra doctor has been disciplined and subjected to practice conditions by the <a href="http://www.ahpra.gov.au/">Australian Health Practitioner Regulation Agency</a> – the Commonwealth authority that replaced the State medical boards a few years ago. The following conditions have been imposed on Dr Timothy Dermott O’Neill, a general practitioner in Dickson: 1. Will not undertake circumcision without the use of adequate analgesia in accordance with the Royal Australian College of Physicians (RACP) guidelines. 2. When performing a circumcision he will only use the appropriate equipment required in each specific case. 3. That he provides the Board every 12 months with a statement of the number of circumcisions he has performed and details of the anaesthetic procedure used in each of the circumcision procedures. This monthly notification is to continue until December 2013. In addition, O’Neill is required: 1. To see a Board appointed psychiatrist, at the Board’s expense, within three months of the publication of this decision. 2. To attend a mentor of his choice, for supervision, once a month for six months. For the mentor to prepare a written report at the end of this period, as to his progress, to the Board. APHRA has not provided the reasons for these conditions, but we may infer from the requirements that when O’Neill performed circumcisions he did not provide an appropriate, adequate or recommended anaesthetic; and that he used inappropriate instruments. The implication is that he was causing an unacceptable level of pain, injury and surgical complications in the unfortunate boys brought to his surgery. The requirement that he see a psychiatrist has disturbing implications, and one would like to know what factors led AHPRA to impose such a condition. When the AHPRA decision was reported in the <a href="http://www.canberratimes.com.au/act-news/unkindest-cut-restrictions-placed-on-doctors-20130216-2ekkn.html">Canberra Times</a> (17 Feb 2013), the name of the offending doctor was suppressed, and the journalist declined to give it to an inquiry from Circumcision Information Australia. Likewise, a request to AHPRA for his name was met with a refusal, and the useless advice that the presence of conditions or other disciplinary action on doctors could be checked on the AHPRA website – but to do this you need the name of the doctor. These obstructive attitudes suggest a greater interest in protecting the business interests of medical practitioners than the health and welfare of the public. Further questions leap to mind. Why is O’Neill performing circumcision operations at all, when Australian medical policy since 1971 has consistently stated that routine circumcision is certainly not necessary and probably undesirable? Is somebody who graduated as long ago as 1973, and who is now required to see a psychiatrist, really the sort of person who ought to be performing delicate surgical operations on small and highly sensitive body parts? We calculate that if O’Neill was 25 when he graduated he must now be 65, an age at which he (like most people) might be expected to be thinking of retirement. Finally, we note the presence of the usual sexist double standard. Why is somebody who damages the genitals of boys treated so much more leniently than somebody who damages the genitals of women, such as Graeme Reeves, widely denounced as a mutilator and recently gaoled in Sydney. (<a href="https://www.circinfo.org/Genital_mutilation_doctor_guilty.html">See report of Reeves’ trial on this site</a>.) No doubt the harm inflicted by O’Neill was less than that inflicted by Reeves, but the principle is not so different, and the judge in Reeves’ appeal case – increasing his gaol sentence – laid great stress on the lack of informed consent on the part of the patient. How many baby boys consent to have part of their penis cut off? Details of the registration of medical practitioners <a href="http://www.ahpra.gov.au/Registration/Registers-of-Practitioners.aspx">may be searched at the AHPRA website here</a>. You will need the name of the doctor and the state in which he/she practices. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Canberra circumcision doctor disciplined darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>Genital cutting without consent ruled a grave offence</h3> The New South Wales doctor who excised a woman’s genitalia “for her health” has had his gaol sentence increased by a further 18 months. In March 2011 former south coast gynaecologist Graeme Reeves was convicted of inflicting grievous bodily harm on a patient, Carolyn DeWaegeneire, and sentenced to two and a half years gaol. Both he and the prosecution then appealed, Reeves because he claimed the jury had been wrongly directed, the prosecution because the sentence was “manifestly inadequate” to the gravity of the offence. On 21 February 2013 the Court of Criminal Appeal rejected Reeves’ appeal and increased his sentence by a further 18 months. The case goes back to 2002, when Mrs DeWaegeneire sought treatment for a small, discoloured (possibly pre-cancerous) patch on her labia. Instead of treating it medically or delicately cutting it out with minimal tissue loss, Reeves performed an operation under general anaesthetic during which he excised most of the woman’s external genitalia – much to her horror and dismay. Mrs DeWaegeneire then faced enormous difficulties and obstruction, and showed amazing fortitude and persistence, before the authorities took action, but eventually Reeves was charged under Section 45 of the NSW Crimes Act, covering female genital mutilation. At his trial in 2010 he claimed that the radical surgery he had performed was necessary to stop the cancer from spreading and thus essential for the woman’s health. In this case the jury was unable to agree on a verdict because Section 45 (3) (a) permits a defence to the cutting of the female genitals if it is “necessary for the health of the person on whom it is performed and is performed by a medical practitioner”. Although Reeves provided no evidence that the lesion was cancerous or likely to spread, sufficient numbers of the jury were evidently persuaded to give him the benefit of the doubt, and a new trial was ordered. For those who are surprised at the absence of a third condition that must be met for a defence against genital cutting, namely, the consent of the subject, it must remembered that Section 45 does not allow consent as a defence against female genital mutilation. This is to ensure that young women are not coerced by their family into giving a consent they do not really feel; although this is a necessary safeguard, it prevents competent adult women from electing genital modification surgery even if they desire it. Without reducing the protection given to the young, it would be possible and a sensible precaution to add “informed consent of the patient” to the relevant sub-section. At his second trial in March 2011 Reeves was charged under a different section of the Crimes Act – Section 33, covering wounding with intent to inflict grievous bodily harm. In this case the defence of “medical necessity” was not available, and although he tried it on, the jury was not convinced and duly found him guilty, largely on the basis that consent had not been given and the accused knew it had not been given. Announcing his appeal, however, Reeves was still trying to rely on “professional judgement” as the excuse for his actions. His barrister even tried to argue that the case should not have come to a criminal trial at all, since he “believed” that what he was doing was for the benefit of his patient. This defence will not hold, however, as doctors can believe (or say they believe) all kinds of cock and bull; the justification for surgical removal of functional body parts is not that a doctor “believes” such an excision to be in a person’s best interests, but if the operation is generally accepted by the medical profession as necessary in the circumstances and the patient has given explicit consent. Without such consent, any interference with another person’s body is assault – as the prosecution correctly argued in its recent appeal. This point was emphasized in the court judgment, which rejected as totally spurious Reeves’ attempt to argue that a patient’s consent meant merely a general authorization for the doctor to do whatever he thought desirable or necessary. On the contrary, Bathurst CJ reiterated the understanding of consent that has prevailed in Australian law since the High Court decision in Rogers v Whitaker (1992) and confirmed the trial court’s verdict that Reeves knew he did not have the patient’s consent for what he did to her. On the question of the sentence, the Chief Justice stated that in view of: <ul> <li>The radical and extensive nature of the surgery undertaken in circumstances in which the respondent knew that he did not have the consent of the complainant;</li> <li>The extensive harm inflicted on the complainant in consequence of the surgery involving the removal effectively of all the external genitalia, including the labia majora, labia minora, clitoris and perineum;</li> <li>The associated physical and emotional suffering resulting from the unauthorised surgery; and</li> <li>The respondent’s action in undertaking the surgery in circumstances involving a significant breach of the trust relationship between himself, as a medical practitioner, and the complainant, as his patient -</li> </ul> the offence committed was an objectively serious offence of a high order. The respondent did not, as he was bound to do, provide a clear explanation of the extensive and radical surgical procedure that he intended to carry out and did subsequently carry out. His failure to provide a proper explanation to the complainant, and his undertaking surgery without obtaining her consent, constituted a gross departure from accepted standards of surgical practice amounting to a grave offence. Accordingly, the sentence was increased to 4 years with a minimum parole period of 2 years. Implications for non-therapeutic circumcision This saga may have implications for medical law in general and for doctors who perform surgery on the genitals in particular. It confirms the old legal principle that any interference with a person’s body without consent is a criminal assault, punishable by imprisonment. It establishes that deliberate wounding of the genitals constitutes grievous bodily harm. It makes clear that doctors may not rely merely on their professional opinion, but must produce evidence for the value of and necessity for any proposed treatment. And it drives home the point that no treatment is permissible without the informed consent of the patient. Because Reeves’ conviction was under gender-neutral provisions of the Crimes Act, these principles apply just as strongly to males as to females, with possible implications for non-therapeutic circumcision of male minors. For there is something eerily familiar about Reeves defence that he was “only trying to save the woman’s life”, and “honestly believed” that the surgery was necessary for her health. We hear it every time enthusiasts for routine circumcision tries to justify the amputation of part of a boy’s external genitalia. “You may not like circumcision”, they say, “but it is necessary for your future health; and if you refuse to accept it voluntarily, it must be imposed on you by force, for your own good.” There is no difference between Reeves’ defence and the arguments of circumcision advocates, both in Australia and overseas. They, too, “honestly believe” that removal of part of a boy’s genitals is necessary to save his life, and they regard issues such as informed consent, medical ethics, human rights and personal preference as tedious, humanistic scruples that merely get in their way. Increasingly, however, it is recognised that the double standard that allows female genital mutilation to be condemned and punished but male circumcision to be tolerated and even promoted as “necessary for health” (as Reeves claimed with respect to Mrs DeWaegeneire) cannot be sustained. If it is wrong to remove a female’s genitals without her fully informed consent, how can it be acceptable to remove part of a male’s genitals without his fully informed consent? In this age of gender equality, this is one form of discrimination that will come under ever-sharpening scrutiny. <h3>What Does “Informed Consent” Mean?</h3> The following definition was given by Justice Woods at Reeves' trial in 2011 As a matter of law, any person has a right to his or her bodily integrity. In the context of this case, the law says that medical surgery cannot be performed on an adult person except with the voluntary and informed consent of the patient. “Consent” means “agreement”. Consent may be in writing, or spoken, so long as it is voluntarily given. To be valid, consent must be “informed”. This means that the medical practitioner must at least explain to the patient the purpose of the operation, the part or parts of the body to be cut or removed, the possible major consequences of the operation, and any options or alternative treatments which may be reasonably available. The explanation must be given at a time when the patient is conscious. If the patient is affected by drugs or anaesthesia, a purported consent at that time may be invalid if the patient cannot understand it. An explanation given in merely technical medical language may also fail to lead to valid consent, because the patient does not understand it or is misled by it. The purpose of the consent procedure is to inform the patient and to obtain the patient’s agreement to what is performed. If the explanation is not communicated adequately, by clear writing and/or words, the meaning of which she can grasp, the patient may not understand the explanation, or a vital part of it. If so, it cannot be said that there is “informed consent.” <a href="http://www.caselaw.nsw.gov.au/action/PJUDG?jgmtid=163170" rel="noopener" target="_blank">Full judgement available at Caselaw New South Wales</a> <h3>Earlier report:</h3> <h2>Genital mutilation doctor guilty of assault</h2> 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. The case outcome has been reported in most of the Australian news media and the ABC. The following report is from the Sydney Daily Telegraph. A FORMER NSW doctor has been found guilty of maliciously inflicting grievous bodily harm on a patient whose genitals he removed without her consent. The doctor had told a nurse that the patient's husband was dead “so it did not matter anyway” that he had taken her clitoris during the operation, the Sydney jury heard. The doctor, who cannot be named for legal reasons, denied maliciously inflicting grievous bodily harm (GBH) on Carolyn DeWaegeneire with intent to cause her GBH in 2002. But late this afternoon, the NSW District Court jury found him guilty after another jury failed to reach a verdict last year. Ms DeWaegeneire, 58 at the time of the operation, told the jury the doctor had informed her he was going to remove a lesion but never mentioned taking anything else, including her clitoris. If he had, “I would never have walked through that hospital door to start with”, she said, adding she “never, never, never, never” would have consented to the removal of her genitals. She had sought treatment for a small patch of discoloured skin on her labia, later identified as a form of pre-cancer. Ms DeWaegeneire said the doctor told her of his intention when she was about to pass out from anaesthesia on the operating table. “He leaned over me and, for my ears only, he said: ‘I’m going to take your clitoris too’,” she said. She told the jury there was “nothing” left of her genital region. It was “all gone”. Theatre nurse Sharon Demmery said she remembered the operation because of the large size of the tissue which was taken from the patient. “I said, ‘That is fairly radical’, and (the doctor) said, ‘Yes, if I didn’t take that much, the cancer would spread’,” Ms Demmery said. She said something came up about the clitoris, and she told the doctor, “You wouldn’t be taking my clitoris, no matter what.” He then said that “the patient’s husband was dead so it did not matter anyway.” The doctor had maintained that, far from having an intention to inflict harm on the woman, he was “trying to save her life”. He said he honestly believed the surgery was needed for her health. Judge Greg Woods will sentence him at a later date. Margaret Scheikowski, Former doctor guilty of removing Carolyn DeWaegeneire's genitals without consent, Daily Telegraph (Sydney), 11 March 2011 <h2>Comment by CIA</h2> <h3>Double standard on genital mutilation must be questioned</h3> While we will all be shocked at this appalling example of medical mayhem, and will applaud the fortitude of Ms DeWaegeneire in facing public humiliation to bring this butcher to justice, we should also spare a thought for the many other victims of genital mutilation whose cases do not reach the courts or the newspapers. We refer, of course, to the thousands of unnecessary circumcision operations performed each year on male infants and boys in New South Wales, all of whom would also have fled from the hospital if they had known what was being done to them and if they had the power to resist or run away. Circumcision may not be as radical or as crippling a surgery as the excisions performed on Ms DeWaegeneire, but it is just as gross an affront of a person’s bodily integrity and human dignity, just as gross a violation of the principles of medical ethics, and just as unnecessary. Without wishing in any way to minimise the enormity of this case, we suggest that in, some ways, routine circumcision of infants and boys is even worse than what was done to Ms DeWaegeneire. She really did have a pre-cancerous lesion on her genitals that needed limited surgery; none of the infants and boys routinely circumcised have anything wrong with their genitals, and did not need any kind of surgery at all. She gave limited consent to a minimal procedure; the infants and boys gave no consent at all. She had already experienced a full life with a complete body and a normal set of genital organs; circumcised infants and boys will never know what it is like to have a complete body and a normal set of natural genitals. The doctor’s defence also demands analysis. He was, he claims, “only trying to save her life”, and “honestly believed” that the surgery was necessary for the woman's health. We have heard this defence somewhere before, namely, in every justification for routine circumcision that has ever been attempted. “You may not like circumcision”, say the circumcision promoters, “but it is necessary for your future health; and if you refuse to accept it voluntarily, it must be imposed on you by force, for your own good.” There is no difference at all between Dr X’s defence here and the arguments put forward by circumcision promoters, both in Australia and overseas. They, too, “honestly believe” that removal of part of a boy’s genitals is necessary to save his life, and they they regard issues such as informed consent, medical ethics, human rights and personal preference as tedious humanistic scruples that merely get in the way of their knives. We wonder whether this doctor was as fond of circumcising male infants and boys as he was of performing mutilating operations on women, and if so, why one of these hobbies is regarded as a monstrous crime and the other as medical treatment. Increasingly, however, it is recognised that the double standard that allows female genital mutilation to be condemned and punished but male circumcision to be tolerated and even promoted as “necessary for health” (as this Dr X claimed with respect to Ms DeWaegeneire) cannot be sustained. If it is wrong to remove a woman’s genitals without her fully informed consent, how can it be acceptable to remove part of a man’s genitals without his fully informed consent? In this age of sexual equality, this is one form of discrimination that cannot be allowed to continue. NOTE: We find it strange and unfair that the name of the doctor has been suppressed, while his victim must face the glare of publicity. We do not know his name, and so cannot reveal it, but we suspect that entering the term “Butcher of Bega” into Google will bring up much relevant and interesting information about somebody who appears rather similar. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Gaol sentence increased for FGM doctor darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>Updated January 2013</h3> People often talk about the “rate” of circumcision but this can confuse two different ideas: incidence and prevalence. Incidence refers to the number of persons in a particular group who are circumcised each year; prevalence means how many in that group are currently circumcised. The prevalence of circumcision for newborn boys is zero, because none is born circumcised, but incidence is about 13% in the first year of life. On the other hand, annual incidence of circumcision for intact men in their 20s is about 0.07%, but prevalence in 2012 was estimated at 26%. Below we provide the most accurate estimates of circumcision incidence and prevalence for Australia available either on the Web or in print. The vast majority of circumcisions in Australia have always been performed routinely on infants. By routine we mean surgery performed without medical indication. The opposite of routine is therapeutic, which means for the treatment of a disease or to correct an anatomical defect. Routine circumcision reached a peak of more than 80% in the 1950s, with most procedures performed on neonates before the birth discharge from hospital. Incidence has fallen steadily since the 1960s, so that today about 85% of boys start primary school still in possession of their foreskins. Further, only 25% of circumcisions for this age group are now performed in a hospital setting; the rest are done in doctors’ rooms, mainly by profit-oriented GPs rather than qualified surgeons working with anaesthetists in theatre. <h2>Incidence</h2> <h2>Children</h2> The number of circumcisions for boys is the sum of Medicare rebates plus procedures performed on public patients in public hospitals. The latter is an important qualification because public hospitals progressively stopped offering this “elective procedure” from the 1990s, and from November 2007 none did (with very partial exceptions in Queensland and the Northern Territory). This is the main reason many people, looking only at Medicare rebates, have claimed that the “circumcision rate” has been going up, when in fact incidence has been very stable over the past decade and has recently begun a renewed decline. Table 1 <img alt="" height="262" src="https://www.circinfo.org/images/0clip_image002.gif" width="435"/> A reader asks if we can obtain a more recent picture of circumcision incidence that includes a State breakdown. There is at least a 2-year lag for release of the relevant hospital data, which are national only. But happily public hospital circumcisions have been of decreasing importance for preschool boys as elective procedures have been phased out. Since Medicare rebates were claimed for 94% of circumcisions in this age group in 2010, Medicare statistics – which are published at monthly intervals – can provide a more current snapshot of incidence, as well as allowing a State breakdown, with only a small loss of accuracy. In order to obtain a more sensitive measure for comparative purposes we can calculate a true rate: rebates per 1000 person-years in this case. The distinction between rate and risk is subtle but important: rate is what actually happened that year for all boys aged 0-4; risk is a prediction of what would happen for boys born that year were the rate to stay the same over the ensuing 4 years. Table 2 <img alt="" height="249" src="https://www.circinfo.org/images/0clip_image004.gif" width="551"/> There are several points to note about this table. First, to obtain a total risk value comparable to that in Table 1, we must add 1 percentage point (based on 2010 data) to the national Medicare estimate. So the total national risk should be 15% in 2011-12, barring unforeseen changes in public hospital practices (for individual States and Territories the equivalent increments vary in ways that are difficult to measure precisely but fall in the range 0.5-1.5%). Second, Victorian and South Australian public hospitals still offered elective circumcision in 2007-08, so the small rate rises in Medicare rebates for these States largely reflected a move from publicly insured to fee-for-service rather than an increase in the actual number of procedures. Third, and most important, it is now clear that after more than a decade of stability the incidence of infant circumcision started a renewed decline from 2008 in Queensland and NSW, the States with the highest incidence. This is not surprising given the falling prevalence among first-time fathers (see below). Finally, religious (ritual) circumcision is increasing in importance and now accounts for the majority of procedures in Victoria; as with Europe, being circumcised in Australia is becoming a marker of religious identity, with fewer than 10% of boys circumcised for secular reasons by the time they start school. <h2>Incidence</h2> <h2>Adults</h2> Since Australian adults are only circumcised in a full surgical setting (public or private hospital, or private free-standing day surgery), we can ignore Medicare data and just use hospital Procedures data for estimates. However, we cannot use total population to calculate a rate, since only intact men can be circumcised. For this we need to know the circumcision prevalence, which was 58% in 2005 for males aged 15-64. Table 3 <img alt="" height="142" src="https://www.circinfo.org/images/0clip_image006.gif" width="208"/> The table indicates that 96% of the 15-year-olds who were intact in 2005 will not be circumcised by their 65th birthday for any reason, if incidence remains the same. But will it? And what are the main reasons for adults being circumcised, anyway? We can use the Principal Diagnosis fields of the same hospital records to answer these questions for phimosis and routine (i.e. elective) circumcision, which combined constitute the reasons for more than 95% of all adult procedures. Table 4 shows the results for men in their 20s, who have seen the most dramatic decline in circumcision prevalence over the past two decades (see Prevalence below). Three-year averages were calculated to “smooth” any random variations in population estimates or case numbers. Table 4 <img align="left" alt="" height="192" src="https://www.circinfo.org/images/0clip_image008.gif" width="334"/> The most striking feature of this table is that as intact men move from being a minority to a large majority in their peer group, they are much less likely to opt for circumcision. This means that the already small risk of adult circumcision (incidence) is actually falling as circumcision prevalence falls. <h2>Prevalence</h2> <h3>Who has been circumcised?</h3> The primary source for prevalence data is the Australian Studies of Health and Relationships, which has conducted large-scale scientific surveys of sexual health issues since 2001. Stratifying this information by birth year and place provides an excellent picture of the changing circumcision status of the adult population, including a breakdown into its Australian-born and overseas-born components (the latter now constituting 30% of the total male population). Figure 1 <img alt="" height="346" src="https://www.circinfo.org/images/0clip_image010.gif" width="415"/> The 2005 intake of this survey confirmed these data and found that prevalence for those born in 1987-89 was 27%, which would indicate that the decline in incidence had started to “flatten out” at that time. It is important for a correct interpretation of this graph to understand that while the measured prevalence for all residents (the red line) born in the 1950s was 70% in 2001-02, it would have been higher in, say, 1960. That’s because net migration depresses total prevalence over time, as long as the blue line (Australian-born) is higher than the green line (overseas-born). Analysis of the latest Census data by country of origin indicates the circumcision rate of recent arrivals is about 15%, which means immigration continues to exert downward pressure on adult circumcision prevalence. Prevalence for Australian-born men closely approximates incidence for each birth year, given the relative rarity of adult circumcision. Another way of looking at the same dataset is to plot the prevalence for an age group over time. Again, it is men in their 20s who are of most interest, since it follows that whatever has happened to them will be the case for men in their 30s ten years later; that is, the circumcision prevalence of men aged 20-29 years in 2002 will closely correspond to that of those aged 30-39 in 2012, since they are largely the same people! Figure 2 <img alt="" height="253" src="https://www.circinfo.org/images/0clip_image012.gif" width="414"/> The fact that in 2005, for instance, 64% of these men were intact means that in 2015 about two-thirds of first-time fathers will also be intact, creating a demographic feedback loop that increasingly protects the next generation, since the biggest risk factor for infant circumcision is circumcised fathers. The trend (red line) shows a steady fall over 20 years of 2.1% a year. One important implication is that even with the active discouragement of routine circumcision by most of the medical profession, it still took two decades to effect a reversal of incidence (roughly from 70:30 to 30:70). This makes calls for “boosting” RIC as an alleged prophylaxis for certain adult sexual health issues particularly quixotic, since in addition to the lead time for the measure to be relevant (median ages of 34 and 69 years for HIV and penile cancer, respectively), one has to factor in the two or three decades it would take to reverse infant circumcision incidence from its current low level (assuming that were even possible, never mind desirable). The final question many people ask about prevalence is: how many living males are currently circumcised? This inevitably involves a little more guess-work than the other calculations offered above, particularly for elderly males (born before WWII), but the last table offers a conservative estimate based on population data for 2011. Table 5 <img alt="" height="103" src="https://www.circinfo.org/images/0clip_image014.gif" width="253"/> Note that even if incidence did not change, total prevalence would continue to fall as older males leave the population, largely intact birth cohorts enter, and younger males age. <h2>Technical notes</h2> <ul> <li>All years are financial years, ending June 30.</li> <li>Percentages and rates are variously rounded to reflect the error levels of the data represented.</li> <li> Sources: Medicare data are from the Health Insurance Commission. Hospital figures are from the National Hospital Morbidity Database, maintained by the Australian Institute of Health and Welfare, and populated by separation data provided by State and Territory health departments. Prevalence data are from the Australian Study of Health and Relationships. Population data are from the Australian Bureau of Statistics. </li> <li class="style2"> Error margins: These apply to prevalence estimates and are inversely proportional to the square root of the sample size. For Figure 1 these average ±4.5% for each 5-year cohort. For Figure 2 these average ±3% for each data point. The 58% estimate for circumcision prevalence in 2005 has a margin of ±1.5%, so the risk calculation in Table 5 is ±0.13%. These margins are calculated at a 95% confidence level. Population data are ABS estimates and should not be considered accurate beyond the third decimal place (i.e. 100s). </li> <li>Incidence data only cover circumcisions performed in a medical setting, thus excluding boys circumcised by mohelim without a Medicare provider number and tribal circumcisions by Aboriginal people. These are unlikely to be statistically significant.</li> <li>Also excluded are persons who did not claim a Medicare rebate for which they were eligible. The number of such cases is unknown but, given the financial incentive to claim, it is probably quite small.</li> <li>There are two possible sources of double-counting, which would inflate incidence figures. The first is circumcised individuals who undergo a “circumcision revision”, which would be recorded simply as a new circumcision in the hospital or Medicare data; the second involves public patients who are nonetheless charged for surgical services (but not the hospital stay) and subsequently claim a rebate. The combined effect of these two factors is also difficult to quantify but probably equals or outweighs sources of under-counting identified in points 5 and 6.</li> </ul> © John Cozijn, 2013 This page is copyright. Any reproduction of this information, in whole or in part, must credit Circumcision Information Australia and/or provide a link to this page. Questions or suggestions should be directed to the author at <a class="__cf_email__" data-cfemail="2c54494940494919196c4b414d4540024f4341" href="/cdn-cgi/l/email-protection">[email protected]</a> <h2> <a id="decline" name="decline"></a>Update 2017: Sharp fall in Australian circumcision incidence</h2> Figures from Medicare show that circumcision incidence in Australia continues to decline and is now at the lowest rate since records were kept. Between Financial Year 2009/10 and 2015/16 the number of circumcisions of boys under 6 months of age fell from 20,246 to 14,880 – a decline of about 30%. The fall was particularly dramatic in New South Wales (down from 8750 to 5923) and Queensland (down from 5611 to 3145). There were small falls in South Australia, the Northern Territory and the Australian Capital Territory, and slight rises in Victoria and Western Australia – where, however, the figures remain well below NSW and Qld (2943 and 1361 cases respectively). See Table 1 for details. These figures are based on claims under Medicare item 30653, circumcision of a male under 6 months of age, and may not include all circumcision operations performed in Australia – those carried out as part of a childbirth “package”, for example, or by community operators, such as Mohels servicing the Jewish community. On the other hand, it is not likely that parents who arrange circumcisions with GPs and so-called specialist clinics would fail to claim the rebate, so it is likely that the figures give a reasonable approximation of the true picture. Even if they understate the incidence, the declining trend is obvious. Although the majority of circumcision procedures are performed on baby boys under 6 months of age, significant numbers are also circumcised at later ages, and a few (very few) adults seek circumcision for their own personal reasons. Table 2 shows national figures for Medicare item 30656 (circumcision of a male between 6 months and 10 years of age); 30659 (circumcision of a male 10 years or over by a GP); and 30660 (circumcision of male 10 years or over by a specialist). From these it appears that while fewer boys between 6 months and 10 years are being circumcised, there is a slight increase in circumcision incidence among males 10 years or older. Some of these are likely to be boys circumcised on the basis of a mistaken or spurious diagnosis of phimosis. <a href="https://www.circinfo.org/phimosiscomment.html">Doctors warned</a> some years ago that too many older boys were being circumcised for phimosis (foreskin tightness or non-retractability), without efforts having been made to treat the problem medically, such as with topical steroids. They further point out that this condition is usually a normal developmental stage that will usually resolve itself without treatment as the boy matures. Even where there is pain or discomfort, most <a href="https://www.circinfo.org/phimosis.html">cases of phimosis</a> can be cured by application of topical steroids. Other reasons given for circumcision, such as balanitis (inflammation of the foreskin or glans) are equally suspect, as most of these conditions can be cured by application of appropriate medications or other non-surgical treatment. <a href="https://www.circinfo.org/AAP_in_retreat.html">Research in Denmark</a> has established that only a tiny percentage of boys need circumcision for medical reasons. It is also likely that a further (but unknown) proportion circumcision procedures in the 10-years-plus category are competent adults (aged 18 years and above) who elect circumcision for themselves, but since Medicare does not provide a more detailed breakdown by age it is not possible to reach a definite conclusion on this point. Since Australian male births are currently running at nearly 160,000 per year, it is clear that the proportion of competent males seeking circumcision for themselves is extremely small. The good news is that the incidence of circumcision among infants and young boys unable to give informed consent is declining steadily, and quite dramatically in the two “problem” states, New South Wales and Queensland. In calendar year 2015, the number of circumcision procedures performed on boys under 6 months of age was 15,176; in the same year, there were 157,088 male births, giving a circumcision incidence of 9.66%. In other words, the current incidence of circumcision in Australia is at its lowest level since records began. Table 2: Claims for circumcision for boys aged over 6 months by Medicare item number <table border="1" width="308"> <tbody> <tr> <td class="grey" width="100">Item No</td> <td class="grey" width="100">Financial year</td> <td class="grey" width="100">Financial year</td> </tr> <tr> <td> </td> <td>2009-2010</td> <td>2015-2016</td> </tr> <tr> <td class="grey">30656</td> <td class="grey">4274</td> <td class="grey">3039</td> </tr> <tr> <td>30659</td> <td>694</td> <td>897</td> </tr> <tr> <td class="grey">30660</td> <td class="grey">2523</td> <td class="grey">3205</td> </tr> </tbody> </table> Table 1: Claims for circumcision of boys aged 6 months and under, by financial year and state <table border="1" width="818"> <tbody> <tr> <td width="100">Year</td> <td width="100">NSW</td> <td width="100">Vic</td> <td width="100">Qld</td> <td width="100">SA</td> <td width="100">WA</td> <td width="100">Tas</td> <td width="100">ACT</td> </tr> <tr> <td class="grey">2009/10</td> <td class="grey">8750</td> <td class="grey">2919</td> <td class="grey">5611</td> <td class="grey">1566</td> <td class="grey">1117</td> <td class="grey">50</td> <td class="grey">178</td> </tr> <tr> <td>2010/11</td> <td>8521</td> <td>2992</td> <td>4036</td> <td>1563</td> <td>1104</td> <td>43</td> <td>197</td> </tr> <tr> <td class="grey">2011/12</td> <td class="grey">8524</td> <td class="grey">3170</td> <td class="grey">3936</td> <td class="grey">1523</td> <td class="grey">1168</td> <td class="grey">44</td> <td class="grey">208</td> </tr> <tr> <td>2102/13</td> <td>7758</td> <td>3007</td> <td>3710</td> <td>1536</td> <td>1268</td> <td>47</td> <td>208</td> </tr> <tr> <td class="grey">2013/14</td> <td class="grey">7288</td> <td class="grey">3019</td> <td class="grey">3478</td> <td class="grey">1487</td> <td class="grey">1283</td> <td class="grey">47</td> <td class="grey">230</td> </tr> <tr> <td>2014/15</td> <td>6841</td> <td>3097</td> <td>3140</td> <td>1275</td> <td>1277</td> <td>56</td> <td>151</td> </tr> <tr> <td class="grey">2015/16</td> <td class="grey">5923</td> <td class="grey">2934</td> <td class="grey">3145</td> <td class="grey">1304</td> <td class="grey">1361</td> <td class="grey">61</td> <td class="grey">112</td> </tr> </tbody> </table> Table 1 (Continued) <table border="1" width="308"> <tbody> <tr> <td width="100">Year</td> <td width="100">NT</td> <td width="100">Total Aust</td> </tr> <tr> <td class="grey">2009/10</td> <td class="grey">55</td> <td class="grey">20246</td> </tr> <tr> <td>2010/11</td> <td>47</td> <td>18503</td> </tr> <tr> <td class="grey">2011/12</td> <td class="grey">43</td> <td class="grey">18616</td> </tr> <tr> <td>2012/13</td> <td>44</td> <td>17578</td> </tr> <tr> <td class="grey">2013/14</td> <td class="grey">47</td> <td class="grey">16897</td> </tr> <tr> <td>2014/15</td> <td>52</td> <td>15889</td> </tr> <tr> <td class="grey">2015/16</td> <td class="grey">40</td> <td class="grey">14880</td> </tr> </tbody> </table> Figures derived from statistics kept by Medicare at http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Incidence and prevalence of circumcision in Australia darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Gaol sentence increased for genital mutilation doctor:</h1> <h3>Genital cutting without consent ruled a grave offence</h3> The New South Wales doctor who excised a woman’s genitalia “for her health” has had his gaol sentence increased by a further 18 months. In March 2011 former south coast gynecologist Graeme Reeves was convicted of inflicting grievous bodily harm on a patient, Carolyn DeWaegeneire, and sentenced to two and a half years gaol. Both he and the prosecution then appealed, Reeves because he claimed the jury had been wrongly directed, the prosecution because the sentence was “manifestly inadequate” to the gravity of the offence. On 21 February 2013 the Court of Criminal Appeal rejected Reeves’ appeal and increased his sentence by a further 18 months. The case goes back to 2002, when Mrs DeWaegeneire sought treatment for a small, discoloured (possibly pre-cancerous) patch on her labia. Instead of treating it medically or delicately cutting it out with minimal tissue loss, Reeves performed an operation under general anaesthetic during which he excised most of the woman’s external genitalia – much to her horror and dismay. Mrs DeWaegeneire then faced enormous difficulties and obstruction, and showed amazing fortitude and persistence, before the authorities took action, but eventually Reeves was charged under Section 45 of the NSW Crimes Act, covering female genital mutilation. At his trial in 2010 he claimed that the radical surgery he had performed was necessary to stop the cancer from spreading and thus essential for the woman’s health. In this case the jury was unable to agree on a verdict because Section 45 (3) (a) permits a defence to the cutting of the female genitals if it is “necessary for the health of the person on whom it is performed and is performed by a medical practitioner”. Although Reeves provided no evidence that the lesion was cancerous or likely to spread, sufficient numbers of the jury were evidently persuaded to give him the benefit of the doubt, and a new trial was ordered. For those who are surprised at the absence of a third condition that must be met for a defence against genital cutting, namely, the consent of the subject, it must remembered that Section 45 does not allow consent as a defence against female genital mutilation. This is to ensure that young women are not coerced by their family into giving a consent they do not really feel; although this is a necessary safeguard, it prevents competent adult women from electing genital modification surgery even if they desire it. Without reducing the protection given to the young, it would be possible and a sensible precaution to add “informed consent of the patient” to the relevant sub-section. At his second trial in March 2011 Reeves was charged under a different section of the Crimes Act – Section 33, covering wounding with intent to inflict grievous bodily harm. In this case the defence of “medical necessity” was not available, and although he tried it on, the jury was not convinced and duly found him guilty, largely on the basis that consent had not been given and the accused knew it had not been given. Announcing his appeal, however, Reeves was still trying to rely on “professional judgement” as the excuse for his actions. His barrister even tried to argue that the case should not have come to a criminal trial at all, since he “believed” that what he was doing was for the benefit of his patient. This defence will not hold, however, as doctors can believe (or say they believe) all kinds of cock and bull; the justification for surgical removal of functional body parts is not that a doctor “believes” such an excision to be in a person’s best interests, but if the operation is generally accepted by the medical profession as necessary in the circumstances and the patient has given explicit consent. Without such consent, any interference with another person’s body is assault – as the prosecution correctly argued in its recent appeal. This point was emphasized in the court judgment, which rejected as totally spurious Reeves’ attempt to argue that a patient’s consent meant merely a general authorization for the doctor to do whatever he thought desirable or necessary. On the contrary, Bathurst CJ reiterated the understanding of consent that has prevailed in Australian law since the High Court decision in Rogers v Whitaker (1992) and confirmed the trial court’s verdict that Reeves knew he did not have the patient’s consent for what he did to her. On the question of the sentence, the Chief Justice stated that in view of: <ul> <li>The radical and extensive nature of the surgery undertaken in circumstances in which the respondent knew that he did not have the consent of the complainant;</li> <li>The extensive harm inflicted on the complainant in consequence of the surgery involving the removal effectively of all the external genitalia, including the labia majora, labia minora, clitoris and perineum;</li> <li>The associated physical and emotional suffering resulting from the unauthorised surgery; and</li> <li>The respondent’s action in undertaking the surgery in circumstances involving a significant breach of the trust relationship between himself, as a medical practitioner, and the complainant, as his patient -</li> </ul> the offence committed was an objectively serious offence of a high order. The respondent did not, as he was bound to do, provide a clear explanation of the extensive and radical surgical procedure that he intended to carry out and did subsequently carry out. His failure to provide a proper explanation to the complainant, and his undertaking surgery without obtaining her consent, constituted a gross departure from accepted standards of surgical practice amounting to a grave offence. Accordingly, the sentence was increased to 4 years with a minimum parole period of 2 years. Implications for non-therapeutic circumcision This saga may have implications for medical law in general and for doctors who perform surgery on the genitals in particular. It confirms the old legal principle that any interference with a person’s body without consent is a criminal assault, punishable by imprisonment. It establishes that deliberate wounding of the genitals constitutes grievous bodily harm. It makes clear that doctors may not rely merely on their professional opinion, but must produce evidence for the value of and necessity for any proposed treatment. And it drives home the point that no treatment is permissible without the informed consent of the patient. Because Reeves’ conviction was under gender-neutral provisions of the Crimes Act, these principles apply just as strongly to males as to females, with possible implications for non-therapeutic circumcision of male minors. For there is something eerily familiar about Reeves defence that he was “only trying to save the woman’s life”, and “honestly believed” that the surgery was necessary for her health. We hear it every time enthusiasts for routine circumcision tries to justify the amputation of part of a boy’s external genitalia. “You may not like circumcision”, they say, “but it is necessary for your future health; and if you refuse to accept it voluntarily, it must be imposed on you by force, for your own good.” There is no difference between Reeves’ defence and the arguments of circumcision advocates, both in Australia and overseas. They, too, “honestly believe” that removal of part of a boy’s genitals is necessary to save his life, and they regard issues such as informed consent, medical ethics, human rights and personal preference as tedious, humanistic scruples that merely get in their way. Increasingly, however, it is recognised that the double standard that allows female genital mutilation to be condemned and punished but male circumcision to be tolerated and even promoted as “necessary for health” (as Reeves claimed with respect to Mrs DeWaegeneire) cannot be sustained. If it is wrong to remove a female’s genitals without her fully informed consent, how can it be acceptable to remove part of a male’s genitals without his fully informed consent? In this age of gender equality, this is one form of discrimination that will come under ever-sharpening scrutiny. <h3>What Does “Informed Consent” Mean?</h3> The following definition was given by Justice Woods at Reeves' trial in 2011 As a matter of law, any person has a right to his or her bodily integrity. In the context of this case, the law says that medical surgery cannot be performed on an adult person except with the voluntary and informed consent of the patient. “Consent” means “agreement”. Consent may be in writing, or spoken, so long as it is voluntarily given. To be valid, consent must be “informed”. This means that the medical practitioner must at least explain to the patient the purpose of the operation, the part or parts of the body to be cut or removed, the possible major consequences of the operation, and any options or alternative treatments which may be reasonably available. The explanation must be given at a time when the patient is conscious. If the patient is affected by drugs or anaesthesia, a purported consent at that time may be invalid if the patient cannot understand it. An explanation given in merely technical medical language may also fail to lead to valid consent, because the patient does not understand it or is misled by it. The purpose of the consent procedure is to inform the patient and to obtain the patient’s agreement to what is performed. If the explanation is not communicated adequately, by clear writing and/or words, the meaning of which she can grasp, the patient may not understand the explanation, or a vital part of it. If so, it cannot be said that there is “informed consent.” <a href="http://www.caselaw.nsw.gov.au/action/PJUDG?jgmtid=163170" rel="noopener" target="_blank">Full judgement available at Caselaw New South Wales</a> <h3>Earlier report:</h3> <h2>Genital mutilation doctor guilty of assault</h2> 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. The case outcome has been reported in most of the Australian news media and the ABC. The following report is from the Sydney Daily Telegraph. A FORMER NSW doctor has been found guilty of maliciously inflicting grievous bodily harm on a patient whose genitals he removed without her consent. The doctor had told a nurse that the patient's husband was dead “so it did not matter anyway” that he had taken her clitoris during the operation, the Sydney jury heard. The doctor, who cannot be named for legal reasons, denied maliciously inflicting grievous bodily harm (GBH) on Carolyn DeWaegeneire with intent to cause her GBH in 2002. But late this afternoon, the NSW District Court jury found him guilty after another jury failed to reach a verdict last year. Ms DeWaegeneire, 58 at the time of the operation, told the jury the doctor had informed her he was going to remove a lesion but never mentioned taking anything else, including her clitoris. If he had, “I would never have walked through that hospital door to start with”, she said, adding she “never, never, never, never” would have consented to the removal of her genitals. She had sought treatment for a small patch of discoloured skin on her labia, later identified as a form of pre-cancer. Ms DeWaegeneire said the doctor told her of his intention when she was about to pass out from anaesthesia on the operating table. “He leaned over me and, for my ears only, he said: ‘I’m going to take your clitoris too’,” she said. She told the jury there was “nothing” left of her genital region. It was “all gone”. Theatre nurse Sharon Demmery said she remembered the operation because of the large size of the tissue which was taken from the patient. “I said, ‘That is fairly radical’, and (the doctor) said, ‘Yes, if I didn’t take that much, the cancer would spread’,” Ms Demmery said. She said something came up about the clitoris, and she told the doctor, “You wouldn’t be taking my clitoris, no matter what.” He then said that “the patient’s husband was dead so it did not matter anyway.” The doctor had maintained that, far from having an intention to inflict harm on the woman, he was “trying to save her life”. He said he honestly believed the surgery was needed for her health. Judge Greg Woods will sentence him at a later date. Margaret Scheikowski, Former doctor guilty of removing Carolyn DeWaegeneire's genitals without consent, <a href="http://www.dailytelegraph.com.au/news/former-doctor-guilty-of-removing-carolyn-dewaegeneires-genitals-without-consent/story-e6freuy9-1226019237310">Daily Telegraph</a> (Sydney), 11 March 2011 <h2>Comment by CIA</h2> <h3>Double standard on genital mutilation must be questioned</h3> While we will all be shocked at this appalling example of medical mayhem, and will applaud the fortitude of Ms DeWaegeneire in facing public humiliation to bring this butcher to justice, we should also spare a thought for the many other victims of genital mutilation whose cases do not reach the courts or the newspapers. We refer, of course, to the thousands of unnecessary circumcision operations performed each year on male infants and boys in New South Wales, all of whom would also have fled from the hospital if they had known what was being done to them and if they had the power to resist or run away. Circumcision may not be as radical or as crippling a surgery as the excisions performed on Ms DeWaegeneire, but it is just as gross an affront of a person’s bodily integrity and human dignity, just as gross a violation of the principles of medical ethics, and just as unnecessary. Without wishing in any way to minimise the enormity of this case, we suggest that in, some ways, routine circumcision of infants and boys is even worse than what was done to Ms DeWaegeneire. She really did have a pre-cancerous lesion on her genitals that needed limited surgery; none of the infants and boys routinely circumcised have anything wrong with their genitals, and did not need any kind of surgery at all. She gave limited consent to a minimal procedure; the infants and boys gave no consent at all. She had already experienced a full life with a complete body and a normal set of genital organs; circumcised infants and boys will never know what it is like to have a complete body and a normal set of natural genitals. The doctor’s defence also demands analysis. He was, he claims, “only trying to save her life”, and “honestly believed” that the surgery was necessary for the woman's health. We have heard this defence somewhere before, namely, in every justification for routine circumcision that has ever been attempted. “You may not like circumcision”, say the circumcision promoters, “but it is necessary for your future health; and if you refuse to accept it voluntarily, it must be imposed on you by force, for your own good.” There is no difference at all between Dr X’s defence here and the arguments put forward by circumcision promoters, both in Australia and overseas. They, too, “honestly believe” that removal of part of a boy’s genitals is necessary to save his life, and they they regard issues such as informed consent, medical ethics, human rights and personal preference as tedious humanistic scruples that merely get in the way of their knives. We wonder whether this doctor was as fond of circumcising male infants and boys as he was of performing mutilating operations on women, and if so, why one of these hobbies is regarded as a monstrous crime and the other as medical treatment. Increasingly, however, it is recognised that the double standard that allows female genital mutilation to be condemned and punished but male circumcision to be tolerated and even promoted as “necessary for health” (as this Dr X claimed with respect to Ms DeWaegeneire) cannot be sustained. If it is wrong to remove a woman’s genitals without her fully informed consent, how can it be acceptable to remove part of a man’s genitals without his fully informed consent? In this age of sexual equality, this is one form of discrimination that cannot be allowed to continue. NOTE: We find it strange and unfair that the name of the doctor has been suppressed, while his victim must face the glare of publicity. We do not know his name, and so cannot reveal it, but we suspect that entering the term “Butcher of Bega” into Google will bring up much relevant and interesting information about somebody who appears rather similar. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource New South Wales doctor guilty of genital mutilation darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> Circumcision is not appropriate for 21st Century Aussie boys. A definitive article in Australia’s leading child health journal confirms the judgement of Australian paediatricians since 1971 that boys should not be routinely circumcised as a health precaution. In a rebuff to the <a href="https://www.darboninstitute.org/child_health_experts_ridicule_american_circumcision_policy_statement" rel="noopener" target="_blank">American Academy of Pediatrics</a> (and by extension the <a href="https://www.darboninstitute.org/centers_for_disease_control_and_male_circumcision_americans_out_of_touch_and_living_in_the_past" rel="noopener" target="_blank">Centers for Disease Control</a>, which repeats its errors) the article endorses the conclusion of the circumcision policy statement issued by the Royal Australasian College of Physicians in 2010, namely, that there is no medical warrant for routine circumcision in the Australian and New Zealand context. The paper, by leading Australian child health authorities, runs through the reasons traditionally cited for non-therapeutic circumcision of infants and finds none of them convincing or sufficient. They particularly reject the common argument that circumcision should be performed in order to reduce the risk of HIV infection. Although there is evidence that circumcision can reduce the risk of disease transmission during unprotected intercourse with an infected female partner, all of it comes from studies of adult circumcision in under-developed African countries with both very high HIV prevalence and social and epidemiological conditions quite different from those in Australia. As the authors point out “Although most of the research on circumcision have sound scientific basis, its findings are usually only applicable to the specific socio-cultural context in which the study was conducted”, and they warn that too many authors “tend to prematurely extrapolate the data in an attempt to set national and international standards.” (Brian Morris: are you listening?) The authors also raise important questions of bioethics and human rights, pointing out that while adult males can give autonomous consent to circumcision for any reason, “it is difficult to argue the same ethical principles for infants.” While parents have “legal rights to consent for a medical procedure if it is in the child’s best interest,” it is difficult to justify circumcision “as being in the best interest of the infant when most uncircumcised Australian adult males themselves … are reluctant to undergo adult circumcision?” In other words, circumcision fails the imputed judgement test and violates the child’s right to a open future. The upshot is that paediatricians should seek to discourage parents from having their boys circumcised, as was the case back in the 1980s. Very few boys are circumcised these days, and the incidence is declining, meaning that the old, silly argument about “looking like his father” is no longer relevant. Quite the contrary: “as fewer children are being circumcised, parents’ priorities might have changed from making the boy to look like his father to allowing the boy to look more like the other uncircumcised boys at school.” The authors conclude that “although there is a benefit of circumcision in those with urogenital tract anomalies, in a healthy newborn, the disease in the foreskin is non-existent.” Taking into account the lack of significant medical benefits, risk of complications, the harms of foreskin loss, and the financial cost, routine circumcision in Australia “cannot be justified. From medical point of view, the ‘price’ is still too high.” Source: Angelika F. Na, Sharman P.T. Tanny and John M. Hutson. <a href="http://onlinelibrary.wiley.com/doi/10.1111/jpc.12825/full" rel="noopener" target="_blank">Circumcision: Is it worth it for 21st-century Australian boys?</a> Journal of Paediatrics and Child Health. Advance access, 12 February 2015. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Circumcision “not worth it” for Aussie boys darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Submission to Medical Benefits Schedule Review, October 2015</h2> <h2>Summary</h2> 1. Medicare guidelines state that benefits are payable only for procedures that are clinically necessary and are not payable for cosmetic procedures. 2. Australian and most world medical authorities have determined that non-therapeutic circumcision is not clinically necessary and is not recommended. 3. Despite this, Medicare pays a benefit for non-therapeutic (clinically unnecessary) circumcision of males at any age. 4. There are strong objections to non-therapeutic circumcision of male minors for medical, bioethical, human rights and financial reasons. 5. In view of Medicare rules and these objections, non-therapeutic circumcision should be deleted from the Medical Benefits Schedule. 6. This objective is most easily and equitably achieved by adding the words “where medically necessary” to each of the circumcision codes. <h2>Background</h2> In 1985, on the recommendation of the National Health and Medical Research Council, circumcision was removed from the Medical Benefits Schedule. For reasons explained below, the decision was soon reversed and the rebate restored. The lesson of the episode is that when Medicare was established in 1984-85 the government’s intention was that it would not cover non-therapeutic circumcision. A review of Medicare in 2011 found evidence that between 2 and 3 billion dollars are spent inappropriately each year. The review, by Dr Tony Webber, noted that Medicare’s no-questions-asked policy led to serious financial abuses and failed to take account of the medical business environment: “The MBS [Medical Benefits Schedule] is riddled with misdirected incentives for practitioners … and has many examples of good public policy being thwarted by the MBS rules”. Among the abuses, he mentions cases where “the Safety Net was used in effect to subsidise cosmetic procedures such as surgery for designer vaginas at $5000-$6000 each”. In a related study, Elshaug et al (2012) identified 150 low value medical procedures whose presence on the MBS demanded scrutiny. Among these (listed in the appendix to their paper) was neonatal circumcision, with the comment “Current evidence fails to recommend widespread neonatal circumcision for the prevention of sexually transmitted infections, urinary tract infections and penile cancer”, citing Perera et al 2010. At the same time a planned review of specifically paediatric surgery was established by the Department of Health and Ageing (2013) with a view to assessing the justification for Medicare coverage of a range of paediatric surgical procedures, including “the safety, effectiveness, cost effectiveness, and appropriate clinical use of excision of pre-auricular sinus (MBS item 30104), repair of tongue tie (MBS items 30278 and 30281), circumcision (MBS items 30653, 30656 and 30660).” In May 2012 a poll in the Sydney Morning Herald found that 67 per cent of respondents were in favour of dropping circumcision from the MBS, and in August a survey in Australian Doctor showed that 51 per cent believed that circumcision was child abuse and should not be done at all, while a further 23 per cent believed that it was an individual choice that should neither be available in public hospitals nor funded by Medicare (Hartley 2012). It is thus evident that there is widespread concern both within the medical community and among the public at large that Medicare continues to subsidise a cosmetic procedure that is increasingly regarded as analogous to designer vaginas, namely, surgery for “designer penises” – that is to say, non-therapeutic (medically unnecessary) circumcision of male infants and boys. This is despite the fact that no medical organisation in the world recommends circumcision as a routine procedure, and that Australian health authorities have consistently recommended against the procedure since 1971. There is no reason why the over-stretched health budget should continue to waste taxpayers’ money by paying for an operation, usually on non-consenting children, that medical authorities judge to be medically unnecessary, risky, potentially harmful, and contrary to accepted principles of medical ethics and human rights. <h2>Introduction</h2> Although Australian medical authorities do not recommend circumcision as a routine or prophylactic procedure, Medicare continues to provide an automatic rebate for such operations, whether medically required or not. The medical validity, appropriateness, ethics and even the lawfulness of this policy have been questioned in recent years. In this submission I argue that for reasons of consistent public policy, financial prudence and respect for established principles of bioethics, human rights, gender equity and law the rebate should be abolished except for cases of proven medical need. The Australian government is under pressure to balance budgets, give more recognition to individual human rights, promote gender equity and protect children from harm. One simple way to make progress on all these fronts is to drop non-therapeutic circumcision from the Medical Benefits Schedule. I follow the definition of non-therapeutic given by the Tasmania Law Reform Institute (2009, p. 7): “A circumcision is non-therapeutic if it is performed for any reason other than remedying or treating an existing disease, illness or deformity of the body. … A circumcision performed for the purpose of preventing or reducing the likelihood of possible future disease, illness or deformity of the body (a prophylactic circumcision) is a non-therapeutic circumcision.” Medicare currently provides an automatic, no-questions-asked rebate for circumcision, despite the fact that the vast majority of these operations have no medical indication, and in defiance of Medicare’s own guidelines. These state that benefits are not payable for “medical services which are not clinically necessary”, nor “surgery for cosmetic reasons”. A medical procedure is clinically necessary only if it is essential to correct a diagnosed disease, injury, deformity or other pathological condition that has not responded to conservative (non-surgical) treatment. Surgery for any other reason, particularly cultural or social reasons, is essentially cosmetic surgery, intended to alter the appearance of the body part in question. As the Royal Australasian College of Surgeons (2008) points out, “male non-therapeutic circumcision is not clinically necessary as it does not treat an underlying pathological process.” <h2>Opinions of medical authorities</h2> Australian medical authorities have sought to discourage routine (medically unnecessary) circumcision since the early 1970s. In fact, the government did drop circumcision from the MBS in 1985, only to restore it a few weeks later, for reasons explained below. Nonetheless, Australian medical authorities have maintained their opposition to the practice, with the result that the incidence of circumcision in Australia continues to decline (Cozijn 2013). The most recent statement (October 2010) by the Royal Australasian College of Physicians states clearly: “After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.” Stronger statements against routine circumcision have been issued by the British Medical Association (2007), the Canadian Pediatric Society (2015), the Royal Dutch Medical Association (2010), the South African Medical Association, and medical authorities in Germany, Denmark, Finland, Norway and Sweden. Even in the United States, where routine circumcision is deeply entrenched as a medicalised cultural ritual, the American Academy of Pediatrics, although stating in its 2012 policy that the benefits exceed the risks, does not recommend the operation or regard it as medically necessary. Even this moderate position has been heavily criticised by child health experts (Frisch et al 2013) and bioethicists (Svoboda and Van Howe 2013; Darby 2015), and it has been rejected by health authorities in Australia. (Na et al 2015; Forbes 2015). In any case, the opinions of the AAP have no weight in Australia, where the relevant authority is the RACP. There are six other reasons why non-therapeutic circumcision should be dropped from the MBS. These relate to the absence of a convincing health case; conformity with international practice; principles of ethics and human rights; gender equity; legal issues; and financial prudence. <h2>1. No health case for routine circumcision</h2> It is not only the authorities mentioned above that have examined the medical literature and concluded that there is no health case for routine circumcision of infants or boys. Studies by Malone and Steinbrecher (2007) and Perera et al (2010) subjected the claims of circumcision advocates to an exhaustive review, and concluded that its value for child health was insignificant. When the medical literature is considered as a whole there is no proof that circumcision provides any significant protection against urinary tract infections, sexually transmitted infections or cancer of the penis. The only evidence for prophylactic efficacy came from Africa, where there was evidence that adult males who got themselves circumcised had a slightly lower risk of contracting HIV through unprotected intercourse with an infected female partner. As Perera et al comment, however, Africa has unique health problems. The circumcision trials were on adult men and can no more be applied to children than the World Health Organisation recommendations for the underdeveloped world can be transferred to a developed country like Australia. In Australia, unlike in Africa, HIV-AIDS is not a heterosexual epidemic, but a relatively rare disease confined to specific sub-cultures – homosexual men and injecting drug users. It is well established that these groups can derive no protection from circumcision at all. In any case, because it is a disease of promiscuous adults, children are not at risk of infection – unless by surgery. When they become sexually active boys are old enough to understand the issues and make their own decisions about how to manage the risks of sexual activity with others. The Australian Federation of AIDS Organisations (2007) has stated that circumcision has no relevance to Australia’s HIV problem, and their conclusion has been endorsed in a paper by Darby and Van Howe (2011) which argues that circumcision is not a surgical vaccine and is not appropriate as an HIV control tactic in developed countries such as Australia. These conclusions have been confirmed by Bossio et al (2014), which points out that the evidence for circumcision having a protective effect against heterosexually transmitted HIV is not applicable to developed countries such as the United States or Australia. <h2>2. International practice</h2> Australia is the only country in the world that provides automatic coverage of circumcision through the health budget. This policy is despite the fact that most State governments (Victoria, Western Australia, Tasmania, New South Wales and South Australia) do not provide free coverage of circumcision in public hospitals, and it is in sharp contrast with the practice of comparable developed nations. • In Britain the National Health Service has never included routine circumcision among its free procedures, and covers it only as a therapeutic procedure in cases of medical necessity. The same is true of New Zealand. • In Canada, where medical insurance is the responsibility of the provinces, the only province to include circumcision in its cover is Manitoba; and even there many doctors refuse to charge the state but bill the parents. • In the United States, the federal government provides the funds for public health insurance to the states, which make their own decisions as to which services they cover. When the program was introduced in 1965 all states covered circumcision, but since then 18 of the 50 states have ceased to fund it, and more are likely to do so as budgetary constraints intensify (Craig and Bollinger 2006). • The Dutch national health insurance service withdrew coverage of non-therapeutic circumcision in 2004 when it was realised that 90 per cent of the procedures were done for religious/cultural rather than for health-related reasons. • Circumcision is not funded by the Israeli government, but remains the responsibility of and a charge to each Jewish family. • Circumcision is not funded by the governments of Israel, Turkey, Indonesia, Iran or any other predominantly Islamic country where the procedure is widely practised as a cultural/religious ritual, not even when the operation is performed in hospitals rather than (as is traditional) in the boy’s home. Further details and references are provided in Darby (2011). <h2>3. Ethics and human rights</h2> For a surgical intervention to be ethically permissible the fundamental requirement is that the person must give informed consent. An adult male can consent to having himself circumcised, but the question becomes difficult when parents wish to circumcise their children because minors can no more consent to surgery than to sexual relations with adults. Circumcision of children thus deprives them of choice and amounts to coercion. The problem is especially relevant to Medicare, since the vast majority of the circumcision procedures that it covers involve children. In FY 2010-11, of 25,842 circumcision procedures funded by Medicare, 22,491 (88%) were on boys aged under 10 years, and of these 18,503 (71% of the total) were aged less than 6 months. Very few of these operations could be regarded as therapeutic or clinically necessary. An additional 2641 procedures were on males aged 10 years or more, but Medicare provides no breakdown as to how many of these are adults and how many are still minors, though it is clear enough that very few adult males elect to have themselves circumcised. Surrogate consent for surgery on minors is valid only for life-saving medical treatment, or where the procedure is manifestly and uncontroversially in the best interests of the child and passes the imputed judgement test – that is, it is an operation the child would choose for himself if he were competent. It has been strongly argued that, in the absence of a life-threatening disorder, surrogate consent for non-therapeutic surgery such as circumcision is ethically problematic and may not be legally valid. When there is no urgency to intervene, it is best to wait until the child can make his own choice. In addition to informed consent, leading bioethicists propose five conditions that must be met in order for a medical procedure to be ethically permissible. Beneficence — Does the proposed procedure provide a net therapeutic benefit to the patient, considering the risk, pain, and loss of normal function? Non-maleficence — Does the procedure avoid permanently diminishing the patient in any way that could be avoided? Proportionality — Will the final result provide a significant net benefit to the patient in proportion to the risk undertaken and the losses sustained? Justice — Will the patient be treated as fairly as we would all wish to be treated? Autonomy — Lacking life-threatening urgency, will the procedure honour the patient’s right to his or her own likely choice? Could it wait for the patient’s assent? Non-therapeutic circumcision of minors fails all these tests. It is not beneficent because it does not provide a therapeutic benefit (nor even a relevant prophylactic benefit, since a child is at zero risk of sexually transmitted infections ). It is malefic because it diminishes the genitals. It is disproportional because the net gain (if any) is out of proportion to the loss, harm and risk of complications. It is unjust because adult preferences show clearly that if he had a choice in the matter the boy would refuse the operation. Finally, and most importantly circumcision fails to respect the boy’s autonomy and preserve his future options as an adult individual (Sarajlic 2014). The British Medical Association and the Royal Dutch Medical Association have issued particularly strong warnings that non-therapeutic circumcision of minors is likely to breach accepted principles of bioethics and potentially of the law. In its policy statement (May 2010) the latter states: “Non-therapeutic circumcision of male minors is contrary to the rule that minors may only be exposed to medical treatments if illness or abnormalities are present, or if it can be convincingly demonstrated that the medical intervention is in the interest of the child, as in the case of vaccinations”; and further that such interventions violate “the child’s right to autonomy and physical integrity.” The RACP agrees: “The option of leaving circumcision until later, when the boy is old enough to make a decision for himself does need to be raised with parents and considered. … The ethical merit of this option is that it seeks to respect the child’s physical integrity, and capacity for autonomy by leaving the options open for him to make his own autonomous choice in the future.” International instruments are also relevant. Article 8 of the UNESCO Declaration on Human Rights and Bioethics (2005) states that “In applying and advancing scientific knowledge, medical practice and associated technologies, human vulnerability should be taken into account. Individuals and groups of special vulnerability should be protected and the personal integrity of such individuals respected.” Children certainly fall into this category. Given the government’s commitment to enhancing Australia’s commitment to individual human rights, it is highly anomalous that it allows Medicare to subsidise and thus encourage a disfiguring operation that denies them to so many children. The ethical status of non-therapeutic circumcision of minors has been under a cloud for the last couple of decades (Svoboda et al 2000) and has been the subject of so many critiques that it must now be regarded as highly controversial; while there is no consensus on the issue, it is clear that the majority view from the bioethical and human rights community is that the procedure is not significantly different from female genital mutilation and should be subject to similar restrictions (Earp 2015). For a summary of current opinion, see the special issue of the Journal of Medical Ethics, July 2013. <h2>4. Gender equity</h2> Australia’s obligations under the Sex Discrimination Act 1984 and as a signatory to the United Nations Convention on the Rights of the Child require the national and State governments to treat males and females equally and without discrimination on the basis of sex, and to take action to eradicate traditional practices harmful to children. Article 24 (3) of the Convention requires parties to take “all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children.” In pursuance of this development several States passed laws to prohibit any form of female circumcision, and in 1995 the Commonwealth specifically excluded such procedures from the Medical Benefits Schedule. Although there was nothing in the wording of the Convention to suggest that it did not include male children, no action has yet been taken to protect boys. This failure is increasingly recognized, in Ranipal Narulla’s (2007) words, as “a hidden human rights violation”. The Commonwealth Sex Discrimination Act, Section 3 (b), states that the Act applies to the administration of Commonwealth laws and programs, while Section 22 (b) makes it illegal to discriminate on the basis of sex in the provision of goods, services and facilities. It could be argued that the exclusion of female circumcision from the MBS is a breach of this provision, since it denies to women a benefit given to men. Whether or not circumcision is regarded as a benefit or a deprivation, it is certainly anomalous and inconsistent that the MBS specifically denies coverage for cutting procedures on the female genitals while providing a no-questions-asked rebate for comparable procedures on the genitals of boys. The simplest way to remove such discrimination and restore the principle of equal treatment is to limit coverage of male circumcision to cases of proven medical necessity. <h2>5. Legal issues</h2> In recent times it is not merely the ethics but even the legality of circumcision that has been questioned. In 1993 the Queensland Law Reform Commission observed that non-therapeutic circumcision of minors was probably unlawful under the common law of assault, as well as specific provisions of the Queensland criminal code covering assault, injury and sexual assault. More recently an exhaustive review of the ethical and legal status of non-therapeutic circumcision by the the Tasmania Law Reform Institute (2012) concluded that there was no medical justification for the operation, that it was dangerously unregulated, and recommended a range of legal reforms, including partial prohibition in the case of incompetent minors. Given the controversial status of non-therapeutic circumcision of minors and the lack of proof as to medical need or even significant benefit, doubts have been raised as to the legality of health insurance payments. A study by a United States legal expert (Adler 2011) argues that payments for non-therapeutic (medically unnecessary) circumcision by the US health insurance scheme Medicaid violate the protocols for benefits under this program and are thus unlawful. 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, 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. Medicare has not been the subject of such a study, but it is quite possible (given the guidelines) that its own payments for non-therapeutic circumcision are not authorised by Parliament and are thus unlawful. <h2>6. Economy and financial prudence</h2> All government welfare programs should be targeted at genuine need and be administered with prudence and economy. An open-slather approach to funding a medically unnecessary procedure is wasteful and invites over-servicing. It also acts as a signal that circumcision is a socially acceptable and even medically recommended operation, thus encouraging more parents to seek to have it done. Assuming 15,000 unnecessary circumcision procedures per year at a cost of between $100 and $1600 each, Katrina Spilsbury and colleagues (2003) have estimated that the removal of medically unnecessary circumcision from the MBS would save between $1.5 million and $24 million per year. They state that “the potential savings to the public purse would be considerable if elective and discretionary circumcision was removed from the Medicare schedule in line with other cosmetic surgeries, leaving rebates for the genuine medically indicated circumcision.” According to figures available on the Medicare website, the total cost of the rebate for all circumcision procedures in FY 2010-11 was $1,577,754, nearly half of which went to subsidise operations on infants less than 6 months old, almost none of whom could have had a genuine medical indication. This is not a large sum in the overall budget context, but the real cost to the government will be considerably higher, given that this figure does not include the cost of treating complications and long-term adverse effects, which may not become apparent until adolescence. A cost-utility analysis of neonatal circumcision by American researcher Robert Van Howe (2004) found that even if the extreme claims of circumcision advocates were true, the associated complications and adverse outcomes would cancel out and exceed the benefit to health by a considerable margin. On top of this there may be losses to revenue arising from tax rebates that parents are able to claim under the Medicare safety net for expenses related to child-bearing. These may not substantial sums in the context of today’s billion-dollar budgets, but when every effort is being made to rein in public expenditure, especially the ever-expanding health budget, every million saved can help to make a difference. If the rebate had been abolished in 1985 as intended, the accumulated savings would have been quite significant. And there are other reasons to predict that if the subsidy is retained expenditure will rise. 1. The high birthrate in Australia’s increasing Muslim community. Muslims traditionally circumcise boys and tend to prefer a clinical operation by a doctor rather than a traditional circumciser, unlike the Jewish people’s use of a mohel. Muslim doctors in Sydney are distributing advertising material which ignores the recommendations of the RACP and instead stresses the “medical benefits” of circumcision, suggesting that they seek to attract paying customers not merely from their co-religionists, but from the public at large. The presence of a financial rebate will make the procedure more attractive to parents and is likely to increase demand. 2. Irresponsible media commentary on the role of circumcision in controlling HIV and other STIs, as well as the efforts of circumcision promoters such as the “Circumcision Academy of Australia” and entrepreneurial circumcision practitioners, aim to generate a mood of alarm. The demand for circumcision could increase if parents are misled by their advocacy and become fearful of the alleged risks of not getting it done. It is thus possible that the cost of the circumcision subsidy will increase unless entitlement is restricted. Economists have shown that price signals are the most effective means of encouraging or discouraging consumer behaviour. This is highly relevant to subsidies for circumcision, as Craig and Bollinger (2006) found that the single most important factor governing the incidence of circumcision in the United States was whether the state provided a rebate under Medicaid. Removal of non-therapeutic circumcision from the MBS will send a clear signal to Australian parents that routine circumcision is not a medically recommended procedure and is not necessary for the health and well-being of their child. The main argument for dropping non-therapeutic circumcision from the MBS is not the cost-saving, however, but the principles of prudent and targeted assistance to those in need; of adherence to stated entitlement guidelines and lawful program administration; of respecting current expert medical advice; of observing accepted principles of ethics and human rights; and of avoiding discrimination on the basis of sex. Allowing Medicare to provide a rebate for non-therapeutic circumcision sends the wrong signals to parents, suggesting that it is a socially and medically approved procedure, and thereby encouraging the practice. <h2>Cultural and religiously motivated circumcision not affected</h2> There is nothing in this proposal that will limit the right of parents to circumcise their children if they feel they have a compelling cultural or religious reason, merely that they will not receive a public subsidy for doing so. There is no intent to restrict the right of Jewish, Aboriginal or Muslim parents to circumcise their children in accordance with their respective traditions; but equally there is no reason why such cultural/religious rites and practices should be funded by the Australian taxpayer through the health budget. It is true that when the Hawke government dropped circumcision from the MBS in 1985 it faced protests from Jewish community leaders and soon backed down, leading to the development of the myth that there was a “community backlash” and discouraging further attempts. This myth has been disproved in my study of the incident, published in the international journal Hygiea (Darby 2011). My conclusions are that the decision was justified on medical and public policy grounds; that there was no wide public outcry and, indeed, that the decision was widely approved; and that the rapid reversal of the decision was the result of inept implementation, failure to consult, and a fortuitous combination of subsequent factors, including, vigorous lobbying by the groups who felt most deeply affected. The main objection of Jewish community leaders was not to the dropping of the rebate in itself, but the fact that it was dropped only from the code for circumcision of boys under 6 months, leaving the rebate in place for operations at later ages. Since Jewish people traditionally circumcise at 8 days, they justifiably felt that this was unreasonable discrimination. It is not clear why the government, rather than abjectly restoring the rebate, did not resolve the problem by requiring a medical indication at all ages, as would have been the simplest, most economical and most equitable course of action. The government now has the opportunity to rectify this mistake. If a proven medical requirement is attached to each of the codes for circumcision, there is no reason why the sensibilities of the Moslem and Jewish communities should be affronted, since the new rules would apply to everybody in the community, without discrimination. The lesson of 1985 is that a controversial procedure such as circumcision must be approached with tact and sensitivity to cultural sensibilities. It may be necessary to consult with Jewish and Muslim community organisations, and it is vital not to repeat the mistakes made in 1985, and especially the deadly mistake of limiting removal of the rebate to a specific age-group. Nobody likes having to pay more for a good or service, but so long as all age groups and cultural identities are treated equally there should be no valid grounds for complaint. <h2>Conclusion</h2> There is no reason why Medicare, and thus the Australian taxpayer, should continue to fund operations that medical authorities have defined as unnecessary and potentially harmful, and which many people regard as an violation of the rights of the child, or even genital mutilation. The government must face up to its responsibilities, bite the bullet, rectify the mistakes it made in 1985, and delete non-therapeutic circumcision from the Medical Benefits Schedule. <h3>Appendix: Relevant MBS codes and payments (as at 1 January 2012)</h3> 30653: Circumcision of a male under 6 months of age Scheduled fee: $45.65; Benefit: $34.25 (75%); $38.85 (85%) 30656: Circumcision of a male under 10 years of age but not less than 6 months of age Scheduled fee: $106.15; Benefit: $79.65 (75%); $90.25 (85%) 30659: Circumcision of a male 10 years of age or over by a GP Scheduled fee: $146.95; Benefit $110.25 (75%); $124.95 (85%) 30660: Circumcision of a male 10 years of age or over by a specialist Scheduled fee: $182.15; Benefit $136.65 (75%); $154.85 (85%) 30663: Haemorrhage, arrest of, following circumcision requiring general anaesthesia Scheduled fee: $141.65; Benefit $106.25 (75%); $120.45 (85%) Until 1995 these codes were unisex and read “circumcision of a person”, thus authorising a benefit for circumcision of females as well as of males. In order to protect girls from genital mutilation as part of the general development of laws and policies against FGM that followed the passage of the UN Convention on the Rights of the Child, “person” was changed to “male”, thus introducing two elements of discrimination: females were denied a service that remained available to males; but males were denied the protection that was accorded to females. The deletion of non-therapeutic circumcision from the schedule can be effected by simply by adding the phrase “where medically indicated” to each of the codes above. “Medically indicated” means a case where (1) there is a medical problem that has not responded to conservative (non-surgical) treatment after reasonable efforts; and (2) this is certified by two qualified medical practitioners, one of whom must be an appropriate specialist, and neither of whom may be the surgeon or other operator who is to perform the surgery. <h2>Selected references</h2> Adler, Peter. 2011. Is it lawful to use Medicaid to pay for circumcision? Journal of Law and Medicine, Vol. 19, December 2011: 335-353. Australian Federation of AIDS Organisations. 2007. Male circumcision has no role in the Australian HIV epidemic. Briefing paper, 23 July 2007. Beauchamp TL, Childress JF. 2009 Principles of Biomedical Ethics (6th edn). Oxford University Press: 2009. Bossio JA, Pukall CF, Steele S. 2014. A review of the current state of the male circumcision literature. J Sex Med. 2014 Dec;11(12):2847-64. doi: 10.1111/jsm.12703 British Medical Association. 2007. <a href="https://www.circinfo.org/doctors.html" rel="noopener" target="_blank">The Law and Ethics of Male Circumcision: Guidance for Doctors</a> (November 2007). Cozijn. J. 2013. <a href="https://www.circinfo.org/statistics.html" rel="noopener" target="_blank">Incidence and prevalence of circumcision in Australia</a>. Craig A. and Bollinger D. 2006. Of waste and want: A nationwide survey of Medicaid funding for medically unnecessary, non-therapeutic circumcision. In George C. Denniston et al (eds.), Bodily Integrity and the Politics of Circumcision: Culture, Controversy and Change (New York, Springer, 2006). Darby, Robert. 2011. “Scientific advice, traditional practices and the politics of health-care: The Australian debate over public funding of non-therapeutic circumcision, 1985.” Hygiea Internationalis: An Interdisciplinary Journal for the History of Public Health, Vol. 10, December 2011. <a href="https://www.academia.edu/7028494/Scientific_advice_traditional_practices_and_the_politics_of_health-care_The_Australian_debate_over_public_funding_of_non-therapeutic_circumcision_1985" rel="noopener" target="_blank">Available at Dr Darby's Academia.edu page</a>. Darby, Robert and Robert Van Howe. 2011. Not a surgical vaccine: There is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia. Australian And New Zealand Journal of Public Health, Vol. 35, October 2011: 459-465. Darby, Robert. 2015. Risks, benefits, complications and harms: Neglected factors in the current debate on non-therapeutic circumcision. Kennedy Institute of Ethics Journal, Vol. 25 (1), March 2015: 1-34. Department of Health and Ageing. 2013. MBS Reviews, Paediatric Surgery – Scope. Discussion paper draft (February). Earp, Brian. 2015. <a href="https://www.dovepress.com/articles.php?article_id=23974" rel="noopener" target="_blank">Female genital mutilation and male circumcision: Toward an autonomy-based ethical framework</a>. MedicoLegal and Bioethics 2015; 5 (3 Oct): 89-104. Elshaug AG, Watt AM, Mundy L, Willis CD. 2012. Over 150 potentially low-value health care practices: an Australian study. Med J Aust 2012; 197: 556-560. doi: 10.5694/mja12.11083. Forbes, David. 2009. <a href="http://www.smh.com.au/national/letters/no-evidence-to-support-routine-circumcision-20090911-fkna.html" rel="noopener" target="_blank">No evidence to support routine circumcision</a>. Sydney Morning Herald, 12 September 2009. Forbes D. 2015. Circumcision and the best interests of the child. J Paediatr Child Health. 2015 Mar;51(3):263-5. doi: 10.1111/jpc.12853. Frisch, Morten, et al. 2013. Cultural bias in the AAP’s 2012 Technical Report and Policy Statement on male circumcision. Pediatrics 131 (4): 796-800. Hartley, Jo. 2012. <a href="https://www.australiandoctor.com.au/news/latest-news/strong-opposition-to-newborn-circumcision" rel="noopener" target="_blank">Strong opposition to newborn circumcision</a>, Australian Doctor, 9 August 2012. See also: <a href="https://www.circinfo.org/news_2012.html#flop" rel="noopener" target="_blank">Morris, Wodak circumcision campaign falls flat</a> <a href="https://www.circinfo.org/news_2012.html#poll" rel="noopener" target="_blank">Aussies give thumbs down to circumcision</a> Malone, Padraig, and Steinbrecher H. 2007. Medical aspects of male circumcision. British Medical Journal 2007; 335: 1206-1209. Na AF, Tanny SP, Hutson JM. 2015. Circumcision: Is it worth it for 21st-century Australian boys? J Paediatr Child Health. 2015 Jun;51(6):580-3. doi: 10.1111/jpc.12825. Narulla, Ranipal. 2007. Circumscribing circumcision: Traversing the moral and legal ground around a hidden human rights violation. Australian Journal of Human Rights, Vol. 12, 2007, 89-118. Perera, C.L, F.H. Bridgewater, et al. 2010. Safety and efficacy of nontherapeutic male circumcision: a systematic review. Ann Fam Med 8(1): 64-72. Royal Australasian College of Physicians. <a href="http://www.racp.edu.au/page/policy-and-advocacy/paediatrics-and-child-health" rel="noopener" target="_blank">Circumcision of Infant Males [Policy statement]</a>. Sydney: October 2010. Available at Royal Australasian College of Surgeons. 2008. Australian Safety and Efficacy Registry of New Interventional Procedures – Surgical. Report No. 65: Male non-therapeutic circumcision. Adelaide: RACS, 2008. Royal Dutch Medical Association. 2010. <a href="https://www.circinfo.org/Dutch_circumcision_policy.html" rel="noopener" target="_blank">Non-therapeutic Circumcision of Male Minors</a> (May 2010). Sarajlic, Eldar. 2014. Can Culture Justify Infant Circumcision? Res Publica 20 (4). November 2014, 327-343. DOI 10.1007/s11158-014-9254-x Spilsbury K, Semmons JB, Wisniewski ZS, Holman CD. 2003. <a href="http://www.cirp.org/library/procedure/spilsbury1/" rel="noopener" target="_blank">Routine circumcision practice in Western Australia 1981–1999</a>. ANZ Journal of Surgery 2003;73(8):610-4. Svoboda JS, Van Howe RS, Dwyer JG. 2000. <a href="http://www.cirp.org/library/legal/conundrum/" rel="noopener" target="_blank">Informed consent for neonatal circumcision: An ethical and legal conundrum</a>. Journal of Contemporary Health Law and Policy 2000;17:61-133. Svoboda, J. Steven and Robert Van Howe. 2013. Out of step: Fatal flaws in the latest AAP policy report on neonatal circumcision. Journal of Medical Ethics 39 (7): 434-41. Sydney Morning Herald 12 May 2012, <a href="https://www.circinfo.org/news_2012.html#poll" rel="noopener" target="_blank">The Question: Should elective circumcision continue to be covered by Medicare?</a> Tasmania Law Reform Institute. 2009: Non-therapeutic Male Circumcision. Issues Paper No. 14. Tasmania Law Reform Institute. 2012. Non-Therapeutic Male Circumcision. Report No 17, August. University of Tasmania. Van Howe RS. 2004. <a href="http://www.cirp.org/library/procedure/vanhowe2004/" rel="noopener" target="_blank">A cost-utility analysis of neonatal circumcision</a>. Medical Decision Making 2004;24:584-601. Webber, T. 2012. What is wrong with Medicare?. Medical Journal of Australia 2012; 196 (1): 18-19. NOTE: This submission was prepared by Dr Robert Darby, Canberra. Australia. <a href="https://independent.academia.edu/RobertDarby" rel="noopener" target="_blank">Also available at his Academia.edu page.</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Medicare should not cover non-therapeutic circumcision darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Puzzling changes to Medicare coverage of circumcision</h1> <h3>Incidence of infant circumcision obscured, circumcision of girls now funded</h3> Despite several reviews and inquiries into medically unnecessary and low-value procedures, Medicare continues to provide a rebate for non-therapeutic circumcision of male infants and boys. Under changes to the codes that became effective in June 2016, however, it is now impossible find out how many circumcision procedures are performed on boys aged under 6 months. Even more alarming, it appears that Medicare is also paying for circumcision of girls – otherwise known as female genital mutilation (FGM). <h2>Background</h2> A <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/26CEC8388EE86854CA2580210016EF82/%24File/MBS-Review-Interim-report-Final-%204%20Oct.pdf" rel="noopener" target="_blank">report to the Minister for Health</a> arising from these inquiries did not pay much attention to circumcision (one of the low-value procedures identified in the reviews), but it did contain the following paragraph: “Less commonly mentioned was unnecessary surgical intervention. However, when this issue did arise, the implications in terms of unnecessary patient risk were often more serious. Commonly cited examples included inductions of labour and caesareans for no medical reason, knee arthroscopy for patients with osteoarthritis, and circumcision in healthy male infants. A number of respondents to the survey indicated that surgery should not be considered unless conservative treatments had been undertaken — for example, physiotherapy for incontinence or prolapse, or physiotherapy for back pain rather than spinal surgery.” Although <a href="https://www.circinfo.org/Medicare_coverage_for_circumcision.html" rel="noopener" target="_blank">several public submissions</a> urged that the rebate for non-therapeutic circumcision be entirely scrapped (as the government intended when Medicare was introduced in 1985), the only major change arising from the inquiries was the replacement of the relevant codes. The old codes were: 30653: Circumcision of a male under 6 months of age 30656: Circumcision of a male under 10 years of age but not less than 6 months of age 30659: Circumcision of a male 10 years of age or over by a GP 30660: Circumcision of a male 10 years of age or over by a specialist 30663: Haemorrhage, arrest of, following circumcision requiring general anaesthesia The new codes, operative since June 2016, are as follows: 30649 HAEMORRHAGE, arrest of, following circumcision requiring general anaesthesia on a person under 10 years of age 30654 Circumcision of the penis (other than a service to which item 30658 applies) 30658 Circumcision of the penis, when performed in conjunction with a service to which an item in Group T7 or Group T10 applies 30663 HAEMORRHAGE, arrest of, following circumcision requiring general anaesthesia on a person 10 years of age or over. <a href="http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Home" rel="noopener" target="_blank">Medicare codes may be searched here</a>. As a <a href="http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/news-2016-11-01-latest-news-Nov">Department of Health news item</a> (November 2016) stated: “The four circumcision items (30653, 30656, 30659 and 30660) have been removed and replaced with two new items (30654 and 30658). Item 30658 is for circumcision procedures performed under anaesthesia and item 30654 is for all other circumcision procedures.” It is not clear from the information readily available whether “under anaesthesia” means with a general anaesthetic (not possible with young babies), or whether “all other circumcision procedures” are performed without any anaesthetic at all. <h2>What is happening? The brute facts</h2> According to figures that can be searched at the <a href="http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp" rel="noopener" target="_blank">Medicare statistics portal</a> of the Department of Health, the number of circumcisions performed under item 30654 (all other procedures) in June 2017 was 854. Following the link to find the ages of these patients reveals the astonishing information that 15 of these procedures were performed on females, with an age breakdown as follows: 0-4 years 5 25-34 years 6 35-44 years 4 Of the 839 males circumcised: 0-4 years 798 5-14 years 20 15-24 years 6 – and the remainder at older ages. Figures for item 30658 (circumcision with anaesthesia) are even more alarming. In the second quarter of 2017 (March-May) 2328 circumcision procedures were performed, including 21 on females and 2307 on males. The age break down for the females was: 1-4 years 7 5-14 years 2 25-34 1 Of the 2307 males circumcised: 0-4 years 1262 5-14 years 399 15-24 years 185 <h2>So what is really happening?</h2> Until 1995 the Medicare circumcision codes were unisex and read “circumcision of a person”, thus authorising a benefit for circumcision of females as well as of males. In order to protect girls from genital mutilation as part of the general development of laws and policies against FGM that followed the passage of the UN Convention on the Rights of the Child “person” was changed to “male”. At the same time the Crimes Acts of all states were amended to make female genital cutting a criminal offence. The new provisions made no exception for culturally or religiously motivated circumcision, but they do allow a defence of medical necessity – that is, if the operation is judged to be necessary for the girl’s or woman’s health, it is then permissible. It is certainly possible that the procedures recorded here were deemed to be medically necessary, and thus not illegal, but it is still surprising to see female infants exhibiting such serious genital pathologies as would require circumcision. On top of that, we wonder who is making the judgement about medical need, and whether there is any safeguard against spurious or fraudulent claims. It also seems rather bizarre that a code described as “circumcision of the penis” can be used to fund circumcision of girls. A similar comment about medical need applies to the large number of baby boys still being circumcised and attracting a Medicare rebate. It does not seem credible that so many boys aged 1 to 4 years (over 1200 in only 3 months) had such serious foreskin problems that circumcision was really necessary, and one suspects that the real reason was cultural or religious, dressed up as medical need for the purpose of attracting the rebate. The report to the Minister noted that people were questioning why healthy boys should be circumcised at the expense of Medicare. In response, it would appear that the Government has changed the presentation of statistics in a way that makes it more difficult to work out how many juvenile circumcisions are taking place and impossible to determine how many neonatal circumcisions (i.e., circumcisions under the age of 6 months or one year) are being performed. Even more surprising, despite the new wording of the codes specifically referring to penises, it appears that little girls are also being subjected to circumcision procedures. <h2>Female genital mutilation: Hiding in plain sight under Medicare</h2> Further investigations by Mr Michael Glass, of Sydney, and Circumcision Information Australia have revealed the astonishing fact that Medicare began to provide a rebate for circumcision of females in 2013, wen the relevant codes were defined as “circumcision of a male”– a phenomenon that continued and increased when the new codes were introduced in 2016. Over the 20 years since Medicare statistics became available (1993-2003) there were more than 450,000 rebates for male circumcision. Although there were some cases where the gender of the patient was not specified, no case was recorded where Medicare paid for the circumcision of a patient classed as female. Starting in July 2013, Medicare began to subsidise the circumcision of women and girls. 4 years of female circumcision under Medicare In the 4 years from 1 July 2013 to 30 June 2017 Medicare paid for the circumcision of 256 girls under the age of 6 months. In the same period, Medicare also paid for the circumcision of 72 girls over the age of 6 months but less than 10 years. From 1 July 2013 to 30 June 2017, Medicare paid General Practitioners for the circumcision of 26 women and girls. 9 of these were girls from 5 to 14 years of age and a further 7 were between the ages of 15 and 24. (The rest were older.) From 1 July 2013 to 30 June 2017, Medicare paid specialists for the circumcision of 38 women and girls. 9 of these were girls from 5 to 14 years of age and a further 5 were between the ages of 15 and 24. (The rest were older.) Female circumcision under the new item numbers From 1 November 2016, the Medicare announced the removal of item numbers 30653, 30656, 30659 and 30660 and their replacement by two new item numbers, 30654 (all other circumcision procedures) and 30658 (circumcision with anaesthesia). In 8 months, Medicare Item number 30654 subsidised the circumcision of 158 women and girls, 44 of whom were under the age of 5 and 5 of whom were between the ages of 5 and 14. In 8 months, Medicare item number 30658, subsidised the circumcision of 53 women and girls, 18 of whom were below the age of 5 and 5 of whom were between the ages of 5 and 14. Altogether, in the 4 years since 1 July 2013, Medicare subsidised the circumcision of 603 women and girls, 272 of them (just over 45%) in the most recent financial year. Cost of the Medicare payments for circumcising females The total cost of the Medicare payments for circumcising females in the 4 years from 1 July 2013 to 30 June 2017 is $59,424. The total cost for circumcising females in the most recent financial year (2016/2017) is $29,347. It cost more than 49% of the total cost for the four years to circumcise just over 45% of the total number of females, so the cost to Medicare had risen even faster than the number of females who were circumcised. <h3>Comment</h3> For the last four years, Medicare appears to have been subsidising the circumcision of hundreds of women, girls and baby girls. Whether this is lawful or criminal depends on whether the operations can validly be judged to be medically necessary for the health of the patient. (This was <a href="https://www.circinfo.org/Genital_mutilation_doctor_guilty.html" rel="noopener" target="_blank">Dr Graeme Reeves' defence</a> and the reason the jury at his first trial was unable to reach a verdict.) While it is plausible that operations on adult women who have given informed consent is lawful, a big question mark hangs over the operations of female minors: is it really likely that hundreds of baby girls suffer from such severe genital pathologies that something called circumcision is required? It seems especially unlikely that the 256 girls below the age of 6 months circumcised between July 2013 and June 2017 really needed the operation for medical reasons. At a time when the government is desperate to save money, the cost of these procedures is also a matter for concern. The Medicare subsidy for this has cost the taxpayer $60,000. The Government and the taxpayer appears to have been defrauded this amount because the item numbers were supposed to be for the circumcision of males. The latest figures show that under the new Medicare numbers, the number of females circumcised has risen dramatically, but the cost to Medicare has risen even faster. <h2>Some parts of puzzle answered, but questions about FGM remain</h2> In response to inquiries from Mr Michael Glass, a Sydney human rights advocate, the Medicare statistics section has explained that the changes to the schedule were made in response to a directive from the Attorney General’s Department following amendments to the Sex Discrimination Act in 2013: According to Carla Cook, “The Department of Human Services complies with the 2013 direction of the Attorney-General’s department that introduced new protections from discrimination** on the grounds of sexual orientation, gender identity and intersex status in many areas of public life. As such, there are no gender based restrictions on accessing Medicare items.” In other words, the 1995 restriction on Medicare providing a rebate for female genital cutting has been removed in the name of non-discrimination. In response to questions about the legality of genital cutting procedures on women and girls Ms Cook further explained that all procedures under Medicare had to be clinically relevant in order to qualify for a rebate: “Medicare benefits are claimable only for ‘clinically relevant’ services rendered by an appropriate health practitioner. A ‘clinically relevant’ service is one which is generally accepted by the relevant profession as necessary for the appropriate treatment of the patient.” She added that “Services listed in the MBS must be rendered according to the provisions of the relevant Commonwealth, State and Territory laws.” ** This refers to a document called <a href="https://www.ag.gov.au/Publications/Pages/AustralianGovernmentGuidelinesontheRecognitionofSexandGender.aspx" rel="noopener" target="_blank">Australian Government Guidelines on the Recognition of Sex and Gender</a> (July 2013), published by Attorney General’s Department Mr Glass’s email and reply from Medicare statistics are below. <h2>Comment: A strange situation</h2> It does seem extraordinary that such startling changes to Medicare procedures should have occurred so quietly, without any comment in the media (so far as we are aware) and no alarm from women’s and human rights groups that it now covers circumcision of girls and women as well as boys and men. The rules state that all benefits (for males as much as females) are payable only for services that are clinically necessary for the person’s health; but the question is whether these rules are being observed and what safeguards are in place to ensure that they are observed and to prevent unscrupulous practitioners from rorting the system, defrauding the government and taxpayer, and (in the case of FGM) performing an illegal operation. We have always argued that the principles of gender equity and non-discrimination require that boys and girls enjoy equal protection under the law; but our position is that this should be achieved by raising the level of protection available to boys, not by reducing the level of protection for girls. If it is a crime to cut a female’s genitals without her informed consent, it should be a crime to cut a male’s genitals without his informed consent – allowing for genuine medical necessity in both cases. It is reasonable that women and girls should be able to receive a rebate for genital cutting operations that are genuinely medically necessary for their health, along with boys and men; it is unreasonable and unacceptable that any person, male or female, should receive a rebate in cases where the cutting is performed for cultural, religious, cosmetic, social or other non-medical reasons. <h3>Vital questions that must be answered</h3> We address the following questions to the Minister for Health: 1. Under the new Medicare codes, circumcision is classified as a therapeutic procedure, i.e. necessary to address a pathological problem that is not susceptible to conservative treatment. Furthermore, the rules state that a Medicare benefit is payable “only for ‘clinically relevant’ services rendered by an appropriate health practitioner”, i.e. a service “generally accepted by the relevant profession as necessary for the appropriate treatment of the patient.” What safeguards are in place to ensure that rebates provided under the new codes are in fact confined to therapeutic procedures, i.e. procedures that are clinically necessary to address a pathological condition? 2. Is the Minister confident that these codes are not being used to provide a rebate for circumcision performed for cultural, religious, social, cosmetic or other non-therapeutic reasons? 3. What safeguards are in place to ensure that the above rules are complied with and that the codes are not misapplied? 4. Information from a report to the Minister on the Department of Health website states that item 30658 is for circumcision performed under anaesthesia, and that item 30654 is for all other circumcision procedures. Does this mean that circumcision under item 30654 is performed without anaesthesia? 5. Is the Minister aware that the current policy of the Royal Australasian College of Physicians is that routine (non-therapeutic) circumcision of male minors is not warranted in Australia or New Zealand? Is she also aware that in 2012 the Tasmania Law Reform Institute, in an exhaustive analysis of the medical, legal and ethical status of non-therapeutic circumcision, concluded that it was medically unnecessary and ethically objectionable, and that it ought to be legally regulated and restricted to certain specified situations? <h2>Accessing Medicare Circumcision statistics</h2> If you look at Medicare statistics, here: http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp A wealth of information can open up. You can find the number of services and the Medicare contribution to the benefit. <ul> <li>This can be expressed as a count or on a per capita basis</li> <li>It can be broken down into states or into both states and over time. The time period can be expressed in months, quarters, calendar years or financial years.</li> <li>The start date of the statistics can be as far back as July 1993 and the end date can be as recent as the previous month or two.</li> <li>You can get age and gender details by clicking on the hyperlinked item number.</li> </ul> <h2>Michael Glass’s questions for the Medicare statistics unit and reply</h2> The following questions were sent by Michael Glass to the Medicare statistics inquiry address. They are reproduced below, with the replies from Carla Cook, Information Strategy, Governance and Release Section, Information Services Branch, Department of Human Services. (Links to web pages have been deleted.) Thank you for your patience with this one, we have now received a response from the business area with relevant advice (please see below) relating to your queries. Please note that the questions highlighted in yellow have been directed to the Department of Health as it best sits with them for response. I hope the information provided is of assistance to you. I will be in contact with you shortly once a response is received from Health. I have some questions about the recent changes in the item numbers regarding circumcision. According to this document some circumcision item numbers have been abolished and replaced with other item numbers. 1. Why were changes made to some of the circumcision-related item numbers? 2 The four circumcision items (30653, 30656, 30659 and 30660) have been removed and replaced with two new items (30654 and 30658). However, as late as July 2017 the older items were still in the Medicare statistical reports. Why is this so? “Medicare statistical reporting captures all claims processed by the Department of Human Services within the specified period. This is not the same as the date the service was originally provided. For example, an item 30653 may have been performed on 15 October 2016 but the claim was not submitted to Medicare until July 2017. In this instance the item 30653 would appear in a statistical report of claims processed in July 2017.” 3. Item numbers 30654 and 30658 include “circumcision procedures” on females. 62 of these were under the age of 5, A further 10 of them were between 5 and 14. However, the descriptions of the item number state that they both were about the circumcision of the penis. What is going on? “The Department of Human Services complies with the 2013 direction of the Attorney-General’s department** that introduced new protections from discrimination on the grounds of sexual orientation, gender identity and intersex status in many areas of public life. As such, there are no gender based restrictions on accessing Medicare items. The Department of Human Services does note that it is the responsibility of the servicing practitioner to ensure that the services are billed against the correct patient on the Medicare card.” ** https://www.ag.gov.au/Publications/Pages/AustralianGovernmentGuidelinesontheRecognitionofSexandGender.aspx Under item 30654, 158 women and girls underwent a “circumcision procedure” up until the end of June, 2017. 44 of these females were aged from 0 to 4 and 5 were aged 5 to 14. Under item number 30658, 53 females underwent a “circumcision procedure up until the end of 2017.18 of these females were aged from 0 to 4 and 5 were aged 5 to 14. (a) How can funding for the circumcision of boys be used to fund “circumcision procedures” on women and girls? “As outlined above, the Department of Human Services complies with the 2013 direction of the Attorney-General’s department that introduced new protection from discrimination on the grounds of sexual orientation, gender identity and intersex status.” (b) Was it the intent of Medicare to also fund the sexual cutting of girls? If so, why? “Health will be able to provide a details answer to this question. However, Medicare benefits are claimable only for ‘clinically relevant’ services rendered by an appropriate health practitioner. A ‘clinically relevant’ service is one which is generally accepted by the relevant profession as necessary for the appropriate treatment of the patient. Services listed in the MBS must be rendered according to the provisions of the relevant Commonwealth, State and Territory laws.” 4. Isn’t the genital cutting of underage girls against the law? If so, why is Medicare funding it? “As outlined above.” 5. According to this web page: https://www.researchgate.net/figure/278675359_tbl2_Table-6-MBS-item-numbers-and-descriptors-for-male-circumcision [See note below] the fee for item number 30653 (circumcision of a child under 6 months) was $46.50; the fee for item number 30656 (circumcision of a child from 6 months but under 10 years) the fee was $108.15; for item number 30659 (circumcision of a male 10 years of age or over by a GP) the fee was $127.30; for item number 30660 (circumcision of a male 10 years of age or over by a specialist) the fee was $139.20 Were these fees still current in October 2016? “The table provided in your email outlines the Fee, in-hospital benefit payable (75%) and out of hospital benefit amount payable (85%) for the item. The fees for these items in October 2016 were as follows: 30653 $46.50 30656 $108.15 30659 $149.75 30660 $185.60 As indicated above, the benefit payable for the service is determined by the hospital status of the patient. Services provided to an admitted patient receive benefits at 75% of the fee for the item. Non-admitted patients receive benefits at 85% of the fee for the item.” 6. According to the latest schedule of fees, there are now only two items for circumcision (a) for item number 30654 (circumcision of the penis) when a nerve block or anaesthetic is NOT being used) the fee is $46.50; (b) for item number 30658 (circumcision of the penis, when performed in conjunction with a regional or field nerve block or anaesthetics) the fee is $142. Does this mean that males can be circumcised without any form of pain relief? Does this mean that general practitioners are now being paid a lot more for circumcisions when pain relief is used? 7. Does this web page mean that item 30654 cost the taxpayer over half a million dollars in 2016-17? “Correct, this report does indicate that the total amount of benefits assigned for item 30654 in the 2016-17 financial year was $525,877.” 8. Does this web page mean that item 30658 cost the taxpayer almost $700,000 in 2016-17? “Correct, this report does indicate that the total amount of benefits assigned for item 30658 in the 2016-17 financial year was $697,927.” <h3>NOTE by Circumcision information Australia</h3> The page referred to is a table from a longer document, MBS Reviews Paediatric Services Male Circumcision Services: Review Report, by Robyn Lambert, Yasoba Atukorale, Alun Cameron, David Tivey, published by the Department of Health in July 2014. This appears to be a review of circumcision practices in Australia, with particular reference to the rebates available from Medicare; but it confesses that it was not able to find much information about Australian circumcision practices, and it has a very limited bibliography that contains nothing on the bioethical, human rights and legal aspects of the question. The paper makes no recommendations, except that “further study needed”. The paper does, however, contain much useful factual information on the number of boys being circumcised up until 2012, the identity of the operators (GPs, ObGyns, surgeons etc) and the associated costs to the public. <a href="https://www.researchgate.net/publication/278675359_MBS_Reviews_Paediatric_Services_Male_Circumcision_Services" rel="noopener" target="_blank">Full text available here.</a> <h2>Further information on this site</h2> <a href="https://www.circinfo.org/Medicare_circumcision_review.html" rel="noopener" target="_blank">Medicare must not pay for medically unnecessary circumcision</a> <a href="https://www.circinfo.org/Medicare_coverage_for_circumcision.html" rel="noopener" target="_blank">Medicare should not cover non-therapeutic circumcision: Submission to Medical Services Review, 2015</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Changes to Medicare coverage, female circumcision now covered darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Royal Australasian College of Physicians disowns Brian Morris</h2> The following letter was sent to the Sydney Morning Herald by Professor David Forbes, Chair of the Paediatrics & Child Health Policy & Advocacy Committee, Royal Australasian College of Physicians. He is commenting on a disgraceful article about the RACP's recently released circumcision policy - an article that is not really a news item at all, but an editorial defending routine circumcision of innocent babies, criticising the RACP for rejecting the practice, and giving sympathetic coverage to the maverick views of the notorious circumcision fanatic, Professor Brian Morris. The article is quite in keeping with the SMH's decrepit pro-circumcision policy and expresses its complete failure to keep up with developments in science, medicine, medical ethics, human rights and law. Wake up, granny! The letter was posted at <a href="http://www.6minutes.com.au/articles/z1/view.asp?id=498029">6minutes - Interesting stuff for doctors today</a>. Please find copied below a letter sent to the SMH today in response to this article from the RACP. Dear Editor, Your Friday 11 article "Doctors circumspect on circumcision" warrants clarification on a number of issues. The key point of the recently released RACP statement on circumcision is that the RACP believes that at the present time there is not evidence to support routine circumcision of newborn and infant males. Your article sends a dangerous public health message that circumcision prevents HIV transmission. It is vital that everyone engage in safe sexual practices such as condom use, whether circumcised or not. Recent reports of circumcision offering some protection against HIV infection in Africa relate to circumcision of adult males, not of infants. Further the stated benefits of protection against urinary tract infection are marginal, and do not justify mass circumcision. Our changing understanding of the relationship between urinary tract infection and chronic renal disease further weakens the case for routine circumcision. There is evidence that circumcision does result in memory of painful experiences, and is not quite as simple and low risk as your report states. The Colleges' recent statement is not anti-circumcision, but clearly states that parents should be informed of risks and benefits, and then supported in their decision. When circumcision is undertaken it should be with appropriate anaesthesia, and by a skilled operator who can minimise the risks of side effects. The option of delaying the decision to circumcise is one way of dealing with the ethical and potential legal issues of undertaking an elective procedure on a minor. The procedure is not to be equated with vaccination, either in its delivery or in its effectiveness. It should be noted that Professor Morris, quoted in your report, is not a member of the RACP and is not and has not been engaged as a reviewer for the College. Yours faithfully, David Forbes, Chair, Paediatrics & Child Health Policy & Advocacy Committee Royal Australasian College of Physicians. 11 September 2009 <a href="http://www.6minutes.com.au/articles/z1/view.asp?id=498029">6minutes - Interesting stuff for doctors today</a> <a href="https://www.historyofcircumcision.com/templates/pages/medical_authorities_maintain_opposition_to_circumcision.html">RACP's new circumcision policy available here</a> <h3>The wit and wisdom of Brian Morris</h3> Professor Morris has been waging a one-man war against the foreskin since the mid-1990s, using his professorial position at Sydney University to give the impression that he speaks with the voice of medical authority. ("As a full professor at Australia's largest medical school I must insist ... etc etc etc".) On at least one earlier occasion in the past the university has felt obliged to caution Professor Morris for claiming to speak on behalf of the university, when he was only uttering his personal opinion. (Though the university has not gone so far as to require Morris to move his eccentric website from the Physiology Department's server.) Among Morris's charming eccentricities are the following gems: <ul style="font-weight: 400;"> <li>Louis XVI of France was forced to get circumcised in order to become capable of having sex with his wife.</li> <li>The former Pope died of a urinary tract infection caused by his foreskin.</li> <li>Boys should be circumcised to prevent their foreskins getting caught in the zipper of their jeans.</li> <li>Uncircumcised men need three showers a day to keep the stench of their foreskin down.</li> <li>Uncircumcised men always make a mess on the bathroom floor when taking a leak.</li> <li>Circumcision must be performed in infancy because if the choice was left up to the individual to make when he grew up he would make the wrong decision.</li> </ul> It is quite disgraceful that the SMH fawns on this maverick and cites his minority opinions against the considered judgement of Australian medical authorities. <h2>Sydney Morning Herald's twisted logic in attacking/defending circumcision</h2> Editorial: Arguments as old as the practice MORE than a billion men are circumcised and billions more have undergone the ritual over the centuries. The practice is both ancient and commonplace. Yet now we are supposed to accept the argument, promoted in some ethical circles, that circumcision is both dangerous and an infringement on the rights of the child. Any surgical procedure, however minor, is dangerous if performed crudely. The world is full of risks, with children the most vulnerable. What matters is proportionality. A report from the Tasmanian Law Reform Institute, released this week, suggests that, in the absence of specific laws relating to the practice of circumcision, it may be an abuse of the rights of the child. The report goes so far as to countenance that circumcision itself may, by its very nature, be an act of cruelty, law or no law. The matter has been given an airing after the Tasmanian Children's Commissioner, Paul Mason, sought guidance from the institute for the handling of cases where, for example, a dispute arises over whether a child should be circumcised. This is a nettlesome legal issue because cultural practice is divided and the law is largely silent. The cultural direction in Australia is moving away from circumcision. Western medical organisations no longer recommend routine neonatal circumcision. What used to be commonplace, involving more than 90 per cent of male infants born in Australia in the 1950s, has become a minority position. Only about one in seven newborn boys are circumcised. The majority of circumcisions involve religious customs, largely the rites of Muslims and Jews. The arguments for and against male circumcision are as old as the practice itself. In Australia, the procedure has a negligible rate of serious physical injury. Proponents argue the practice leads to lower rates of infection from sexually transmitted diseases, and has no adverse impact on sexual function. Opposition has largely come in the form of ethical arguments over the rights of the child being compromised by a procedure performed for no reason other than cultural practice, with the possibility of later psychological injury. The argument that circumcision involves psychological risks is finding growing support in medical studies. Common sense suggests that in a dispute between or within families over whether to circumcise, prudence favours leaving the child untouched. Common sense also suggests that where both parents want their child circumcised there are no compelling medical, legal or ethical grounds for not doing so. <a href="http://www.smh.com.au/news/opinion/editorial/tough-cop-on-site/2009/06/03/1243708503896.html?page=2" style="font-weight: 400;">Sydney Morning Herald, 4 June 2009</a> <h3>Comment</h3> The Sydney Morning Herald's editorial is quite in accord with its longstanding practice of giving prominent publicity to every half-baked slander against the foreskin that posthephobic toilers in America's bloated medical research industry cook up, and ignoring the vast body evidence to the effect that circumcision of minors is a harmful, cruel and unnecessary procedure that violates the rights of the child and is already technically illegal under existing laws of assault, mayhem and molestation - as the <a href="http://www.cirp.org/library/legal/QLRC/">Queensland Law Reform Commission found in 1993</a>. So long as ignorant editorial writers use their unaccountable power to champion bad habits it is unlikely that there will be any laws to restrict the practice of male genital mutilation, let alone the degree of protection from female genital mutilation afforded to women. The key facts that refute the editorial's concluding pontification are its earlier admissions that circumcision has always been a controversial and contested operation, and on a world scale a minority practice. These facts alone dictate that the only person entitled to make an irreversible decision about the shape of his penis is its owner. At least the SMH had the decency to publish Paul Mason's letter, pointing out the crazed illogic in the editorial's position. The way some circumcision promoters attempt to argue, you would think it was a large chunk of their brain that had been surgically removed in infancy. <a href="http://www.law.utas.edu.au/reform/">The paper by Tasmanian Law Reform Institute is here</a>. <h2>Stopping circumcision a matter of human rights</h2> Your editorial ("Arguments as old as the practice", June 4) misrepresents my input into the Tasmanian Law Reform Institute's issues paper on the validity of parental consent to unnecessary circumcision, and reveals a glaring non sequitur. You conclude that "there are no compelling medical, legal or ethical reasons for not" operating on a boy without his informed consent -- but only after observing that "the law is silent"; that circumcision "may be an act of cruelty"; that medical organisations no longer recommend routine circumcision; that "the possibility of ... psychological risks is finding growing support in medical studies"; and that "prudence favours leaving the child untouched". I did not refer the issue to the institute in connection with cases where a dispute arises whether to circumcise: the law is pretty clear that it will not proceed in those cases. I referred it in the context that babies are human beings and all human beings have the right to bodily integrity assured by the Universal Declaration of Human Rights (1948). I referred it in the context that the first principle of the Hippocratic Oath is "Do no harm" and that the irreversible, invasive and painful removal of any neurologically complex external organ of a powerless patient at the request of a third party is an ethical travesty. Your editorial seeks to seduce readers into denying babies and children their legal and human rights, while taxpayers are footing the bill through Medicare - circumcision is the only item that requires no medical indication for payment. One reason for its declining popularity in the West since the 1970s may be the influence of women, who see their babies as perfect and not for cutting: from this perspective unnecessary circumcision is a feminist issue. Paul Mason Commissioner for Children, Hobart <a href="http://www.smh.com.au/news/opinion/letters/stopping-circumcision-a-matter-of-human-rights/2009/06/05/1243708622222.html" style="font-weight: 400;">Letter: Sydney Morning Herald, 6 June 2009</a> <h2>Australian children healthier than ever: Boys with foreskins are happier</h2> The health of Australia's children continues to improve, according to the latest report on child health from the Australian Institute of Health and Welfare. During the period 1986-2006 there was a dramatic decline in infant and child deaths (which fell by half), improved survival in cases of cancer, and a reduction in the incidence of asthma. These are significant findings, given that the period 1986 to 2006 witnessed a huge decline in the incidence of circumcision, from about 40 per cent of boys in the early 1980s to about 10 per cent in 2006. It is thus good empirical proof that "lack of circumcision" does not increase child health problems. Even more significantly, it is a decisive refutation of "scientific" predictions by Terry Russell, Brian Morris and other diehard promoters of routine circumcision that the fall in the circumcision rate would lead to an explosion of genito-urinary problems in boys and an ever-increasing death toll from urinary tract and bladder infections. No such problems are identified in this report, which does not even mention any health problems affecting the genito-urinary area. On the contrary, the halving of the death rate among infants and children suggests that leaving the foreskin in place has significantly improved child health outcomes and contributed to the decline in infant and child mortality. It is, after all, quite illogical to claim that a boy with great wound in his penis is somehow healthier than a boy who has not been injured there. As the British child health expert N.R.C. Roberton points out, "it is fundamentally illogical that mutilating someone might be beneficial." * Problems identified by the AIHW report include an increasing incidence or diabetes and obesity, more, tooth decay, too much television, not enough vegetables, and persistent poor health among indigenous Australians. It is hard to see how even a fanatic like Brian Morris could blame "lack of circumcision" for children not eating their vegetables. The Australian Institute of Health and Welfare is the Australian Government's premier health research foundation. <a href="http://www.aihw.gov.au/publications/index.cfm/title/10704">The full report and press release can be downloaded from the AIHW website. </a> Reference N.R.C. Roberton, "Care of the Normal Term Newborn Baby," in Textbook of Neonatology, eds. Janet M. Rennie, N.R.C. Roberton, 3rd edn. (Edinburgh: Churchill Livingston, 1999), 378-379. <h2>Circumcision criticised in Human Rights Consultation: Submission argues that boys need protection even more than girls</h2> The Commonwealth Government is holding a <a href="http://www.humanrightsconsultation.gov.au/">National Human Rights Consultation</a>, providing the individuals with an opportunity for you to express their views on human rights. The Consultation is run by an independent Committee, supported by a Secretariat within the Attorney-General's Department. The Consultation is a chance to hear people's ideas about human rights and talk about ways to protect and promote human rights in the future. The questions in which it is most interested are <ul> <li>Which human rights and responsibilities should be protected and promoted?</li> <li>Are human rights sufficiently protected and promoted?</li> <li>How could Australia better protect and promote human rights?</li> </ul> The Committee has called for public submissions that address these questions and any other human rights about which people are concerned. <a href="http://www.humanrightsconsultation.gov.au/">For further details see the website.</a> A substantial submission from Dr Robert Darby has raised the question of circumcision and asked why boys are given no protection from unwanted alterations to their genitals when similar operations on girls or women are a serious criminal offence in most states. The submission argues that human rights include the right to bodily integrity and to protection from unwanted surgical interventions: In this submission it is argued that there is a glaring gap in the Australian human rights framework, namely, that boys are not given any protection against unwanted and unnecessary surgical interventions such as circumcision. It is suggested that boys are entitled to as much protection from circumcision (male genital mutilation) as girls from female genital mutilation (female circumcision). Since it is unlikely that any such protection will be provided by legislative measures, alternative means such as public education and the removal of financial incentives are proposed. <a href="http://www.humanrightsconsultation.gov.au/www/nhrcc/nhrcc.nsf/Page/Publicsubmissions_Submissions-Childrenandyoungpeoplesrights">Read the full submission here.</a> <a href="https://www.historyofcircumcision.com/templates/pages/human_rights_and_bodily_integrity.html">Submission text also available on this site.</a> <h2>Circumcision of male children "a hidden human rights violation"</h2> In the April 2007 issue of the Australian Journal of Human Rights, Ranipal Narulla argues that circumcision of male minors should be recognised as a violation of human rights. Synopsis Male circumcision is an accepted practice within Australian society, despite the fact that female circumcision is widely reviled in the Western developed world. This article will consider why society and the law treat circumcision of males and female differently. Analysis will focus upon the circumcision of male children in Australia, with reference to the United Kingdom and the United States of America. The similar social history of the practice within these jurisdictions is instructive when critically analysing the Australian context. The discussion will encompass the circumcision of all male children, as the issues of lack of consent and the imposition of a parent's religious and cultural norms upon the child are consistent for all minors, with specific focus on neonatal children where such extreme youth creates additional vulnerability. The absence of domestic law in Australia dealing with the circumcision of male children invites analysis of the protection afforded under international human rights instruments to which Australia is legally bound. This article deconstructs the medical myths that surround the circumcision of male children, and in so doing makes a strong argument for the need to recognise circumcision of male minors as a human rights violation. Ranipal Narulla, "Circumscribing circumcision: Traversing the moral and legal ground around a hidden human rights violation", Australian Journal of Human Rights, Vol. 12, April 2007, pp. 89-118 The Australian Journal of Human Rights is published by the <a href="http://www.ahrcentre.org/content/research_ajhr.htm" style="font-weight: 400;">Australian Human Rights Centre </a>at the University of New South Wales <a href="http://www.austlii.edu.au/au/journals/AJHR/" style="font-weight: 400;">On-line issues available from AustLii</a> <h4>Tasmanian Children's Commissioner wants circumcision banned</h4> <a href="http://www.childcomm.tas.gov.au/" style="font-weight: 400;">Tasmania's Children's Commissioner</a>, Paul Mason, wants the State Government to ban the non-medical circumcision of young boys. Female genital mutilation is illegal in Tasmania. Mr Mason said it's unfair that boys aren't given the same protection. "We're discriminating against the little baby boys themselves, because they're not safe whereas the little girls are," he said. He said circumcision is an abuse of human rights and should be outlawed until the person is old enough to decide for themselves. "It's a permanent procedure. They get no choice. It's painful -- even under anaesthetic." Mr Mason has prepared a report on the issue for the Council of Obstetric and Paediatric Mortality and Morbidity. The Council will forward a recommendation to the State Government. <a href="http://www.abc.net.au/news/stories/2007/08/13/2002944.htm?site=hobart" style="font-weight: 400;">ABC News, 13 August, 2007</a> <h4>Circumcision specialist censured and fined for improper conduct</h4> Dr Terry Russell, the ageing Queensland GP who has made a career and a fortune out of amputating the foreskins from baby boys, also seems keen to cut boys' tongues. In 2004 he was fined and censured by the Commonwealth Professional Services Review of Medicare services for falsely diagnosing "tongue tie" when the boys were brought to be circumcised, and cutting their tongue as well as their penis. The frenulum that tethers the tongue to the floor of the mouth is very similar to the frenulum that tethers the foreskin to the rest of the penis. Perhaps Dr Russell feels that any body part resembling the foreskin should be removed "just to be on the safe side". There was a time, back in the nineteenth century, when many doctors believed that surgery to correct so called "tongue tie" should be as routine as cutting off the foreskin. The Review reported that Dr Russell had been reprimanded, counselled and ordered to repay the $4,488.88 he had claimed from Medicare. The Committee noted that there was no clinical indication for cutting the tongue and thus that there was no basis for performing the procedure, nor for claiming the cost of the service under Medicare. Had the Committee looked into the cases of the boys brought in to be circumcised, it would have found that there was no clinical indication for circumcision either, and thus that there was no basis for that procedure to be charged to Medicare. Apparently, the government believes that it is OK to alter the appearance and function of the (highly visible) penis without the consent of the owner, but not to interfere with anybody's (usually concealed) tongue. The Medicare guidelines state clearly that Medicare does not cover "medical services which are not clinically necessary" or "surgery solely for cosmetic reasons". Why, then, does it continue to waste taxpayers' money on clinically unnecessary circumcision procedures? The full text of the report on Dr Russell follows. Director Dr John Holmes The Hon. Tony Abbott MHR Minister for Health and Ageing Parliament House Canberra ACT 2600 Dear Minister In accordance with subsection 63(1) of the Public Service Act 1999 and section 106ZQ of the Health Insurance Act 1973, I provide you with the 2003-2004 Annual Report of Professional Services Review for your presentation to Parliament. This report has been prepared in accordance with the Requirements for Annual Reports approved on behalf of the parliament by the joint Committee of Public Accounts and Audit under section 63 of the Public Service Act 1999. Yours sincerely John Holmes 5 October 2004 Dr Charles Terence Russell, General Practitioner, Qld Dr Russell practiced at Macgregor and Browns Plains in Queensland during the referral period of 1 January 1999 to 31 December 1999 inclusive. In relation to the rendering of MBS item 30278 (repair of tongue-tie) Dr Russell's conduct was found by the committee to be unacceptable to the general body of general practitioners. In the majority of services examined, the patients had seen Dr Russell for circumcision procedures. He subsequently performed repairs to tongue-ties. Given this pattern, the committee was concerned that while parents consulted with Dr Russell for circumcisions, he opportunistically diagnosed tongue-tie. The committee found there were no clinical indications for the services. The services were examined in accordance with an approved sampling methodology which resulted in a finding that 90 per cent of MBS item 30278 services rendered by Dr Russell during the referral period were inappropriate. The committee detailed its reasons in a final report to the Determining Authority. Dr Russell did not make a submission on the draft determination. The Authority issued a final determination directing that Dr Russell be reprimanded, counselled and repay $4 488.88. The determination came into effect on 13 February 2004. <a href="http://72.14.253.104/search?q=cache:qEsyOtL7VSwJ:www.psr.gov.au/docs/publications/PSRAR04.rtf+Russell+%2B+tongue-tie+%2B+Medicare&hl=en&ct=clnk&cd=3&gl=au" style="font-weight: 400;">Text available on-line here.</a> If the link does not work, <a href="https://www.google.com.au/search?source=ig&hl=en&rlz=&q=Russell+%2B+tongue-tie+%2B+Medicare&btnG=Google+Search&meta=cr%3DcountryAU%3E" style="font-weight: 400;">search for Russell +tongue tie +Medicare on Google</a>. <h4>Age op-ed writer calls circumcision male genital mutilation</h4> It's child abuse and it's time it was cut out Catherine Deveny <a href="http://www.theage.com.au/news/opinion/its-child-abuse-and-its-time-it-was-cut-out/2007/10/23/1192941062383.html" style="font-weight: 400;">The Age (Melbourne), October 24, 2007</a> People give plenty of reasons for circumcising their male children, writes Catherine Deveny. But most of them don't amount to anything. NO ONE seems to be able to explain to me why the circumcision of baby boys is not considered child abuse. Why in 2007 is it still acceptable for parents to have their babies' foreskins ripped off? How can it be legal, let alone ethical, for any human being to choose for another human being's body to be irreversibly mutilated? No medical reason, no rational thought and in many cases no aesthetic. Just because. I suggest that we should ban the use of the term "circumcision" and force people to use the term "genital mutilation". Because that's what it is. It's not "a personal choice", because that person is not making a choice. It's human rights abuse. The We Circumcised For Religious Reasons camp justify genital mutilation citing religion. They embrace the parts of religious texts that suit them and dismiss the ones that don't. And when I say "they", not all of them do. Many believers I know have all applied a little rational thought to the equation and just decided not to inflict unnecessary pain on their child or expose them to avoidable risk. They've decided to file that bit of the Holy Book under the other things that just don't fit; like selling your daughter into slavery or killing your neighbour if they work on the Sabbath. What kind of God would disapprove of you, stop loving you, or not give you eternal life if you don't mutilate your child's genitals? That doesn't sound like a nice kind of God. And what caring community would shun you, judge you or ostracise you for not inflicting genital mutilation on your child? Then we have the We Circumcised Our Boys So They Look The Same As Their Father camp. Sure, it's not fair for me to pick on people less fortunate in the brains department than the rest of us, but when they are subjecting innocent children to genital mutilation I'm going in swinging. I'm not going to bother asking the hard question "why do you need them to look like their father?", because you cannot reason with something that has not come from reason but from mindlessness. I ask the So They Look The Same As Their Father camp, why stop there? If you want them to look the same as their father, dye their hair, have them undergo cosmetic surgery and if the father has any tattoos or facial hair, sort that out too. Related to this camp is the We Circumcised Our Boys Because A Circumcised Penis Looks Nicer camp. We are talking the shallow end of the intelligence pool here. How would they feel if they had had their nipples, nose or ears cut off by their parents when they were a child because their parents thought "it looked nicer"? I must say that I do applaud these two camps on their frankness and honesty despite it revealing their stunning stupidity. After all, they could do what others do and make the decision for no rational reason and then rationalise it by joining the We Circumcised Our Boys For Health And Hygiene Despite Looking Closely At The Research camp. I have read the various studies suggesting that circumcision may reduce the spread of HIV and cervical cancer. I have also read the studies disproving the circumcision-reduces-infection myth. Here in Australia, all of these risks can be effectively and safely managed with condoms and cleanliness. That's right, a bit of frangers and face washers, rubbers and rubbing. Why would you expose a child to an unnecessary medical procedure and all the risks that come with it when you could teach them how to clean themselves and use a condom? Because you can, I suppose. By the same logic, removing all your children's teeth would prevent them getting fillings. Unless, of course, there is a sound medical reason to circumcise. And when I say sound, I mean sound as in last resort. I don't mean that you walk into a GP with a seven-year-old with a constricted foreskin that is not retracting and walk out with a referral to a surgeon to have your child's genitals mutilated, as a family I know could have. One of their sons had that very problem. They were offered a referral to a surgeon to have him circumcised. They didn't like the sound of that. Luckily they didn't have private health insurance, because that meant that they were given a referral to the Royal Children's Hospital, where they saw a general pediatric surgeon, or as their son referred to her, a Dick Doctor. Yes, she said, he could be circumcised, but she was having great success using an ointment available over the counter from the chemist. Three days later, the boy had a retracting foreskin. And two years later, he still does. The wonders of a health service on a budget as opposed to a private business. So if he wants to get himself circumcised as an adult, that's his choice. And he'll have that choice. Because when you circumcise someone, you can't uncircumcise them. <h4>Professor fails history:</h4> <h4>No evidence that Louis XVI was circumcised</h4> In the latest rewrite of his familiar list of "compelling" reasons as to why boys must not be allowed to keep their foreskins [1], Professor Brian Morris makes the extraordinary claim that Louis XVI, King of France 1754-93, was prevented from consummating his marriage to Marie Antoinette by his "tight foreskin", and was obliged to submit to circumcision so that he could perform his marital duties. This assertion is presented as one of the numerous reasons why circumcision is "a biomedical imperative" for the 21st century. The first point to make is that there is no evidence at all that Louis XVI was circumcised. Professor Morris seems to be awkwardly aware of the absence of evidence, for the only citation he provides for his claim is a reference to his own website. The story is one of the many anecdotes recorded as "compelling reasons" for circumcision by the notoriously unreliable circumcision evangelist <a href="https://www.historyofcircumcision.com/templates/pages/1902_dr_remondino_blasts_anti_circumcision_activists.html">Peter Charles Remondino</a>, who wrote in the 1890s that the King "was afflicted by a congenital phimosis which prevented the flow of semen from properly discharging itself". But even a fanatic such as Remondino was forced to concede that that there was no truth in the circumcision rumours, for even if it had been suggested, Louis refused to submit to the operation. Instead, according to Dr Remondino, he worked on dilating his foreskin manually, with such success that he soon fathered three children. [2] There has been much speculation as to why Louis and Marie took eight years to produce an heir. Explanations offered have included their strict religious educations, their traumatic childhoods, the extreme youth of the two spouses, and the condition of the King's foreskin. A reliable review of the case is provided by the Greek urologist G. Androutsos, who concludes that there is no evidence that Louis was circumcised, but suggests that he was probably late in reaching puberty and also that he might have had an associated persistent <a href="http://www.cirp.org/library/treatment/phimosis/">phimosis</a> or a short frenulum <a href="http://www.circumstitions.com/Frenbrev.html">(frenulum breve)</a> that made intercourse difficult. If so, it is possible that the problem was corrected by a very mild surgical intervention, involving no more than nicking the strands of tissue that tethered the foreskin, and not by amputating anything from the royal person. [3] This would have been similar to the operation for phimosis later recommended by the French sexual health authority Philippe Ricord, and practised in England by William Acton. [4] There is no firm evidence that Louis ever had any kind of surgery on his penis, but if he did have an operation, this is the most likely contender. Professor Morris's airy assertion that Louis was circumcised at the insistence of Marie-Antoinette's brother, Joseph II of Austria, is plainly false. References 1. Brian Morris, "Why circumcision is a biomedical imperative for the 21st century", BioEssays, November 2007 2. Peter Charles Remondino, History of Circumcision from the Earliest Times to the Present: Moral and Physical Reasons for its Performance, Philadelphia and London, F.A. Davis, 1891, pp. 201-2 3. Androutsos G., Le phimosis de Louis XVI (1754-1793) aurait-il ete a l'origine de ses difficultes sexuelles et de sa fecundite retardee?. Prog Urol. 2002; 12(1):132-7. <a href="https://www.historyofcircumcision.com/templates/pages/the_truth_about_louis_xvis_marital_difficulties.html">An English translation of this article is available on this site.</a> <ol> <li style="font-weight: 400;">William Acton,A Practical Treatise on the Diseases of the Urinary and Generative Organs (in Both Sexes), 2nd edition, London, Churchill, 1851, pp. 77-78</li> </ol> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Circumcision in the news in Australia darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> Confirming previous studies <a href="https://www.circinfo.org/news_upto2010.html#News5">summarised on this site</a>, reports issued this year by the Australian Institute of Health and Welfare show that the health of Australian children continues to improve, and that while males generally are less healthy than women, their problems have nothing to do with lack of circumcision. Most strikingly, the infant mortality rate has more than halved since 1986, the very period during which the incidence of routine circumcision fell from around 40 per cent of boys under 6 months to around 12 per cent today. The most serious child health problems identified by the report are asthma, lack of breast feeding, and arising from social factors such as poverty and Aboriginality. These reports offer good empirical proof that “lack of circumcision” does not increase child health problems. Even more significantly, it is a decisive refutation of “scientific” predictions by various antiquated circumcision enthusiasts that the fall in the circumcision rate would lead to an explosion of genito-urinary problems in boys. No such problems are identified in these reports, which do not even mention any health problems affecting the genito-urinary area. If we were to be as unscrupulous in mixing up correlation with causation as many pro-circumcision zealots tend to be, we could reasonably conclude that Australian children have become healthier because the incidence of circumcision has fallen, not merely at the same time. But there is no need to go that far. At the very least, A Picture of Australia’s children is definitive proof that there is zero connection between circumcision and improved child health outcomes. The reporst tells a similar story with male health, finding that the main risk factors for poor health problems to be living in remote or country areas; being poor; getting old; and being of Aboriginal or Torres Strait Islander descent. None of these social factors has anything to do with circumcision. Further information on this site <a href="https://www.circinfo.org/health.html#child" rel="noopener" target="_blank">Health and disease</a> <a href="https://www.circinfo.org/Circumcision_and_public_health.html" rel="noopener" target="_blank">Circumcision and public health</a> <h3>Health of Australia’s males: Summary</h3> This report is the second in a series on the health of Australia’s males. It examines the distinct health profiles of five population groups, characterised by Aboriginal and Torres Strait Islander status, remoteness, socioeconomic disadvantage, region of birth, and age. Key findings Aboriginal and Torres Strait Islander males generally experience poorer health than the overall population, highlighted by a life expectancy of 67 years (11.5 years less than that for non-Indigenous males). Factors that contribute to this poorer health status include: <ul> <li>high rates of tobacco smoking, risky alcohol consumption and illicit substance usage;</li> <li>higher rates of chronic diseases (such as lung cancer, diabetes and kidney disease) and health conditions (such as scabies, trachoma and acute rheumatic fever) that are uncommon in the general population;</li> <li>higher rates of hospitalisation, with 45% of these for dialysis.</li> </ul> Remoteness is associated with poorer health. Males living in remote areas generally have a shorter life expectancy and poorer self-assessed health status. As remoteness increases, the following health-related factors also increase: <ul> <li>rates of obesity, tobacco smoking and risky alcohol consumption;</li> <li>new cases of lung cancer, and deaths from chronic obstructive pulmonary disease, diabetes and suicide;</li> <li>hospitalisations for Type 2 diabetes mellitus.</li> </ul> Socioeconomic disadvantage is also associated with poorer health. Males living in more socially disadvantaged areas generally have a shorter life expectancy. As socioeconomic disadvantage increases, the following health-related factors also increase: <ul> <li>rates of obesity and tobacco smoking;</li> <li>new cases of lung cancer, and deaths from coronary heart disease, lung cancer, chronic obstructive;</li> <li>pulmonary disease, diabetes and suicide;</li> <li>hospitalisations for Type 2 diabetes mellitus.</li> </ul> Males born overseas generally enjoy better health than other males, with fewer risk factors and lower overall mortality and hospitalisations. There are areas where males born overseas experience poorer health, compared with males born in Australia, with: <ul> <li>lower rates of physical activity and bowel cancer screening;</li> <li>higher rates of lung cancer, and more deaths from diabetes and lung cancer;</li> <li>higher rates of hospitalisations for Type 2 diabetes mellitus and heart attack.</li> </ul> Older males (aged 65 and over) are living longer than ever before, and generally have fewer risk factors such as overweight/obesity and tobacco smoking than younger males. As age increases, the following health-related factors also increase: <ul> <li>inadequate vegetable intakes and inadequate physical activity;</li> <li>new cases of bowel cancer and melanoma, and rates of dementia and of injury from falls;</li> <li>all hospitalisations, including cardiac rehabilitation, cataract and melanoma of the skin.</li> </ul> The AIHW is a major national agency set up by the Australian Government to provide reliable, regular and relevant information and statistics on Australia's health and welfare. <a href="http://aihw.gov.au/publication-detail/?id=10737421980" rel="noopener" target="_blank">The full report can be downloaded from the AIHW website</a> <h2>Health of Aussie kids continues to improve as incidence of circumcision declines</h2> <h3>Infant deaths halved since 1986</h3> A picture of Australia's children 2012 provides the latest information on the health and wellbeing of Australia's children aged 0-14. Many are faring well, but there is scope for further gains, particularly among Aboriginal and Torres Strait Islander children and those living in areas with the lowest socioeconomic status. The good news Death rates for infants (aged under 1) and children (aged 1-14) more than halved between 1986 and 2010, with rates slightly ahead of the Organisation for Economic Co-operation and Development (OECD) average for infants, and equal to the average for children under 5. Notably, child deaths from injuries halved between 1997 and 2010. The prevalence of asthma has decreased, while the incidences of diabetes and cancer have remained stable. Almost three-quarters of children aged 0-2 have stories read or told to them regularly, and most children achieve above the national minimum standard for reading and numeracy. Australia's average score for mathematics was in the top half of OECD countries. Smoking in households with children has decreased, while rates of risky drinking and smoking among children have declined. Most parents rate their health as excellent, or (very) good, and the majority of households with children perceive their neighbourhood as safe. Most households with children, including Indigenous, reported that they could get assistance from outside the household in times of crisis. Areas where improvement needed Around 1 in 7 women smoked during pregnancy, and about half of pregnant women drank alcohol. Exclusive breastfeeding was initiated for 90% of infants at birth; however only 2 in 5 infants were exclusively breastfed to around 4 months. An estimated 45% of children aged 6 and 39% of children aged 12 experienced dental decay. Almost a quarter of children were developmentally vulnerable on one or more domains of the Australian Early Development Index at school entry. About 15% of parents were affected by mental health problems. Aboriginal and Torres Strait Islander children experience higher death rates, including from injuries, than the national average. They were less likely to have achieved the reading and numeracy minimum standards, and had higher smoking rates than the general child population. Children living in the lowest socioeconomic status (SES) areas were less likely to have stories read or told to them regularly, more likely to be exposed to tobacco smoke in the home, and more likely to smoke themselves than children living in the highest SES areas. Teenage birth rates were higher in the lowest SES areas than in the highest SES areas, and parents living in the lowest SES areas were more likely to report fair/poor health and poorer mental health compared with those in the highest SES areas. AIHW media release <h3>Most Aussie kids doing well, room for further gains</h3> Most Australian children are doing well in terms of their health and wellbeing, but there is room for improvement for some, according to a report released by the Australian Institute of Health and Welfare (AIHW). The report, A picture of Australia's children 2012, shows that death rates for infants and children halved since 1986, the prevalence of asthma among children has dropped, and rates of risky drinking and smoking among children aged 12-14 are down. Smoking in households with children has also dropped. Almost three-quarters of children aged 0-2 have stories read or told to them regularly and most children achieve above the national minimum standard for reading and numeracy. The majority of households with children in Australia perceive their neighbourhood as safe. Most households also reported that they could get assistance from outside the household in times of crisis. “The report indeed shows that most Australian children are faring well, but despite this good news, there are several areas where improvements could be made,” said AIHW spokesperson Dr Fadwa Al-Yaman. For example, while exclusive breastfeeding was initiated for 90% of infants at birth, only 40% of infants were exclusively breastfed to around 4 months (exclusive breastfeeding is recommended to 6 months). Around 45% of children aged 6 have dental decay, as do 39% of children aged 12. The report also shows that almost one-quarter of children are developmentally vulnerable at school entry. About 7% of Australian children had a disability in 2009 and, of these, over half had profound or severe core activity limitations. The most common disability types among children were intellectual, affecting 161,600 children (3.9%), and sensory/speech (119,100 children or 2.9%). Injury and cancer are the two leading causes of death in children. In 2008-2010, injuries contributed to 662 deaths of children-a rate of 5 per 100,000 children. Infants (aged less than one year) had the highest rate of injury death (11 per 100,000 infants). Over the period 2004-2008, an average of 583 new cases of cancer were diagnosed annually among children, and in 2008-2010, there were 274 cancer deaths among children-a rate of 2.2 per 100,000 children. This accounted for around 5% of all child deaths. Additional challenges exist among Aboriginal and Torres Strait Islander children and children living in areas of low socioeconomic status. Aboriginal and Torres Strait Islander children experience higher death rates than the national average. They also had higher smoking rates than the general child population and were less likely to have achieved reading and numeracy minimum standards. Children in the lowest socioeconomic status (SES) areas were less likely to be read to on a regular basis than children living in the highest SES areas, and their parents were more likely to report poorer physical and mental health. <a href="http://aihw.gov.au/publication-detail/?id=10737423343" rel="noopener" target="_blank">The full report can be downloaded from the AIHW website</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Health of Aussie boys and men improves as incidence of circumcision declines darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> Despite a series of reviews over the past few years aimed at containing costs and simplifying the system, there have been no significant changes to Medicare coverage of circumcision. The only changes have been to reduce the number codes (from four to two) and to make them unisex. This had had the unfortunate effect of making it impossible to calculate the number of circumcision procedures by age (thus obscuring the fact that the vast majority are of infants and young boys) and allowing circumcision of girls, as <a href="https://www.circinfo.org/Medicare_Coverage_Female_Circumcision.html" rel="noopener" target="_blank">previously documented on this site</a>. The latest report from one of the working groups, the Urology Clinical Committee, has proposed no changes to the circumcision codes at all, except for the requirement for analgesia (pain control). This is a desirable reform, but a less important issue than the fact that Medicare will continue to fund non-therapeutic (medically unnecessary) circumcision, including circumcision desired for religious, cultural and other social/cosmetic reasons. This is contrary to the provisions of the Health Insurance Act and the Medicare guidelines, which state clearly that benefits are payable only for “clinically relevant” services – i.e. procedures for which there is a demonstrated medical need. <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mbs-review-2018-taskforce-reports-cp/%24File/v2%20-%20Urology%20Clinical%20Committee%20-%20Report.pdf" rel="noopener" target="_blank">The Committee report is available here</a>; the section relating to circumcision are on pages 68-70. <h2>Medicare should not pay for non-therapeutic circumcision</h2> For some years the Commonwealth Government has been concerned at the ever-rising costs of the ever-expanding health budget, particularly the cost of Medicare. In 2015 it resolved to establish a reform process, the aim of which was to simplify the system and reduce costs by eliminating services of low medical value. Non-therapeutic circumcision was identified as an example of such a low-value service, giving rise to the expectation that it would be dropped from the Medicare Benefits Schedule. This has not happened. In the first round of reforms all that happened is that the codes for circumcision were reduce from four (distinguished by age) to two (distinguished by type of anaesthesia) – thus making it impossible to determine how many infants and boys were being circumcised. In addition, the codes were made gender-neutral, allowing them to be used for circumcision of females – as is apparently happening. In a further round of reforms the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/MBSR-consult-2018-taskforce-reports" rel="noopener" target="_blank">Urology Clinical Committee</a> tackled the circumcision codes and managed to produce a very small mouse. Of nearly 6000 items on the MBS, it managed to eliminate 18, of which circumcision was not one. The Committee’s sole recommendation was to require analgesia (pain control) for circumcision procedures, “thus ensuring patient wellbeing.” This is certainly a welcome move in the right direction, but it is not the main issue. More significantly, the Committee made no attempt to limit the availability of the circumcision rebate; on the contrary, it accepted the prevailing situation in which it is readily available for procedures carried out for religious or cultural reasons: The Committee noted that item 30654 should continue to include circumcisions conducted for religious and cultural reasons, reflecting both current practice and the need to ensure safe circumcisions. While this does not appear to be a formal recommendation, it presumably has the force of one. It is difficult to see how subsidising religious or cultural practices could be a legitimate use of the health budget, particularly as the Health Insurance Act and the Medicare guidelines state clearly that the rebate is available only for “clinically relevant” services – i.e. medical treatment that is actually needed for medical reasons. The policy is certainly in contradiction to the fundamental objective of the reform process: to rein in and control costs. The stated objectives of the reviews were to achieve: <ul> <li>Affordable and universal access</li> <li>Best-practice health service</li> <li>Value for the individual patient</li> <li>Value for the health system</li> </ul> An open-ended subsidy (essentially a blank cheque) for procedures of zero clinical relevance makes no contribution to achieving these objectives, and is in fact in complete contradiction to them, especially the last. Examining the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mbs-review-2018-taskforce-reports-cp/%24File/v2%20-%20Urology%20Clinical%20Committee%20-%20Report.pdf" rel="noopener" target="_blank">Urology Clinical Committee’s recommendations and observations on circumcision</a> in more detail, it is possible to raise six major objections to them, as set out below. Further information on this site <a href="https://www.circinfo.org/Medicare_circumcision_review.html" rel="noopener" target="_blank">Medicare Circumcision Review details</a> <a href="https://www.circinfo.org/Medicare_coverage_for_circumcision.html" rel="noopener" target="_blank">Medicare coverage of non-therapeutic circumcision criticised in submission</a> <a href="https://www.circinfo.org/Medicare_Coverage_Female_Circumcision.html" rel="noopener" target="_blank">Medicare coverage of female circumcision?</a> <h2>Medicare Benefits Schedule Review: Report of the Urology Clinical Committee</h2> <h3>A rational critique</h3> This response is directed at the recommendations relating to circumcision, at pages 68-70. 5.5.1 Recommendation 14 Amend the item descriptor to mandate the use of analgesia for this procedure. 5.5.2. Rationale for Recommendation 14 The item descriptor has been amended to mandate the use of analgesia, which ensures patient wellbeing. Comment While this is a progressive and desirable reform, it should be noted that analgesia does not necessarily “ensure patient wellbeing”, only that he is given a painless operation. The Committee noted that item 30654 should continue to include circumcisions conducted for religious and cultural reasons, reflecting both current practice and the need to ensure safe circumcisions. Comments 1. This proposal is regressive and inappropriate in that it is essentially offering a blank cheque to all parents who desire to have their boys circumcised, whatever their reason, as well as to those rare individuals who desire circumcision for themselves. The specification “religious and cultural” is meaningless and ineffective in the absence of a verification mechanism by which the religious/cultural credentials of the parents can be checked. Such a system is not proposed, and it would be complex to administer, and expensive even if the obvious difficulties could be overcome. In effect, the Committee has legitimised the existing open slather by which any individual who desires circumcision for himself or any parent who wishes to get a boy circumcised for any reason can require the public purse to meet part of the cost. Considering that the original objective of the various Medicare reviews was to rein in costs by eliminating procedures of low medical value, this seems highly counter-productive. 2. The argument about past practice is feeble and unacceptable. Merely because a certain policy has been followed in the past does not mean that it is desirable in or appropriate to current conditions; past practice is not best practice. The objective of reform exercises is to eliminate bad policies and replace them with good policies. Historical longevity is no basis for approving any practice in the contemporary world. As a matter of historical record, the government attempted to remove circumcision from the MBS in 1985, suggesting that in its original conception, Medicare was not intended to cover non-therapeutic circumcision at all. [1] 3. Related to (2), it is likely that payments for religious/cultural circumcision under Medicare are unlawful because the relevant act and associated guidelines provide that benefits are payable only for clinically needed procedures. As Michael Ryan, Assistant Secretary, MBS Policy and Specialist Services Branch, Department of Health, explains to Mr Peter Khalil MP (letter dated 6 November 2017, copy held by author): “The Medicare Benefits Schedule (MBS) provides benefits (or rebates) for a range of professional medical services, including circumcision. The Health Insurance Act 1973 stipulates that Medicare benefits are only payable for clinically relevant services provided by health practitioners. A clinically relevant service is one that is generally accepted by the relevant profession as necessary for the appropriate treatment of the patient. “On 1 November 2016 the MBS items for circumcision were restructured from four items to two items to separate them by the type of anaesthesia used, rather than by patient age. However, there have been no changes to the legal requirement that services must be clinically relevant, and there are no benefits available for non-therapeutic procedures.” In its current policy statement on circumcision the Royal Australasian College of Physicians concluded: “After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.” That being the case, non-therapeutic circumcision (including circumcision procedures desired for religious/cultural reasons), must be regarded as clinically not-relevant, and hence ineligible for a Medicare rebate. 4. The argument about the need to avoid the risk of additional harms or complications that might arise if needy parents (those who claim to be unable to meet the full cost) would resort to less expensive unqualified operators (as in the backyard abortions and kitchen-table surgery of infamous memory) fails for 2 reasons. First, the argument about avoiding the risk of additional harm is not a reply to the proposal that parents etc should meet the full costs of medically unnecessary procedures, but to the proposition that such procedures should be legally prohibited. The Royal Dutch Medical Association, which would like to see non-therapeutic circumcision of minors banned, raised this point as the only consideration which deterred the from making such a recommendation in their 2010 circumcision policy statement. [2] But the current proposal is not that circumcision should be prohibited or restricted in any way at all, merely that individuals or parents who desire a medically unnecessary circumcision should meet the full costs. The mere fact that the procedure is covered by Medicare does not guarantee “safe circumcisions”. Complications and “botches” are still common in clinical settings, and at the hands of fully credentialed operators, often requiring expensive surgical repairs and sudden appearances in hospital emergency departments. [3] Ensuring patient safety is not the task of the MBS, but of the medical regulatory authorities. Further evidence for this point is provided by the two Medicare items for “arrest of haemorrhage following circumcision”, items 30649 and 30663; from a policy perspective the risks and complications of circumcision are real enough and recognised. There is thus a question as to whether these circumcision-related MBS benefits encourage unnecessary risk-taking behaviour on the part of parents and compliant practitioners. But what level of complications is acceptable in a clinically-unnecessary procedure? Second, the test of whether a person really values a good or service is how much he is willing to pay for it. Members of the religious/cultural groups that traditionally practise circumcision may be insistent that it is vitally necessary, but if they are not willing to put a price on it – if they do not wish to meet the actual costs involved – it suggests that they do not really regard it as necessary at all. To allow the rebate in this situation would be like allowing low-income families to drive a car without paying the full costs of vehicle registration because the expense is a strain on their resources. And here the full cost includes the insurance component, to cover the cost of accidents etc; the parallel with surgical complications of circumcision and the cost of repairing “botches” is quite exact. Most people regard the ability to drive as so vital that they are willing to meet whatever costs are involved. Moreover, some religious groups celebrate the circumcision with a lavish family party. If they are willing to pay for that, they should also be willing to meet the full costs of the surgery that is the occasion for the event. One assumes that they do not expect the taxpayer to subsidise the party. 5. Now that the Medicare circumcision codes have been made unisex or gender neutral, there is the danger that retaining coverage of religious/cultural circumcision will lead to Medicare providing a rebate for circumcision or other forms of genital cutting on girls. There is in fact evidence that this is already happening. [4] The religious/cultural groups that practise circumcision or other forms of genital cutting on girls regard the procedures as just as important and meaningful as circumcision of boys; if they see the rebate available for circumcision of the latter, they are likely to expect or even demand it for the former as well. And if cultural/religious affiliation is to be the deciding factor, how can their request be denied? [5] 6. While some defenders of circumcision have begun to advocate toleration of “mild” forms of female genital cutting, partly as a way of reducing the blatancy of the double standard (FGM legally prohibited, with heavy criminal penalties, circumcision of boys legal and generally unregulated), a stronger current of opinion stresses the importance of “genital autonomy” and the need to protect all children – male, female, intersex – from any form of non-therapeutic genital cutting. [6-10] It is puzzling and disappointing that the Committee displayed no awareness of these developments. References 1. Robert Darby. Scientific advice, traditional practices and the politics of health-care: The Australian debate over public funding of non-therapeutic circumcision, 1985. Hygiea Internationalis: An Interdisciplinary Journal for the History of Public Health, Vol. 10, December 2011. Available at https://www.academia.edu/7028494/Scientific_advice_traditional_practices_and_the_politics_of_health-care_The_Australian_debate_over_public_funding_of_non-therapeutic_circumcision_1985 2. Details at http://www.circinfo.org/Dutch_circumcision_policy.html 3. Gold, G. et al. Complications following circumcision: Presentations to the emergency department. Journal of Paediatrics and Child Health 51 (12) 2015: 1158-63; Jacques Gallant. Secrecy questioned about baby’s death after circumcision. The Star (Toronto), 26 October 2015. https://www.thestar.com/news/gta/2015/10/26/secrecy-questioned-about-babys-death-after-circumcision.html 4. See for example http://www.circinfo.org/Medicare_Coverage_Female_Circumcision.html 5. Brian Earp. Between moral relativism and moral hypocrisy: Reframing the debate on FGM. Kennedy Institute of Ethics Journal 26 (2) 2016: 105-144. Available at: https://www.academia.edu/10197867/Between_moral_relativism_and_moral_hypocrisy_reframing_the_debate_on_FGM_ 6. Brian Earp and Rebecca Steinfeld. Gender and genital cutting: A new paradigm. Euromind Global, 6 April 2017. Available at: http://euromind.global/en/brian-d-earp-and-rebecca-steinfeld/?lang=en 7. Robert Darby. The child’s right to an open future: Is the principle applicable to non-therapeutic circumcision?” Journal of Medical Ethics 39 (2013): 463-468. Available at: https://www.academia.edu/17264543/The_childs_right_to_an_open_future_Is_the_principle_applicable_to_non-therapeutic_circumcision 8. Eldar Sarajlic. Can Culture Justify Infant Circumcision? Res Publica 20 (4) 2014: 327-343. 9. Steven Munzer. Examining non-therapeutic circumcision. Health-Matrix: The Journal of Law Medicine 28 (2018). Available at: https://scholarlycommons.law.case.edu/healthmatrix/vol28/iss1/5/ 10. Kai Möller. Ritual male circumcision and parental authority. Jurisprudence 8 (3) 2017: 461–79. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Lack of progress on Medicare reform criticised darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Medicare should not pay for medically unnecessary circumcision</h1> A recent review of Medicare found evidence that between 2 and 3 billion dollars are spent inappropriately each year. The review, by Dr Tony Webber as Director of the Professional Services Review, noted that Medicare’s no-questions-asked policy led to serious financial abuses and failed to take account of the medical business environment. “The MBS [Medical Benefits Schedule] is riddled with misdirected incentives for practitioners … and has many examples of good public policy being thwarted by the MBS rules”, Webber writes. Among the scandals, he mentions cases where “the Safety Net was used in effect to subsidise cosmetic procedures such as surgery for designer vaginas at $5000-$6000 each” (Tony Webber, “What is wrong with Medicare?”, Medical Journal of Australia, 16 January 2012.) What is equally scandalous about Medicare is that it continues to subsidise cosmetic procedures such as surgery for “designer penises” – namely, non-therapeutic (medically unnecessary) circumcision of male infants and boys. There is no reason at all why the over-stretched health budget should continue to waste taxpayers’ money by paying for an operation, usually on non-consenting children, that medical authorities judge to be medically unnecessary, risky, potentially harmful, and contrary to accepted principles of medical ethics and human rights, including the principle of gender equity. The Commonwealth Sex Discrimination Act, Section 3 (b), states that the Act applies to the administration of Commonwealth laws and programs, while Section 22 (b) makes it illegal to discriminate on the basis of sex in the provision of goods, services and facilities. It could be argued that the exclusion of female circumcision from the MBS is a breach of this provision, since it denies to women a benefit given to men; whether or not circumcision is regarded as a benefit or a deprivation, it is certainly anomalous that the MBS specifically denies coverage for cutting procedures on the female genitals while providing no-questions-asked coverage for comparable procedures on the genitals of boys. Medicare should never have covered a non-therapeutic procedure such as circumcision. When Medibank was first introduced in 1975, Australian medical authorities <a href="https://www.circinfo.org/doctors.html">had already determined</a> that boys should not be circumcised; and when it was re-established as Medicare by the Hawke government in 1984-85 they had reaffirmed and strengthened their policy. Unfortunately, the politicians and health bureaucrats seem to have been behind the times. It is high time that medically unnecessary (non-therapeutic) circumcision was dropped from the Medical Benefits Schedule, and Medicare confined to its stated requirement to cover only “procedures that are clinically necessary”. UPDATE 2015 In response to calls for public comment on various reviews of the Medical Benefits Schedule, aimed at eliminating outdated or inappropriate services, <a href="https://www.darboninstitute.org/medicare_should_not_cover_non_therapeutic_circumcision" rel="noopener" target="_blank">a detailed submission on why Medicare should not cover non-therapeutic circumcision was prepared and submitted</a>. <h2> <a id="medi1" name="medi1"></a>1. Medicare should not cover non-therapeutic circumcision</h2> Dr Robert Darby’s letter to Medical Journal of Australia in response to Tony Webber’s article Any review of Medicare arising from Tony Webber’s critique [1] must reconsider its coverage of non-therapeutic circumcision. Australia is the only country in the world to provide a no-questions-asked rebate for such procedures, despite the fact that most have no medical indication and in defiance of Medicare’s own guidelines. These state that benefits are not payable for “medical services that are not clinically necessary”, nor “surgery for cosmetic reasons”. [2] A medical procedure is clinically necessary only if required to correct a diagnosed disease, injury or other pathological condition that cannot be treated conservatively. Surgery for any other reason, particularly cultural or social reasons, is cosmetic surgery, intended merely to alter the appearance of the body part in question. As the Royal Australasian College of Surgeons points out, “male non-therapeutic circumcision is not clinically necessary as it does not treat an underlying pathological process.” [3] The issue is doubly serious in that most circumcision procedures are on infants and other minors, few of whom present any pathology requiring surgery, thus contradicting the policy of the Royal Australasian College of Physicians that routine circumcision is not warranted. Since minors cannot give consent, payments for such operations are questionable from a bioethical and human rights perspective, and may even be unlawful. [4] There have been several calls to delete non-therapeutic circumcision from the Medical Benefits Schedule, including Spilsbury et al, who point out that “the potential savings to the public purse would be considerable if elective and discretionary circumcision was removed from the Medicare schedule in line with other cosmetic surgeries, leaving rebates for the genuine medically indicated circumcision.” [5] In 1985 the government did drop circumcision from the MBS, only to reinstate it after objections from Jewish community leaders, leading to the myth that the original decision aroused a community backlash. Recent research has established that the decision represented sound public policy, was widely supported, and that the objections were based on a sense of discrimination: their real concern was that the rebate was deleted only for boys younger than six months. [6] It is not clear why the government, rather than restoring the rebate, did not resolve the problem by requiring a medical indication at all ages, as would have been the simplest and most equitable course of action. It now has the opportunity to rectify this mistake. Medicare should no more fund the designer penises created by circumcision than the designer vaginas created by other cosmetic procedures. References 1. Webber, TD. What is wrong with Medicare? Med J Aust 2012; 196 (1): 18-19. 2. “What does Medicare cover?”, at http://www.medicareaustralia.gov.au/public/claims/what-cover.jsp. Accessed 21 January 2012. 3. Australian Safety and Efficacy Registry of New Interventional Procedures – Surgical. Report No. 65: Male non-therapeutic circumcision. Adelaide: Royal Australasian College of Surgeons, 2008. 4. Adler, P. Is it lawful to use Medicaid to pay for circumcision? J Law Med 2011; 19: 335-353. 5. Spilsbury K, Semmons JB, Wisniewski ZS, Holman CD. Routine circumcision practice in Western Australia 1981–1999. ANZ J Surgery 2003; 73(8): 610-614. 6. Darby, R. Scientific advice, traditional practices and the politics of health-care: The Australian debate over public funding of non-therapeutic circumcision, 1985. Hygiea Internationalis: An Interdisciplinary Journal for the History of Public Health 2011; 10: 53-73. Available at http://www.ep.liu.se/ej/hygiea/. Accessed 21 January 2012. (This letter was sent to the Medical Journal of Australia in response to Tony Webber’s article, but was not published.) <h2> <a id="medi2" name="medi2"></a>2. Medicare should not pay for medically unnecessary circumcision: Our viewpoint</h2> Although Australian medical authorities do not recommend circumcision as a routine or prophylactic procedure, Medicare continues to provide an automatic rebate for such operations, whether medically required or not. The propriety, ethics and even the lawfulness of this policy have been questioned in two recent studies, one by an American legal expert who argues that payments for non-therapeutic circumcision by the United States health insurance program Medicaid are unlawful; and the other by Australian medical historian Dr Robert Darby, who has examined the attempt by the Hawke government to drop circumcision from the Medical Benefits Schedule in 1985. He dispels the myth that the decision aroused widespread protest and shows, on the contrary, that it represented sound public policy and was widely supported. Taken together, these analyses raise serious questions about current Medicare policy on the circumcision rebate; here Robert Darby argues that, for reasons of consistent public policy, financial prudence and respect for established principles of human rights and gender equity, the rebate should be abolished except for cases of proven medical need. <h3>Introduction</h3> The Australian government is under pressure to balance budgets, give more recognition to individual human rights, promote gender equity and protect children from harm. One simple way to make progress on all these fronts is to drop non-therapeutic circumcision from the Medical Benefits Schedule. Medicare currently provides an automatic, no-questions-asked rebate for circumcision, despite the fact that the vast majority of these operations have no medical indication, and in defiance of Medicare’s own guidelines. These state that benefits are not payable for “medical services which are not clinically necessary”, nor “surgery for cosmetic reasons”. A medical procedure is clinically necessary only if it is essential to correct a diagnosed disease, injury, deformity or other pathological condition that has not responded to conservative (non-surgical) treatment. As the Royal Australasian College of Surgeons points out, “male non-therapeutic circumcision is not clinically necessary as it does not treat an underlying pathological process.” Surgery for any other reason, particularly cultural or social reasons, is essentially cosmetic surgery, intended to alter the appearance of the body part in question. According to its own published guidelines, Medicare should not cover such procedures. <h3>Opinions of medical authorities</h3> It is strange that it still does so, considering that Australian medical authorities have sought to discourage routine (medically unnecessary) circumcision since the early 1970s. In fact, the government did drop circumcision from the MBS in 1985, only to restore it a few weeks later, for obscure reasons, explained below. Nonetheless, Australian medical authorities have maintained their opposition to the practice, with the result that the incidence of circumcision in Australia continues to decline. The most recent statement (October 2010) by the Royal Australasian College of Physicians states clearly: “After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.” Stronger statements have been issued by the British Medical Association, the Canadian Pediatric Society, the Royal Dutch Medical Association, the South African Medical Association, and medical authorities in Denmark, Finland, Norway and Sweden. Even in the United States, where circumcision is deeply entrenched as a medicalised cultural ritual, the American Academy of Pediatrics does not recommend the operation or regard it as medically desirable, much less as necessary. This being the case, a study by a US legal expert argues that payments for non-therapeutic (medically unnecessary) circumcision by the United States health insurance scheme Medicaid violate the protocols for benefits under this program and are thus unlawful. The article, in the December 2011 issue of the Journal of Law and Medicine, 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, 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. Medicare has not been the subject of such a study, but it is quite possible (given the guidelines) that its own payments for non-therapeutic circumcision are not authorised by Parliament and are thus unlawful. <h3>Why Medicare should not pay for circumcision</h3> There are at least five other main reasons why non-therapeutic circumcision should be dropped from the MBS. These relate to the absence of a convincing health case; conformity with international practice; principles of ethics and human rights; gender equity; and financial prudence. 1. No health case for routine circumcision It is not only the authorities mentioned above that have examined the medical literature and concluded that there is no health case for routine circumcision of infants or boys. A survey by British experts Malone and Steinbrecher acknowledged the medical claims for routine circumcision, but concluded that the only definite indications in childhood were phimosis caused by balanitis xerotica obliterans and recurrent balanoposthitis. Preputial adhesions, ballooning on urination, and a non-retractile foreskin do not require treatment. Relative indications (meaning that therapeutic circumcision could be warranted in individual cases) were recurrent urinary tract infections plus an abnormal tract. They point out that most circumcisions are done for religious cultural reasons, and that complications “are well documented and can be drastic”. A study by researchers in Adelaide, published in Annals of Family Medicine, subjected the claims of the circumcision lobby to an exhaustive review, and concludes that its value for child health was close to zero. When the literature is considered as a whole (rather than cherry picked for papers supporting a particular thesis) there is no proof that circumcision provides any significant protection against urinary tract infections, sexually transmitted infections or cancer of the penis The only evidence for prophylactic efficacy came from Africa, where there was evidence that adult males who got themselves circumcised had a slightly lower risk of contracting HIV through unprotected intercourse with an infected female partner. And I say “slightly lower risk” because I do not consider a risk reduction of between 40 and 60 per cent to be impressive, particularly when compared with the 90 to 95 per cent protection offered by a condom. As the authors of the paper comment, Africa has unique health problems. The circumcision trials were on adult men and can no more be applied to children than the World Health Organisation recommendations for the underdeveloped world can be transferred to a developed country like Australia. In Australia, unlike Africa, HIV-AIDS is not a heterosexual epidemic, but a relatively rare disease confined to specific sub-cultures – homosexual men and injecting drug users. It is well established that these groups can derive no protection from circumcision at all. In any case, because it is a disease of promiscuous adults, children are not at any risk of infection – unless, of course, by surgery. When they become sexually active boys are old enough to understand the issues and make their own decisions about how to manage the risks of sexual activity with others. The Australian Federation of AIDS Organisations has stated that circumcision has no relevance to Australia’s HIV problem, and their conclusion has been endorsed by a paper in the Australian and New Zealand Journal of Public Health, which argues that circumcision is not a surgical vaccine and is not appropriate as an HIV control tactic in developed countries such as Australia. 2. International practice Australia is the only country in the world that provides automatic coverage of circumcision through the health budget. This policy is despite the fact that most State governments (Victoria, Western Australia, Tasmania, New South Wales and South Australia) do not provide free coverage of circumcision in public hospitals, and it is in sharp contrast with the practice of comparable developed nations. <ul> <li>In Britain the National Health Service has never included routine circumcision among its free procedures, and covers it only as a therapeutic procedure in cases of medical necessity. The same is true of New Zealand.</li> </ul> <ul> <li>In Canada, where medical insurance is the responsibility of the provinces, the only province to include circumcision in its cover is Manitoba; and even there doctors refuse to charge the state but bill the parents.</li> </ul> <ul> <li>In the United States, the federal government provides the funds for public health insurance to the states, which make their own decisions as to which services they cover. When the program was introduced in 1965 all states covered circumcision, but since then 18 of the 50 states have ceased to fund it, and more are likely to do so as budgetary constraints intensify.</li> </ul> Circumcision is not funded by the governments of Israel, Turkey, Indonesia, Iran or any other predominantly Islamic country where the procedure is widely practised as a cultural/religious ritual, not even when the operation is performed in hospitals rather than (as is traditional) in the boy’s home. The Dutch national health insurance service withdrew coverage of non-therapeutic circumcision in 2004 when it was realised that 90 per cent of the procedures were done for religious/cultural rather than for health-related reasons. 3. Ethics and human rights For a surgical intervention to be ethically acceptable (and indeed legal) the fundamental requirement is that the person must give informed consent. An adult male can consent to having himself circumcised (it’s his choice), but the question becomes difficult when parents wish to circumcise their children because minors can no more consent to surgery than to sexual relations with adults. Circumcision of children thus deprives them of choice and amounts to coercion. The problem is especially relevant to Medicare, since the vast majority of the circumcision procedures that it covers involve children. In FY 2010-11, of 25,842 circumcision procedures funded by Medicare, 22,491 (88%) were on boys aged under 10 years, and of these 18,503 (71% of the total) were aged less than 6 months. Very few of these operations could be regarded as therapeutic or clinically necessary. An additional 2641 procedures were on males aged 10 years or more, but Medicare provides no breakdown as to how many of these are adults and how many are still minors, though it is clear enough that very few adult males elect to have themselves circumcised. Surrogate consent for surgery on minors is valid only for life-saving medical treatment, or where the procedure is manifestly in the best interests of the child and passes the imputed judgement test – that is, it is an operation the child would choose for himself if he were a competent adult. It has been strongly argued that, in the absence of a life-threatening disorder, surrogate consent for non-therapeutic surgery such as circumcision is ethically problematic and may not be legally valid. When there is no urgency to intervene, it is best to wait until the child can make his own choice. In addition to informed consent, leading bioethicists propose five conditions that must be met in order for a medical procedure to be ethically permissible. Beneficence — Does the proposed procedure provide a net therapeutic benefit to the patient, considering the risk, pain, and loss of normal function? Non-maleficence — Does the procedure avoid permanently diminishing the patient in any way that could be avoided? Proportionality — Will the final result provide a significant net benefit to the patient in proportion to the risk undertaken and the losses sustained? Justice — Will the patient be treated as fairly as we would all wish to be treated? Autonomy — Lacking life-threatening urgency, will the procedure honour the patient’s right to his or her own likely choice? Could it wait for the patient’s assent? Non-therapeutic circumcision of minors fails all these tests. It is not beneficent because it does not provide a therapeutic benefit (nor even a relevant prophylactic benefit, since a child is at zero risk of sexually transmitted infections ). It is malefic because it diminishes the genitals. It is disproportional because the net gain (if any) is out of proportion to the loss, harm and risk of complications. It is unjust because adult preferences show clearly that if he had a choice in the matter the boy would refuse the operation. Finally, circumcision fails to respect the boy’s autonomy and preserve his future options as an adult individual. The British Medical Association and the Royal Dutch Medical Association have issued particularly strong warnings that non-therapeutic circumcision of minors is likely to breach accepted principles of bioethics and potentially of the law. In its policy statement (May 2010) the latter states: “Non-therapeutic circumcision of male minors is contrary to the rule that minors may only be exposed to medical treatments if illness or abnormalities are present, or if it can be convincingly demonstrated that the medical intervention is in the interest of the child, as in the case of vaccinations”; and further that such interventions violate “the child’s right to autonomy and physical integrity.” The RACP agrees: “The option of leaving circumcision until later, when the boy is old enough to make a decision for himself does need to be raised with parents and considered. … The ethical merit of this option is that it seeks to respect the child’s physical integrity, and capacity for autonomy by leaving the options open for him to make his own autonomous choice in the future.” International instruments are also relevant. Article 8 of the UNESCO Declaration on Human Rights and Bioethics (2005) states that “In applying and advancing scientific knowledge, medical practice and associated technologies, human vulnerability should be taken into account. Individuals and groups of special vulnerability should be protected and the personal integrity of such individuals respected.” Children certainly fall into this category. Given the government’s commitment to enhancing Australia’s commitment to individual human rights, it is highly anomalous that it allows Medicare to subsidise and thus encourage a disfiguring operation that denies them to so many children. 4. Gender equity Australia’s obligations under the Sex Discrimination Act 1984 and as a signatory to the United Nations Convention on the Rights of the Child require the national and State governments to treat males and females equally and without discrimination on the basis of sex, and to take action to eradicate traditional practices harmful to children. Article 24 (3) of the Convention requires parties to take “all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children.” In pursuance of this development several States passed laws to prohibit any form of female circumcision, and in 1995 the Commonwealth specifically excluded such procedures from the Medical Benefits Schedule. Although there was nothing in the wording of the Convention to suggest that it did not include male children, no action has yet been taken to protect boys. This failure is increasingly recognized, in Ranipal Narulla’s words, as “a hidden human rights violation”. The Commonwealth Sex Discrimination Act, Section 3 (b), states that the Act applies to the administration of Commonwealth laws and programs, while Section 22 (b) makes it illegal to discriminate on the basis of sex in the provision of goods, services and facilities. It could be argued that the exclusion of female circumcision from the MBS is a breach of this provision, since it denies to women a benefit given to men; whether or not circumcision is regarded as a benefit or a deprivation, it is certainly anomalous and inconsistent that the MBS specifically denies coverage for cutting procedures on the female genitals while providing a no-questions-asked rebate for comparable procedures on the genitals of boys. The situation is doubly discriminatory in that girls are denied a "benefit" that is given to boys, while boys are denied a protection from harm that is enjoyed by girls. The simplest way to remove such discrimination and restore the principle of equal treatment is to limit coverage of male circumcision to cases of proven medical necessity. 5. Economy and financial prudence All government welfare programs should be targeted at genuine need and be administered with prudence and economy. An open-slather approach to funding a medically unnecessary procedure is wasteful and invites over-servicing. It also acts as a signal that circumcision is a socially acceptable and even medically recommended operation, thus encouraging more parents to seek to have it done. Assuming 15,000 unnecessary circumcision procedures per year at a cost of between $100 and $1600 each, Katrina Spilsbury and colleagues have estimated that the removal of medically unnecessary circumcision from the MBS would save between $1.5 million and $24 million per year. They state that “the potential savings to the public purse would be considerable if elective and discretionary circumcision was removed from the Medicare schedule in line with other cosmetic surgeries, leaving rebates for the genuine medically indicated circumcision.” According to figures available on the Medicare website, the total cost of the rebate for all circumcision procedures in FY 2010-11 was $1,577,754, nearly half of which went to subsidise operations on infants less than 6 months old, almost none of whom could have had a genuine medical indication. This is not a large sum in the overall budget context, but the real cost to the government will be considerably higher, given that this figure does not include the cost of treating complications and long-term adverse effects, which may not become apparent until adolescence. A cost-utility analysis of neonatal circumcision by American researcher Robert Van Howe found that even if the extreme claims of circumcision advocates were true, the associated complications and adverse outcomes would cancel out and exceed the benefit to health by a considerable margin. On top of this there may be losses to revenue arising from tax rebates that parents are able to claim under the Medicare safety net for expenses related to child-bearing. These are not substantial sums in the context of today’s billion-dollar budgets, but when every effort is being made to rein in public expenditure, especially the ever-expanding health budget, every million saved can help to make a difference. Not only this: given the irresponsible media commentary on the role of circumcision in HIV control and the efforts of scaremongering evangelists and entrepreneurial circumcision practitioners to generate a mood of panic, the demand for circumcision could increase if parents are misled by their propaganda and become fearful of the alleged risks of not getting it done. It is thus possible that the cost of the circumcision subsidy will increase unless entitlement is restricted. Removal of non-therapeutic circumcision from the MBS will send a clear signal to Australian parents that routine circumcision is not a medically recommended procedure and is not necessary for the health and well-being of their child. Parental right to circumcise for religious reasons not affected The main argument for dropping non-therapeutic circumcision from the MBS is not the cost-saving, but the principles of prudent and targeted assistance to those in need; of adherence to stated entitlement guidelines and lawful program administration; of respecting current expert medical advice; of observing accepted principles of ethics and human rights; and of avoiding discrimination on the basis of sex. Allowing Medicare to provide a rebate for non-therapeutic circumcision sends the wrong signals to parents, suggesting that it is a socially and medically approved procedure, and thereby encouraging the practice. There is nothing in this proposal that will limit the right of parents to circumcise their children if they feel they have a compelling cultural or religious reason, merely that they will not receive a public subsidy for doing so. There is no intent to restrict the right of Jewish, Aboriginal or Muslim parents to circumcise their children in accordance with their respective traditions; but equally there is no reason why such rites and practices should be funded by the Australian taxpayer through the health budget. <h3>The Hawke government’s thwarted attempt to drop circumcision from the MBS in 1985</h3> It is true that when the Hawke government dropped circumcision from the MBS in 1985 it faced protests from Jewish community leaders and soon backed down, leading to the development of the myth that there was a “community backlash” and discouraging further attempts. This myth has been disproved in a detailed study of the incident by Dr Robert Darby, published in Hygiea, an international journal for the history of public health. His conclusions are that the decision was justified on medical and public policy grounds; that there was no wide public outcry and, indeed, that the decision was widely approved; and that the rapid reversal of the decision was the result of inept implementation, failure to consult, and a fortuitous combination of subsequent factors, including, vigorous lobbying by the groups who felt most deeply affected. The main objection of Jewish community leaders was not to the dropping of the rebate in itself, but the fact that it was dropped only from the code for circumcision of boys under 6 months, leaving the rebate in place for operations at later ages. Since Jewish people traditionally circumcise at 8 days, they justifiably felt that this was unreasonable discrimination. It is not clear why the government, rather than abjectly restoring the rebate, did not resolve the problem by requiring a medical indication at all ages, as would have been the simplest, most economical and most equitable course of action. The government now has the opportunity to rectify this mistake. If a proven medical requirement is attached to each of the codes for circumcision, there is no reason why the sensibilities of the Moslem and Jewish communities should be affronted, since the new rules would apply to everybody in the community, without discrimination. <h3>Conclusion</h3> There is no reason why Medicare, and thus the Australian taxpayer, should continue to fund operations that medical authorities have defined as unnecessary and potentially harmful, and which many people regard as an violation of the rights of the child, or even genital mutilation. The government must face up to its responsibilities, bite the bullet, rectify the mistakes it made in 1985, and delete non-therapeutic circumcision from the Medical Benefits Schedule. <h3>Appendix: Relevant MBS codes and payments (as at 1 January 2012)</h3> 30653: Circumcision of a male under 6 months of age Scheduled fee: $45.65; Benefit: $34.25 (75%); $38.85 (85%) 30656: Circumcision of a male under 10 years of age but not less than 6 months of age Scheduled fee: $106.15; Benefit: $79.65 (75%); $90.25 (85%) 30659: Circumcision of a male 10 years of age or over by a GP Scheduled fee: $146.95; Benefit $110.25 (75%); $124.95 (85%) 30660: Circumcision of a male 10 years of age or over by a specialist Scheduled fee: $182.15; Benefit $136.65 (75%); $154.85 (85%) 30663: Haemorrhage, arrest of, following circumcision requiring general anaesthesia Scheduled fee: $141.65; Benefit $106.25 (75%); $120.45 (85%) Until 1995 these codes were unisex and read “circumcision of a person”, thus authorising a benefit for circumcision of females as well as of males. In order to protect girls from genital mutilation as part of the general development of laws and policies against FGM that followed the passage of the UN Convention on the Rights of the Child, “person” was changed to “male”, thus introducing two elements of discrimination: females were denied a service that remained available to males; but males were denied the protection that was accorded to females. The deletion of non-therapeutic circumcision from the schedule can be effected by simply by adding the phrase “where medically indicated” to each of the codes above. “Medically indicated” means a case where (1) there is a medical problem that has not responded to conservative (non-surgical) treatment after reasonable efforts; and (2) this is certified by two qualified medical practitioners, one of whom must be an appropriate specialist, and neither of whom may be the surgeon or other operator who is to perform the surgery. <h3>Selected references</h3> Adler, Peter. “Is it lawful to use Medicaid to pay for circumcision?” Journal of Law and Medicine, Vol. 19, December 2011: 335-353. Australian Safety and Efficacy Registry of New Interventional Procedures – Surgical. Report No. 65: Male non-therapeutic circumcision. Adelaide: Royal Australasian College of Surgeons, 2008. Australian Federation of AIDS Organisations. Male circumcision has no role in the Australian HIV epidemic. Briefing paper, 23 July 2007. Beauchamp TL, Childress JF. Principles of Biomedical Ethics (6th edn). Oxford University Press: 2009. British Medical Association, The Law and Ethics of Male Circumcision: Guidance for Doctors (November 2007). Available at http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp Darby, Robert. “Infant circumcision in Australia: A preliminary estimate, 2000-2010”. Australian and New Zealand Journal of Public Health, Vol. 35, August 2011 Darby, Robert and Robert Van Howe. “Not a surgical vaccine: There is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia.” Australian And New Zealand Journal of Public Health, Vol. 35, October 2011: 459-465. Available at http://onlinelibrary.wiley.com/doi/10.1111/j.1753-6405.2011.00761.x/full Darby, Robert. “Scientific advice, traditional practices and the politics of health-care: The Australian debate over public funding of non-therapeutic circumcision, 1985.” Hygiea Internationalis: An Interdisciplinary Journal for the History of Public Health, Vol. 10, December 2011. Available at http://www.ep.liu.se/ej/hygiea/ Forbes, David. “No evidence to support routine circumcision.” Sydney Morning Herald, 12 September 2009. On-line at: http://www.smh.com.au/national/letters/no-evidence-to-support-routine-circumcision-20090911-fkna.html Malone, Padraig and Henrik Steinbrecher. “Medical aspects of male circumcision.” British Medical Journal 335 (8 December 2007): 1206-1209. Narulla, Ranipal. “Circumscribing circumcision: Traversing the moral and legal ground around a hidden human rights violation”. Australian Journal of Human Rights, Vol. 12, 2007, 89-118 Royal Australasian College of Physicians. Circumcision of Infant Males [Policy statement]. Sydney: October 2010. Available at http://www.racp.edu.au/page/policy-and-advocacy/paediatrics-and-child-health Royal Dutch Medical Association. Non-therapeutic Circumcision of Male Minors (May 2010). Available at http://knmg.artsennet.nl/Diensten/knmgpublicaties/KNMGpublicatie/Nontherapeutic-circumcision-of-male-minors-2010.htm Spilsbury K, Semmons JB, Wisniewski ZS, Holman CD. “Routine circumcision practice in Western Australia 1981–1999”. ANZ Journal of Surgery 2003;73(8):610-4. Available at http://www.cirp.org/library/procedure/spilsbury1/ Svoboda JS, Van Howe RS, Dwyer JG. “Informed consent for neonatal circumcision: An ethical and legal conundrum.” Journal of Contemporary Health Law and Policy 2000;17:61-133. Available at http://www.cirp.org/library/legal/conundrum/ Van Howe RS. “A cost-utility analysis of neonatal circumcision.” Medical Decision Making 2004;24:584-601. Available at http://www.cirp.org/library/procedure/vanhowe2004/ <h2> <a id="colorado" name="colorado"></a>A comparable case in Colorado</h2> In the United States of America, where even the most minor local issues tends to be politicised, insurance coverage of non-therapeutic circumcision tends to become a political football. Last year Colorado dropped payments for circumcision from Medicaid (the USA equivalent of Medicare), but this year politicians in the state legislature who had been misled by the usual scaremongering propaganda put out by the usual suspects tried to restore it. Their arguments - for example, that the foreskin caused spina bifida, or that circumcision was good because it deadened the penis and discouraged teenage sexual activity - demonstrate why politicians should not get involved in these questions unless they have done some research.** Colorado drops circumcision from Medicaid A bill that would have restored Medicaid funding for circumcisions in Colorado died Friday. The measure squeaked through a hearing in the House Health and Environment Committee on Thursday, then died in Appropriations Friday morning. Opponents, who included health professionals, budget hawks and anti-circumcision activists told health committee members on Thursday that circumcision is cosmetic and potentially harmful, and taxpayers should not fund it. Proponents for the bill argued that funding for circumcision for babies on Medicaid is a social justice issue. In general, insurance companies pay for the procedure for insured Colorado babies even though the American Academy of Pediatrics does not deem circumcisions to be “medically necessary.” Meanwhile, low-income parents who want their babies circumcised are being put on waiting lists for the procedure until parents can prove they’ve paid in advance. Sen. Irene Aguilar, D-Denver, an internal medicine doctor for Denver Health, testified on behalf of restoring public funding for circumcision. Last year, Colorado lawmakers decided to save money and cut funding for Medicaid circumcisions. They were following the lead of 17 other states. Proponents wanted taxpayers to once again pay for the procedures for parents who choose to have their infants circumcised. Fiscal analysts estimated that covering the procedures again would cost the state about $195,000 next year and $230,000 the year after that. “As a physician, I don’t try to influence parents one way or the other,” Aguilar said. “People make this decision based on religious and cultural reasons.” She said that there is some evidence that infant boys who don’t get circumcised have higher rates of urinary tract infections and that adult men who are uncircumcised and live in poverty tend to have increased rates of HPV, which can lead to higher rates of cervical cancer in female partners. [What business does a medical doctor have performing unnecessary surgery based on religious or cultural reasons?] Only one other doctor testified on behalf of circumcision. The rest of the witnesses opposed public funding for the procedure for a variety of reasons. They included Dr. Jennifer Johnson, a family physician who works with Medicaid and uninsured patients at Clinica Family Health Services. “I’ve done at least 100 circumcisions and just recently decided to stop,” Johnson testified. She said she and her husband, who is Jewish, decided not to circumcise their own son, who is now 4. She said she was concerned when she researched the issue and found that removing the foreskin from a boy’s penis damages numerous nerve endings. While circumcision is traditional in the Jewish community, Johnson said her husband was open to new research about the potential harms from circumcision. If boys or men decide to remove the foreskin as adults, then they can make that decision, Johnson said. But she decided that as a physician, she should no longer do a procedure that is potentially harmful. “This is not a necessary procedure,” Johnson said. “It’s a healthy, normal body part. There are a lot of medical needs in our population. We have no business using limited health care dollars on a medically unnecessary cosmetic procedure.” One lawmaker, Rep. Sue Schafer, D-Wheat Ridge, elicited laughter in the hearing room when she asked Dr. Johnson if circumcision might help reduce teen pregnancy rates and teen sexual activity by reducing nerve sensation in boys’ penises. “I’m wondering if there’s a risk of more sexual activity, more male irresponsibility” for uncircumcised boys, Schafer asked. Johnson answered that teen pregnancy is certainly a problem, but said circumcision won’t halt teen sexual activity. “Circumcision is not a cure for behavior. That’s about education,” she said. While circumcision is an ancient tradition in some religions, circumcision opponents said it became popular in the U.S. as a method to prevent masturbation among boys. Later, fathers wanted their sons to look like them. “Frankly that’s cosmetic surgery…and I strongly urge you to vote against it,” said Dr. Matt Mason, a physician from Telluride. He was skeptical about cost estimates and said circumcision is now rare in Western Europe, Canada and New Zealand. [He might have added Australia; circumcision has always been rare to vanishing point in all Europe, not just the west.] Source: Katie Kerwin McCrimmon, <a href="http://www.healthpolicysolutions.org/?s=circumcision+colorado&x=0&y=0">Circumcision bill dies in Colorado House, Health Policy Solutions</a>, 5 May 2012 ** Take the example of a local senator, who claimed in an email to constituents that “Reliable studies prove that male circumcision reduces instances of infectious disease, some congenital obstructive urinary tract anomalies, neurogenic bladder, spina bifida and urinary tract infections.” He continued to dispense this fiction despite having been challenged previously by a competent physician, Dr. Mat Masem, who stated, “There are rare therapeutic indications for male circumcision, which generally relate to pathologic conditions of the foreskin. However, a number of the conditions you mentioned as being positively affected by circumcision have absolutely nothing to do with the foreskin. Spina bifida is an anomaly of the spine; congenital obstructive urinary tract anomalies are related to urethral strictures or other abnormalities of the urinary tract; and neurogenic bladder is a neurological condition. ” Source: Jere DeBacker, <a href="http://www.healthpolicysolutions.org/2012/05/01/opinion-lawmakers-clueless-about-circumcision-research">Opinion: Lawmakers clueless about circumcision research</a>, Health Policy Solutions, 1 May 2012. Social disadvantage vs anatomical/physiological disadvantage As for the argument that Medicaid/Medicare should cover circumcision because otherwise poor people cannot afford it (“Circumcision a health right of the poor”, as Brian Morris and Jake Waskett have claimed) - surely it’s bad enough to be poor. Why should poor people be deprived of their foreskins as well? That is merely adding injury to insult. <h2> <a id="hawke" name="hawke"></a>4. The Hawke government's unsuccessful attempt to drop circumcision from the MBS</h2> Robert Darby, Scientific Advice, Traditional Practices and the Politics of Health-Care: The Australian Debate over Public Funding of Non-Therapeutic Circumcision, 1985. <a href="http://www.ep.liu.se/ej/hygiea/" rel="noopener" target="_blank">Hygiea Internationalis: An Interdisciplinary Journal for the History of Public Health</a>, Vol. 10, December 2011. ABSTRACT In 1985 the Australian Government sought to delete circumcision of infants from the benefits payable under its newly established universal health scheme, Medicare. Although the decision had been recommended by the government’s health advisers and was welcomed by medical authorities, it was soon reversed after protests from Jewish community leaders. I present a detailed narrative of this affair and explain why a decision based on sound medical knowledge advice was rescinded after quite mild objections. The answer is found to lie partly in contingent factors, such as the details of the policy change, the personalities of the government figures involved, and problems with implementation and communication; and partly in the sensibilities of the ethnic/religious communities most directly affected. I dispel the misconception that the original decision aroused widespread opposition and show, on the contrary, that it was based on good advice, represented sound public policy, and was widely supported. I conclude that the episode may have useful lessons for other governments seeking to implement or resist policy changes that affect the sensitivities of cultural minorities. <a href="https://independent.academia.edu/RobertDarby" rel="noopener" target="_blank">Available at Robert Darby's Academia.edu page</a> <h2> <a id="smh" name="smh"></a>5. Sydney Morning Herald, The Question - Should elective circumcision continue to be covered by Medicare?</h2> <h3>Medicare should not cover non-therapeutic circumcision</h3> (a) Medical historian, Dr Robert Darby The Australian government is under pressure to balance budgets, give more recognition to individual human rights, promote gender equity and protect children from harm. One simple way to make progress on all these fronts is to drop non-therapeutic circumcision from the Medical Benefits Schedule. Medicare currently provides a no-questions-asked rebate for circumcision, despite the fact that most of these operations have no medical indication, and in defiance of Medicare’s own guidelines. These state that benefits are not payable for “medical services which are not clinically necessary”, nor “surgery for cosmetic reasons”. A medical procedure is clinically necessary only if it is essential to correct a diagnosed disease, injury, deformity or other pathological condition. Surgery for cultural or social reasons is essentially cosmetic surgery, intended to alter the appearance of the body. According to the Royal Australasian College of Surgeons, “male non-therapeutic circumcision is not clinically necessary as it does not treat an underlying pathological process.” Medicare should not, therefore, cover such procedures. There are five further reasons. 1. No health case for routine circumcision. All the medical authorities that have issued policies on routine circumcision have rejected the operation as unwarranted and potentially harmful, most recently the Royal Australasian College of Physicians in a lengthy statement of October 2010. 2. Consistency with international practice. Australia is the only country in the world that provides an automatic rebate for medically unnecessary circumcision. Even in the United States, 18 states have dropped circumcision from the list of benefits, and more are considering the question. 3. Ethics and human rights. The vast majority of circumcision procedures funded by Medicare are on infants and other minors, few of whom present any pathology requiring surgery. Since minors cannot give consent and may prefer to keep their foreskins, payments for such operations are questionable from a bioethical and human rights perspective, and may even be unlawful. 4. Avoiding sex discrimination. Girls are legally protected from any mutilation of their genitals; the least we can do for boys is not provide a public subsidy for needlessly modifying theirs. 5. Economy and financial prudence. Government welfare programs should be targeted at genuine need and be administered with prudence and economy. An open-slather approach to funding a medically unnecessary procedure is wasteful and invites over-servicing. For reasons of consistent public policy, financial prudence and respect for established principles of bioethics and gender equity, the rebate for circumcision should be abolished except for cases of proven medical need. NOTE: This is the original text of Robert Darby’s contribution to the <a href="http://www.smh.com.au/opinion/the-question/should-elective-circumcision-continue-to-be-covered-by-medicare-20120511-1yhqb.html">Question of the Week, Sydney Morning Herald, Saturday 12 May 2012</a>. The text as published was slightly edited. Dr Darby is an independent scholar who has written extensively on the history and ethics of male and female circumcision. His publications include A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain (University of Chicago Press, 2005) and, most recently, “Scientific advice, traditional practices and the politics of health-care: The Australian debate over public funding of non-therapeutic circumcision, 1985.” Hygiea Internationalis: An Interdisciplinary Journal for the History of Public Health, Vol. 10, December 2011. Available at http://www.ep.liu.se/ej/hygiea/ (b) Urologist Dr Stan Wisniewski Male circumcision is performed for religious, medical and social reasons. Religious circumcision is performed outside the ambit of the public health purse and is cost neutral, as long as no complications occur. Advocates of universal circumcision in newborn infants believe the procedure is a prophylaxis against future disease and that the phallus looks better and somehow functions better. Circumcision for infection, poor skin retraction or neoplastic changes is required in 5 to 10 per cent of males in the West. This means more than 90 per cent would not need the procedure in their lifetime. Infections in the foreskin or urinary tract are rare in infancy. The foreskin becomes retractile between 5-10 years of age and teaching hygiene should be intrinsic to healthcare. Contraction and transmission of sexually contracted diseases cannot be prevented by circumcision. The argument that AIDS is not transmitted by circumcised males is not factual. Penile skin cancer is rare and seen in situations of neglect and poor hygiene. One would need to perform 100,000 circumcisions to prevent one case of penile cancer. The idea that circumcision improves virility or sexual prowess is not scientifically validated. The foreskin has many sensory receptors important for sensual pleasure, and the mechanics of intercourse change when foreskin mobility is removed. The reason for performing surgery on neonates is a matter of expediency rather than scientific dictum. The operation is often performed without appropriate analgesia and screams and wriggling are ignored. Studies show many boys carry psychological scars afterwards, leaving them agitated and irritable for long periods, sometimes into adulthood. Physical consequences such as excessive skin removal, penile shortening, disfigurement and complications with bleeding and death are all reported. Many circumcised men express anger at parents for their decisions which they now regret, to the point of parents being sued. This is not a benign procedure free of problems. Rates of neonatal circumcision in educated, sophisticated societies continue to fall. A Medicare rebate for prophylactic neonatal circumcision would allow crusaders to continue to perpetuate a practice that is not substantiated. Nature, honed by millennia of evolution, decrees the foreskin is part of the perfection of humans. Until the time that other changes transmute, why do we think we can do better? Dr Stan Wisniewski is past president of the Urological Society of Australia & New Zealand. Source: <a href="http://www.smh.com.au/opinion/the-question/should-elective-circumcision-continue-to-be-covered-by-medicare-20120511-1yhqb.html">Should elective circumcision continue to be covered by Medicare</a>, Sydney Morning Herald, 12 May 2012 <h2> <a id="anu" name="anu"></a>6. ANU law student writes on why Medicare should not continue to pay for non-therapeutic circumcision</h2> The following paper was written in 2009 by a third year Law student at the Australian National University, as an assignment for a medical law and ethics unit. The author wishes to remain anonymous. It’s time for Medicare Australia to stop providing rebates for infant male circumcision ABSTRACT Infant male circumcision is a controversial procedure that has been debated for years. The overwhelming body of Australian medical opinion is firmly against the procedure and clearly classes it as non-therapeutic, yet the procedure is still covered by Medicare, despite their own guidelines stating they do not cover non-therapeutic procedures. This means the Australian government is indirectly authorising a non-recommended procedure. With the medical opinion firm, and in light of recent debates about the ethics and legality of male circumcision, now is the time for Medicare to stop covering this procedure. * * * * * * For years the potential benefits, disadvantages and ethical issues surrounding male infant circumcision have been debated in Australia and overseas. While male infant circumcision used to be common, even routine, in Western nations including Australia, it has dropped significantly in popularity as doctors and parents have become aware that it is not medically necessary or even recommended. Currently, it is estimated that around 10% of newborn baby boys are circumcised in Australia each year, at parental choice. As Medicare provides a rebate for circumcision of a boy under 6 months old, this unnecessary procedure costs Medicare, and therefore the Australian taxpayers, roughly $2 million each year. This is despite Medicare’s own statements that they do not provide rebates for clinically unnecessary procedures. Recent policies, reviews and cases relating to the medical, ethical and legal aspects of infant circumcision – such as the Tasmanian Law Reform Institute review, the Royal Australian College of Physicians new policy statement, and a case from the Oregon Supreme Court – highlight the importance of there being a swift policy change in Australia so that Medicare and the Australian Government come in line with current medical opinion and no longer indirectly endorse a non-therapeutic, non-recommended procedure fraught with legal and ethical uncertainties. <a href="https://www.circinfo.org/documents/Natasha-Medicare.pdf">To read full text, download document as PDF here</a> <h1>Lack of progress on Medicare reform attracts criticism</h1> Despite a series of reviews over the past few years aimed at containing costs and simplifying the system, there have been no significant changes to Medicare coverage of circumcision. The only changes have been to reduce the number codes (from four to two) and to make them unisex. This had had the unfortunate effect of making it impossible to calculate the number of circumcision procedures by age (thus obscuring the fact that the vast majority are of infants and young boys) and allowing circumcision of girls, as <a href="https://www.circinfo.org/Medicare_Coverage_Female_Circumcision.html" rel="noopener" target="_blank">previously documented on this site</a>. The latest report from one of the working groups, the Urology Clinical Committee, has proposed no changes to the circumcision codes at all, except for the requirement for analgesia (pain control). This is a desirable reform, but a less important issue than the fact that Medicare will continue to fund non-therapeutic (medically unnecessary) circumcision, including circumcision desired for religious, cultural and other social/cosmetic reasons. This is contrary to the provisions of the Health Insurance Act and the Medicare guidelines, which state clearly that benefits are payable only for “clinically relevant” services – i.e. procedures for which there is a demonstrated medical need. <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mbs-review-2018-taskforce-reports-cp/%24File/v2%20-%20Urology%20Clinical%20Committee%20-%20Report.pdf" rel="noopener" target="_blank">The Committee report is available here</a>; the section relating to circumcision are on pages 68-70. <h2>Medicare should not pay for non-therapeutic circumcision</h2> For some years the Commonwealth Government has been concerned at the ever-rising costs of the ever-expanding health budget, particularly the cost of Medicare. In 2015 it resolved to establish a reform process, the aim of which was to simplify the system and reduce costs by eliminating services of low medical value. Non-therapeutic circumcision was identified as an example of such a low-value service, giving rise to the expectation that it would be dropped from the Medicare Benefits Schedule. This has not happened. In the first round of reforms all that happened is that the codes for circumcision were reduce from four (distinguished by age) to two (distinguished by type of anaesthesia) – thus making it impossible to determine how many infants and boys were being circumcised. In addition, the codes were made gender-neutral, allowing them to be used for circumcision of females – as is apparently happening. In a further round of reforms the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/MBSR-consult-2018-taskforce-reports" rel="noopener" target="_blank">Urology Clinical Committee</a> tackled the circumcision codes and managed to produce a very small mouse. Of nearly 6000 items on the MBS, it managed to eliminate 18, of which circumcision was not one. The Committee’s sole recommendation was to require analgesia (pain control) for circumcision procedures, “thus ensuring patient wellbeing.” This is certainly a welcome move in the right direction, but it is not the main issue. More significantly, the Committee made no attempt to limit the availability of the circumcision rebate; on the contrary, it accepted the prevailing situation in which it is readily available for procedures carried out for religious or cultural reasons: The Committee noted that item 30654 should continue to include circumcisions conducted for religious and cultural reasons, reflecting both current practice and the need to ensure safe circumcisions. While this does not appear to be a formal recommendation, it presumably has the force of one. It is difficult to see how subsidising religious or cultural practices could be a legitimate use of the health budget, particularly as the Health Insurance Act and the Medicare guidelines state clearly that the rebate is available only for “clinically relevant” services – i.e. medical treatment that is actually needed for medical reasons. The policy is certainly in contradiction to the fundamental objective of the reform process: to rein in and control costs. The stated objectives of the reviews were to achieve: <ul> <li>Affordable and universal access</li> <li>Best-practice health service</li> <li>Value for the individual patient</li> <li>Value for the health system</li> </ul> An open-ended subsidy (essentially a blank cheque) for procedures of zero clinical relevance makes no contribution to achieving these objectives, and is in fact in complete contradiction to them, especially the last. Examining the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mbs-review-2018-taskforce-reports-cp/%24File/v2%20-%20Urology%20Clinical%20Committee%20-%20Report.pdf" rel="noopener" target="_blank">Urology Clinical Committee’s recommendations and observations on circumcision</a> in more detail, it is possible to raise six major objections to them, as set out below. Further information on this site <a href="https://www.circinfo.org/Medicare_circumcision_review.html" rel="noopener" target="_blank">Medicare Circumcision Review details</a> <a href="https://www.circinfo.org/Medicare_coverage_for_circumcision.html" rel="noopener" target="_blank">Medicare coverage of non-therapeutic circumcision criticised in submission</a> <a href="https://www.circinfo.org/Medicare_Coverage_Female_Circumcision.html" rel="noopener" target="_blank">Medicare coverage of female circumcision?</a> <h2>Medicare Benefits Schedule Review: Report of the Urology Clinical Committee</h2> <h3>A rational critique</h3> This response is directed at the recommendations relating to circumcision, at pages 68-70. 5.5.1 Recommendation 14 Amend the item descriptor to mandate the use of analgesia for this procedure. 5.5.2. Rationale for Recommendation 14 The item descriptor has been amended to mandate the use of analgesia, which ensures patient wellbeing. Comment While this is a progressive and desirable reform, it should be noted that analgesia does not necessarily “ensure patient wellbeing”, only that he is given a painless operation. The Committee noted that item 30654 should continue to include circumcisions conducted for religious and cultural reasons, reflecting both current practice and the need to ensure safe circumcisions. Comments 1. This proposal is regressive and inappropriate in that it is essentially offering a blank cheque to all parents who desire to have their boys circumcised, whatever their reason, as well as to those rare individuals who desire circumcision for themselves. The specification “religious and cultural” is meaningless and ineffective in the absence of a verification mechanism by which the religious/cultural credentials of the parents can be checked. Such a system is not proposed, and it would be complex to administer, and expensive even if the obvious difficulties could be overcome. In effect, the Committee has legitimised the existing open slather by which any individual who desires circumcision for himself or any parent who wishes to get a boy circumcised for any reason can require the public purse to meet part of the cost. Considering that the original objective of the various Medicare reviews was to rein in costs by eliminating procedures of low medical value, this seems highly counter-productive. 2. The argument about past practice is feeble and unacceptable. Merely because a certain policy has been followed in the past does not mean that it is desirable in or appropriate to current conditions; past practice is not best practice. The objective of reform exercises is to eliminate bad policies and replace them with good policies. Historical longevity is no basis for approving any practice in the contemporary world. As a matter of historical record, the government attempted to remove circumcision from the MBS in 1985, suggesting that in its original conception, Medicare was not intended to cover non-therapeutic circumcision at all. [1] 3. Related to (2), it is likely that payments for religious/cultural circumcision under Medicare are unlawful because the relevant act and associated guidelines provide that benefits are payable only for clinically needed procedures. As Michael Ryan, Assistant Secretary, MBS Policy and Specialist Services Branch, Department of Health, explains to Mr Peter Khalil MP (letter dated 6 November 2017, copy held by author): “The Medicare Benefits Schedule (MBS) provides benefits (or rebates) for a range of professional medical services, including circumcision. The Health Insurance Act 1973 stipulates that Medicare benefits are only payable for clinically relevant services provided by health practitioners. A clinically relevant service is one that is generally accepted by the relevant profession as necessary for the appropriate treatment of the patient. “On 1 November 2016 the MBS items for circumcision were restructured from four items to two items to separate them by the type of anaesthesia used, rather than by patient age. However, there have been no changes to the legal requirement that services must be clinically relevant, and there are no benefits available for non-therapeutic procedures.” In its current policy statement on circumcision the Royal Australasian College of Physicians concluded: “After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.” That being the case, non-therapeutic circumcision (including circumcision procedures desired for religious/cultural reasons), must be regarded as clinically not-relevant, and hence ineligible for a Medicare rebate. 4. The argument about the need to avoid the risk of additional harms or complications that might arise if needy parents (those who claim to be unable to meet the full cost) would resort to less expensive unqualified operators (as in the backyard abortions and kitchen-table surgery of infamous memory) fails for 2 reasons. First, the argument about avoiding the risk of additional harm is not a reply to the proposal that parents etc should meet the full costs of medically unnecessary procedures, but to the proposition that such procedures should be legally prohibited. The Royal Dutch Medical Association, which would like to see non-therapeutic circumcision of minors banned, raised this point as the only consideration which deterred the from making such a recommendation in their 2010 circumcision policy statement. [2] But the current proposal is not that circumcision should be prohibited or restricted in any way at all, merely that individuals or parents who desire a medically unnecessary circumcision should meet the full costs. The mere fact that the procedure is covered by Medicare does not guarantee “safe circumcisions”. Complications and “botches” are still common in clinical settings, and at the hands of fully credentialed operators, often requiring expensive surgical repairs and sudden appearances in hospital emergency departments. [3] Ensuring patient safety is not the task of the MBS, but of the medical regulatory authorities. Further evidence for this point is provided by the two Medicare items for “arrest of haemorrhage following circumcision”, items 30649 and 30663; from a policy perspective the risks and complications of circumcision are real enough and recognised. There is thus a question as to whether these circumcision-related MBS benefits encourage unnecessary risk-taking behaviour on the part of parents and compliant practitioners. But what level of complications is acceptable in a clinically-unnecessary procedure? Second, the test of whether a person really values a good or service is how much he is willing to pay for it. Members of the religious/cultural groups that traditionally practise circumcision may be insistent that it is vitally necessary, but if they are not willing to put a price on it – if they do not wish to meet the actual costs involved – it suggests that they do not really regard it as necessary at all. To allow the rebate in this situation would be like allowing low-income families to drive a car without paying the full costs of vehicle registration because the expense is a strain on their resources. And here the full cost includes the insurance component, to cover the cost of accidents etc; the parallel with surgical complications of circumcision and the cost of repairing “botches” is quite exact. Most people regard the ability to drive as so vital that they are willing to meet whatever costs are involved. Moreover, some religious groups celebrate the circumcision with a lavish family party. If they are willing to pay for that, they should also be willing to meet the full costs of the surgery that is the occasion for the event. One assumes that they do not expect the taxpayer to subsidise the party. 5. Now that the Medicare circumcision codes have been made unisex or gender neutral, there is the danger that retaining coverage of religious/cultural circumcision will lead to Medicare providing a rebate for circumcision or other forms of genital cutting on girls. There is in fact evidence that this is already happening. [4] The religious/cultural groups that practise circumcision or other forms of genital cutting on girls regard the procedures as just as important and meaningful as circumcision of boys; if they see the rebate available for circumcision of the latter, they are likely to expect or even demand it for the former as well. And if cultural/religious affiliation is to be the deciding factor, how can their request be denied? [5] 6. While some defenders of circumcision have begun to advocate toleration of “mild” forms of female genital cutting, partly as a way of reducing the blatancy of the double standard (FGM legally prohibited, with heavy criminal penalties, circumcision of boys legal and generally unregulated), a stronger current of opinion stresses the importance of “genital autonomy” and the need to protect all children – male, female, intersex – from any form of non-therapeutic genital cutting. [6-10] It is puzzling and disappointing that the Committee displayed no awareness of these developments. References 1. Robert Darby. Scientific advice, traditional practices and the politics of health-care: The Australian debate over public funding of non-therapeutic circumcision, 1985. Hygiea Internationalis: An Interdisciplinary Journal for the History of Public Health, Vol. 10, December 2011. Available at https://www.academia.edu/7028494/Scientific_advice_traditional_practices_and_the_politics_of_health-care_The_Australian_debate_over_public_funding_of_non-therapeutic_circumcision_1985 2. Details at http://www.circinfo.org/Dutch_circumcision_policy.html 3. Gold, G. et al. Complications following circumcision: Presentations to the emergency department. Journal of Paediatrics and Child Health 51 (12) 2015: 1158-63; Jacques Gallant. Secrecy questioned about baby’s death after circumcision. The Star (Toronto), 26 October 2015. https://www.thestar.com/news/gta/2015/10/26/secrecy-questioned-about-babys-death-after-circumcision.html 4. See for example http://www.circinfo.org/Medicare_Coverage_Female_Circumcision.html 5. Brian Earp. Between moral relativism and moral hypocrisy: Reframing the debate on FGM. Kennedy Institute of Ethics Journal 26 (2) 2016: 105-144. Available at: https://www.academia.edu/10197867/Between_moral_relativism_and_moral_hypocrisy_reframing_the_debate_on_FGM_ 6. Brian Earp and Rebecca Steinfeld. Gender and genital cutting: A new paradigm. Euromind Global, 6 April 2017. Available at: http://euromind.global/en/brian-d-earp-and-rebecca-steinfeld/?lang=en 7. Robert Darby. The child’s right to an open future: Is the principle applicable to non-therapeutic circumcision?” Journal of Medical Ethics 39 (2013): 463-468. Available at: https://www.academia.edu/17264543/The_childs_right_to_an_open_future_Is_the_principle_applicable_to_non-therapeutic_circumcision 8. Eldar Sarajlic. Can Culture Justify Infant Circumcision? Res Publica 20 (4) 2014: 327-343. 9. Steven Munzer. Examining non-therapeutic circumcision. Health-Matrix: The Journal of Law Medicine 28 (2018). Available at: https://scholarlycommons.law.case.edu/healthmatrix/vol28/iss1/5/ 10. Kai Möller. Ritual male circumcision and parental authority. Jurisprudence 8 (3) 2017: 461–79. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Medicare should not pay for medically unnecessary circumcision darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>“No normal child needs to be circumcised”</h3> Parents can safely stop agonising over whether their baby boys need to be circumcised, thanks to a new medical policy statement. According to Australian and New Zealand child protection advocates, the revised policy on circumcision recently released by the Royal Australasian College of Physicians means that parents can simply forget about the idea of circumcising. “The circumcision decision is actually a fake dilemma”, said Sydney paediatrician and child heath specialist Dr George Williams. “No normal baby needs to be circumcised. Thanks to the new policy, parents can stop worrying about surgery and focus instead on the important things that a new baby needs – love, warm clothes and breast milk.” After a lengthy review of the medical evidence, the RACP concludes that routine infant circumcision is not warranted in Australia and New Zealand. This is because the diseases from which circumcision may give some protection are too rare or not a threat to children; because it does not protect enough; and because the resulting harm is too great and the complication rates are too high. “The authors of the policy have gone into great detail about those diseases and the levels of protection they may offer, but that’s the bottom line,” said Dr Williams “Circumcision is not medically necessary or even desirable, and is not recommended as a health precaution.” “They’ve gone into less detail about the harm, complications and risks of circumcision, but these go all the way up to death – for example, from unnoticed bleeding, or infection with diseases such as meningitis. That’s an unacceptable risk for a surgical operation that the RACP says is unnecessary.” Tasmania’s Children’s Commissioner, Paul Mason, praised the RACP for recognising the importance of ethical and human rights issues in the circumcision decision; for recognising that the foreskin has significant sexual functions and is actually the most sensitive part of the penis; and for pointing out that the operation is non-therapeutic (i.e. does not fix anything) and that the infant is unable to give consent. For these reasons it acknowledges that circumcision of minors has been under heavy fire from bioethics and human rights advocates for many years. “This is an untested area, but we believe it cannot be ethical for parents to decide to remove a healthy, functional body part from a baby, or for a doctor to perform a medically unnecessary surgery on a patient who has not given his consent. We doubt the law will continue to hold a parent’s consent to be valid”, Mr Mason said. The RACP also deserved praise for recognising that many men bitterly resent having being circumcised. “Thousands of men in previously circumcising countries (Australia, USA, Canada, UK) are using DIY methods to restore a semblance of their foreskins. Although some men might wish they had been circumcised as a baby, they are far fewer and have an easy remedy – to get circumcised now. It is not so simple for a man whose foreskin was surgically removed when he was too young to protest.” With fewer than one baby in five circumcised anywhere in Australia these days, and fewer than one in 20 in several states, and virtually no Pakeha or Maori babies circumcised in New Zealand, circumcising for conformity’s sake is a dead issue. “Indeed”, said Ken McGrath, Senior Lecturer in Pathology at Auckland University of Technology, “if parents are worried about peer acceptance, their best plan is to leave the boy’s penis alone.” Mr McGrath commended the RACP for rejecting the aggressive lobbying of a small pro-circumcision faction, who have been pushing hard for the introduction of near universal circumcision in Australia, supposedly as a public health measure. “Some of the reasons they give for circumcising – such as to prevent splashes on the toilet seat or to avoid zipper injuries – are simply absurd. “The fact is that the medical arguments for routine (medically unnecessary) circumcision are dead as a doornail.” Further information Paul Mason Commissioner for Children Tasmania, Australia +61 438 555 473 </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource New RACP policy welcomed by child protection advocates darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Morris is a man on a mission to rid the world of the male foreskin</h2> Since the mid-1990s Brian Morris, at that time a respected professor of molecular biology at the University of Sydney, has been waging a one-man war against the foreskin, and more particularly a relentless campaign in favour of circumcising baby boys. He started with a website, then managed to persuade a university press to publish a little booklet, In Favour of Circumcision (1999), in which he rehashed a mass of largely nineteenth century medical wisdom, as well as informing us that Abraham circumcised himself in order to cure a “foreskin problem” and that uncircumcised men needed three showers a day to keep down the smell. The book did not find favour with health experts, however: <a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=64&Itemid=50" rel="noopener" target="_blank">reviewing it in Venereology</a>, Professor Basil Donovan described Morris as “a man on a mission to rid the world of the male foreskin”, and some of the claims so misleading that the publishers ought to withdraw the book. It was, he concluded, “a serious disservice to parents”; since Morris was not suggesting that adult men ought to get themselves circumcised as a health precaution, it is obvious that parents were the target audience. Undeterred, Professor Morris pressed on, hoping to influence the policy of the Royal Australasian College of Physicians, which had been anti-circumcision since the early 1970s. When this effort failed in 2002, 2004 and again 2010, and in response to his <a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=category&sectionid=14&id=78&Itemid=71" rel="noopener" target="_blank">public disowning by the RACP,</a>, he set up his own organisation, the Circumcision Academy of Australia, with a small group of like-minded academics and medical practitioners, some of whom derive their income from performing circumcision procedures, and who thus have a vested financial interest in emphasising its benefits. During this period Professor Morris became a prolific contributor to medical journals, trotting out one article after the other on the sins of the RACP and other anti-circumcision activists, and insisting that he and his friends were the only people observing the principles of evidence-based medicine, and thus the true source of medical wisdom. In fact, most of the articles (despite a varying cast of co-authors) were pretty much the same, largely repeating the familiar litany of the benefits of circumcision that he had first set out in his booklet. Where all this frantic industry has led him can now be seen in a couple of articles that attempt to quantify the benefits of circumcision, and the results have been dramatic. <h2>Foreskin health risk doubles in 2 years</h2> A couple of years ago Brian Morris drew a certain amount of attention to himself with the claim that the benefits of circumcision outweighed the risks by 100 to 1. At the time child health authorities ridiculed the claim as scientifically baseless, exaggerated, implausible, absurd, frankly preposterous and just crazy. His additional suggestion that circumcision was just like vaccination and should be compulsory was described as the dumbest idea ever. Undeterred by these harsh words, our fearless anti-foreskin warrior has now published a further article in which he claims that the benefits of circumcision outweigh the risks by 200 to 1, and that 50 per cent of all uncircumcised men will experience medical problems as a direct result of their regrettable genital anatomy. This means that the danger to health posed by the foreskin has doubled in only 2 years, and should imply that boys and men all over the world (but especially in Europe, Britain and Australia) should be swarming into hospital emergency departments with crippling foreskin-related diseases. If the risk continues to soar at this rate, it will not be long before uncircumcised men are dropping like flies in the street. The fact that none of this is happening, however, does lend a certain air of unreality to Professor Morris’s alarmism, and perhaps explains the fact that, while his earlier (2014) claim met with ridicule and refutation, his latest anathema against the foreskin has left health authorities dumbfounded and speechless with amazement. The 100 to 1 claim was made in a respectable journal as an aside to an article that was really a speculation on the possible effects of the American Academy of Pediatrics 2012 circumcision policy on United States circumcision incidence. It is noteworthy that Professor Morris’s 200 to 1 claim appears in the very obscure Chinese-based World Journal of Clinical Pediatrics. Despite its grandiose title, this is a recently established, low-ranking organ that was included in Beale’s list of <a href="https://en.wikipedia.org/wiki/Predatory_open_access_publishing" rel="noopener" target="_blank">predatory open access publishers</a>. It had, in fact, already been the target of a <a href="http://retractionwatch.com/2016/11/22/journal-editor-resigns-over-firestorm-from-circumcision-article/" rel="noopener" target="_blank">speeding ticket from Retraction Watch</a> for dodgy publication practices – in this case, failure to ensure objective peer review. Still, one can’t blame Morris for that: if you are going to make claims as outlandish as those made by him and his coterie at the Circumcision Academy of Australia it is not surprising that you have to scrape the bottom of the barrel. <h2>The war of words</h2> Professor Morris seems to think that the war against the foreskin will be won by the weight of artillery and the number of shells that each side can fire – rather like the donkey generals of the First World War. If he can cite more articles in favour of circumcision than critics can cite articles against, the case for circumcision will be proved. Hence the bloated reference lists at the end of his numerous repetitive articles. But this is to overlook two vital factors: the quality of the articles and the burden of proof. It is one thing to cite dozens of papers, but if they turn out to be no more than letters to the editor, opinion pieces, viewpoints and literature reviews, and if they are published in obscure or low-ranking journals, they carry far less weight than if they are reports of real studies (i.e. of actual data), meta-analyses and other relevant literature. In the case of Morris’s most recent effort in the World Journal of Clinical Pediatrics, no fewer than 27 of the 160 references are to papers by Morris himself or close associates; at this rate it will not be long before he can prepare a “systematic review” consisting solely of his own work. Papers published in high-ranking journals carry more weight than those published in obscure or low-ranking journals, such as the World Journal of Clinical Pediatrics – a title cited in Beale’s list of predatory open access publishers, and already under criticism for failure to ensure objective peer review. Morris himself has stated that the only papers that need be taken seriously are “good research studies published in reputable journals” [1]. On that basis, there would seem to be no reason to pay any attention to his two most recent articles, neither of which is a “good research study”, and both of which are published in an obscure journal with no reputation at all. <h2>Peer review, or endorsement by mates?</h2> The quality of the peer review process is also an important factor to consider when judging the credibility of any paper or article. In fact, an earlier paper by Morris in the same journal was the target of a complaint to Retraction Watch because the sole peer reviewer was an associate and frequent collaborator with Morris. The editor agreed to retract the paper, and when this did not happen resigned. In the case of his most recent “systematic review”, the sole reviewer has been <a href="https://www.researchgate.net/profile/Webster_Mavhu" rel="noopener" target="_blank">named as Webster Mavhu</a> and his comments to the author made public; there is not much to them: COMMENTS TO AUTHORS: This a well-conducted and well-written systematic review of the current scientific evidence of the protection afforded by early infant male circumcision against infections and other adverse medical conditions. I have only a few minor comments: Suggest changing USA to Us throughout. p3 Core tip - insert 'of'. Our systematic review of... p8 Last paragraph, 2nd sentence - '...increased in... (not is). p10 Give a brief explanation of UTI and phimosis (as you do with paraphimosis) p10 References [33-46] and [47] - format different from the rest. pages 11,12 and Table 1, give full form of approx. p16 i.e., 6% - missing a point after e. Mr Mavhu, a health official from Zimbabwe, turns out to be an ardent believer in the efficacy and acceptability of non-therapeutic circumcision of minors, and is professionally involved in the “roll-out” of the African circumcision programs – hardly the sort of authority to give an objective and impartial assessment of Morris’s arguments. <h2>Burden of proof</h2> There is also the question of where the burden of proof lies. Since the foreskin is normal human anatomy (indeed, common to all mammals, male and female) it is not up to the circumsceptics to prove that circumcision is harmful, but up to the circumcision advocates to prove that it is so dangerous to health that it must be removed from as many boys as possible before it can do too much damage. In an article a few years ago Professor Morris claimed that the benefit/risk ratio was 100 to 1; in his most recent paper the ratio has increased to 200 to 1. According to him, in only a couple of years the danger of the foreskin to health has doubled. This news may come as a surprise to the 75 per cent of men worldwide who seem to be coping quite satisfactorily despite such a malevolent anatomical disadvantage and it would appear to be contradicted by “a good research study” (i.e. one using actual patient data) showing that <a href="https://www.circinfo.org/AAP_in_retreat.html" rel="noopener" target="_blank">95 per cent of boys never experience any foreskin problems</a>, and that only a tiny minority of these require circumcision to correct it. In relation to the burden of proof, the situation is analogous to a court of law where the foreskin is charged with the offence of being a menace to individual and public health – a situation where the accused is innocent until proved guilty. The prosecution can bring in as many witnesses as it likes, but as in a court of law the defence does not have to prove anything. It does not even have to produce witnesses of its own or require the foreskin to make any statement in its own defence. The outcome of the case depends on the credibility, consistency and force of the evidence presented by the prosecution, as judged by the jury, the members of which must assess its validity and relevance. Are the claims plausible? Could the prosecution witnesses be mistaken? Have they misinterpreted what they think they saw? Do they agree? Could they be motivated by personal malice or ideology? How credible are these authorities? How consistent are they? Has the case for a guilty verdict been made beyond reasonable doubt? In this situation it would not matter if there was not a single article n a medical or other journal contesting the claims of the circumcision advocates (though in fact there are a great many) – the prosecution would still have to prove its case to an impartial jury. In fact, the medical literature is as contested and inconclusive as it is vast; as when witnesses give contradictory accounts of “what happened,” it is thus difficult to draw firm conclusions. But if firm conclusions cannot be drawn the verdict arrived at must be “Not Guilty” (or as the Scots say, Not Proven), and the foreskin discharged. The real question is not whether it might have been guilty, but why a normal feature of human sexual anatomy should have to justify its existence to the likes of Professor Morris. <h2>Non-therapeutic circumcision like elephant repellent</h2> Recommending circumcision as a prophylactic of childhood diseases is reminiscent of the old joke about the fairground snake oil salesman flogging elephant repellent. Confronted by sceptical customers who point out that there are no elephants around, he has the compelling reply, “Proof of how effective it is!” The point is, that even if the repellent were effective, you do not need it in regions where elephants are not normally encountered, nor if elephants are not really very dangerous and can be scared away by saying “Shoo!” The key question, therefore, is not whether circumcision might have health benefits, or even if the benefits outweigh the risks, but whether the net benefits (i.e. after taking all harms into account) are great enough to justify performing the operation on children who cannot give informed consent. In making this assessment it is not enough to dredge through the vast accumulation of medical literature to find studies supporting some degree of risk reduction; nor is it enough when considering the cons to consider merely the risk of surgical complications, as the American Academy of Pediatrics and the Centers for Disease Control have done. The calculation required is far more complex. First you must consider the frequency, severity, transmissibility and curability of the diseases etc to which circumcision is claimed to provide protection. Then (2) you must make a comprehensive study of the physical harms, including impact on sexual experience, surgical complications and other adverse outcomes, not merely in the immediate post-operative period, but long-term, until sexual maturity. Then (3) you must factor in the sexual, aesthetic, and personal value of the foreskin to the individual and the psychological impact of removing it. Next (4) you must assess the ethical harms and damage to human rights arising from operating without informed consent. Finally (5), you must find some widely acceptable formula for weighting all these disparate factors to produce a final judgement. <h2>Using a flame-thrower to swat a blowfly</h2> No circumcision advocate, and certainly not Professor Morris, for all their diligent labours, have ever come close to performing such an exercise. They have rather confined themselves to selective literature reviews, picking out studies that show, or appear to show, the foreskin increasing the risk of this or that disease, while ignoring or disparaging critiques of these, as well as dismissing studies that reach different conclusions. Despite his impressive productivity, Professor Morris’s own papers tend to repetition – a familiar litany of the benefits of circumcision, along with assurances that it carries a minimal risk of complications and makes no difference to sexual experience. They also ignore the frequency, severity, transmissibility and curability of the diseases etc to which circumcision is claimed to provide protection; in fact, most of them are rare, mild in effect, non-transmissible or of low virulence, and readily curable with antibiotics or other medications. Using circumcision to prevent or cure trivial penis problems such as inflammation (balanitis); or urinary tract or venereal infections that can be cured with antibiotics or prevented by behavioural strategies is like using a flame-thrower to swat a housefly. Nowhere in his extensive list of publications does Professor Morris tell us what material weighting he would give to the 5 factors listed above, most of which he simply ignores. How, then, can he arrive at the triumphant conclusion that the benefits of circumcision outweigh the risks by a factor of 200 to 1? One feels that the figure must have been plucked out of the air, having about as much scientific validity as phlogiston. <h2>Range of opinions on circumcision – but Morris and coterie at extreme edge</h2> Professor Morris would like us to believe that there are basically two positions on circumcision: the pro-circumcision position, represented by himself, the American Academy of Pediatrics, the United States Centers for Disease Control and many other responsible health authorities; and the anti-circumcision position, represented by a few misguided medical ethics wonks and some ratbag community activists. In fact, there are at least 6 major positions on circumcision, which may be summarised as follows: 1. Professor Morris and his coterie at the Circumcision Academy of Australia and the Early Infant Circumcision Advocacy Group who believe that parents should be strongly encouraged or compelled to get their baby boys circumcised. 2. The American Academy of Pediatrics and the US Centers for Disease Control, which do not recommend circumcision, but consider that the benefits of circumcision exceed the risk of surgical complications (though not by much). 3. Paediatric authorities such as the Royal Australasian College of Physicians and the Canada Paediatric Society which consider that the risks and harms of circumcision outweigh the benefits and that circumcision is neither warranted nor desirable, and certainly not necessary. 4. Medical authorities such as the Royal Dutch Medical Association, others in Europe and (marginally) the British Medical Association who consider that circumcision is both physically harmful and ethically unacceptable, and therefore that doctors and public health institutions should actively discourage the practice. A number of independent researchers, epidemiologists and paediatricians are also included in this group. 5. Legal authorities such as the Tasmania Law Reform Institute, the Cologne Court of Appeal and numerous legal, bioethical and human rights scholars who consider that non-therapeutic circumcision of minors violates accepted principles of bioethics and human rights, and should be treated in much the same way as female genital mutilation – that is partially prohibited or at least strictly regulated. 6. Community organisations and individuals who regard circumcision as genital mutilation and consider that it should be legally prohibited, and perpetrators prosecuted. As you can see, there is an extensive spectrum of opinion on circumcision from right to left, from compulsory at one end to legal prohibition outright at the other. It is also evident that by far the greater weight of opinion on a world scale is against circumcision, and that Professor Morris and friends are at the extremist end of the scale. The AAP must tremble at the thought of being defended by such fanatical allies – though in truth it is strange that no other supporters are speaking up in their favour, and that its own position is very much at variance from those of all other child health authorities. <h2>Does Professor Morris really matter?</h2> For all his industry and zeal, however, Professor Morris cannot claim many victories. His efforts to influence the RACP have failed; his attempt to get the Australian and New Zealand Public Health Association to adopt a resolution in favour of circumcision got nowhere; the AAP has not recommended circumcision; the <a href="https://www.circinfo.org/CanadaCircumcisionPolicy.html" rel="noopener" target="_blank">Canada Pediatric Society</a> came out against circumcision; circumcision incidence in the United States and Australia continues to decline; legal, bioethical and human rights authoritie <a href="https://www.circinfo.org/Brit_judge_on_FGM_and_circumcision.html" rel="noopener" target="_blank">increasingly question the practice</a>. The increasing desperation of the circumcision lobby is shown in the escalating stridency and implausibility of its claims (200 to 1: really!), and its marginalisation by reliance on low-status, low-credibility publications. They really might as well pack up their gomcos and plastibels and devote their considerable energy to something more useful and productive than destroying foreskins. 1. “Circumcision facts trump anti-circ fiction”, Australian Skeptic 27 (4) Summer 2007. See also <a href="https://www.circinfo.org/Circumcision_and_sand.html" rel="noopener" target="_blank">reply by Robert Darby</a>, showing that Professor Morris’s respect for evidence is not all that it might be, and that he has trouble giving correct citations to sources. <h2>Further reading</h2> <a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=64&Itemid=50" rel="noopener" target="_blank">Basil Donovan’s review of In Favour of Circumcision</a> Brian Earp & Robert Darby, <a href="https://www.skeptic.org.uk/magazine/onlinearticles/infant-circumcision/" rel="noopener" target="_blank">Does science support infant circumcision? A sceptical reply to Brian Morris</a> <a href="https://www.academia.edu/9872471/Does_science_support_infant_circumcision" rel="noopener" target="_blank">Expanded version of above</a> <a href="http://retractionwatch.com/2016/11/22/journal-editor-resigns-over-firestorm-from-circumcision-article" rel="noopener" target="_blank">Journal editor resigns over firestorm from circumcision article</a> Robert Darby, <a href="https://www.academia.edu/12035421/Risks_benefits_complications_and_harms_Neglected_factors_in_the_debate_on_non-therapeutic_circumcision" rel="noopener" target="_blank">Risks, benefits, complications and harms: Neglected factors in the debate on non-therapeutic circumcision</a> Robert Darby, <a href="http://journals.sagepub.com/doi/full/10.1177/2158244016649219" rel="noopener" target="_blank">Targeting patients who cannot object? Re-examining the case for non-therapeutic infant circumcision</a> <a href="http://www.circumstitions.com/morris.html" rel="noopener" target="_blank">Brian Morris fact check</a> <a href="http://www.circumstitions.com/news/news64.html#vernon9" rel="noopener" target="_blank">Is Professor Morris connected with Gilgal Society and convicted child molester Vernon Quaintance?</a> Morten Frisch and Brian Earp. <a href="http://www.tandfonline.com/doi/full/10.1080/17441692.2016.1184292" rel="noopener" target="_blank">Circumcision of male infants and children as a public health measure in developed countries: A critical assessment of recent evidence</a>. Global Public Health, on-line first, 16 May 2016. Brian Earp. <a href="http://quillette.com/2016/02/15/the-unbearable-asymmetry-of-bullshit/" rel="noopener" target="_blank">The unbearable asymmetry of bullshit</a>. Quillette, 15 February 2016. Robert Van Howe. Expertise or ideology? A response to Morris et al. 2016, ‘Circumcision is a primary preventive against HIV infection: Critique of a contrary metaregression analysis by Van Howe.’ <a href="http://www.tandfonline.com/doi/full/10.1080/17441692.2016.1272939" rel="noopener" target="_blank">Global Public Health, on-line first, January 2017</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Professor Brian Morris: relentless circumcision activist darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Britain</h2> <h3>Circumcision in Britain</h3> In Britain circumcision was not practised at all until the eighteenth century, and never as a routine or preventive procedure until the late nineteenth century. Men valued their foreskins as "the best of your property" and regarded circumcision as a humiliating disfigurement. In the eighteenth century surgeons started treating serious venereal infections of the penis by amputation of the diseased tissue. Since the venereal sores were usually on the foreskin, this was analogous to circumcision, but it was only done in advanced cases of disease, and only if the men agreed to it (which many did not). Such sores often caused phimosis by producing scabs which fused the foreskin to the glans, again requiring treatment; some surgeons treated the condition by amputating the foreskin (recommended by the English Robert James in his Medicinal Dictionary, published in the 1750s), others preferred conservative treatments and operated only if gangrene was present or threatened (such as recommended later by the French venereal disease expert, Philippe Ricord). The rise of extreme medical anxiety about masturbation in eighteenth century (the masturbation phobia) turned the normal fondling of the penis which all young boys and many babies did into a wicked and harmful vice which had to stamped out. This led to the gross medical error which characterised the normal phimotic condition of the infant and child penis as a pathological abnormality requiring immediate surgical correction. The main reason advanced for circumcision in Britain from 1840s onwards was to cure phimosis: that is surgically "correct" the natural condition of the penis. The later claims that circumcision could prevent cancer, epilepsy, paralysis, convulsions etc were all based on the original medical error that "phimosis" was pathological and had to be fixed. Various theories were advanced as to how, such as the tight foreskin pressing on the glans and causing imbalance of nerve force. Even those who did not support circumcision believed that the infant foreskin had to be separated from the glans and forced to retract within a few weeks of birth. It was not until the 1930s that this dogma was questioned, and not until Douglas Gairdner's article on 1949 that the error was dispelled (at least in Britain, though not for a while in Australia, and not for even longer in the USA). Circumcision in childhood was first introduced by French and English doctors as a treatment for masturbation in the 1830s and also recommended for spermatorrhoea (involuntary loss of semen) in adult men. Much of this was based on the crazy theories of <a href="http://www.whonamedit.com/">Claude-Francois Lallemand (1790-1853)</a>, whose vast treatise Les Pertes seminales involontaires (Involuntary seminal losses) was published in three volumes in the 1830s and translated into English in the 1850s. Circumcision as a treatment for phimosis had the same origin: nobody had worried about phimosis in childhood until masturbation became an issue, but once that was seen as a problem, phimosis also became a problem because the "secretions" it was supposed to trap caused irritation and led boys to fondle and scratch their penis (equals masturbation). Circumcision was not routine at this stage or even common, only done by a few over-anxious and highly punitive parents. It took nearly a century of advocacy and the invention of additional "health" reasons (the most important of which was the claim that it provided protection against syphilis, first raised in the 1850s, but not seriously pushed until the 1890s), and then various forms of cancer, before it became general. <h4>Circumcision folklore</h4> Various absurd stories are told about circumcision in the English royal family, among the British in India and in the case of Louis XV of France, who is supposed to have suffered from such severe phimosis that he was obliged to submit to circumcision before he could perform his most important royal duty. All these stories are nonsense. The story that Queen Victoria imagined she was descended from the biblical King David and had her own sons circumcised was invented by the British Israelites and given wider currency by a popular writer using the pen name Bud Berkeley. The story about Robert Clive getting circumcised by Indian Moslems is a fairy tale made up by Allen Edwardes in The rape of India, a work largely of fiction masquerading as a factual history book. He invented a whole sequence of scenes involving circumcision as a pornographic fantasy, and footnoted them to imaginary documents and records. His exposure and disgrace is mentioned by Ronald Hyam in Empire and sexuality: The British experience. It is true that some hundreds of British soldiers were captured, forcibly circumcised and enslaved by the Muslim Sultan Tipu of Mysore after their defeat in the Battle of Pollilur in 1780, but that is a different matter. (1) As for Louis XV, a recent article proves that he could not have been circumcised, but that he might have had a short frenulum (<a href="http://www.circumstitions.com/Frenbrev.html">frenulum breve</a>) that was quickly and simply fixed with a touch of the bistoury. (2) <h4>Semi-routine operation</h4> Circumcision became "routine" (i.e. done by adults to children showing no signs of disease or abnormality) and widespread among the rich at the end of the nineteenth century as a result of a combination of several factors, any one of which would not have been enough. It received an immense boost from the claim that it provided significant protection against syphilis, the AIDS of that era. The rate of infant circumcision in Australia doubled between 1910 and 1920, the decade which marked the height of the syphilis scare, and increased substantially in Britain. (There's a parallel here with AIDS today). Circumcision was recommended as a preventive of masturbation, nervous diseases, syphilis, and cancer, not to mention bed-wetting, epilepsy, pimples and hip joint disease, all of which were equally important in securing its widespread acceptance; by itself, none of these factors could have tipped the balance. The age at which circumcision was done in Britain varied. It was often done in infancy, but it was also common in childhood, particularly just before a boy started school, as a precaution against picking up the habit of masturbation there. Many boys were not circumcised as a routine thing, but because it was found that their foreskin was not retractable (as was perfectly normal in boys before puberty), or because they were caught masturbating: it was a treatment/punishment as much as a preventive. Where it was done to correct "congenital phimosis" it was on the basis of a serious medical error and failure to understand normal penile development. Nor was the style and technique of circumcision standardised until much later, probably with the invention of the Gomco clamp in the 1930s. In the late nineteenth century there was immense disagreement among doctors about how it should be done and how much tissue should be excised; some urged the maximum possible, others the minimum needed to free the glans, others a middle course. Jewish practice was often taken as a model, but it was the modern Jewish style, involving the tearing back of the foreskin and its radical removal which attracted the most support. In fact, English (and then American) circumcision techniques turned out to be significantly more severe than most ritual or tribal varieties. Little was known about Islamic circumcision techniques, but Moslems they did not enjoy the high status achieved by Jewish people, who came to be regarded as exemplars of sanitary wisdom in the late nineteenth century. <h4>Dissent</h4> Herbert Snow made much of these disagreements and used them to try to discredit circumcision in his attack on the practice (<a href="https://www.historyofcircumcision.com/templates/pages/the_barbarity_of_circumcision_1890.html">The barbarity of circumcision as a remedy for congenital abnormality</a>, 1890), but so deeply had the myth of phimosis as a congenital defect sunk in by the 1890s that even he conceded that something had to be done about non-retractability in early childhood, and he had little to offer on the functions and value of the foreskin. Circumcision was never classified as serious surgery (and thus reserved to qualified surgeons), but as a minor procedure (like scratching off a wart) which any GP, medical student or expert in women's health could do. The crude and ugly results bore witness to the fallacy of that assumption. Circumcision always had its critics in Britain. Parts of this vehement denunciation from Elizabeth Blackwell in 1894 still has relevance today: A serious warning against the unnatural practice of circumcision must here be given. A book of "Advice to mothers" by a Philadelphia doctor was lately sent to me. This treatise began by informing the mother that her first duty to her infant boy was to cause it to be circumcised! Her fears were worked upon by an elaborate statement but false statement of the evils which would result to the child were this mutilation not performed. I should have considered this mischievous instruction unworthy of serious consideration, did I not observe that it has lately become common among certain short-sighted but reputable physicians to laud this unnatural practice, and endeavour to introduce it into a Christian nation. Circumcision is based upon the erroneous principle that boys, i.e. one half of the human race, are so badly fashioned by Creative Power that they must be reformed by the surgeon; consequently that every male child must be mutilated by removing the natural covering with which nature has protected one of the most sensitive portions of the human body. The erroneous nature of such a practice is shown by the fact that although this custom (which originated amongst licentious nations in hot climates) has been carried out for many hundreds of generations (by Moslems and Jews), yet nature continues to protect her children by reproducing the valuable protection in man and all the higher animals, regardless of impotent surgical interference. Appeals to the fears of uninstructed parents on the grounds of cleanliness or of hardening the part are entirely fallacious and unsupported by evidence. It is a physiological fact that the natural lubricating secretion of every healthy part is beneficial, not injurious to the part thus protected, and that no attempt to render a sensitive part insensitive is either practicable or justifiable. The protection which nature affords to these parts is an aid to physical purity by affording necessary protection against constant external contact of a part which necessarily remains keenly sensitive; and bad habits in boys and girls cannot by prevented by surgical operations. Where no malformation exists, bad habits can only be forestalled by healthy moral and physical education. The plea that this unnatural practice will lessen the risk of infection to the sensualist in promiscuous intercourse is not one that our honourable profession will support. Parents, therefore, should be warned that this ugly mutilation of their children involves serious danger, both to their physical and moral health. Elizabeth Blackwell, The human element in sex: Being a medical enquiry into the relation of sexual physiology to Christian morality (1884; 2nd edition, London, 1894), pp. 35-6 Elizabeth Blackwell (1821-1910) was born in Britain and emigrated in childhood to the United States, where she became the first woman to take a medical degree. She later practised in both the USA and Britain, where she played a significant role in the campaign to repeal the Contagious Diseases Act during the 1880s. She also denounced masturbation and fornication but believed they should be controlled by moral willpower. See American National Biography (1999), Vol. 2. <h4>Statistics</h4> There are no reliable statistics on the circumcision rate in Britain, but it was overwhelmingly an upper class phenomenon. Circumcision was very common among the richer and better educated, but rare among the poor, labourers, farmers etc. The key was the respectable obsession with "cleanliness": the rich had baths and washed themselves, the poor and working class were the great unwashed, and their foreskins were the final proof of how filthy they were. As George Orwell pointed out, the middle class believed the working class smelled. The cleanliness of the circumcised boy was the guarantee of his superior social status, plus the fact that the scare over masturbation was most concentrated in the richer and better educated classes, and was an obsession at the public schools they attended. An example of how unpredictably the knife fell in Britain during the period when circumcision was common is given in the autobiography of the eminent classical scholar, <a href="https://en.wikipedia.org/wiki/Kenneth_Dover">Sir Kenneth Dover</a>, who also reveals that boys were more likely to resent the operation than to accept it. As he writes: I was born at a time when the craze for circumcision, which infected England in the latter part of the nineteenth century, was reaching its peak, and I was one of its millions of victims. Of the dozen boys I knew best at my school, at least five were circumcised, but at least five were not, and these included Alec and Martin, to whom I was closest. Each of us naturally championed his own kind of cock. One night, however, just before I went to sleep, a message which seemed to come from outside myself told me, with magisterial finality, that foreskins are good and circumcision is bad. This message was not articulated in words, but invaded me in two shock waves about a second apart: whoof! ... whoof! I felt that my whole system of values had been turned upside-down, and from that moment I have never been reconciled to my mutilation. [...] My dislike of circumcision did nothing to make me anti-Jewish, partly because I don't think anything could have done, and partly because I knew from my reading in anthropology and ancient history that it wasn't the fault of the Jews; it began independently in Egypt, from which it has spread into central and eastern Africa, over the whole Islamic world, and in some areas of the south-west Pacific. I am pretty sure, however, that it turned me off Semitic languages, in which I was beginning to be interested, and reinforced my loyalty to the Greeks and Romans, who rejected and ridiculed circumcision. Source: Marginal Comment: A Memoir (London: Duckworth, 1994) p. 20 Two surveys of army and airforce recruits in the early 1950s (i.e. men born in the 1930s) showed that about one third were circumcised, but these would have been mainly from the higher socio-economic groups. Before the 1950s the incidence of circumcision in Britain was strongly correlated with wealth: the rich generally had it done, the poor generally did not. A friend of mine who was a pupil at a (minor) public school in the early 1960s recalls that slightly less than half the boys (born late 1940s, early 50s) were circumcised even then. He was not, but his younger brother was - not as a routine thing, but because of a supposed phimotic problem in childhood. Circumcision had never been publicly financed in Britain and was already dying out in the 1940s, probably because hospital resources were stretched by the war, before Douglas Gairdner gave it the death blow. <h4>Notes</h4> 1. Robert Darby "Captivity and captivation: Gullivers in Brobdingnag", Eighteenth Century Life, Vol. 27, Fall 2003. 2. G. Androutsos, "Le phimosis de Louis XVI (1754-1793) aurait-il ete a l'origine de ses difficultes sexuelles et de sa fecundite retardee?" Progres Urologique, 12 (1), 2002 </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource History of circumcision - Britain darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> The crotchets of Sir Jonathan Hutchinson, father of routine male circumcision Anything may be proved by statistics, and ... anything may be seen by the aid of a microscope. ... Upon this subject of epidemics we want facts and faithful records -- Quaesitor, Lancet, 6 January 1855 For every problem there is a neat, simple solution, and it is always wrong -- H.L. Mencken Until very recently Jonathan Hutchinson was familiar only to a few medical historians as the surgeon who did not shrink from recommending castration in chronic cases of masturbation. If he was remembered by medical science it was as the closest thing to an authority on venereal disease nineteenth century England managed to produce: the Oxford Companion to Medicine pays tribute to him as a medical polymath who gave the world "Hutchinson's triad" â€“ three signs by which congenital syphilis could be recognised in young children. (1) At a time when no effective treatment was available the value of such a diagnosis to the child was slight, but it seemed evidence of the medical profession's insight into the mysterious world of disease, and at least warned parents that they should start saving for the funeral. It was not the sort of physiological discovery or therapeutic breakthrough on which enduring reputations are normally built. Surprisingly, however, the early work of Hutchinson has recently been cited by an international group of (mainly Hispanic, but largely US-trained) researchers, led by Dr Xavier Castellsague, who seem to be intent on reviving the old theory that the male foreskin is a major risk factor for cervical cancer in women. (2) This idea was first aired by enthusiasts for mass circumcision in the 1930s, when the natural preputial secretions were imagined to be the causative factor. The association was disproved for developed nations by many studies since the 1960s, (3) but this has not prevented Xavier's team from claiming that the link is valid for Third World countries, or at least among poor and ignorant populations with high birthrates, a lot of smoking and malnutrition, poor hygiene, a high incidence of sexual promiscuity (especially with prostitutes) and a low level of condom use â€“ all minor factors, however, compared with those troublesome foreskins which are the real cause of the problem, or a least a cause which is easily fixed. A virus (HPV) has been identified as the infectious agent, but the scent of quackery lingers. The researchers have hailed Hutchinson as their precursor on the basis of his report, in 1855, that circumcision might prevent syphilis â€“ and quite appropriately, for he did indeed claim this, and more. Among his many other gifts to medical understanding were the convictions that Jews were immune to syphilis; circumcision of male infants was necessary to discourage masturbation and promote continence; contraception was morally objectionable and physically harmful; and leprosy was a form of tuberculosis, caused by eating bad fish. (Sir) Jonathan Hutchinson (1828-1913) is an unlikely subject for positive revaluation. A reserved and gloomy Quaker whose watchword was self-denial, he was a puritanical workaholic even by Victorian standards. His youthful diary shows him rising before dawn each day to study his medical books and read the Bible: his text for 28 December 1848 was Hebrews XI, "a most eloquent and beautiful chapter", to which he responded: "My supplications were poured forth at the footstool of almighty power for an increase of faith, lest, privileged to live under a great and glorious covenant of mercy, I might by any means fall short of the better things which God has provided for us". He was only twenty. (4) Other favourite readings were the sufferings of Job and St Paul's Epistle to the Galatians â€“ the one in which he reproaches them for continuing to practise circumcision, forgetful that Christ's sacrifice had made such fleshly signs of righteousness unnecessary. Hutchinson seems not to have approved of Paul, however, but to have agreed with the learned Dr Copland, author of the widely read Dictionary of practical medicine, that there would be much less masturbation among boys if the early Christians had not dropped the Judaic rite. (5) His own reasons for advocating routine circumcision owed more to moral sentiment than medical science, though he did his best to give them a statistical gloss. In his practice at the Metropolitan Free Hospital, Hutchinson recorded the incidence of venereal cases among his Jewish and non-Jewish patients during 1854 and came up with the following table: <table border="1"> <tbody> <tr> <td> </td> <td>Venereal cases</td> <td>Gonorrhoea</td> <td>Syphilis</td> </tr> <tr> <td>Non-Jews</td> <td>272</td> <td>107 (39.3%)</td> <td>165 (60.6%)</td> </tr> <tr> <td>Jews </td> <td>58</td> <td>47 (81%) </td> <td>11 (19%)</td> </tr> </tbody> </table> On the basis of these figures he claimed he had demonstrated a conclusion "long entertained by many surgeons of experience": that "the circumcised Jew is ... very much less liable to contract syphilis than an uncircumcised person", and the reason was obvious: circumcision rendered "the delicate mucous membrane of the glans hard and skin-like". Hutchinson provided no elaboration of his reasoning as to why a damaged ("hard and skin-like") glans should provide this protection, nor what non-injurious alternatives might be recommended if it really did, but he showed no such reticence when it came to the clinical implications. Given these facts, Hutchinson suggested that it was probable that circumcision was by Divine command made obligatory upon the Jews, not solely as a religious ordinance, but also with a view to the protection of health. ... One is led to ask, witnessing the frightful ravages of syphilis in the present day, whether it might not be worthwhile for Christians also to adopt the practice. (6) It was a flimsy foundation on which to erect such an ambitious therapeutic edifice. All his observations showed is that, while non-Jewish venereal cases had more syphilis than gonorrhoea (60.6 to 39.3 per cent), Jewish cases had more gonorrhoea than syphilis (81 to 19 per cent). Although Hutchinson insisted that the high level of gonorrhoea among the Jews proved that less promiscuity could not have been the reason for the difference, the statistics revealed nothing about the relative susceptibility of cut and normal men to venereal infection, and could as well be cited to show that circumcision increased the likelihood of getting gonorrhoea. By comparing the syphilis cases with the Jewish and non-Jewish population of London in the 1850s it is actually quite easy to manipulate these figures in such a way as to suggest a conclusion radically different from that reached by Hutchinson. In 1851 London held about 2,360,000 people, (7) and in 1858 there were about 36,000 Jews in England, of which two thirds (24,000) lived in the metropolis. (8) Taking Hutchinson's patients as a proportion of the respective populations, we arrive at the following table: <table border="1"> <tbody> <tr> <td> </td> <td>Syphilis cases</td> <td>London population</td> <td>Rate of syphilis</td> </tr> <tr> <td>Non-Jews</td> <td>165</td> <td>2,336,000</td> <td>0.007%</td> </tr> <tr> <td>Jews</td> <td>11</td> <td>24,000</td> <td>0.046%</td> </tr> </tbody> </table> It can readily be seen that circumcised Jews had a rate of syphilis many times higher than their gentile neighbours. The point is that you can make the rate of syphilis anything you like, depending how you select the catchment population against which to calculate the proportion. Nobody would take these extrapolations seriously, yet they are scarcely more illegitimate than the implications drawn from Hutchinson's own figures, which were taken so seriously that for the next century they were regarded as the "hard data" needed to prove the health-giving value of pre-emptive foreskin amputation. In 1900 E. Harding Freeland cited them to prove that "circumcision of every male in infancy" would reduce the incidence of syphilis by 49 per cent. (9) In 1914 Abraham Wolbarst relied on them to support his call for "Universal circumcision as a sanitary measure". (10) As late as 1947 Newsweek praised Hutchinson as the first to discover that "syphilis and gonorrhoea were uncommon among Jewish people" and asserted that circumcised men "are not likely to contract venereal disease". (11) That nobody until the 1890s even questioned Hutchinson's figures (12) is an indication of how strongly the tide of medical opinion was running in favour of circumcision: any evidence would apparently do. Hutchinson's enthusiasm for circumcision increased as he grew older. In 1890 he issued "A plea for circumcision" in which he insisted that "the superior cleanliness of a Hebrew penis" was in itself an argument for the amputation of the foreskin: "It constitutes a harbour for filth, and is a constant source of irritation. It conduces to masturbation and adds to the difficulties of sexual continence. It increase the risk of syphilis in early life, and of cancer in the aged." (13) Later that year he published a further article in which he urged circumcision as a disincentive to masturbation and regretted that public opinion would not permit the introduction of castration as a more radical approach to the problem. (14) Three years later he advised the circumcision of baby boys as "imperatively required whenever the prepuce is unusually long and contracted", but added that the surgeon should also "avail himself of every possible opportunity of inducing parents to have their male children circumcised", an operation with "great advantages" on which he provided detailed procedural instructions. Although he stated that the surgery had "no drawbacks whatever", he warned that haemorrhage was a danger and that "many children have died after the operation as a consequence of carelessness in this matter." (15) He seems to have felt it was better to die quickly from uncontrollable bleeding as an infant than to waste away slowly from the effects of masturbation or syphilis in adulthood. Hutchinson returned to the topic at the turn of the century with a lecture, "The advantages of circumcision", widely reported in British and US medical journals. His strongest argument in favour of "the general practice of circumcision" was that it "would reduce the prevalence of syphilis", in support of which opinion he recalled his statistics from 1854, "which proved" that, while gonorrhoea was as common among Jews as Christians, syphilis was "much less frequent". This fact showed that it was not superior morality which gave Jews their "comparative immunity", but some "adventitious advantage" which could only be "the absence of the prepuce"; and not surprisingly, for it would be "difficult to contrive an appendage more likely to facilitate the implantation of the syphilitic virus". Hutchinson assured the public that no measure for the prevention of syphilis was as efficient as circumcision, but he made no mention of condoms (mass produced and available since the 1880s), (16) probably because he "regarded with disgust artificial means to prevent having children. Such practices are prejudicial to both moral and physical health." (17) Indeed, he seems to have held a deeply puritanical objection to non-procreative sex: Measures, such as the inspection of prostitutes, have a collateral influence prejudicial to morality. Professedly making irregular sexual intercourse less dangerous, they possibly increase its amount to an extent which more than counterbalances their supposed advantages. They are also injurious to the sense of decency, to say nothing of modesty, and detrimental to the moral conscience of a community. It is no so with circumcision. Effected in early infancy, and with other avowed objects [that is, curbing masturbation] it would silently become the means of preventing on a large scale the prevalence of a loathsome and misery-producing disease. The extent to which this diminution of risk might tend to increase sexual folly would probably be infinitesimal. (18) In other words, in controlling syphilis circumcision was preferable to condoms or health checks because it would discourage pre- and extra-marital sex. The value of the operation would be enhanced by its effect in diminishing the sexual appetite: The only function which the prepuce can be supposed to have is that of maintaining the penis in a condition susceptible of more acute sensation than would otherwise exist. It may be supposed to increase the pleasure of the act and the impulse to it. These are advantages, however, which in the present state of society can well be spared, and if in their loss some degree of increased sexual control should result, one should be thankful. (19) Such a frank acknowledgment of the effect of circumcision on sexual function showed a greater sense of realism than some of Hutchinson's other pronouncements on disease. Notable among these was his obstinate belief that leprosy was caused by eating rotten fish. He first wrote a paper on the subject in 1863, and even the discovery of the guilty bacillus in 1874 did not turn him from his path: Why was leprosy associated with coast-dwelling peoples? Why was it common in Europe in the Middle Ages, when everybody ate fish on Fridays, but rare today, when the practice was less strictly followed? Neither the public nor his colleagues were convinced, so in 1906 he wooed them with a book called On leprosy and fish eating, in which he not only amassed the statistical evidence, but demanded strict government regulation of the fish industry as the only effective means to address the problem. Among his scientific claims were that leprosy could be cured by abstention from fish and the use (both internally and externally) of "Chaulmoogra oil" (whatever that was); and that the bacilli of tuberculosis and leprosy were "differentiated forms of the same organism". (20) Hutchinson was not able to produce statistics as telling as those which proved that circumcision conferred protection against syphilis, and doctors had nothing to gain from closer supervision of the fish trade, so the "Fish â€“ control of leprosy regulations" did not emerge to complement the public health advantages of routine infant circumcision, and a startling epidemiological insight faded quietly away. As it turned out, Hutchinson's theories of syphilis prevention were as wrong as his ideas about leprosy. Gradually it was realised that any reduced incidence of venereal disease among Jews was the result of cultural and lifestyle factors: the quarantine effect of segregation and a low level of sexual promiscuity. The position was put clearly by Ephraim Epstein, a Russian Jew practising as a physician in Cincinnati, USA, who commented in 1874: In common with others ... once I believed that circumcision affords a protection against venereal [diseases], but my practice in Vienna ... and in this country since 1862 persuaded me fully to the contrary. The apparent immunity which the Jews of Russian and European Turkey ... seem to enjoy from venereal diseases arises from their greater chastity and the practice of early marriage. ... The singular pre-eminence of the Jews in health is a mere fiction, propounded either by those who are not acquainted with the Jewish race in this country, or by certain Jewish enthusiasts who have a special axe to grind. (21) It was also realised (as even Hutchinson had admitted) that the operation, in the days before aseptic surgery, actually infected many babies and children with syphilis, tuberculosis and other diseases, not to mention ordinary gangrene. (22) Circumcision played no role in the eventual conquest of syphilis, which was tamed by growing use of screening and early identification, condoms, Metchnikoff's ointment and Salvarsan, and defeated in the 1940s by penicillin. (23) Hutchinson's broad theory of disease causation belonged firmly to the eighteenth century: a mixture of divine providence and human error. He agreed with Thomas Sydenham (an English medical writer of the seventeenth century) that "of acute diseases, God is the cause; of chronic ones, ourselves". (24) Yet there is not such a yawning gulf between his approach and that of agenda-driven researchers like Dr Castellsague's team, both of which know what they want to find and are inclined to ignore contradictory or confounding data. Hutchinson all but admitted that he sought evidence only for what he already wanted to prove: as he confessed in 1890, "I had long ago adopted the rule, to believe only what I thought likely to be true". (25) Following this principle, it would be impossible to discover anything that would shake his opinions. His decision to collect statistics on the incidence of VD among his Jewish and non-Jewish patients arose from his certainty, "long entertained by many surgeons", as to the prophylactic value of an early circumcision; his aim was to support the opinion he had "long shared" with his friend Mr Forster that infants with tight foreskins should always be circumcised. (26) Commending Dr Castellsague's study, and welcoming the clinical implications, the editorial writers of the New England Journal of Medicine affirmed that it had merely verified what they had "long ... suspected": that (male) circumcision reduced the risk of cervical cancer. (27) The deeper truth is that the NEJM has been sniping at the foreskin for decades, deplores the decline of routine male circumcision in the USA and is very annoyed with the American Academy of Pediatrics for changing its policy in 1999. During the nineteenth century (as the Boston Medical and Surgical Journal) it regularly published articles like "Seminal weakness: Castration" (Vol. 29, 1843), "Insanity cured by excision of the external organs of generation" (Vol. 32, 1845), "Surgical treatment of hopeless cases of masturbation and nocturnal emissions" (Vol. 109, 1883), and "Excision of the clitoris as a cure for masturbation" (Vol. 66, 1862). Its latest attack on the male body is quite in accord with its finest traditions. Why, indeed, would you single out a certain part of the body for investigation unless you wanted to find evidence for its guilt in some wrongdoing? Reading the NEJM and its colourful press release, you would think that the cause of cancer was the foreskin, not a virus. And why the sex discrimination? Doctors are not blaming women for infecting men with HPV, but where else do they get it from? If the foreskin provides a nest for the virus, so does the clitoral hood and the folds of the labia in females; perhaps routine circumcision of women would reduce the incidence of HPV infection and penile cancer in men. Because western doctors now regard amputation of any part of the female genitals as mutilation, however, they no longer have any interest in exploring this intriguing therapeutic possibility, and they do not seek associations between normal female anatomy and risk of disease. It is different in the Islamic cultures which practise various forms of female circumcision, where doctors and religious leaders make similar claims about its benefits for women's health.(28) An Egyptian Muslim cleric who overturned a government ban on female circumcision in 1997 not only thanked God for preserving a religious requirement handed down by mothers and grandmothers for fourteen centuries, but stated that the operation protected the nation from AIDS by reducing promiscuity. (29) In explaining the link between circumcision and disease control in behavioural rather than anatomical terms, the priest showed a better understanding of the epidemiology of STDs than many medical researchers. It would seem that the agenda in 2002, as it was in 1855, is to find a scientific/medical rationale for a culturally-derived impulse to circumcise male infants. But why stop there? Think how much healthier the whole population would be if other troublesome body parts were amputated before they could get up to mischief. Mucous membranes seem to be a weak link in the body's defences, so off with the lips for a start; and perhaps we could revive the painful nineteenth century practice of cauterising the urethra with silver nitrate so as to reduce susceptibility down there. Excising a lung would cut down the surface area of treacherous pulmonary mucosa by 50 per cent, thus reducing vulnerability to airborne infections like tuberculosis and bronchitis. Amputation of the right hand in all men at birth would do much to protect women from the slaps, punches and beatings they routinely receive from abusive fathers, husbands and lovers, and give them a greater chance of resisting rape. One of the major sources of injury and disease in boys are cuts and fractures on the legs, arising from the fact that normal boys are born with two and are thus inclined to run about recklessly. Later they play rough sports and ride motorbikes, the accidents from which are a serious burden on the public health system. Jonathan Hutchinson's own omission with respect to such excess risk should be lesson to us. One of his sons died as a result of tetanus caught from a graze on his leg sustained in a fall. Had he been the beneficiary of a thoughtful pre-emptive leg amputation in infancy he would not have been running around so promiscuously, would not have fallen over, would not have cut his leg and caught a fatal disease, and he might well have lived long enough to make contributions to medical knowledge and human happiness as great as those of his father. <h3>References</h3> 1. Oxford Companion to Medicine, New York 1986, Vol. 1, p. 569 2. Xavier Castellsague et al, "Male circumcision and penile Human Papillomavirus infection and cervical cancer in female partners", New England Journal of Medicine, Vol. 346, 2002, pp. 1105-1112 3. For the connection: Handley WS. The prevention of cancer. Lancet 1936 May 2;1(5879):987-91; Wynder EL et al, A study of environmental factors in carcinoma of the cervix. Am J Obstet Gynecol 1954;68:1016-52. Against the connection: Aitken-Swan J, Baird D. Circumcision and cancer of the cervix. Br J Cancer 1965 Jun;19(2):217-27; Terris M, Wilson F, Nelson JH Jr. Relation of circumcision to cancer of the cervix. Am J Obstet Gynecol 1973 Dec 15;117(8):1056-66; Brinton LA, Reeves WC, Brenes MM, Herrero R, Gaitan E, Tenorio F, de-Britton RC, Garcia M, Rawls WE. The male factor in the etiology of cervical cancer among sexually monogamous women. Int J Cancer 1989 Aug. 15;44(2):199-203. See also George Denniston, "Tyranny of the victims: An analysis of circumcision advocacy", in George C. Denniston, Frederick Hodges and Marilyn Milos (eds), Male and female circumcision: Medical, legal and ethical considerations in pediatric practice, New York, Kluwer Academic/Plenum Publishers, 1999, pp. 226-7. It has recently (2003) been established by Israeli reserachers that the reduced susceptibility of Jewish women to cervical cancer is the effect of a protective genetic mutation: See Menczer J. The Low Incidence of Cervical Cancer in Jewish Women: Has the Puzzle Finally Been Solved? IMAJ 2003;5:120-3. <a href="http://www.cirp.org/library/disease/cancer/menczer1/" rel="noopener" target="_blank">Full text available here.</a> 4. Herbert Hutchinson, Jonathan Hutchinson: Life and letters, London, Heinemann, 1946, p. 30 5. James Copland, A dictionary of practical medicine, 4 vols, London, Longman, 1844-58, "Pollution", Vol. III, pp. 442, 445 6. Jonathan Hutchinson, "On the influence of circumcision in preventing syphilis", Medical Times and Gazette, NS Vol. II, December 1855, pp. 542-3 7. Ben Weinreb and Christopher Hibberd (eds),The London encyclopaedia, London, Macmillan, 1983, p. 614 8. V.D. Lipman, A history of the Jews in Britain since 1858, Leicester University Press, 1990, pp. 12, 14 9. E. Harding Freeland, "Circumcision as a preventive of syphilis and other disorders", Lancet 1900 (2), 29 December, pp. 1869-71 10. Abraham Wolbarst, "Universal circumcision as a sanitary measure", Journal of the American Medical Association, Vol. 62, 1914, pp. 93-4 11. "Circumcision and VD", Newsweek, 21 July 1947, p. 31 12. Herbert Snow, The barbarity of circumcision as a remedy for congenital abnormality, London, Churchill, 1890, p. 32-3 13. Jonathan Hutchinson, "A plea for circumcision", Archives of Surgery, Vol. II, 1890, p. 15 14. Jonathan Hutchinson, "On circumcision as a preventive of masturbation", Archives of Surgery, Vol. II, 1890, pp. 267-9 15. Jonathan Hutchinson, "On circumcision", Archives of Surgery, Vol. IV, 1893, pp. 379-80 16. Richard Davenport-Hines, Sex, death and punishment: Attitudes to sex and sexuality in Britain since the Renaissance, London, Collins, 1990, p. 194 17. Hutchinson, Life and letters, p. 200 18. "The advantages of circumcision", Medical Review, Vol. 3, 1900, p. 641 19. "The advantages of circumcision", pp. 641-2 20. Hutchinson, Life and letters, Chap. XXII, esp. p. 209 21. Ephraim Epstein, "Have the Jews any Immunity from Certain Diseases?", Medical and Surgical Reporter (Philadelphia), Vol. XXX, 1874, pp. 40-41, part quoted in Sander Gilman, Freud, race and gender, Princeton University Press, 1993, p. 64 22. Gilman, pp. 60-70; John M. Efron , Medicine and the German Jews: A history, New Haven, Yale University Press, 2001, pp. 177, 222-30 23. Milton Lewis, Thorns on the rose: The history of sexually transmitted diseases in Australia in international perspective, Canberra, AGPS, 1998 24. Hutchinson, Life and letters, p. 28 25. Hutchinson, Life and letters, p. 203 26. J. Cooper Forster, "A few remarks on the surgical diseases of children: Part 1, Congenital phimosis", Medical Times and Gazette, NS Vol. II, November 1855, pp. 491-2 27. Editorial "Cervical cancer and the elusive male factor", New England Journal of Medicine, Vol. 346, 2002, p. 1160 28. David Gollaher, Circumcision: A history of the world's most controversial surgery, New York, Basic Books, 2000, Chap. 8, esp. p. 199; Sami A. Aldeeb Abu-Sahlieh, Male and female circumcision among Jews, Christians and Muslims: Religious, medical, social and legal debate, Warren PA, Shangri-La Publications, 2001, pp. 185-7 29. Los Angeles Times, 25 June 1997 </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The crotchets of Sir Jonathan Hutchinson darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>Sir James Paget foreshadows modern research</h3> In recent times there has been a considerable effort to retrieve and restore the traditional knowledge about the <a href="http://www.cirp.org/library/sex_function/" rel="noopener" target="_blank">importance of the foreskin</a> for male sexual function (and <a href="http://www.cirp.org/library/anatomy/ohara/" rel="noopener" target="_blank">female sexual enjoyment</a>) that was common before the rise of the masturbation phobia and the consequent establishment of circumcision as a valid medical intervention. While several studies have shown that the presence of the foreskin makes a significant contribution to male sexual sensation, the Canadian pathologist John Taylor has gone further to suggest that the foreskin also plays an important role in the reflex actions that govern both erection and ejaculation. On these points, it is interesting to find that his hypotheses were anticipated by the prominent nineteenth century physiologist, James Paget, who recognised the role of the prepuce in reflex actions as early as the 1850s. Whether Paget's comments were ever published in a medical journal or in one of his own publications must await further research, but we do have a letter that he sent to William Acton, published in the first and second editions (1857 and 1858) of his best-selling treatise, The Functions and Disorders of the Reproductive Organs. Acton dropped Paget's comments from all subsequent editions of this book, and the reason is not far to seek. The decision had nothing to do with the scientific validity of Paget's suggestions, but was determined because Acton wanted to promote circumcision â€“ as an aid to chastity, a preventive of masturbation, and a protection against syphilis â€“ and was well aware any evidence as to the physiological significance of the foreskin had to be suppressed. If people were aware that the foreskin made a difference to male sexual response, it would be much harder to convince them to cut it off. Although Acton wanted to assert that there is no difference in sexual sensation between the normal and the circumcised penis, he was at least honest enough to admit that the question is difficult, if not impossible, to answer. The same degree of honesty is not, sadly, apparent in some of his anti-foreskin disciples today. The relevant passages from Functions and Disorders of the Reproductive Organs (2nd edition, 1858) are reproduced below. <h4>Sexual congress, or the act of copulation</h4> In order to fulfil the purposes of the Creator, sexual congress is necessary. This is brought about by the influence of the sex-passion; and for its more certain fulfilment is attended with a considerable degree of pleasure. Mr Paget thinks that the prepuce is of importance in exciting the reflex action. He has kindly committed his opinion to paper. He says â€” "The function of the prepuce in the act of copulation is explicable on the principle that, other things being equal, the force of a reflex act is directly proportionate to the force of the incident impression which it follows. The contraction of the pupil is thus a measure of the intensity of light on the retina: the quantity and rapidity of secretion of saliva is proportionate to the quantity and strength of an irritant taken into the mouth; and so on, in numerous instances. "In like manner, the energy of the secretion and expulsion of the seminal fluid during copulation will (other things being equal) be proportionate to the quantity of highly excitable surface which is stimulated by the act. The mucous membrane of the prepuce, naturally reverted during copulation, supplies a large extent of highly-excitable surface; and the stimulus of its nerves, added to that of the nerves of the glans, increases the force of the incident impression on the spinal cord (and brain), and thus increases, in the same measure, the force of all the reflex acts. The importance of the prepuce, in this view, may be estimated by the difference between the sensibility of its mucous membrane and that of the common integument of the penis, or that of such a scar as may remain after circumcision." [The preceding passage is found only in the 1st and 2nd editions, 1857 and 1858; it was removed from all subsequent editions. The following paragraphs were substantially retained in subsequent editions, but heavily revised. Acton's following comments explain why.] Admitting, as I do, that this distinguished physiologist is right in the abstract, I still am of opinion that the prepuce in man (at least in civilized life) is the cause of much mischief, and that we could well spare that organ. As affording an additional surface for the excitement of the reflex action, this fold of membrane, in the present state of society, aggravates an instinct rather than supplies a want. The tenor of all I daily observe shows that, in the unmarried, it additionally excites the sexual desires, which it is our object to repress. In the act of sexual congress its existence may, I grant, give additional pleasure; and as age advances it may be necessary to copulation. Without it there may be a difficulty in exciting the flagging powers; but in the present state of society, all tends to prove that we require restraint, not excitement. In animals, the prepuce, I admit, not only protects the delicate glans penis from injury, but enables the intromittent organ of the male to be brought into an erect state by yielding to an extent that is not required in the human being. ... In monkeys there is no fraenum, [1] and this, doubtless, serves some good purpose, although we may fail to discover it. Man, in a state of nature, and the lower classes of civilized society, receive thorough protection from the foreskin; but to the sensitive, excitable, civilized individual the prepuce often becomes an additional source of mischief. In the East, the collection of the secretions between it and the glans causes irritation and its consequences; hence the origin of circumcision. That the existence of the foreskin predisposes to many forms of syphilis, no one can doubt; and, lastly, I am fully convinced that the excessive sensibility induced by a narrow foreskin, and the difficulty of withdrawing it, is often the cause of emissions, masturbation, or undue excitement of the sexual desires, which it becomes very difficult for the sufferer to endure. That Jews and those who have undergone circumcision enjoy as much pleasure in the copulative act as the uncircumcised admits of no decisive proof; but I am assured by those well able to speak upon the subject, that the former do not complain. Source: William Acton, The Functions and Disorders of the Reproductive Organs in Youth, in Adult Age and in Advanced Life. Considered in their Physiological, Social and Psychological Relations, 2nd edn (London: John Churchill, 1858), pages 23-24 <h4>Note</h4> 1. In fact, chimpanzees, the closest relative to humans, have a foreskin but no glans, suggesting that the former is the more important structure. It is conventionally assumed that the key element of the penis is the glans and often said that the main function of the foreskin is to "protect it", but the fact that the only penile features common to all primates are the prepuce and corpus cavernosum suggests the plausibility of John Taylor's contrary suggestion that the glans may well be there to protect and support the foreskin. See Cold and Taylor, "The prepuce", 1999; Chris Cold and Ken McGrath, "Anatomy and histology of the penile and clitoral prepuce in primates: Evolutionary perspective of specialised sensory tissue in the external genitalia", in George C. Denniston, Frederick Hodges and Marilyn Milos (eds), Male and female circumcision: Medical, legal and ethical considerations in pediatric practice (New York: Kluwer Academic/Plenum Publishers, 1999), p. 23; and Taylor et al, The Prepuce, 1996. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The reflex action of the foreskin darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>Athol Johnson discovers a new and hopeful treatment for masturbation</h3> The following article was published in The Lancet â€“ then, as now, one of the leading British medical journals â€“ in 1860. You will note that Mr Johnson also recommends clitoridectomy in serious cases of masturbation in girls, but considers that this will rarely be necessary, since they are less prone to the habit than boys. The subject of this communication is one of high importance in its relation to the physical as well as to the moral well-being of too large a number of persons in early life. Its repulsive nature, however, and the natural desire to ignore the existence of such a practice as onanism, have prevented the attention of our profession from being willingly turned to it, and have caused too frequently those who are actually suffering from its effects, or who can be terrified into the belief that such may be the case, to fall easy victims to the rapacity of advertising quacks and of ignorant extortioners. Even now, I shall gladly confine my observations to the disease (for such it really becomes) of onanism as we meet with it in infancy or early childhood. The following case, which I was lately urged to take charge of at the Hospital for Sick Children, will serve as a fair specimen of the course the affection takes, the origin from which it may spring, and the consequences it may induce. [The case of George A] George A--, six years of age, was admitted under my care in January of the present year. He had been in good heath till he was two years and ten months old, at which time he was sent from home into the country, where he was put to sleep with a girl fourteen or fifteen years of age. Soon after this his health appeared to fail, and he became weak and ailing, but without any definite malady. Under tonic treatment some improvement took place, followed, however, by frequent relapses, and five months ago a new symptom manifested itself in the shape of deafness. He was then removed to London, and again came under the care of his parents, who were distressed to find, in addition to his deafness, that his appearance was much changed, and that from being a fine, stout child he had the aspect of a little old man. It was soon noticed that his hand was frequently applied to his penis, which was often in a state of erection, and that the prepuce was somewhat elongated. He was taken to a dispensary, where he was sounded, under the impression that a calculus might be present, but no stone was detected, and in fact no irritation of the bladder really existed. Suspicion arising on the part of his parents, a close watch was set upon him, when it was discovered that he was nightly in the habit of practising onanism. To put a stop to this, various means were adopted, including severe punishments by his father, after which he would promise to abstain, but during sleep he would get restless and excited, and on waking up would continue the practice, emission taking place. His hands were then fastened out of bed, but he still effected his purpose by a peculiar convulsive or instinctive movement of the thighs. Repeated immersion in cold water at these times, and all other plans suggested having been employed ineffectually, as a last resource he was brought to the hospital. The child confesses readily that the practice began from the time of sleeping with the girl, and that it had been continued at least once nightly ever since. He promises and appears anxious to leave it off, but owns that he cannot restrain himself when he gets excited. He was directed to sleep with his hands out of bed, and under the immediate surveillance of the night nurse. After the first night or two, the restlessness and movements were resumed, but of course immediately arrested. He was then placed on bromide of potassium, and afterwards on belladonna. Perfect cleanliness was inculcated, especially with regard to any secretion between the foreskin and the glans; and bathing etc was ordered. At the same time he was informed that it would be necessary, on account of his health, to perform an operation, with the hope that the dread of this might prove effectual; but the nocturnal excitement still continued, and I have at last removed a portion of the foreskin, without placing him under chloroform. Since the operation he has been perfectly quiet, and he has now left the hospital, with instructions that he is to be brought back if any relapse occurs. [Discussion] This case shows us how deeply rooted the vicious habit may become even at a very early age, for it was probably commenced in this instance soon after the child attained his third year; it also points out the ill consequences which may arise from placing male children to sleep with young females, and the care which should be taken in this respect even in infancy. My attention has been more drawn to this danger from my having another case at the same time under my care at the Children's Hospital, in which a boy seven years old was admitted with severe gonorrhoea and buboes, apparently contracted from a servant girl fifteen years of age, with whom he had been in the habit of sleeping. [Literature review] It must not be thought that the case of onanism I have related is a very exceptional one, nor that it is confined to the male sex, for it prevails amongst very young girls much oftener than is generally supposed. Many writers have noticed the very early age at which children give themselves up to it. Barthez and Rilliet, for instance, in their celebrated work on the "Diseases of Children", state that it cannot be concealed that "it is often very young children who abandon themselves to it with fury;" and they place this among the causes which may give rise to tuberculosis. M. Marjolin is reported, in the Gazette des Hospitaux, to have stated that "the youngest children are not exempt from the vice; that it is observed at the Hopital des Enfans Malades, and even sometimes, which may appear almost incredible, in children still at the breast. Fournier and Bergin assert that they have several times observed it in infants, and detail the case of a girl four years of age, who gave herself up to masturbation, as it were instinctively. The real nature of the affection was not discovered for four years, and, notwithstanding the means adopted, the child ultimately expired in a state of frightful marasmus, carrying on the practice to the very last moment of her existence. Vogel, too, alludes to a little girl three years of age, in whom repeated attacks of epilepsy occurred, after onanism had been indulged in for six months. Zimmerman notices the frequency of the occurrence; and Dr Van Bambeke relates three cases in children from three to twenty months old, the first child being a male, the other two females. In infancy, and even at a slightly more advanced age, the attention of the parents is the less directed to the practice because the hand is commonly not employed, the irritation being effected by a kind of instinctive or convulsive movement of the thighs, as was seen in the boy at the Children's Hospital. These movements, when noticed, are naturally not attributed to their real cause, but referred to the irritation of worms, or to some other innocent origin, and allowed to go on unchecked. According to Dr Van Bambeke, who has written an interesting article on the subject in L'Union Medicale, the face of the infant at this time becomes injected and covered with sweat, the eyes are brilliant, and the child is abstracted from objects around. It generally lies down rather than sits, fixing itself against some object by way of fulcrum. The spasmodic condition, he continues, is followed by pallor and depression; and in one of the little girls, in whom the periods of excitement were very frequent, the erectile organs had acquired a pretty considerable development. [Evil consequences of masturbation] The consequences of this practice are probably more serious at an early age than at a later period. In infancy the nervous system, especially its excito-motory portion, is highly excitable, and its functions are performed with great activity; but reaction and subsequent exhaustion are keenly felt. It is probable, therefore, that the repeated and violent excitation of the system may lead to derangement as regards both its intellectual and organic functions. The irritability of the mind and body, the peevishness, the alteration of the habits and general tone, together with the deterioration of the mental faculties occasionally observed in children, may possibly, in some cases, be attributable to this cause, and be the less amenable to treatment as their origin is hardly likely to be suspected. The disturbance of the nervous system is attended, usually, with some derangement of digestion and nutrition â€“ functions of the highest importance at this age. The appetite becomes capricious, the muscles get weak and flabby, there is general wasting and, in some cases, a decided state of marasmus. I have already stated that Barthez and Rilliet place this vice amongst the causes which may lead to tuberculosis. The special senses, too, are occasionally impaired; that of hearing, for example, in the child whose case I have given; and of vision, as noticed by Mr Kane, who attributes some forms of night-blindness, as well as of amaurosis, to indulgences of this description. I may mention also that Marjolin asserts that "almost all children affected with Pott's disease" (of the spinal column) "give themselves up to onanism with a sort of fury"; though whether, supposing any connexion to exist between the two, the disease of the spine is the consequence or the cause of the practice may possibly admit of a question. As a predisposing cause we may possibly refer to the excitability of the nervous system in early life, which is much more marked â€“ at least as regards the generative organs â€“ in some children than in others, and varies, perhaps, in different nations; for I hope that in this country the habit in question is more uncommon than would appear to be the case in France. At the period of dentition, this irritability of the nervous system is more noticeable; and Dr Van Bambeke is inclined to assign the origin of the practice, in many cases, to this cause. [Treatment in infancy] Everything, however, which contributes to the excitation of he genitals may lead to the evil, for an act from which a pleasurable sensation is once experienced by the infant, may, unfortunately, degenerate into a habit. When any suspicion, therefore, exists great care should be taken with respect to the child's bed, which should be neither too soft nor too warm, whilst the custom should be early acquired of sleeping with the arms outside the clothes. In males, a deposit of sebaceous secretion under the prepuce, and around the corona glandis, frequently occasions considerable pruritis, especially when a tendency to phymosis is present; and in both sexes the irritation of the parts from the existence of herpetic or other slight inflammatory affections may induce masturbation. The genital organs, therefore, ought in all cases to be carefully examined, and any source of irritation at once removed. The existence of thread-worms in the rectum, or between the labia, where they may often insinuate themselves, should likewise be sought for, and means taken for their extirpation. The condition of the urine should also be attended to, for irritation of the neck of the bladder from certain conditions of this secretion, leads to great excitement of the genitals and, not unfrequently, to their being pulled about, as is seen so commonly in cases of actual or suspected stone. In infancy, if these points are looked to, and if care is taken instantly to check the movements as soon as the attention of the other is directed to their nature, a victory may soon be gained; for surveillance in these cases, as Dr Van Bambeke remarks, is easy, the infant seeking no concealment. Cleanliness, of course, is of the greatest importance, and the sudden dash of cold water over the parts, at the very time of the excitement, will perhaps produce such a shock as to arrest the practice at once and for ever. [Treatment in childhood] At a somewhat later age â€“ that is, in early childhood â€“ when the habit has been persevered in for some time, the cure becomes more difficult. Any appeal to the moral sense, of any description of the evil consequences which may ultimately ensue, though recommended by some authors, I believe to be not merely useless, but injurious. If the child has not already acquired the vice you run a great risk of teaching it to him; and if he has, an indefinite and unknown future evil will never lead such a child to abandon a present gratification. Great prudence, therefore, should be exercised in our investigations; and it may be desirable to be acquainted with a test which Dr Donne asserts will enable us occasionally to recognise the existence of the practice â€“ namely, the examination of the urine, which will present, shortly after the completion of the paroxysm, some mucus mixed with oxalate of lime. The same care should be exercised at this age as in infancy in the removal of any exciting cause which can be discovered; the greatest cleanliness should be enjoined, cold bathing ordered, and the condition of the urine carefully attended to. During the day, a full amount of muscular exercise should be enforced, so that at night the consequent fatigue should render sleep prompt and necessary. Careful surveillance should be employed, and the hands kept outside the bedclothes, or actually fastened down; in extreme cases, too, we may adapt a shield of gutta percha, or other suitable material, so constructed as to prevent friction of the parts either by the hand or in the manner already alluded to. I have made a short trial of bromide of potassium, in consequence of its asserted emasculating properties; and of belladonna, on account of its great power in relieving the irritation which leads to nocturnal enuresis; neither of these remedies, however, had much effect. [Benefits of circumcision] The means I have related will often fail of even temporary benefit, for the act can be accomplished simply by the muscular movements already alluded to. In such cases we must, I believe, break the habit by inducing such a condition of the parts as will cause too much local suffering to allow of the practice being continued. For this purpose, if the prepuce is long, we may circumcise the male patient with present and probably with future advantage; the operation, too, should not be performed under chloroform, so that the pain experienced may be associated with the habit we wish to eradicate. In the female, Dr Gros has advocated, in like manner, complete to partial amputation of the clitoris; this, however, would seldom be called for, except, perhaps, in those cases where furious masturbation is associated with congenital malformation of the organ. In both sexes, if the use of the knife should be considered unavoidable, and the practice be still continued after all obvious exciting causes have been removed, various irritating applications may be used locally, so as to render any movements of the parts painful. These are most likely to be called for in boys, for in female children, with the exception of the congenital cases I have alluded to, the practice seems to be more easily checked by surveillance than it is in males. [Conclusion] In conclusion, I have only again to call attention to the great care and caution to be exercised in the selection of those, whether of the same or of the opposite sex, with whom we allow children even of tender years to sleep or associate familiarly. Bad habits are easily acquired, but are lost with difficulty; ill health at the time and formidable disease in the future, mental impairment and moral degradation, may be the lamentable consequences of negligence in this respect on the part of the parents. Athol A.W. Johnson, FRCS,* "An injurious habit occasionally met with in infancy and early childhood", The Lancet, 7 April 1860, p. 344-5 * Surgeon to the Hospital for Sick Children and Lecturer on Physiology at St George's Hospital </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Masturbation and circumcision darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Editorial, Medical Times and Gazette, 13 April 1867</h2> <h2>Background</h2> Although this is one of the most hypocritical documents in British medical history, its is also one of the most useful for illuminating the origins and nature of the double standard on male and female genital mutilation which persists to this day in English speaking countries. While it seeks to quarantine "mere circumcision" from real mutilation, it nonetheless makes a cogent and powerful case against any form of genital alteration which is performed without informed consent. The editorial was a response to the disgrace of Isaac Baker Brown, a prominent gynaecologist and dextrous surgeon who had made a name for himself as an authority on the female genitals, and the advocate of a procedure intended (guaranteed!) to cure many obscure nervous diseases â€“ clitoridectomy. Brown claimed that conditions such as hysteria, epilepsy and catalepsy, as well as the masturbation which gave rise to them, could be prevented by the excision of the clitoris, and he insisted that he was merely following the lead of surgeons such as Jonathan Hutchinson, who had similarly asserted that masturbation in boys could be stopped by amputation of the foreskin. We should particularly note Brown's insistence that clitoridectomy is neither more nor less than circumcision of the female; and as certainly as that no man who has been circumcised has been injured in his natural functions, so it is equally certain that no woman who has undergone the operation of excision of the clitoris has lost one particle of the natural functions of her organs. In his genius for self-promotion, as well as in his conviction that he had found the magic bullet for the most intractable diseases of his age, he might be regarded as the Roger Short of the mid-nineteenth century. During the early 1860s Brown enjoyed considerable celebrity, but his methods came under attack in 1866, and the following year he was disgraced and expelled from the Obstetrical Society. In this editorial the Medical Times and Gazette explains why clitoridectomy is both scientifically unsound as medical therapy and a violation of medical ethics in terms which are still relevant today. Although it tries to quarantine male circumcision from female genital mutilation in a manner all too familiar to us, its reasoning here is feeble and the discrimination fails. The foreskin is also "an organ of exquisite sensitiveness, well supplied with blood vessels and nerves"; like clitoridectomy, circumcision is also an operation "occasionally attended with serious bleeding".* On the principle stated here â€“ that sensitive organs, well supplied with blood vessels and nerves should not be excised without the informed consent of their owner â€“ the editorial may be read as an attack on both clitoridectomy and circumcision, and a clear statement of why each procedure is an offence against both medical science and medical ethics. * Indeed, while there are numerous reports in nineteenth century medical journals of deaths and complications from circumcision, similar reports on clitoridectomy are very hard to find, suggesting that the latter was in fact the safer operation. <h4>Further reading:</h4> J.B. Fleming, "Clitoridectomy: The disastrous downfall of Isaac Baker Brown FRCS (1867)", Journal of Obstetrics and Gynaecology of the British Empire, Vol. 67, 1960, pp. 1017-34 Ornella Moscucci, "Clitoridectomy, circumcision and the politics of sexual pleasure in mid-Victorian Britain", in Andrew H. Miller and James Eli Adams (eds), Sexualities in Victorian Britain, Bloomington, Indiana University Press, 1996 Robert T. Morris, "Is evolution trying to do away with the clitoris?", Transactions of the American Association of Obstetricians and Gynaecologists, Vol. 5, 1892, pp. 288-30 <a href="http://www.cirp.org/library/ethics/" rel="noopener" target="_blank">CIRP ethics and human rights pages</a> Margaret Somerville, "<a href="http://www.intact.ca/canary.htm" rel="noopener" target="_blank">Altering baby boys' bodies: The ethics of infant male circumcision</a>" <h3>Clitoridectomy and Medical Ethics</h3> Medical Times and Gazette Saturday, April 13, 1867 THE operation of clitoridectomy, as performed under the conditions described in Mr. Baker Brown's writings and denounced in Dr. West's lectures, is an offence against Medical science and Medical ethics. 1. It is an offence against Medical science in the first place, that it should be described as a mere circumcision. (Note a) Instead of taking away a loose fold of skin, it removes a rudimentary organ of exquisite sensitiveness, well supplied with blood vessels and nerves, and the operation is described by the author as occasionally attended with serious bleeding ; in these respects it differs widely from circumcision. It is a second error to assume that if a woman desired to continue filthy habits this operation would stop her. The organ removed is but one amongst many susceptible of intense excitement. (Note b) In the third place, it is against all Medical science to remove such a part because "subject" (or subjected?â€”see note) "to unbearable irritation." Intense itching is a common malady, but this itching does not depend on local causes, and it may generally be relieved by proper measures. To cut off part of the body because it itches is monstrous. If indeed the clitoris be diseased, that is another thing ; but as clitoridectomy is practised, the part is cut off without any signs of disease in it. It is nothing to the purpose to affirm that clitoridectomy may have been successful in postponing epileptic fits or lengthening their interval. Any positive line of treatment will do that for a time. Many young men believe for three months that they have found a specific for epilepsy. An intimate friend lately thought he had found one in colchinum. Give enough of any potent drug to make the patient ill, break a leg, or cut off the clitoris, and the fits will probably be interrupted for a time. Neither is it to the purpose to accuse Mr. Brown of having performed an operation rashly, groundlessly, and unsuccessfully Many such operations have been performed in the best faith. Marshall Hall used to propose tracheotomy for epilepsy ; a living Surgeon once performed castration for the same malady ; each operation thoroughly unsuccessful, and not to be defended, save on the ground of the good faith of the proposers, and of an enthusiasm which had carried them beyond the bounds of sound discretion. Although, then, clitoridectomy must be condemned as an offence against Medical science, if that were all, it might let pass into oblivion without further notice. It is the offence against Medical ethics which it involves, which has secured for it the reprobation of the Profession. 2. It is an ethical offence, in the first place, if the Practitioner who is consulted for any common complaint, say hysteria, or fissure of the rectum, set himself to consider whether or not the patient is guilty of immoral practices, which have nothing to do with the case before him. Thus, as we said in our last number, and as we implied in the Med. Times and Gaz. June 4, 1864, if the clitoridectoral theory and practice were established, no parent who sent a daughter to any Medical man for any complaint whatever, could be sure that she might not return tainted with filthy inquiries, or branded by filthy suspicionsâ€”a thing incompatible with the honour of the Profession, and the possibility of that unrestrained frank intercourse between Practitioner and patient that happily exists now. As an illustration of this kind of breach of Professional honour and its consequences, we will mention a case which was shortly touched on in our first article in the number for June 4, 1864. A young lady was brought by her friends,* ten or twelve years ago, to a Surgeon practising specially on the rectum, for a fistula. He did not content himself with exploring the fistula, but ascertained that she had lost her virginity, and told her father so. The consequences were frightful, including a painful trial, and loss of honour, character, and position to the parties concerned. All this, because the Surgeon had gone out of the path of his duty, and, instead, of confining himself to the malady for which he was consulted, had gratuitously imported into it certain moral considerations with which he had nothing to do. If this were a habit with Medical men, there would be an end to the present free an honourable intercourse with their patients. We should be accused, and justly, of making prurient, or indecent, or degrading inquiries, and of bringing a knowledge of evil to minds from which it had been absent. Affirming then, in the first place, that the very entry of thoughts of pollution into the Practitioner's mind respecting his patients is an offence of the deepest dye, this offence is aggravated by the kind of evidence which the clitoridectomist is taught to accept as proof of his patient's guilt. That evidence consists, partly, in certain physical signs detailed in Mr. Baker Brown's bookâ€”a "peculiar straight and coarse hirsute growth," a peculiar follicular secretion, and other phenomena detected by inspection, which are as frivolous as they are disgusting. It is said by credible witnesses, that at a clitoridectomical operation nose as well as eyes were called into requisition, and that a respectable Practitioner was invited to apply his nose to the parts implicated, in order to satisfy his mind, by this test, that these parts had been subjected to abnormal irritation. The thing is almost too beastly to tell of, but we want to deal with this subject once for all, and to let our readers know why clitoridectomy does not stand in the same category as any other unsuccessful operation. But says Mr. Brown, "before commencing treatment, I have always made a point of having my diagnosis confirmed by the patient or her friends." And this brings us to what we may call the moral evidence on which the patient's guilt is assumed, the process of obtaining which is one of the most heinous offences against good sense and Professional ethics that can be conceived. We have heard of questions put (not by Mr. Brown) to female out-patients after the following fashion:â€”"Do you feel any irritation in certain organs?" "Is it very bad?" "Does it induce you to rub them?" "Does the rubbing ever make you feel faint?" And if the patient answers these questions affirmatively it is said that the evidence of unnaturally excitation is regarded as complete. Nervous young women, as it s well known, may be profoundly ignorant of the nature and drift of such questions. They delight to magnify their own sensations, they enjoy the Physician's sympathy and are sure to answer " yes " to any leading question whatever. But we say that if young women are subjected to such inquiries as these in out-patient rooms at Hospitals and Dispensaries, or by private Practitioners, the sooner the Profession speaks out the better. A Medical consultation may involve the worst contamination to the patient. We think we are justified in saying that the kind of evidence on which the guilt of the woman is assumed is itself an ethical offence. That the performance of clitoridectomy on a woman without her knowledge and consent, as detailed by Dr. West, is an offence against Medical ethics, needs not to be said. We suspect it is amenable to the criminal law of the land. It is an offence against Medical ethics, also, to obtain the woman's consent, nominally, while she is left in ignorance of the real scope and nature of the mutilation, and of the moral imputations which it involves. Consent to a thing whose nature is not known, is like the consent of an infant or lunaticâ€”null and void. Equally do we repudiate, as an offence against Medical ethics, the performance of such an operation, even with the consent, nominal or real, of the patient, but without the full knowledge and consent of the persons on whom she is dependent, as wife or daughter. As the woman's character affects theirs, they have a right to decide whether a female relative should undergo this operation, with the disgrace it involves, or whether relief shall be sought from other means. We may be pardoned for adding that not one of the supposititious cases alleged by Dr. Routh at the late meeting of the Obstetrical Society has the least bearing on or analogy with the performance of clitoridectomy without the knowledge of the patient or her friends. Dr. Routh argued that all the details of every operation cannot be described to patients. But it is not the detailsâ€”it is the moral questions involved in clitoridectomy, which ought not to be kept secret. Dr. Routh argued, also, that there are cases in which a Practitioner is bound to keep a patient's secrets from her husband ; but in cases before us, it is not secrets imparted by the patient, but dishonourable surmises and filthy imputations generated in the mind of the Practititionerâ€”the nature of the mutilation and its disgraceâ€”that are kept secret. Thus, then, we have shown, as shortly as possible, the real position of clitoridectomy as an offence against science and morality, and the reasons why the Medical Profession, as an honourable, moral Profession, whose members have free and familial access to families, must repudiate and utterly reject it. Note a: "Let it be known, once for all, that clitoridectomy is neither more nor less than circumcision of the female; and as certainly as that no man who has been circumcised has been injured in his natural functions, so it is equally certain that no woman who has undergone the operation of excision of the clitoris has lost one particle of the natural functions of her organs. I would here protest against the cruel insinuation made against me by my accusers, that my reasons for performing the operation are because women are subjected to immoral habits ; when, as I have distinctly again and again asserted, I operation because there is undue and unbearable irritation of the clitoris, and in such cases alone is the operation likely to be successful."â€” (Mr. Baker Brown's "Replies to the Remarks of the Council," Nos. 12 and 13.) Note B: For evidence, see Baker Brown on Curability, etc., pp. 12, 18, etc.** <h3>Notes</h3> * "Friends" means close relatives. ** Isaac Baker Brown, On the curability of certain forms of insanity, epilepsy, catalepsy and hysteria in females (London 1866) </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clitoridectomy and medical ethics darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Jonathan Hutchinson on the advantages of circumcision</h2> <h3>1. A plea for circumcision, 1890</h3> It is surely not needful to seek any recondite motive for the origin of the practice of circumcision. No one who has seen the superior cleanliness of a Hebrew penis can have avoided a very strong impression in favour of removal of the foreskin. It constitutes a harbour for filth, and is a constant source of irritation. It conduces to masturbation, and adds to the difficulties of sexual continence. It increases the risk of syphilis in early life, and of cancer in the aged. I have never seen cancer of the penis in a Jew, and chancres are rare". "A plea for circumcison", Archives of Surgery, Vol. II, 1890, p. 15; reprinted in British Medical Journal, 27 September 1890, p. 769 <h3>2. On circumcision as a preventive of masturbation, 1890</h3> The appended letter has been sent to me from the Refractory Gallery of a lunatic asylum. The patient who sends it is himself a surgeon. I venture to bring it before my readers because I believe that the subject to which it refers is an important one, and that my correspondent's views on it are worthy of consideration. The subject is not a novel one. My late colleague, Mr Curling, I know held the opinion that circumcision was of advantage as preventing the tendency to masturbation. At one time he tried to collect facts in order to institute a comparison between Jews and others in respect to that habit, but the distasteful nature of the inquiry I believe caused him to abandon it. It is indeed one upon which it is impossible to collect statistics. General impressions are all that can be had. I have myself, from considerable experience, formed a strong opinion that Jewish young men do not suffer nearly so frequently as others from the maladies which we associate more or less definitely with masturbation and nocturnal emissions. We must remember, however, that in their case we are dealing with the circumcision of infants as preventive, not with that of adults as curative. Under the latter conditions the operation is far less hopeful. Still, I am inclined to believe that it may often accomplish much, both in breaking the habit as an immediate result, and in diminishing the temptation to it subsequently. I know that the reply from specialists will be that the disorder is in the nervous system, and not in the organs, and this no doubt is in part true. The reiterated complaints and confessions of young men, however, force on me the conviction that he habit in question is very injurious to the nerve-tone, and that it frequently originates and keeps up maladies which but for it might have been avoided or cured. I confess I see no reason why a man admitted into an asylum for ailments associated with that vice should not be allowed such chance of relief as the operation offers. I may indeed go further than this and avow my conviction that measures more radical than circumcision would, if public opinion permitted their adoption, be a true kindness to many patients of both sexes. [Letter quoted] The Hospital for the Insane, W â€”, E â€” Oct. 31, 1890 Dear Sir, â€” The British Medical Journal of the 27th of September, 1890, on p. 769, under the heading "A plea for circumcision", gives this quotation: "It is surely not needful to seek any recondite motive for the origin of the practice of circumcision. No one who has seen the superior cleanliness of a Hebrew penis can have avoided a very strong impression in favour of removal of the foreskin. It constitutes a harbour for filth, and is a constant source of irritation. It conduces to masturbation, and adds to the difficulties of sexual continence. It increases the risk of syphilis in early life, and of cancer in the aged. I have never seen cancer of the penis in a Jew, and chancres are rare". "I have been an inmate here, Sir, for more than seven years, and shall feel exceedingly obliged if you will kindly tell me whether you are aware of any reason why, if I am a confirmed masturbator, circumcision should not be performed upon me? "Will you kindly also tell me whether you think that any good reason can be advanced why Messrs L â€”, S â€”, H â€”, and D â€” (the first three quite young men), who have told me that they masturbate, should not also have circumcision performed upon them? "I mention these gentlemen's names because it seems necessary to establish the facts I mention, so that in the event of an inquiry into the truth of my statement being made, you will find that the above gentlemen have been locked up here for many months past, that they have been masturbators during nearly, if not quite, all that time, and that nothing worth calling efficient medical or surgical treatment has been given them, or been done to them, by either of the medical men, for the cure of this imperious habit." I trust it will not be supposed from what I have written above that I believe that the removal of the testes or ovaries will either completely or in all cases subdue the sexual passion. All that I contend for is that such operations are often and in most persons conducive to that end. "On circumcision as a preventive of masturbation", Archives of surgery, Vol. II, 1890, p. 267-9 <h3>3. On circumcision, 1893</h3> 1. Under what circumstances is the operation of circumcision in infancy desirable? 2. How should it be performed? 3. What special risks attend it? 1. It is imperatively required whenever the prepuce is unusually long and contracted at its orifice. The surgeon should, however, avail himself of every possible opportunity of inducing parents to have their male offspring circumcised. The operation confers great advantages in several different directions. If properly done it has no drawbacks whatever. 2. For the performance of circumcision the surgeon should be provided with two pairs of straight scissors â€“ one large, the other small. Drawing the prepuce a little forward, he should include all that is in front of the glans between the handles of his smaller scissors, and nipping it tightly, should then with the larger ones cut all the projecting part away. This will remove a broad ring of skin and leave the glans covered by only the mucous membrane. Next, with his smaller scissors, he should slit up the mucous membrane and cut it cleanly away level with the corona. Not more mucous membrane than a strip of about one eighth of an inch in width should be left. If any adhesions are present they should be carefully broken down. What remains of the fraenum should now be tied; no other vessels will need attention. Stitches are quite unnecessary, and generally inconvenient and injurious. 3. By far the most important risk is haemorrhage, and very careful attention should be given to the ligature of the fraenum. Many children have died after the operation in consequence of carelessness in this matter. The only other risks are poisoning of the wound by unclean instruments, and the introduction of syphilis by the dressings, etc. (Footnote: In my work on syphilis I have recorded a series of cases in which a Jewish circumciser communicated syphilis by unclean lint. I have recently been consulted in a case in which, in all probability, an operating surgeon did the same by his instruments.) "On circumcision", Archives of surgery, Vol. IV, 1893, pp. 379-80 <h3>4. The advantages of circumcision, 1900</h3> The first advantage of removal of the foreskin is cleanliness. In childhood this is important. In adults the habit of withdrawing the skin and washing the glans has usually been learned, though often it is not practised with sufficient frequency. In children it is, as a rule, never attempted; most boys would regard the attempt as indecent, and in many paraphymosis would result.. Apart from this risk, the practice would be injurious to the morals of the child. Yet the accumulation of smegma and its decomposition is a source of annoyance and irritation to many boys. Any irritation of the surface of the glans penis is liable to produce reflex excitement of an undesirable character. In middle life the possession of a prepuce is to many a source of more or less habitual annoyance. Seborrhoea, balanitis and herpes are common, and sometimes troublesome. As old age comes on the danger of cancer to those who suffer from phymosis is considerable. The number of middle-aged and senile persons who would be both more comfortable and more secure if they had been circumcised in infancy, is large. But the argument in favour of the general practice of circumcision which carries the most weight is that it would reduce the prevalence of syphilis. Mr Hutchinson [that is, yours truly!] many years ago collected statistics as to gonorrhoea and syphilis in Jews, which prove that whilst the former was quite as common [actually x times more common] amongst them as amongst Christians, the latter was much less frequent. This seems to show, what perhaps scarcely needed proof, that it is not to stricter morality but to some adventitious advantage that the comparative immunity of Jews from syphilis is due. The only advantage which can be alleged is the absence of the prepuce. It would, indeed, be difficult to contrive an appendage more likely to facilitate the implantation of the syphilitic virus than the prepuce. By it folds of delicate mucous membrane are kept constantly in a condition the most suitable for the retention and absorption of any virus which may be brought into contact with them. No other measure for the prevention of syphilis which has ever been proposed is so efficient as this. Its effects would be enormous. Most other measures, such as the inspection of prostitutes, have a collateral influence prejudicial to morality. Professedly making irregular sexual intercourse less dangerous, they possibly increase its amount to an extent which more than counter-balances their supposed advantages. They are also injurious to the sense of decency, to say nothing of modesty, and detrimental to the moral conscience of a community. It is not so with circumcision. Effected in early infancy, and with other avowed objects, it would silently become the means of preventing on a large scale the prevalence of a loathsome and misery-producing disease. The extent to which this diminution of risk might tend to increase sexual folly would probably be infinitesimal. The gain would be without any drawback. let it be remembered that a large proportion of the syphilis extant is contracted by young men who are by no means habitually incontinent. It is an open question whether the removal o the prepuce tends appreciably to increase the power of sexual control. Its influence, so far as it has any, must be in that direction. The only function which the prepuce can be supposed to have is that of maintaining the penis in a condition susceptible of more acute sensation than would otherwise exist. It may be supposed to increase the pleasure of the act and the impulse to it. These are advantages, however, which in the present state of society can well be spared, and if in their loss some degree of increased sexual control should result, one should be thankful. "The advantages of circumcision", Medical Review, Vol. 3, 1900, p. 641-2 <h4>Note</h4> Hutchinson was convinced that circumcision reduced the risk of contracting syphilis, but he had no proof of this, only dubious statistical correlations and impressions derived from the reportedly low incidence of syphilis among the Jewish population of east London. On the other hand, as this article and numerous others in the British Medical Journal from this period show, there was incontrovertible proof that circumcision itself was the cause of syphilis, tuberculosis and other diseases in an unknown number of cases (dozens reported, many more likely), as well as deaths arising from the operation itself. Given two sets of facts to choose from, one dubious, the other certain, Hutchinson's prior inclination towards circumcision is proved by his plumping for the former. His procedure is rather like those tunnel-visioned researchers today who, on the basis of some equally suspicious statistical correlations, say that little African boys should be forcibly circumcised to save them from AIDS; yet who, like Hutchinson, ignore the fact that circumcision itself is a significant cause of death among African boys. (Indeed, it is likely that more <a href="http://www.cirp.org/library/death" rel="noopener" target="_blank">African teenagers die as a "complication" of circumcision</a> than from <a href="http://www.cirp.org/library/disease/HIV/" rel="noopener" target="_blank">sexually acquired AIDS</a>.) </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Hutchinson on circumcision darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h4>Herbert Snow's attempt to turn the tide</h4> One of the reasons why circumcision remained a minority practice in Britain is that it never commanded the unanimous assent of the medical profession and, unlike in the USA, there were always vocal critics from within the medical fraternity itself. One of the earliest of these was Herbert Snow, who wrote a short book against the rising tide as early as 1890, and which he called The barbarity of circumcision as a remedy for congenital abnormality. <h3> <a name="the"></a>The context</h3> It is not possible to hail Snow's text as a model for today's critics of routine circumcision, much less as a source of reliable anthropological or biological knowledge; what is interesting is not that Snow was ahead of his time, but the extent to which he was bound by the limited and erroneous knowledge of his place and period. The most serious instance of this is his acceptance of the theory of congenital phimosis and consequent belief that the infant's foreskin should be mobile and retractable within a few days of birth. His argument was not that this theory was wrong, but that circumcision was an inhumane and barbaric way to deal with the problem; the right way was by dilation of the foreskin. He thus became one of the founders of the "dilatation vs circumcision" debate, which dominated the discussion of the issue until Douglas Gairdner disproved the theory of congenital phimosis in 1949. Snow's discussion of the historical evolution of circumcision as a religious rite is less off the track, but even there he was often misled by the limitations of the anthropological research available to him. <h4>Snow's argument</h4> In his booklet, The barbarity of circumcision as a remedy for congenital abnormality, Snow's stated aim was "the abolition of an antiquated practice involving the infliction of very considerable suffering upon helpless infants; and sanctioned, on very questionable grounds, by men of eminent authority". This statement concisely set out the terms of his opposition: circumcision was an antiquated religious custom, not a modern medical therapy; it meant suffering and harm to a class of patient who had not given consent; and the grounds advanced to justify it were spurious. He also implied that the advance of circumcision was an effect of the authority of its promoters, not of the quality of their scientific reasoning. On the first point, Snow rejected hygienic explanations for the origin of ritual circumcision and accepted the argument of anthropologists that it was a sacrifice intended for a deity which obviously required appeasement, and probably an attenuated form of what had once been the sacrifice of something yet more precious, such as the entire genitalia or living children. He took the view that the tribes who practised circumcision were barbarians whose customs did not warrant emulation by modern Britons. On the second point Snow made the reasonable suggestion that "no sane man who possessed the advantages of a sound and entire prepuce would willingly sacrifice it without just and sufficient cause being shown". He described circumcision as the abstraction of a structure, not indeed of paramount importance to the organism, but obviously evolved by Nature for wise ends as a protective covering. Were there no necessity for its presence it would not occur; and without overwhelming evidence that such mutilation is unavoidable and beneficial, it must be held ethically criminal thus to lay rough hands upon a perfectly normal organ. Snow then argued that the four advantages claimed by the proponents of circumcision did not stand up to scrutiny. He dismissed "enhanced local cleanliness" as trivial and irrelevant in modern conditions, commenting that nobody advocated similar tactics like shaving the head or pulling out the toenails. On the argument for greater chastity and "preclusion of immoral personal habits", he agreed about the importance of chastity but considered the evidence to be inconclusive; he countered that plenty of Jewish and other circumcised men were known to masturbate, and made the desperate and improbable claim that early removal of the prepuce encouraged infantile fondling. On the argument for protection from venereal disease, he found the case "not proven", and he pointed out that even Hutchinson's statistics showed that (circumcised) Jews were more prone to gonorrhoea. On the claim for protection against cancer of the penis, Snow replied that this was a rare disease of adults, more likely caused by phimosis and poor hygiene than the foreskin per se. Disadvantages of circumcision Turning to the offensive, Snow then listed the "disadvantages and dangers of circumcision", and devoted several pages to a discussion of what are now called "risks and complications": the most common injuries inflicted during the procedure and some of the longer term side effects. He commented that the traditional Jewish practice of metsitsah (the sucking of the penis following the cutting of the foreskin) had been largely discontinued among modern communities because of its role in transmitting syphilis and tuberculosis. He also warned that infection, haemorrhage, ulceration and damage to glans, meatus and shaft were regular occurrences when circumcision was performed in surgical settings, but his case lacked force because he could not produce figures: nobody was recording instances even of immediate injury and death, let alone the longer term problems (such as excessive tissue loss) which might not become apparent until puberty brought the penis to its full size. If official statistics in the 1940s showed 16 deaths each year from surgical complications, it seems likely that the number of fatalities before antibiotics must have been considerably higher. Snow was rare among medical commentators in showing some regard for the boy being operated on as a subject with his own feelings and opinions, rather than a mere object at the mercy of guardians and doctors: An American operator ... speaks of the difficulty of keeping children's knees out of the way after removal of the prepuce, and of the consequent torture to them. Even after healing, contact with flannel napkins and other clothing must long be very painful. There can be little doubt what would be the verdict â€“ could they only give it utterance â€“ upon the immediate results of the operation in question, returned by these inarticulate (if far from mute) victims of hygienic orthodoxy. If Snow was unusual in showing scruples about consent, he was even more radical in admitting that "an objection to circumcision of wholly sentimental character [is] not the less worthy of practical consideration". Why shouldn't boys be emotional about their penis? <h4>Its reception</h4> The barbarity of circumcision was reviewed cautiously by the British Medical Journal, which had reservations about Snow's sweeping rejection of circumcision; and sympathetically by the Lancet, which was "inclined to endorse most of what he says". It agreed that circumcision was a relic of primitive man, pointing out that the peoples which still practised it were "many of the least civilized peoples on the face of the globe". More significantly, it accepted Snow's argument that an operation was rarely necessary "for the relief of congenital phimosis", and it actually proposed that "the prepuce is not the valueless or mischievous appendage that some would have us believe"; although "non-separation of the prepuce from the glans penis is constantly mistaken for phimosis", only genuine cases of the latter required operative treatment. The reviewer did not go so far as to suggest that an adherent prepuce needed to treatment at all, but he supported Snow's view that "forcible retraction" and its "daily repetition for a short time" was all that was required. It is thus clear that Snow was not an isolated voice, but equally apparent that the misconceptions about genital anatomy and preputial development which had originally led to the craze for widespread circumcision were very deeply ingrained. The full text of the reviews in the BMJ and the Lancet are below. <h4>Limitations of Snow's argument</h4> The effectiveness of Snow's intervention was limited by two serious weaknesses. First, he accepted the current medical wisdom that the adherent and non-retractable foreskin was indeed a pathological defect which required speedy correction. he went so far as to write that "a perfectly healthy condition of the male generative organs is compatible only with perfect mobility of the prepuce over the glans", and further conceded that it was "universally agreed" that "the adhesions between the prepuce and the glans can nearly always be broken down ... during the first few weeks after birth". Where he differed from most of his colleagues was in his insistence that this could be achieved by manipulation and dressing, rather than amputation. It was, however, very hard to defend the foreskin by thus conceding the major complaint of its enemies, for it was this very "phimosis" which formed the basis of their charge that it led to childhood masturbation, nervous diseases and increased susceptibility to syphilis and cancer. Snow argued that all these risks could be managed conservatively, but his methods were a lot of bother, and it is little wonder that many doctors and parents preferred the quick snip. Secondly, for all the depth of his conviction that possession of one's foreskin was advantageous, Snow was hard-pressed to articulate what those advantages were. The best he could do was cite Dr Willard (from Keating's Cyclopaedia of diseases of children) that its functions were "to protect the head of the organ during the years when the penis is but a portion of the urinary apparatus; and later, by its friction over the sensitive corona, to enhance the ejaculatory orgasm". He actually rejected Willard's largely correct echo of Aristotle's master-piece, that foreskin and glans worked in tandem to generate sexual sensation (though even he emphasised the final orgasm at the expense of the pleasures of getting there). Snow replied with the ignorant majority that "since the prepuce is completely retracted during coition ... no friction over the corona can well take place". But even if this were true (and there is obviously much variation from one individual to another), the foreskin would still increase sensation by the mere fact that its nerve-rich surfaces were now redeployed along the shaft of the erect penis. All Snow was left with was the rather lame protestation that the foreskin was necessary to protect the glans â€“ a plea which fell easy prey to the sallies of Clifford and Remondino, who simply countered that the protection needed by naked savages leaping over thornbushes was no longer essential for civilized men wearing underpants. Without appreciation of the complex innervation and physiological role of the foreskin, and thus awareness that it had significant value in its own right, it was difficult to argue effectively against its dismissal as a redundant scrap of skin. <a name="dow"></a>This title page is taken from an interesting copy of Snow's book. It shows that this copy was owned by Ernest Hart, editor of the British Medical Journal, and that he presented it to the library of the British Medical Association. It may well be the very copy that Snow sent for review to the journal, in which case it is also possible that Hart himself was the reviewer. <h3> <a name="rev"></a>Reviews of The barbarity of circumcision</h3> The Lancet The barbarity of circumcision as a remedy for congenital abnormality, by Herbert Snow, MD, Surgeon to the Cancer Hospital We must confess to sympathy with the main contention of this brochure, which is that circumcision is a relic of barbarism which has survived in certain races because elevated into a religious rite. Its origin in barbarism is seen by its being practised by many of the least civilized peoples on the face of the globe. But it is the surgical argument which is of most interest, and while we cannot go with Dr Snow to the extreme to which the zeal of the advocate has led him, we are inclined to endorse most of what he says. The prepuce is not the valueless or mischievous appendage that some would represent it to be, nor its removal so entirely harmless as some would have us believe. The great fact, however, on which we would lay stress is the rarity of any necessity for circumcision for the relief of congenital phimosis. Non-separation of the prepuce from the glans penis is constantly mistaken for phimosis, and while the latter requires some kind of operative treatment, the former never does in infant and little boys. The forcible retraction of the prepuce (very slight force is really needed), and the daily repetition of this for a short time, brings about in a perfectly harmless and only slightly painful manner a better result than the operation of circumcision effects. The Lancet, 20 June 1891, p. 1386 British Medical Journal Dr Snow has a strong objection to circumcision as a remedy for congenital phimosis, and brings forward facts and arguments in this little book in order to prove that the operation, whilst causing much suffering to helpless children, is as a rule quite unnecessary. Although, as is acknowledged in the preface, no one could expect without presumption to abolish this practice altogether, it is probable that many of those who peruse this book will be induced to question the propriety of resorting very frequently to circumcision in the treatment of certain abnormal conditions of the prepuce. The first chapter is devoted to an historical sketch of circumcision as a religious rite. Dr Snow's work is too small for a satisfactory discussion of so large a subject, but he has collected many interesting facts, and presents good grounds for the view he holds that circumcision , as regularly practised by very numerous races of diverse origin, is essentially a sacrificial and religious act, and has no title to any hygienic character or purpose. In a subsequent section there is a full discussion of the arguments in favour of the removal of the prepuce in cases of supposed congenital abnormality. The author holds that the operation does not conduce to local cleanliness in after-life, or to greater chastity and, moreover, that it does not serve to protect the subject from venereal disease or render him less prone to cancer. In many cases, it is asserted, death has been caused by circumcision, and the operation in most instances entails as an immediate result much suffering, and as a remote result contraction of the meatus urinarius. Even in cases of acquired phimosis and in adult subjects circumcision, it seems, is not free from risk. Indeed, Dr Snow would reserve the operation for some few exceptional cases of chronic acquired phimosis. With regard to the congenital form, he holds that the common-sense and most satisfactory treatment is dilatation, associated in complicated cases with limited incisions. With the results of such treatment the author states that he is entirely satisfied. There can be little doubt, we think, that circumcision has frequently been performed in cases in which [a] careful and prolonged bloodless plan of treatment might have effected a cure. Dilatation, however, is by no means a novel plan of treatment, and, as Dr Snow tells us, it "must have been repeatedly resorted to by many practitioners of the past." many and varied forms of instruments have been devised for carrying out such treatment, some of which are described in this book. This fact, together with that of the advocacy of circumcision in cases of congenital phimosis by many very cautious and experienced surgeons, would seem to us to suggest that the dilatation method may not be invariably satisfactory, and that a certain number of cases may remain in which operative treatment will be found necessary. British Medical Journal, 16 May 1891, p. 1078 </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The barbarity of circumcision (1890) darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>The old dilation vs circumcision debate gets interesting</h2> <h3>Introduction</h3> As the incidence of routine circumcision in Britain reached its peak in the early 1930s, a controversy in the correspondence columns of the British Medical Journal revealed that just about as many doctors were opposed to the procedure as in favour of it. The correspondence is notable for the dismal quality of much of the argument, depressing lack of knowledge about male anatomy and sexuality, and blythe disregard for medical ethics. Anecdotes and "wise saws" were tossed around as though they were hard facts; nobody was aware of existing research which showed infantile phimosis to be normal or that assumptions about the "greater erotic sensitivity" of the glans were erroneous; and there was no suggestion that boys might miss their foreskin or were entitled to a say in whether they were allowed to keep it. [1] The dominant obsession â€“ with the squeaky cleanliness of the glans â€“ harks right back to William Acton's nervousness about the role of "secretions" in "premature sexual arousal" and masturbation. Much of the discussion centred on such Victorian medical principles as the physical dangers of masturbation, and the necessity for instant action against "congenital phimosis". If these points in favour of circumcision did not impress, advocates trotted out their clinching argument: that it provided protection from, if not immunity, to syphilis. But the debate is also remarkable for an entirely new note in British medical discourse: the suggestion that doctors should not be concerned with moral issues like masturbation, and the revolutionary suggestion that phimosis in infants was not a disease or abnormality at all. Although most of the opponents of circumcision laboured under the delusion that "congenital phimosis" in infants had to be treated urgently, the provocative Dr Ainsworth dared to state that phimosis was an "imaginary disease" and even recommended that the infant foreskin be left entirely alone, thus pointing the way toward <a href="http://www.cirp.org/library/general/gairdner/" rel="noopener" target="_blank">Douglas Gairdner's demolition</a> of "congenital phimosis" the following decade. The controversy was kicked off by a letter from D.I. Connolly, who deplored the high rate of injury and death arising from infant and childhood circumcision, and proposed his own patent method for separating and stretching the foreskin. Much of the resulting debate was the old circumcision vs. dilation argument which still gripped <a href="http://www.historyofcircumcision.net./templates/pages/should_he_be_circumcised_1941.html">Alan Guttmacher in 1941</a>. The zeal with which Connolly and his commentators recommended their patent methods for either cutting or stretching was not matched by the clarity of their exposition; most gave such a confused description of their technique that one wonders whether they could have given clear instructions for making a cup of tea, let alone for operating on one of the most complex sites of the male body. <h3>The letters</h3> <h4>The controversy is sparked off</h4> Although circumcision is performed frequently in all parts of the world, yet I think that this minor operation is capable of causing much trepidation even to the most experienced of surgeons. Complications occur now and again, but the most dreaded sequel of all is haemorrhage. This latter has been known to be the cause of death. It is not necessary to stress this fact; it is known only too well to many amongst us. Shock also may be an immediate cause of death. Other complications such a sepsis and ulceration do arise, and the latter may have serious later consequences. Hence the question arises: Is there any reliable, efficient method of treating severe phimosis other than by a cutting operation? In my opinion there is such a method, and one worthy of extensive trial. This method â€“ or operation rather â€“ should be performed as early as possible, say within the first week of the infant's life. No anaesthetic is needed. After thoroughly cleansing all the parts, using any reliable antiseptic â€“ for example, bichloride of mercury â€“ and wiping with antiseptic spirit, the child's legs are held firmly by an assistant standing at the head of the infant and the latter lying on his back. Strict asepsis must be practised as in any major operation. The instruments necessary are: Spencer Wells forceps, dressing or sinus forceps, and a blunt probe. The operator should draw the prepuce downwards with the index finger and thumb of his left hand. Gently insert the closed blades of the Spencer Wells forceps into the prepuce, of course avoiding the urinary meatus. Using care, push the blades gently upwards and at the same time opening the blades and thoroughly stretching the outer layer of the prepuce. Keep the blades in this position and manoeuvre the prepuce back beyond the glans penis. Then separate the inner layer of the prepuce from the glans by means of the blunt probe. Apply the blades of the sinus or dressing forceps to the inner layer of the prepuce and repeat to it what has already been done to the outer layer â€“ that is, manoeuvre it back to beyond the neck of the glans. Clean away all smegma and secretion that may have accumulated on the surface of the glans penis. The next and important step is the dressing. It is absolutely necessary to keep the entire prepuce in the position as described for the next few days. To do this, I have devised a circumcision dressing shield made of fine rubber, perforated with holes to allow the passage of fine tapes. These latter can be carried round the groins and tied off securely there. The shields are made up in sealed antiseptic cartons ready for use. They are impregnated with a zinc oxide cum boric powder. If necessary, some ribbon aseptic gauze may be first applied firmly around the retracted prepuce, and then the shield may be applied. Usually the mother is intelligent enough to be able to reapply the shield (if necessary). The child may be brought to the hospital or the surgery for redressing. The whole procedure should not take more than five minutes. The points in favour of it are: (1) absolute efficiency; (2) no haemorrhage; (3) fouling of the wound is reduced to a minimum â€“ the child is not able to kick off the shield dressing when efficiently applied and tied, hence sepsis is not so likely to occur; (4) if care and gentleness are used in the operation, shock is negligible; (5) anxiety and worry as to haemorrhage is removed from the surgeon's mind. The circumcision shields are made to my design by F. Whitehead and Co, Pickets Street, London S.W. 12. D.I. Connolly BMJ, 24 August 1935, p. 359 <h4>Responses</h4> I was interested in the technique described by Dr D.I. Connolly, as I endorse his view that circumcision can be followed by many unfortunate consequences. Apart from the immediate physical effects, there is considerable evidence that an operation which is a perfect result from a surgical point of view may yet cause psychological trauma, which may either show itself at once, or become obvious only in adult life. As the likelihood of such psychological trauma appears with the age of the child, it seems wise to deal with the condition at the earliest age possible, whether the prepuce is already adherent or the opening so small that adhesions are likely to occur. I first learned from Mr Geoffrey Keynes about five years ago that stretching the foreskin was a useful alternative to circumcision, and since that time I have not found it necessary to operate on any male child in my practice except in the case of orthodox Jews. My method is to stretch and free the foreskin daily, using a probe and sinus forceps, and doing it so gently that the child does not protest. This method will entail daily visits for one or two weeks, but after that the foreskin is quite free and can be pushed back by the mother when the child is washed as often as seems necessary to keep the glans clean. The stretching may be started soon after birth, and as a rough guide that a baby can stand this amount of interference, I usually wait until it has regained its birth weight. With adequate patience the whole thing can be done entirely without pain or risks, and to my mind the operation of circumcision in childhood is now seldom justifiable. Cecile Booysen Dr Connolly is to be congratulated on having taken a first step towards the treatment of phimosis. May I hope that he will soon take a second? The cool assumption of some surgeons that they know better than providence how little boys should be made is laughable and irritating. it is quite time that this horrible mutilation should no longer be regarded as having any sanitary or therapeutic value, and phimosis should be relegated to the list of imaginary diseases. Circumcision is, and always was, a tribal rite, and has no place in surgery. R. Ainsworth Referring to Dr D.I Connolly's letter, I am glad to hear of someone at last who is opposed to unnecessary circumcision: the majority of doctors and most nurses are obsessed with the idea that 90 per cent of male infants should be circumcised. The prepuce has its definite uses, which need not be gone into here. I myself have practised a similar method to the one described by Dr Connolly for over thirty years â€“ with success, but with this difference: I always use a local anaesthetic and no dressings or appliances. After separation of the prepuce from the glans penis, the prepuce is completely retracted, a mild antiseptic ointment is applied, and the foreskin is replaced in its normal position. All that is necessary thereafter is that the prepuce should be completely retracted once daily and the ointment applied by the nurse or mother until it goes back easily and the mucous membrane, when abraded, is seen to be healed. This usually requires about seven to ten days. Subsequently the prepuce should, for purposes of cleanliness, be retracted in the daily bath and cleaned with a little wet cotton-wool. D. Gordon Carmichael Although severe phimosis in infants may occasionally require circumcision, I was once told by a surgeon with twenty years in general practice that he had almost entirely avoided the operation by completely stripping back the foreskin, aided by dilatation if necessary, in the newborn and others, and by instructing the mother to see that it would peel back and to clean behind it each time the child was bathed. My own small experience is confirmatory. Every urologist would welcome the instilling of this particular habit of cleanliness into possible future patients. Malcolm Baillie Dr D.I. Connolly's very excellent procedure in the treatment of phimosis has one serious drawback â€“ the prepuce still remains. The teaching that the male should be circumcised on the eighth day has stood the test of time, and still remains sound. That the prepuce should be removed, whether phimosis is present or not, is an opinion which deserves the careful consideration of every doctor practising midwifery. Circumcision becomes a gentle art if practised in accordance with this theory. Joseph McAuley BMJ, 7 September 1935, p. 472 <h4>More responses</h4> Your correspondent Dr R. Ainsworth has apparently overlooked one important and well known fact when he writes that "circumcision is and always was a tribal rite and has no place in surgery", namely, the occurrence of carcinoma of the penis in the uncircumcised, and the extreme rarity of its occurrence â€“ if ever at all â€“ in those who have been circumcised. M.M. Posel In India, where I practised for over twenty years, no Hindu is ever circumcised; it is the mark of the Mohammedan. (In the Moplah rising, the Mohammedans forcibly circumcised Hindus who fell into their hands.) Imagine the reception a European doctor would meet with who practised it on all and sundry! This being so, what was to be done with Hindu infants who, having phimosis, had well developed rupture due to straining? I asked a ell-known Brahmin doctor with a large practice in the Punjab â€“ R.B. Balkishau Kaul of Lahore. He said that, whatever the difficulty, circumcision could never be done on a Hindu infant. All that was needed was to roll the prepuce sideways between finger and thumb, which broke down any adhesions, and then to push it back over the glans. This method was the same as that practised by Indian dais (midwives) when drawing milk from a woman's breasts. The nipple is gently trolled between finger and thumb. It is then easy to milk out any coagulum. Kathleen Vaughan Divergent views having been expressed on this subject, may I attempt to sum up and clarify the position? Dr McAuley's letter raises the point which is the crux of the matter: Should the prepuce be removed whether phimosis is present or not? I suggest that phimosis, especially if extreme, demands circumcision for these reasons. (1) Many infants so affected cry excessively until the operation is done: thereby (2) they may develop hernia. (3) Various troubles â€“ for example, nocturnal enuresis, "fits", and, in later life, epithelioma of the glans and paraphimosis â€“ are associated with phimosis. (4) In patients with phimosis suffering from gonorrhoea, complications arise, and treatment is more difficult than in the circumcised. (5) The disadvantages in the event of marriage are obvious. Although difficult of proof, there is little doubt that the prepuce, especially a long one, renders boys more likely to acquire the habit of masturbation. For this very good reason alone I think circumcision desirable, phimosis apart, If the reasons given for circumcision are sound, then stretching operations find no place. I venture to describe the method I use, as it is not the orthodox one. It is well to wait until the infant is 2 to 3 weeks old, and feeding is well established. Local anaesthesia is always used, novutox or locosthetic (P.D. & Co), being injected with a fine needle at the root of the penis on the dorsum and below at the peno-scrotal junction. This makes the operation entirely painless, as I have repeatedly proved. After thorough sterilising of all the parts with spirit and biniodide solution, the end of the prepuce is seized on the dorsum on each side of the middle line with small, narrow-bladed Spencer Wells forceps. Traction on these parts puts the prepuce on the stretch. A similar forceps is then passed down under the prepuce (dorsally), and opened widely, stretching the prepuce and freeing it from the glans, right down to the neck of the latter. The blade of a pair of straight, blunt-pointed scissors is then passed under the prepuce and the latter slit down dorsally to the neck of the glans. The prepuce is then separated, if necessary, from the glans on each side, and cut away, beginning at the fraenum and ending on the dorsum. The cutting is carried round close to the neck of the glans, leaving just enough skin and mucous membrane to be stitched together. During these various manoeuvres traction is made on the forceps originally applied, so as to steady and stretch the prepuce. Often no vessels need tying â€“ at the most, one on the dorsum and one on the fraenum. The free edges of the skin and mucous membrane are united by a few sutures of fine iodised catgut, using a small, half-circle Hagedorn needle. A narrow strip of sterile gauze is wrapped round and tied on. The operation takes very little longer than the usual one, and the skin edge left is almost a perfect "circle"; any after-trimming of the edges is rarely necessary. The advantages of this method are two: (1) there is no possible risk of injury to the glans; and (2) seeing exactly what one is doing, it is possible to remove the whole of the prepuce, which is the main point. results are entirely satisfactory, and in my experience shock, sepsis, haemorrhage etc are unknown. Stitches absorb or work out, and healing is complete in five to ten days. I hope I have shown, in reply to the flagrant statements of one of your correspondents, that "circumcision" is not a "horrible mutilation", that it "has a sanitary and therapeutic value", and, being ordained by Providence from very early times (doubtless for good reasons), it is not a "cool assumption" on the part of surgeons doing this operation that they "know better how little boys should be made". And if phimosis is to be relegated to the list of imaginary diseases, why not make a clean sweep, and say that cancer, tuberculosis, and the rest do not exist? G.W. Thomas This subject, like the big gooseberry, seem to crop up every few years, but nothing very fresh has been said on either side, and too often arguments are built up on irrelevant facts or theories. An example of this is given by Dr R. Ainsworth: "Circumcision was and is a tribal rite"; ergo, there is nothing more to be said in its favour. But was not fire itself at first an object of savage worship â€“ yet we do not discard our kitchen stoves? Again, the argument is brought up that the prepuce "being a work of providence" (with a small p, however), must be perfect. This strange argument would seem to abolish all evolution from the present-day perfection of everything, and one wonders was the five-toed horse perfect in its day and, if so, why was our one-toed animal evolved? But these are side issues. The crux of the whole matter is: Does removal of the prepuce lessen the incidence of syphilis? If this can be answered on the affirmative â€“ and surely the Jewish practice can provide statistics to settle it â€“ then circumcision is surely a duty in all cases. F.G. BMJ, 21 September 1935, p. 560 <h4>Another contribution</h4> It is 42 years since I qualified. For many of these years I circumcised most of the boys. Latterly it is never done. Dr D.I. Connolly describes "unfortunate consequences", which I fully confirm â€“ severe haemorrhage (one death from this cause), obstruction caused by sticky lymph at the urethral orifice, eczema round the scar, irritation of the glans penis. With firm determination the prepuce can always be pressed back. A few years ago Messrs C.H. Fagge and F. Steward of Guy's [Hospital] discontinued the operation, and there now exists a widespread objection to it, as shown by the correspondence in your columns. It may be worthy of record that I have been compelled to perform he little operation for a man of 80 years and, last year, for a man of 52 years, both with excellent results. Vaughan Pendred BMJ, 28 September 1935, p. 603 <h4>Yet further correspondence</h4> To the other not negligible points in favour of circumcision already recorded by many of your correspondents, I hope you will permit me to add that all those whom Providence (with a capital P) has cast for the lot or doom, of working in a venereal disease clinic (and especially one for seafarers) can have only preference for the circumcised patient. He is cleaner, easier to handle and treat, and his condition is easier to diagnose. While there is no convincing evidence yet presented of less incidence of syphilis in the circumcised, our observation here is that in patients with primary syphilis presenting themselves for diagnosis and treatment, there is a higher proportion of sero-negative cases among the circumcised. Obviously the lesion has been the sooner noted by its circumcised bearer; and this is true of all the other lesions occurring on the glans or frenum or on under-surface of prepuce. The sooner noted the sooner is treatment sought. Venereal warts and buboes are rarer in the circumcised. Many adult males who have experienced sexual intercourse before and after circumcision have, on questioning, reported either "no difference" or "better"; none has said worse. Mr Havelock Ellis records the preference of the copulating woman for the circumcised male. And look you, Sir, providence (surely now with a small p) has contrived that gorilla and chimpanzee be born without prepuce. [2] H.M. Hanschell If your correspondent F.G. would refer to the Journal of January 27th, 1934, (p. 144) he would find reported some facts relevant to the question "Does the removal of the prepuce lessen the incidence of syphilis?" [3] An inquiry into the relation between presence or absence of the prepuce and acquired venereal disease in 400 consecutive patients attending the department for venereal diseases at Guy's Hospital failed to show any appreciable differences, and we were led to believe that as far as our own facts went, there was no lessened risk of acquired syphilis in the circumcised. V.E. and N.L. Lloyd No doubt more than enough has already been written in your columns on circumcision, and views have been expressed with almost religious fervour. I feel, however, that the letter of Dr Cecile Booysen should not go unchallenged. She writes: Apart from the immediate physical effects, there is considerable evidence that an operation which is a perfect result from a surgical point of view may yet cause psychological trauma, which may either show itself at once, or become obvious only in adult life. I do not know, nor does she tell us, on what evidence this assertion is based; but I am confident that the treatment she practises in place of circumcision will most certainly tend to bring about a most serious psychological trauma â€“ namely, the habit of masturbation at a not very much later date. As I understand it, the treatment consists of stretching and freeing the foreskin daily for "one or two weeks", and when it is free the mother is instructed to carry on "when the child is washed as often as seems necessary to keep the glans clean". She adds, "with adequate patience the whole thing can be done entirely without pain or risks". I have no doubt that the child exhibits no sign of pain, but rather of pleasure, for as every child's nurse knows, nothing quiets a child so much as gentle manipulation of his genitals. At the same time, nothing is more apt to start the habit of masturbation than regular and long-continued manipulation of the penis. We are many of us familiar of us with the melancholy sight of a child of 3 or 4, or even younger, masturbating, and most investigators in this field are satisfied that this practice in the very young is the result of unwise handling by parent or nurse, which has taught the child he possibility of pleasurable sensations from friction on those parts. In a letter in he next column Dr Carmichael advocates much the same procedure. His treatment requires seven to ten days intensive manipulation, followed by occasional handling at bath time. In my view, if the glans can only be kept clean by regular manipulation of the foreskin, then it had better be left dirty or its covering removed surgically. Whether it is any more necessary to cleanse the male glans than it is to wash out the virgin vagina I will leave to your readers, but in my view the increased liability to syphilis and cancer in the uncircumcised is sufficient justification for removing the foreskin. C.E. Gautier-Smith BMJ, 5 October 1935, p. 642 <h4>The debate continues</h4> I am afraid that I must have earned, in my short time, the disapprobation of a number of your readers, for in my blundering ignorance I have assumed the mantle of a divinity and "shaped the ends" of some thousands of small boys. Yet I am unrepentant, for never have I had a complaint as regards ill after-effects. In view of my own slight experience I should unhesitatingly have any male children of my own circumcised within the first four weeks. The benefit conferred in respect of cleanliness alone is well worth any so-called risk of psychological trauma. I cannot convince myself of the reality of this phenomenon occurring in any child under, say, 5 years of age. I have a distinct recollection of my own circumcision at the age of 2, yet I altogether fail to perceive any gross mental lesion resultant therefrom. No person with any great experience of more or less routine circumcision in all cases of even "tightness" of the prepuce, as distinct from real phimosis, can have failed to appreciate the resultant benefit in the general health and well-being of the children. This was not the case in children whose prepuce was merely "well stretched". In almost all cases when such was done it was later found necessary to circumcise the child, whereupon all trouble ceased. "Bad technique!" exclaim all the "stretching" experts. No doubt but the technique was exactly that employed by Dr D.I. Connolly. Complications are, in my experience, due in almost all cases to poor nursing and careless mothers, and, even with the poorer classes in Glasgow as out-patients, were notable by their slight incidence. Haemorrhage need never occur with skill and careful ligation, and in cases where there is any tendency to general oozing I always found that a touch of adrenaline upon the dressing was always quite sufficient. I am interested in the theory that the operation may lessen the liability to syphilitic infection. Your letter from the Drs Lloyd seems to negative this, but I do think it is worthy of full investigation. At present I have twelve continuous treatment cases under my care. Of these only four have been circumcised. one can form no valid conclusion from such small figures, but it would be interesting to hear from some hospital authorities or VD clinics whether circumcision does, apparently, lessen the risk. D.W. Walker For many years I have been interested in circumcision as practised both in males and females in various parts of the world, and in my book to be published soon this essentially "tribal rite", as rightly described, will be fully investigated. When we come to inquire into the origin of this strange custom we meet many difficulties, but certain facts give support to the view that it originated from entirely different motives, such as (1) hygienic and prophylactic (useless, of course); (2) a possible association with phallic worship (and that, as we know it today, the remains of prehistoric human sacrifice connected with the cult); (3) a sacrifice of a portion to the gods to preserve the rest from harm, a practice well illustrated in other parts of the body; (4) to promote chastity â€“ history supplies examples of its total failure in this respect. Where did the practice originate? It was not compulsory, except among the priesthood, in ancient Egypt, and there is strong evidence that it was introduced into that country by the Negroes. It has been practised in West Africa for over five thousand years, without variation, and today the circumcision societies are still in a flourishing condition. It is general among the Jews, who took the custom from either the Babylonians or the Negroes, probably the latter. It is untrue to say the spread of the custom in Africa is due to Islam; it existed, of course, thousands of years, before Islam. It is interesting to note that during the Roman occupation of Egypt any doctor performing the barbaric operation was executed â€“ a harsh measure, but I believe some punishment should be reserved for those who waste valuable space in medical journals advocating the mutilation. T. Gerald Garry BMJ, 12 October 1935, p. 702-3 <h4>More arguments</h4> While avoiding the pros and cons of circumcision of male infants and children, I should like to express my entire agreement with Dr C.E. Gautier-Smith â€“ that manipulative surgery should find no place in the treatment of phimosis and allied conditions. The operation of circumcision, anaesthetic apart, is attended with very few risks. Haemorrhage should be very rare if the fraenal vessels are first tied before any incision is made and a simple tourniquet applied at the root of the organ (inch jaconet folded in three and held firmly in Spencer Wells forceps); a clean cut with a scalpel is made, taking care not to remove too much foreskin â€“ that is, flaying the glans penis. Redundant mucous membrane having been cut away, two lateral and one dorsal catgut sutures (Halstead) are inserted; a dressing applied, such as gauze impregnated with tinct. benz. co. does quite well. It is understood that the tourniquet is first released to make sure that there is no oozing before applying the gauze. Primary healing should be the rule, as soiling of the wound is prevented. Some of my colleagues have informed me that where necessary they sometimes do a circumcision on a newborn infant while awaiting the arrival of the placenta, with gratifying results. Of this line of treatment I myself have no experience. It has the great merit, however, that there is no anaesthetic risk, and it is done at a time when an infant can best tolerate trauma; but personally I would consider it a somewhat hurried proceeding. S.A. Montgomery With regard to your correspondence on circumcision the following case may be of interest. My son, now aged 6, was born with a long, tight foreskin. As I was against circumcision at the time, he was left uncircumcised. When he was 6 months old I noticed that he continually handled his penis. A colleague found adhesions, which he freed, and since then the foreskin has been pushed back every night at bath time and the parts thoroughly washed. There has been no recurrence of the handling on his part, except on one or two occasions when nightly washing has been omitted and there has been some slight inflammation. The boy now does the washing himself as a matter of routine, which falls into place with the cleaning of ears, teeth etc. The points I wish to stress are: (a) it is really difficult to keep the parts clean in the uncircumcised, and (b) regular pushing back of the foreskin and washing does not always conduce to masturbation, whereas dirty, itching parts do. I hesitate to have the boy circumcised now because I think it quite likely that a psychological trauma may result from the operation at this age. I know of at least one case where a boy of 4 years, one of twins, was circumcised, in which the operation was undoubtedly a great shock, and this may have farreaching results. With regard to what Dr H.M. Hanschell says of the preference of copulating women for the circumcised male: this may be due to the fact that the glans is less sensitive after circumcision in infancy and that therefore coitus can be prolonged. If this is the explanation it is an argument in favour of circumcision which should not be overlooked. Ejaculatio praecox with its concomitant unhappiness to both partners is common enough to call for investigation. W.M.C. My own personal experience leads me to echo Dr D.W. Walker's advice, although my experience is admittedly trivial in comparison. My elder brother and myself both required this attention at school age; two of my friends required it when medical students; recently an official in my town hall, with two grown-up children, had to absent himself for circumcision â€“ a very uncomfortable kind of operation for an adult, apart from the inevitable ribaldry as to change of faith and so on which ensues among the easily amused. I was foolish enough myself to listen to the advice of one of our maternity and child welfare staff, who stretched he prepuce of my elder son, with the result that he required at school age the operation he should have had as an infant. It is too bad that boys should suffer discomfort or be subjected to an operation at school age or later which should be carried out in infancy. M.D., D.P.H. I suggest that all male children should be circumcised. This is "against nature", but that is exactly the reason why it should be done. Nature intends that the adolescent male shall copulate as often and as promiscuously as possible, and to that end covers the sensitive glans so that it shall be ever ready to receive stimuli. Civilization, on the contrary, requires chastity, and the glans of the circumcised rapidly assumes a leathery texture less sensitive than skin. Thus the adolescent has his attention drawn to his penis much less often. I am convinced that masturbation is much less common in the circumcised. With these considerations in mind it does not seem apt to argue that "God knows best how to make little boys". R.W. Cockshutt BMJ, 19 October 1935, p. 763-4 <h4>Will the letters never cease?</h4> The question of circumcision seem to lead to a partisanship as violent as politics. I fancy that this enthusiasm for universality, apart from what has been called "tribal rites", is of fairly recent origin. I do not recall any clamour for it in the 1880s. At that time it was regarded as a tiresome minor operation, sometimes required on account of an objectionable and adherent prepuce. It was. I think, in the naughty nineties that the idea of promiscuous circumcision began to gain ground. For a time I fell in with the fashion. But it annoyed me to see the healthy progress of the infant sometimes even temporarily interrupted; and in still more to see occasionally the lactation of the mother interfered with by her worrying over the child. Still more was I upset by two unusual cases which occurred in the practice of a friend (who was, by the way, a very capable surgeon, priding himself particularly on his thoroughness in this minor operation). In each of these the cicatrix contracted and drew the loose skin of the penis up over the glans to form a fresh false prepuce. In one case the operation had to be done three times. In the other the difficulty was obviated by slitting the false prepuce longitudinally, so that any subsequent contraction would tend to pull the skin off the glans instead of over it. On discussing these cases with a well-known gynaecologist, I was surprised when he gave his opinion that it was very seldom necessary to resort to circumcision. From that time I reverted to "detachment and dilatation", with careful instruction as to subsequent daily cleansing of the parts beneath the prepuce. I never had any reason to be dissatisfied with the result of this method as a substitute for circumcision. Of course, neglect of such regular cleansing may lead to minor troubles later on. But the ill results of uncleanliness are not confined to the penile region. I do not know of any statistics which suggest that the circumcised are less liable to venereal disease. Nor have I any reason to believe that the uncircumcised are more prone to masturbation; on the contrary, I can recall the cases of two mothers, who each had one sone circumcised and the other not. The complaint of each of these mothers was that the circumcised boy was always "playing with his penis"; but the uncircumcised boy did not do so. I have no use for the argument that was once used to me â€“ that I was throwing away fees for operation. A.H. Williams Brevity is the soul of wit: I will be brief. If the technique I have described is followed closely and the dressing shield applied to the retracted prepuce, there will be no need for any other operation. But â€“ and this is most important â€“ the prepuce must be kept back for at least four to five days after the stretching etc. I have a long experience of the older radical method of circumcision. I would not think of doing it any more. My object in writing to the Journal was to advocate an extensive trial of the method of stretching plus dressing shield pressure; also, I started on the assumption that something must be done to overcome the severe phimosis. I am grateful to all those who have stated their experiences. it was not my intention to enter into the question of the functions of the prepuce, nor into any abstruse problems concerning the origins of circumcision. These are, however, of great interest. Has it ever occurred to anyone that a vaccine prepared from the smegma bacillus may possibly be of practical use â€“ for example, in connexion with tuberculosis therapy? D.I. Connolly I have been waiting in vain to see someone mention what I consider to be by far the best treatment for phimosis, and which I have used for thirty years. When a male child is born the penis is at once examined, and if the glans cannot be properly exposed I ask the mother and father whether they will have the child circumcised. I make arrangements with the nurse (usually the district nurse) for the next day. having seen the mother we go into the next room, and the nurse holds the child between her knees. A probe and a blunt pair of scissors are probably all that is necessary. Having separated all the foreskin from the glans a straight cut is made down the dorsum to the base of the glans. The foreskin is rolled back to form a scar around the penis on a level with the base of the glans. Occasionally one or two stitches are put in. A small piece of gauze is wrapped round it, to be renewed if it gets washed off. I explain that the penis may appear rather swollen on the second or third day, but that [this] need not be worried about. On the tenth day it has healed, and the foreskin has entirely disappeared. I have never had the slightest trouble over bleeding, as the fraenal artery is not approached, and the dressing has never given any trouble. I have done this on a few occasions to adults, under local anaesthesia, with the result that after a few months the foreskin has entirely disappeared. Of course, a few stitches have to be used. Norman H. Joy I have been watching the correspondence regarding this operation to see if any improvements on the technique of the late Mr A. Richardson of Leeds emerged, but so far have been disappointed. There is no question that the instruments used by the Jews, fashioned after the style of an Army button stick, which is slipped over the prepuce before section, is far and away the safest protection for the glans, and causes no trauma to the foreskin remaining. The key to the reconstruction is a stitch introduced on the left of the median raphe and passed obliquely to the right of the fraenum; it acts as a ligature to the fraenal artery; moreover, it puts the whole in position and avoids a knot of tissue beneath the penis. It is essential to ligature the two dorsal arteries, which can be done by passing a needle through the skin and mucosal cuff, and throwing the Spencer Wells forceps (already applied) over the ligature, thus serving two purposes. [4] Those who deny the existence of phimosis remind me of the old lady who, on visiting the zoo, was shown a giraffe. "There is no such animal", she exclaimed. A.P. Bertwhistle BMJ, 26 October 1935, p. 822-23 <h4>The discussion brought to a close</h4> I have been very much interested in the correspondence on circumcision. What it all comes to is this. Are doctors to be governed by purely medical reasons or not? Such arguments as those put forward that it lessens the likelihood of masturbation and the sensitivity of the penis, that it increases the pleasure of the partner in copulation etc, are scarcely in the realm of medicine, but of morality. Masturbation is a normal and harmless manifestation, except where it occurs in excess as a symptom of mental ill-health, and it savours if Jovian omniscience to interfere with the naturally provided erotic mechanism, although, of course, the untutored savage does not hesitate to do so, and could no doubt give many reasons for excising the clitoris or rupturing the perineum or ripping open the male urethra. To those who instance the occurrence of preputial lesions necessitating amputation in later life as a reason for preventive circumcision in infancy, one would say â€“ Why not eradicate the appendix, the tonsils? Why not expose the child to measles, mumps, whooping cough, and chicken pox? Or is the doctor supposed to be a prophet? Circumcision of the male prepuce, except when done in the presence of a definite physical lesion, as is the case with all the other bodily organs which are liable to disease, is a propitiatory gesture, incapable of justification on surgical grounds. J.L. Faull The description of a method of treating phimosis by the dorsal slit of the foreskin urges me to add yet another to the numerous letters on this matter. I too tried this as a substitute for the usual circumcision, but found the results far from satisfactory. With a lengthy foreskin, two flaps resulted, which hung down like miniature elephant's ears, and frequently became irritated from contact with urine. In more than one case a subsequent operation of circumcision was necessary to remedy this condition. I have now for many years used the following simple technique, which has given entire satisfaction. The foreskin is retracted, and after separation from the glans the preputial orifice is snipped at three points, one on the dorsum, the other two on each side of the fraenum, so that the three incisions are equidistant from each other. The foreskin is then fully retracted, and if the three snips have been accurately judged the foreskin should remain in this position. If too tight it is a simple matter to enlarge the incisions somewhat and secure an easy fit. The incisions made in the long axis of the penis become stretched to form three segments of a circle, and heal without producing any deformity such as that described above. The usual dressing is a strip of gauze soaked in sterile Vaseline, which effectually prevents soiling with urine. Should the opening be too wide the foreskin may slip forward, but it is not a difficult task for the nurse to push it back daily, and healing occurs perhaps more slowly, but equally satisfactorily. J.A. Pottinger The simplest method of relieving a phimosis in the newborn has not so far been mentioned in the discussion. This consists in simply splitting the foreskin with scissors, putting in three stitches, one at the corona and one at each anterior corner. Practically no interference with either the nerve or blood supply happens, and cosmetically the result is excellent. W.L. English I do not agree with Dr R.W. Cockshut that the less sensitive glans of the circumcised is conducive to chastity and forms a shield against sexual perversions. The Mohammedan is not any more chaste than the non-Mohammedan, nor is he free from sexual perversions. I should also have thought that the exposed glans would have attracted the adolescent's attention more than the covered one. As regards manipulative surgery in phimosis, I fail to see the objections raised by some of your correspondents. It has its place wherever practicable, and I have seen no ill effects follow its practice. Circumcision is the last resource, and it is possible that there is a certain amount of "psychic trauma" attending its performance on an introspective boy. Can it be that the circumcision of a highly sensitive and gifted boy made him inflict on the world his "castration complex"? M.P.K. Menon It seems that the opinion of the majority of your recent correspondents on the subject of circumcision in childhood for phimosis is that (1) it should be done when required; (2) the risk of operation and its consequences are small; (3) the manipulative stretching method has its drawbacks; (4) from a psychological point of view, it is undesirable and even embarrassing for the mother, nurse or, later on, the child himself, to pay so much and constant attention etc to his genital organs; (5) if venereal disease is contracted, the circumcised are in a cleaner and more hygienic state; and finally (6) some uncircumcised people fail to keep themselves clean, as is well illustrated in the following case. Some six or seven years ago a young Englishman, who acted as a representative for a British firm in Germany, came to me while on holiday in London on account of some white discharge from his penis. As he had been exposed to possible infection he was sure that he suffered from gonorrhoea. On examination, however, I found that his foreskin was adherent to the glans, and that between the two there was a thick layer of yellow-white cheesy smegma or concretion. It was very adherent, and owing to some inflammation it took me a few days to remove it gradually with warm alkaline lotion, and so separate the adhesions etc. The patient was, however, greatly surprised when I told him he did not suffer from gonorrhoea, but from the effects of local uncleanliness. L.B. Sheinkin A somewhat provocative letter which I wrote as a soporific in the hot hours of an early August morning has been followed by such a long correspondence that I wonder if you will allow me to thank those who have tried to point out my errors and to lead me into the right way. Many of the writers are so lost in admiration of their own techniques that reasons for their procedure are obviously of secondary consideration with them. But the one with whom I am most in sympathy is Dr H.M. Hanschell. He says that with universal circumcision his patients in a venereal disease clinic would be cleaner and easier to handle and treat. Not, be it noted, that the incidence of such disease would be lessened, or that treatment would be more efficient, but that Dr Hanschell would have an easier time. And if I were in his place I have no doubt that I should be of the same opinion. Now with regard to the condition known as phimosis, may I point out the elementary fact that the preputial orifice is surrounded by a fibro-elastic ring, and that fibro-elastic tissue stretches with varying degrees of ease and rapidity in different individuals. Anyone who as patiently watched the slow stretching of the perineal region in a primipara must realize this; and also that a very small opening can be gradually dilated to a great size without injury, provided that ample time is taken and the force exerted is not too great. Similarly, a small preputial orifice which cannot be stretched to the size of a threepenny bit in half a minute is not a pathological condition; and there is no justification whatever for losing one's patience and forcibly cutting or stretching it. If I innocently ask why it is so necessary that a baby's prepuce should be retracted at the earliest possible moment I know I shall be met with a sniff and a snort, and be shrivelled up by the magic word "cleanliness". So to those of the profession who have time to think, may I leave a few questions for consideration? What is the use of Tyson's glands, [5] and at what age do they begin to function; when does a natural secretion become dirt; and what dreadful thing will happen if a baby's prepuce is left entirely alone? R.W. Ainsworth This corespondence is now closed. - Ed. BMJ, 2 November 1935, p. 876-77 <h3>NOTES</h3> 1. In 1894 German researchers using the newly invented aesthesiometer discovered that the glans was quite insensitive, and their findings were confirmed by the English neurologist Henry Head in 1908. In his Studies in neurology (1920) he reported that the glans was about as sensitive as the heel of the foot. Other German researchers had established the rich and complex innervation of the prepuce in a study published in 1893, but there was no further work on the subject until the 1930s. The denser innervation of the foreskin was confirmed by R.K. Winkelmann in the 1950s, and again (quite decisively) by Chris Cold and John Taylor in the 1990s. A good summary and the full text of most of the key articles <a href="http://www.cirp.org/library/sex_function/" rel="noopener" target="_blank">is available at the CIRP</a>. On the normality of infantile phimosis, it is interesting to note that this had been written as early as 1916: <div>It is not widely enough realized, particularly by the lay public, that a condition of phimosis is normal at birth. It is inconceivable that children are born with actual deformities in this region as often as the statistics of circumcision would lead an observer to suppose. It is not until the penis undergoes its final development at puberty that the proper balance between the prepuce and the glans is struck.</div> Geoffrey Jefferson, "<a href="http://www.cirp.org/library/anatomy/jefferson/" rel="noopener" target="_blank">The peripenic muscle; some observations on the anatomy of phimosis</a>", Surgery, Gynecology, and Obstetrics (Chicago), Vol. 23, 1916, pp. 177-81 2. The truth about apes is quite the reverse: chimpanzees have a foreskin but no glans. This was observed as early as the 1690s in the first-ever anatomical description of a young chimp by Edward Tyson (1651-1708), who reported: "Whether there was any Balanus or Glans in the Penis of our Pygmie, or what it was, I am uncertain: I do not remember I observed any". (Orang-Outang, sive Homo Sylvestris, or the Anatomy of a Pygmie, London 1699, facsimile reprint, with introduction by Ashley Montague [London: Dawsons, 1966], p. 45). This has been confirmed by <a href="http://www.cirp.org/library/anatomy/cold-taylor/" rel="noopener" target="_blank">Cold and Taylor 1999</a>, and in Chris Cold and Ken McGrath, "<a href="http://www.cirp.org/library/anatomy/cold-mcgrath/" rel="noopener" target="_blank">Anatomy and histology of the penile and clitoral prepuce in primates</a>", in George C. Denniston, Frederick Hodges and Marilyn Milos (eds), Male and female circumcision: Medical, legal and ethical considerations in pediatric practice, New York, Kluwer Academic/Plenum Publishers, 1999. For further information on Tyson, see Ashley Montagu, Edward Tyson MD and the rise of human and comparative anatomy in England (Memoirs of the American Philosophical Society, Vol. 20, 1943), and Stephen Jay Gould "To show an ape", in The Flamingo's smile (Penguin 1986), pp. 263-80. Although both Montagu and Gould praise Tyson's skill as an anatomist, he did sow the seeds of much future confusion by claiming to discover glands under the foreskin which were supposed to secrete "smegma", thus giving rise to the mythical "Tyson's glands", which have proved such a stand-by for posthephobes and others who imagine the foreskin to be unclean. See also Note 5. Montagu later wrote a <a href="http://www.nocirc.org/symposia/second/montagu.html" rel="noopener" target="_blank">powerful essay against routine circumcision</a>, "Mutilated Humanity", given at the Second International Symposium on Circumcision, San Francisco, California, April 30-May 3, 1991. 3. The reference is to V.E. and N.L. Lloyd, "Circumcision and syphilis", British Medical Journal, 27 January 1934, pp. 144-6. For further discussion see Robert Van Howe, "<a href="http://www.cirp.org/library/disease/STD/vanhowe6/" rel="noopener" target="_blank">Does circumcision influence sexually transmitted diseases? A literature review</a>", BJU International, Vol. 83, Supplement 1 (January) 1999, pp. 52-62; and Robert Darby, "Where doctors differ: The debate on circumcision as a preventive of syphilis, 1855-1914", Social History of Medicine, Vol. 16, 2003, pp. 57-78 4. In his article, "Juvenile circumcision: A plea for a standardised technique", (Lancet, 12 January 1936, pp. 85-6), Bertwhistle expressed surprise that every modern textbook described a different method of circumcision, and also concern that the results were "by no means uniformly good". He commented that a repeat operation was often necessary "because of cicatrization of a foreskin left unduly long, and an objectionable lump [near] ... the frenum". Despite the pleas, <a href="http://www.cirp.org/library/complications/" rel="noopener" target="_blank">complications remained common</a>, and Gairdner reported <a href="http://www.cirp.org/library/death/" rel="noopener" target="_blank">16 deaths per year</a> in the 1940s. 5. Although one finds references to them everywhere (from new baby bulletin boards and circum-fetishist/posthe-phobic Yahoo groups to serious works of reference such as Wiley's International Dictionary of Medicine and Biology (1986, Vol. 3, p. 1207) and the new Oxford Dictionary of National Biography (entry for Edward Tyson, Vol. 55, p. 819), there is no such thing as Tyson's glands. The moisture beneath the prepuce consists simply of water, shed skin cells, secretions from the prostate, seminal vesicle and urethral glands, various sterols and fatty acids which normally protect skin surfaces, and a variety of benign bacteria. Very few men, and even fewer boys, generate any visible smegma. (See articles by Satya Parkash et al 1980 and 1982, and by Cold and Taylor 1999, <a href="http://www.cirp.org/library/sex_function/" rel="noopener" target="_blank">all available at CIRP</a>.) Cold and Taylor comment: <div>Even in modern textbooks, Tyson's glands are often described as the source of smegma; however, no evidence of Tyson's glands has ever been described outside of Cowper's macroscopic description of these glands in 1694. This may be one of the longest held myths in medicine. Cowper's description of Tyson's glands in the human is actually of hirsutoid papillomas of the glans penis, which are fibroepithelial structures and not glandular structures. Although other mammals have true clitoral and penile preputial glands which secrete sex pheromones, there is no current evidence of these glands in humans. (<a href="http://www.cirp.org/library/anatomy/cold-taylor/" rel="noopener" target="_blank">See CIRP web version for references</a>.)</div> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource For and against circumcision darby