6 10 240 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"> <h1>Yet another wonderful benefit of circumcision?</h1> Do green jellybeans cause acne? <a href="http://xkcd.com/882/">As this cartoon neatly demonstrates</a>, the claim that they might is hardly less plausible than recent media headlines suggesting that the foreskin causes cancer of the prostate, and concluding (quite illogically) that circumcision of baby boys is, therefore, a desirable measure of public and individual health. There are three issues here: (1) whether “lack of circumcision” does significantly increase the risk of cancer of the prostate; (2) the hyperbolic newspaper reporting of one small study which claimed that perhaps it did, even if only a little bit; and (3) even if this claim were true, whether circumcision of infants was a logical and ethically acceptable response. <h2>Foreskin and risk of prostate cancer</h2> The claim that the presence of the foreskin increases the risk of prostate cancer, and therefore that all men ought to be circumcised, was first made in the 1940s by a cranky American doctor called Abraham Ravich, who believed that the disease was less common among his Jewish patients than in others. He managed to get a couple of articles published in American medical journals (always so hospitable to anti-foreskin propaganda), and in his old age compiled and self-published a whole book, Preventing VD and Cancer by Circumcision, in which he extolled the Mosaic code as the key to good health and a long life. A series of subsequent studies failed to find any association between lack of circumcision and increased risk of prostate cancer, however, and in its <a href="http://www.racp.edu.au/page/policy-and-advocacy/paediatrics-and-child-health">2010 policy statement on circumcision</a> the Royal Australasian College of Physicians noted tersely: “This association [between lack of circumcision and prostate cancer] has not been consistent, and more recent reviews have failed to confirm it.” This is a polite way of saying that the claim of a connection is bullshit. Just recently (March 2012) a paper in the American journal Cancer claimed that there was a slight difference in the incidence of cancer of the prostate between uncircumcised men and men who had been circumcised before their first sexual intercourse. The research was a retrospective case-control study of men who self-reported their circumcision status, sexual histories and some other information. There were 1754 men with prostate cancer and 1645 without prostate cancer in the study. Of the first group, 1207 (68.8%) were circumcised; of the second group, 1176 (71.5%) were circumcised – a difference of a mere 2.7%. This absolute difference was then translated by a series of statistical manipulations into a relative risk of 15%. <a href="http://skepticalscalpel.blogspot.com.au/2012/03/overhyped-research-on-prostate-cancer.html">As the Skeptical Scalpel points out</a>, however, the relative risk of developing prostate cancer was not significantly different in circumcised and uncircumcised men until the researchers looked at those who had been circumcised after their first episode of sexual intercourse. The number of men who had been circumcised after their first sexual encounter was only 68 (3.9%) of the men with prostate cancer and 41 (2.5%) of those without. Although the relative risk reduction was 15%, the confidence intervals were too wide (73% to 99%) to have much significance. Most importantly, this is only a relative risk reduction, not an absolute risk reduction, and it thus of no relevance to the question of whether men ought to get themselves circumcised, much less whether boys ought to be circumcised. A further weakness of the study is that it did not control for race or age – important issues, as African American men have double the rate of prostate cancer compared with whites and an overall circumcision incidence of only only 43%, and because the likelihood of prostate cancer rises sharply with increasing age. In addition, the study relied on self-report of circumcision status, which is wildly unreliable. It is, in short, a clinically unimportant finding based on self-report. The real questions are how such a poorly designed study got through peer-review and then published, and why it has been hyped so irresponsibly by the media. <a href="http://skepticalscalpel.blogspot.com.au/2012/03/overhyped-research-on-prostate-cancer.html" rel="noopener" target="_blank">See further discussion at Skeptical Scalpel</a> <a href="http://www.circumstitions.com/cancer-pros.html" rel="noopener" target="_blank">As Circumstitions points out</a>, if those members of the study population who were circumcised after their sexual debut had not been merged with those never circumcised, the figures would have no significance at all. The much vaunted 15% reduction in relative risk amounts to a 2.7% reduction in absolute risk. The age-adjusted risk of prostate cancer for Caucasians in the United States is 150 per 100,000 person-years, or 0.0015 per year. The lifetime risk is about 72 times this, 0.108 or 1 in 9.25. Circumcision reduced this risk in only 2.7% of those with prostate cancer in this study, with 71.5% of controls circumcised. If this is adjusted up to 100% circumcision the reduced risk would affect a mere 3.77% of those with prostate cancer. The overall Absolute Risk Reduction would then be 0.108x0.0377 or 0.0040716. This means that TWO HUNDRED AND FORTY-FIVE babies would need to be circumcised to prevent one (old) man from getting prostate cancer. This would be quite absurd for many reasons, not least because of the cost. <h2>The rabbi was wrong: Media hype misrepresents findings of prostate-circumcision study</h2> It is truly amazing how any study that appears to show the foreskin in a bad light gets worldwide publicity, when journal articles critical of circumcision and statements against the practice from responsible medical authorities are ignored. Of course the media seized on this study, with the usual wild headlines: “Circumcision Cuts Prostate Cancer Risk” (Scientific American); “Circumcision reduces prostate cancer risk” (UPI); “Circumcision Linked to Lower Risk for Prostate Cancer, Study Finds” (Yahoo News); and best of all, “Males of the Mideast Rejoice: Circumcision Reduces Prostate Cancer” (Asian News International) or, even more ridiculous, "The rabbi was right: Prostate cancer prevention from birth" (Bradenton Herald). It will be observed that all these news reports are from circumcising cultures, naturally pleased that science appears to be confirming their traditional wisdom. The last headline is particularly misleading, because it was not the rabbis who introduced circumcision to the Jewish religion, but the priests during the period of Temple Judaism, around 600 BC. What the rabbis introduced in the early Christian period was a new phase to the rite – metsitsah, in which the mohel (ritual circumciser) was required to suck the blood from the wounded penis after cutting off the foreskin. Needless to say, it would be hard to imagine anything more unhygienic, or more likely to spread disease, and there can be little doubt that devotion to metsitsah has been responsible for the deaths of countless Jewish babies over the centuries. The practice was largely abolished by Jewish reformers in the late nineteenth century, though it survives among some ultra-orthodox communities – notably in New York, where there have been <a href="http://www.circumstitions.com/news/news44.html#metzitzah12">several recent cases</a> of babies dying from herpes infection after being circumcised by orthodox mohels. What is even more bizarre about the scaremongering media coverage is that this latest study did not suggest even circumcision as a means of further lowering the risk (already quite small) of prostate cancer, but was most interested in a related question: the contribution of infection with human papilloma virus (HPV) to the risk of developing prostate cancer. There is a widely held belief that circumcised men are less likely to be infected with HPV, a view based largely on studies in Africa, but not confirmed by studies in the developed world; <a href="https://www.circinfo.org/news_2011.html#busk">the most recent study, by Van Buskirk et al</a> , found no difference. The whole sorry exercise seems to be just another chapter in the long history of the <a href="http://www.historyofcircumcision.net/">demonization of normal male anatomy</a>. <a href="http://xkcd.com/882/" rel="noopener" target="_blank">This cartoon</a> is a perfect representation of how the media reports circumcision studies <h2>Prostate cancer issue not relevant to debate about infant circumcision</h2> But even if the results of this study were valid, and circumcision did reduce the risk of a male developing prostate cancer by 15%, it would not be an argument for prophylactic circumcision of infants or boys. There are three main reasons for its irrelevance. (1) Although cancer of the prostate is one of the most common cancers affecting males, it still affects quite small numbers, and quite unpredictably; the risk factors appear to be age, race (or other genetic factors), smoking and exposure to HPV (through sexual intercourse with an infected partner.) The small numbers and risk reduction, as <a href="http://www.circumstitions.com/cancer-pros.html">Circumstitions points out</a>, are not sufficient to warrant general circumcision as a precaution against such a remote threat. (2) Cancers increase in frequency as people get older; an ageing population automatically means more cancers, irrespective of other factors, as the replication functions of bodily cells break down as we get older and wear out. It would be both illogical, unethical and highly cost-ineffective to circumcise over 200 babies now in order to prevent prostate cancer in one of them in 60 or 70 years time. Who knows what additional curative and preventive options we may have at our disposal by then? (3) Since HPV is acquired sexually, we can say that to some extent prostate cancer is a sexually transmitted infection. But since infants and children are not sexually active, they are at zero risk of STIs, protection against which does not become an issue until boys grow up and become sexually active. Even then, it is only those who engage in high risk behaviour who are at risk of infection. The only policy consistent with evidence-based medicine and medical ethics, therefore, is to leave boys’ foreskins alone until they are mature enough to understand the medical issues and possible effects of circumcision, advise them of the risks of unsafe sex and other high risk behaviour, alert them to the protective options, and allow them to make up their own minds about how they wish to manage them. The automatic assumption that circumcision means circumcision of (non-consenting) infants or young boys is based on the tacit understanding that very few adult males, or boys who have discovered the delights and pleasures of their foreskin, would volunteer to have it cut off. But if the average adult would refuse circumcision, it would clearly be a violation of bioethical principles to coerce a child, merely because he was too young to put up effective resistance. Men are perfectly entitled to prefer to run a slightly greater risk of prostate cancer in old age in return for more fun and a better sex life in youth; some would prefer the other option, but the essential point is that circumcision is the individual male’s right to choose. It is not a decision to be made by others, no matter how well-meaning: his penis, his decision. <a href="https://www.circinfo.org/Foreskin_owner_decide.html" rel="noopener" target="_blank">See further discussion on “Let the foreskin owner decide” page</a> <h2>Plenty of sex, better nutrition and more exercise mean a healthier prostate?</h2> Other studies suggest that more sex, better nutrition and adequate physical exercise will reduce risk of prostate cancer. <h3>1. Plenty of sex</h3> Douglas Fox, Masturbating may protect against prostate cancer, New Scientist, 16 July 2003 It will make you go blind. It will make your palms grow hairy. Such myths about masturbation are largely a thing of the past. But the latest research has even better news for young men: frequent self-pleasuring could protect against the most common kind of cancer. A team in Australia led by Graham Giles of The Cancer Council Victoria in Melbourne asked 1079 men with prostate cancer to fill in a questionnaire detailing their sexual habits, and compared their responses with those of 1259 healthy men of the same age. The team concludes that the more men ejaculate between the ages of 20 and 50, the less likely they are to develop prostate cancer. The protective effect is greatest while men are in their twenties: those who had ejaculated more than five times per week in their twenties, for instance, were one-third less likely to develop aggressive prostate cancer later in life. The results contradict those of previous studies, which have suggested that having had many sexual partners, or a high frequency of sexual activity, increases the risk of prostate cancer by up to 40 per cent. The key difference is that these earlier studies defined sexual activity as sexual intercourse, whereas the latest study focused on the number of ejaculations, whether or not intercourse was involved. The team speculates that infections caused by intercourse may increase the risk of prostate cancer. “Had we been able to remove ejaculations associated with sexual intercourse, there should have been an even stronger protective effect of other ejaculations,” they suggest. “Men have many ways of using their prostate which do not involve women or other men,” Giles adds. Macho exaggeration Giles accepts the possibility that the men who completed the questionnaires could have lied about their habits. But he doubts this skewed the results, since questions about masturbation are unlikely to evoke the same macho exaggeration as questions about, say, number of sexual partners. But why should ejaculating more often cut the risk of prostate cancer? The team speculates that ejaculation prevents carcinogens building up in the gland. The prostate, together with the seminal vesicles, secretes the bulk of the fluid in semen, which is rich in substances such as potassium, zinc, fructose and citric acid. Generating the fluid involves concentrating these components from the bloodstream up to 600-fold - and this could be where the trouble starts. Studies in dogs show that carcinogens such as 3-methylcholanthrene, found in cigarette smoke, are also concentrated in prostate fluid. “It’s a prostatic stagnation hypothesis,” says Giles. “The more you flush the ducts out, the less there is to hang around and damage the cells that line them.” Sexual repertoire His findings suggest an intriguing parallel between prostate cancer and breast cancer, as recent studies indicate that lactating reduces a woman’s risk of breast cancer, perhaps because this also flushes out carcinogens. Alternatively, ejaculation might induce prostate cells to mature fully, making them less susceptible to carcinogens. “All these mechanisms are totally speculative,” cautions breast cancer expert Loren Lipworth of the International Epidemiology Institute in Rockville, Maryland. But if the finding is confirmed, future health advice from doctors may no longer be restricted to diet and exercise. “Masturbation is part of people’s sexual repertoire,” says Anthony Smith, deputy director of the Australian Research Centre in Sex, Health and Society at La Trobe University in Melbourne. “If these findings hold up, then it’s perfectly reasonable that men should be encouraged to masturbate,” he says. Source: Douglas Fox, <a href="http://www.newscientist.com/article/dn3942-masturbating-may-protect-against-prostate-cancer.html">Masturbating may protect against prostate cancer</a>, New Scientist, 16 July 2003 ABSTRACT OF THE ORIGINAL ARTICLE G.G. Giles et al, <a href="http://onlinelibrary.wiley.com/doi/10.1046/j.1464-410X.2003.04319.x">Sexual factors and prostate cancer</a>, BJU International 92 (3), August 2003, 211-216 OBJECTIVE To assess whether prostate cancer might be related to hormone levels and, by inference, to differences in sexual activity. PATIENTS, SUBJECTS AND METHODS In a case-control study of men with prostate cancer aged < 70 years at diagnosis and age-matched control subjects, information was collected on two aspects of sexual activity; the number of sexual partners and the frequency of total ejaculations during the third to fifth decades of life. RESULTS There was no association of prostate cancer with the number of sexual partners or with the maximum number of ejaculations in 24 h. There was a negative trend (P < 0.01) for the association between risk and number of ejaculations in the third decade, independent of those in the fourth or fifth. Men who averaged five or more ejaculations weekly in their 20s had an odds ratio (95% confidence interval) of 0.66 (0.49–0.87) compared with those who ejaculated less often. CONCLUSIONS The null association with the number of sexual partners argues against infection as a cause of prostate cancer in this population. Ejaculatory frequency, especially in early adult life, is negatively associated with the risk of prostate cancer, and thus the molecular biological consequences of suppressed or diminished ejaculation are worthy of further research. <h3>2. Better nutrition and more exercise reduce cancer risk</h3> Hot on the heels of the Cancer report comes a study in the Medical Journal of Australia which found that better nutrition and more exercise can significantly reduce the risk of many cancers, including prostate cancer. The abstract reads as follows: Objective: To estimate the number of cancers to be diagnosed in 2025 that could be prevented solely due to changes in diet and physical activity. Design and setting: We used an Australian population-based cancer database to estimate the total number of cancers to be diagnosed in 2025, by applying published age- and sex-specific population projections to current cancer incidence rates, and multiplying the projected numbers of cancers by estimates of population-attributable fractions. Main outcome measures: Projected number of preventable cancers that would be diagnosed in 2025. Results: Our projections suggest that there will be about 170 000 Australians diagnosed with cancer in 2025. This represents an increase of about 60% on the 2007 incidence. Almost 43 000 of these cancers (low estimate, 42 295; middle, 42 657; high, 43 990) could be prevented through improvements to diet and physical activity levels, including through their impact on obesity. It is likely that this is an underestimate of the true figure. The most preventable cancer types in 2025 were estimated to be bowel cancer and female breast cancer (10 049 and 7273 preventable cases, respectively). Conclusions: About 25% of cancers, or about 43 000 cancers in 2025, can potentially be prevented through improvements in diet and physical activity. It is imperative that governments, clinicians and researchers act now if we are to reduce the significant future human and financial burden of cancer. There is wide variation in the preventability of different kinds of cancer by diet and exercise, with cancer of the oesophagus at the top (72%) and cancer of the prostate at the bottom (16%). But a 16% absolute reduction in the number of prostate cancer cases is a far more impressive result than 15% relative risk reduction - and achieved by far more agreeable means. Peter D. Baade, Xingqiong Meng, Craig Sinclair and Philippa Youl, <a href="https://www.mja.com.au/journal/2012/196/5/estimating-future-burden-cancers-preventable-better-diet-and-physical-activity">Estimating the future burden of cancers preventable by better diet and physical activity in Australia</a>, Medical Journal of Australia 196, 19 March 2012 <h2>Further criticism of "lack of circumcision-prostate cancer" link</h2> <a href="https://www.youtube.com/watch?v=PZ602vTzs0c" rel="noopener" target="_blank">David Smith from Norm-UK criticises latest prostate cancer speculations</a> (Youtube video) </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 Cancer of the prostate and 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"> The following correspondence is from a reader of this site who grew up in Victoria in the late 1940s and 1950s. In these letters, he gives a vivid picture of the discrimination against cavaliers “as uncircumcised penises were often known in those days" at the hands of the dominant and frequently intolerant roundheads. As he reports, circumcision was the norm in those days, and commonly done automatically in the hospital or soon after, without even the formality of seeking permission from the parents. The name of the author has been changed to protect privacy <h2>David Priestly to RD:</h2> I have recently come across your site and articles regarding circumcision which I have found most interesting and informative. As one of the very few Australian born males born in the 1940s to have escaped circumcision, I was particularly interested in your sections about circumcision in Australia. Being one of a very small minority of boys (my estimate for 1944, the year of my birth, being 5%) who had foreskins and were thus significantly different in appearance from all the others, I not surprisingly became interested in circumcision and why I was not circumcised. I daresay you are contacted by many people interested in circumcision, in one way or another and probably suffer from information overload on the topic. However, I wonder if I might correspond with you on this matter regarding my experiences and views on it? <h2>RD to DP:</h2> Thanks for your message. I'd be very interested in hearing more about your own views and experiences, particularly as you were one of the few Australian boys born in the 1940s who were not circed - though I find it hard to believe that the proportion nationally was as low as 5 per cent. I do receive some correspondence on the topic, but I find that most cut men don't want to talk about the issue at all, and that most uncut men can't see that there is an issue to discuss. It's only a small minority of the former whose resentment is strong enough to drive them to any sort of action, and only an even smaller minority of the latter who have sufficient sympathy with their deprived peers to do more than count their own blessings. I do have a fair bit of testimony from circed men who resented it (and I understand that a paper of mine analysing their feelings will be published in a collection of essays later this year), but I have not seen much from uncut men who grew up in a cut world - at least, not in Australia, though there is a fair bit available in the USA. I would thus, as I mentioned, be most interested in your recollections and reflections of growing up in Australia. <h2>DP to RD:</h2> Thank you for your email and for allowing me to correspond with you. Given the puritanical strictures which in my view encompass almost all experience in Australian life, this is something from which I've felt inhibitedfrom doing hitherto. Perhaps I should begin at the beginning, as they say, with my birth. But first, re 5%, I don't know that I mean nationally, but in my experience. I was born in Geelong in 1944 and lived in several places in Victoria - the Mildura area (Sunraysia), Melbourne, a fishing port on the Victorian coast, and the Wimmera - until I left home at 16 to go to university in Melbourne. In both Melbourne and the Wimmera almost no-one had even seen a foreskin, and I was regarded as some sort of anthropological specimen, whilst in the rural areas around Mildura and at the fishing port, perhaps 20% of boys were uncircumcised. Given the respective populations involved, I think that this would average out to about 5%. In the Wimmera, it was well known and remarked on that I was one of only about half a dozen Australian-born boys in the local high school (none of whom was locally born) out of about 200, who were uncircumcised. There were perhaps another half dozen uncircumcised boys who had been born in Europe. Later I lived in at a university college in Melbourne, where there were boys for all over Victoria and beyond and it became apparent that I was the only boy in my year to have a foreskin. Still later, when I was about 25 years old, I was working in the Public Service, and in our area there was a Jewish man, who one day announced that he was uncircumcised. I replied that he could not be a Jew and to look at his Old Testament. After a fairly testy exchange, he asked what I would know about such things; to which I replied that I also was uncircumcised. He answered that therefore I was not an Australian, as he had lived here most of his life and had been to state schools and Melbourne High School and had never seen an Australian who was uncircumcised. (This being "Not Australian" was an issue for me). However, back to the beginning! I am 5th generation Australian and was born in Geelong whilst my father was away during the war. My mother's family had settled in the area from Tasmania in 1840, and my mother and elder brother were living there with my grandparents whilst he was away on active service. As I mentioned in my first email, one of the things which most intrigues me is how boys like me escaped the knife. I know in only three cases, including my own. (Basically I have been too shy to raise the matter.) I knew that it was medical dogma when I was born that boys should circumcised and that my brothers and all other males in our extended family, except my maternal grandfather who was born in 1881, had been done. Why wasn't I? Around the time of my marriage, I decided to ask my mother. She told me that I was born in a small maternity hospital, in a house near where we lived. I was delivered by a midwife and just not circumcised there. However, before she left a few days later, our doctor made an appointment for her to bring me to his surgery at a fortnight old to be circumcised. This she did, and I was prepared by his nurse for circumcising, with my mother holding me. (Gruesome!). When the doctor came he first checked my foreskin and found it, although ample, completely retractile. He told my mother that I did not need circumcising and declined to do it. He did, however, in spite of its looseness, further stretch the foreskin, which apparently caused me to hit the roof, so I can imagine the pain which circumcised boys must have felt. He also told her that the foreskin had to be drawn back, the head washed and the foreskin replaced every day. The same procedure took place during drying. This continued daily until I was six, when I was allowed to bath myself; since I disliked the feeling of my foreskin being pulled back, and even more the wiping of the glans, I then ceased the practice, to no apparent disadvantage. For a couple of years upon my father's return from the war we lived with a great uncle, who had a housemaid. She also had oversight of my elder brother and myself, sometimes including bathing. If I misbehaved she made sure that the attention she paid to my penis was unpleasant, thus ensuring good behaviour on my part! In the other two cases in which I know why boys were not circumcised, one was born prematurely and unable to be circumcised at birth and was just overlooked later on, while the other was born with jaundice and again could not be circumcised at birth. Both of these boys were circumcised as adults One told me that he hated being uncircumcised and was circumcised by his own choice. The other had severe tightness of the foreskin, never having been able to retract it. Both stated that they were very happy to have been circumcised. I also know a couple of other boys who were circumcised as children. The elder a close friend was circumcised at age 7 (This was before I knew him, and it was he who first told me about circumcision.) because he had a very long and unretractile foreskin and infections. He was happy having been circumcised, but not so his brother. He was 6 when the elder was circumcised, and apparently the doctor asked the parents if they had any other uncircumcised sons, and he'd do them too. They replied yes, one. So even though my friend said his brother had a completely loose and short foreskin, he was circumcised against his wishes, "Just in case". He told me that he envied me still having mine, whilst his elder brother used tell me how awful mine was and that I should get it cut off. Once or twice boys previously uncircumcised re-appeared after school holidays, without their foreskin, but I have no idea why. <h2>RD to DP:</h2> Thanks David, that's most interesting. I have a few questions and comments. What were your own feelings about not being circed? What about your father? You don't specifically mention whether he was circed or where he was born. From what you say he was away at the war when you were born (1944?), so where did the decision to get you circed come from? Was it the Dr giving instructions to your mother? Was this your usual family Dr? Do you happen to remember who he was? Your social situation: if you had a maid, you were presumably in an upper-ish socio-economic situation. Do you think circumcision was more common as you went up the social scale? Was it wealth or respectability that counted most? What did you study at university? What were the circumstances in which you got to check out the condition of the other boys' cocks? Showers at school after sport? Boarding school? Games of "I'll show you mine if you'll show me yours"? How was it that in the various places you mention you were regarded as an anthropological curiosity: why would the condition of your cock be such common knowledge? Or do you just mean that it was viewed in this way by the few people who saw it - but if so, what were the circumstances? Or did you talk about it? You insist that only a very small proportion of your contemporaries were not circed (5 per cent), but I am wondering just how comprehensive your sample could have been. Were you really able to check out the cocks of all the boys at your schools and at your university college? Surely you were not all showering together when you got to university? I can accept that only about 5 per cent of the boys you saw were not circed, but I should think that the uncirced boys might well be shy at that time and would go to great trouble to hide themselves. Comments It's interesting that you confirm that the fundamental reason for circumcision in those days was the myth of congenital phimosis. Although I analysed the error in some detail in my book, I am still astonished that as late as the 1940s medical authorities were insisting that mothers go through that ridiculous and harmful routine of pulling the foreskin back every day and washing underneath. The myth really was deeply ingrained. Also interesting about the boy with the tight foreskin who complained of "infections". There is no way that a normal foreskin, no matter how tight, can get infections, so one wonders what the problem was. Two possible explanations: first, that he was producing a lot of sub-preputial moisture, which does resemble pus if it is allowed to accumulate as smegma and ooze out; second, that he was continually suffering cuts and abrasions from the efforts to pull his foreskin back and that these were getting infected, or at least inflamed from the injury. Even to this day, premature retraction of the foreskin is a major cause of penis problems. (You were lucky and unusual in having a foreskin that was detached and retractable at birth.) <h2>DP to RD:</h2> Perhaps if I answer your questions, firstly, by saying that I am profoundly glad that I was "lucky and unusual in having a foreskin that was detached and retractable at birth"! I have, however, not always felt that way, as it is not easy being a small and derided minority as a child, or I suppose at any other time. Secondly, if I explain how I came to be aware that I was different and my deep and abiding shock in learning why â€“ that is, what circumcision is. This may clarify some of your queries, although I will individually address them as best I am able. Apart from being aware as a young boy of what a penis was, what it did, both sexually (I did live on a farm) and as an excretory organ, I had absolutely no interest in them, and I was blissfully unaware that all my brothers were different from me in that respect, even though I often bathed with them. I was therefore amazed when, during a game of hide and seek at a children's party when I was about 8 or 9, I was whisked away by two older boys (about 12 or14) to hide with them in the shedding (it was on another farm) and was asked to show them my cock. I wondered why anyone would want to look at such a thing and said, "No, who'd want to look at one of those". This only led to further requests, threats and offers, such as "You can look at ours etc". So eventually I said, if they'd show me theirs, I'd show them mine. They did, and I'd never seen anything like them! They looked like strange pink and white mushrooms and, to my idea, very ugly. I was dumbfounded, but had to show mine. They were likewise amazed and commented on how strange and ugly my penis looked and that they'd never seen anything like it before. I was frightened and "lost". Then the elder said, "Oh yes, I've seen something like that before, it's the same underneath", and he yanked back my foreskin to reveal the head well decked with cheese. (I'd stopped washing it, as I said in the last letter, and probably hadn't pulled my foreskin back for 2 or 3 years). They thought that I was disgusting, and I thought they looked like something from outer space. I was also shocked by the smegma, as I'd never seen it before and wondered if I had something wrong with me. When I next bathed with my brothers, I noticed that they all had pink and white mushrooms too, and, as, I observed during or after swimming (we often swam naked in the water channels), so did most other boys, with just a few like me. No one ever commented on this, so I assumed that boys were born with either of two types of penis, those like mine and the others. A year or two later the boy who I mentioned in my previous letter, who had been circumcised at around 7 years, had become a friend. He was some 2 or 3 years older than me. At some stage he saw my penis (pissing, swimming or after sport - I can't remember) and spoke to me about it in a very derogatory way. Eventually he asked me why I thought I looked as I did. I said I thought I'd been born that way. He then asked me why I thought he looked the way he did, and I replied likewise. He then said that his foreskin had been cut off. I was aghast and refused to believe him, saying, "No one would do that to their children". We argued for some time, as I could not believe it. Eventually he said, "Ask your Mother." Although our family life was, even by today's standards, very open and encompassed friends and relations whose personal preferences and lives were perhaps not quite of the mainstream, I thought long and hard about this. Eventually I plucked up the courage to ask my mother what I though to be a totally insane question: Why did I have a long piece of skin hanging down from the end of my penis? She was cross and straight away asked if I and my friends had been playing with each other. I said no, but that I wanted to know why I was different from most other boys. She asked what I thought, and I gave my opinion and the views of my friend, saying that I thought his view was mad, as no-one would do such a thing to their children! She replied that he was right, and asked if I'd like it done. Upon my vehement "No", she said "Well, you'd better be careful, or you will be circumcised whether you like it or not." My mother also told me that I was in no circumstances to talk about this to my brothers, though she realized later that it would be difficult for a boy to be telling his brothers that their parents had cut off part of their penis. Later, around the time of my marriage, when I asked her about my non-circumcision, she asked me what I thought about not being cut. I replied that I was very happy the way I was, though I had not been so as a child, because I had been different from most of the other boys and had been derided by some of them. This led to a lot of self-doubt. My mother added that if she had insisted the doctor would have cut me, and that she regretted that she had not insisted. Still later, when my first child was due, my mother told me that it was important to let doctors know well in advance of anything that I wanted them to do or not to do with young children. I asked her if she was referring to circumcision. She said yes, partially, since she assumed that if the baby was a boy I would not want him circumcised. But she said it was important to tell this to the doctor in advance, as my two younger brothers had been circumcised just like that, without any discussion or permission at all. To go back to your questions: What were your own feeling at not being circed? I have answered above. I would not be writing to you if I were not glad of this! What about my father? He was born in 1916 in Maryborough or Bendigo (Vic), where his family had been mine-owners. He told me much later that he'd been circumcised during the war (i.e. WW2). I later came to realise that he was very pro-circumcision and had been to an Aboriginal initiation in the Kimberleys. He was away when I was born and I believe, from what my mother has told me, that all decisions were made by our usual family doctor, whose name, I believe, was Dr Beck, and who was, I believe, an older man. I'm told he died some few years after I was born. I am forever grateful that he spared my foreskin, no matter on what wrongheaded basis. Your social situation? When I was born and we initially lived with my grandparents, who were very well off. We were comfortably off and employed "help" at times. Our upbringing was very different from that of today. By descent I am on one side Cornish/German on the other Cornish/Irish. I don't think that circumcision was a "class" thing. I think that it was brought in by the medical profession and applied as they found possible - in some areas from top down, so to speak, and in others, from bottom up. In my view, working class and lower middle class people are the ones most likely to follow the custom of circumcising. Certainly, a couple of families of our family friends had 2 or 3 boys, none of whom was cut. I presume it was family choice. What did you study at Uni? Arts. Within our family higher education, as it is now called, was widespread, with people going to the University of Melbourne from the 1890s onwards. Whether they were successful or not, was another matter. What were the circumstances where you were able to check out other boys cocks? Often I thought that I was the "Checkee" rather than the "Checker"! Usually it was in the showers after sport, as I played cricket (which I hated), football and swimming etc. In those days, one often seemed to be naked! Why were you regarded as an anthropological specimen? Because to be uncut was so rare. Often people thought you were deformed or that something else was wrong. When I went to school in Melbourne I boarded with a family. One night I'd had first bath, and their elder son had second. As I was drying my towel fell off. He looked at my penis and said, "What's that?" I said, "My cock". He then asked, "Are you a girl?" Incidentally, in the case of the boy who got circumcised as an adult because he hated it, his feelings came from having being tormented at school (not my school). Why would the condition of your penis be such common knowledge? In schools where lots of sport was played, we were often seen naked, dressing, undressing or showering. If you looked like me, people seemed to say something like "That boy has a funny cock." I never spoke of my own cock, but I never tried to hide it. That's a part of what I am, or a part of what is me. University college life? In those days university colleges were like extensions of boarding schools, and strictly single-sex. The older buildings had cubicles for baths, but the showers were open, and it was quicker and simpler to take a shower. Even there I sometimes got comments to my face about not being circumcised â€“ but I always ignored such talk. I have a nephew, now adult, who is uncircumcised. (One of the good things I've perhaps passed on in life, probably by osmosis, is that my brothers, after having to put up with a freak who had a foreskin, did not circumcise their own boys). He knows of my state, having stayed with us often when he was younger, and he told me that a few years back, in the football club of which he was a member, he was regularly pointed out to all and sundry as the only uncut in the team! You insist that I could have seen only a small proportion of my contemporaries. My sample was simply what I saw after sport etc, or sometimes on remarks passed. It may well be wrong and was certainly not scientifically based, but I suspect it is fairly close to the mark. I simply seldom saw anyone looking like myself. Being uncircumcised was then a pretty solitary calling! Comments I've read medical journals etc, and felt vindicated on first reading <a href="http://www.cirp.org/library/general/gairdner/" rel="noopener" target="_blank">Gardiner's comments re circumcision</a> in 1949. At one stage at about age 13, when things were very difficult, I remember thinking, "But I'm normal". By this I meant that all boys are born with foreskins; therefore it can't be normal or right to cut them off. One of the reasons why I am so grateful that I am not circumcised is that I did not have to endure the public humiliation and torture that is involved in the operation. Some of the alternatives described in the BMJ, though, sound even worse -- the one where the foreskin is firmly detached, then both layers stretched and forcibly retained behind the glans is enough to make one weep. Even if it were ever able to be brought forwards afterward, it would be useless. When my mother told me even what had happened to me -- which on the scale of these things was very mild -- I was angry and hurt to think of my own mother being willing to hold me whilst my foreskin was tortured. You can also take it from me, that unlike the view of the man who thought that having one's glans wiped and cleaned was like masturbation, it most certainly was not in the least bit pleasant to have the head of one's infant cock rubbed. Even gently, with a towel, it was not pleasurable. Once, after swimming at the beach, whoever was drying me got me to stand up on the seat and, after wiping around my buttocks, pulled back my foreskin and proceeded to wipe the head of my penis with a sandy towel. I screamed and started yelling, to his great surprise. He said, "Sorry, I was only wiping the sand off." Of course there wasn't any sand there! Clearly even when a foreskin like mine was perfectly loose and mobile some adults had the urge to interfere with it and somehow desensitise it and reduce it to the same condition as the skinless model. It doesn't differ greatly in degree from the verbal abuse dished out for simply being the way one was. I have spoken to other men who, as boys, were reduced to tears by such torment. </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 Cavalier among the roundheads 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>New “circumcision guidelines” show that Centers for Disease Control ignores medical evidence</h3> After seven years of argument and paper shuffling, the bureaucrats in the glass towers that house the United States Centers for Disease Control have decided to follow the American Academy of Pediatrics in affirming that the benefits of circumcision outweigh the risk of complications. Although this was the headline conclusion of the AAP’s 2012 policy statement, it was an arbitrary assertion that did not follow from the evidence. Since the AAP was unable to quantify either the risks or the benefits of circumcision, it was logically impossible for them to reach such a conclusion. Even more seriously, as Brian Earp points out below, complications are only a small part of the story: for a non-therapeutic procedure involving the amputation of a significant body part it is not enough to assess the risk of complications (bleeding, infection etc); it is also necessary to factor in the value of that part and the harm of losing it. There is abundant evidence that men like having a foreskin, and thus that it removing it - especially if it is done without consent from an infant or child - is not quite the same thing as amputating a gangrened finger. The failure of both the AAP and the CDC to consider such a fundamental aspect of the circumcision decision means that their policies and guidelines are fatally flawed at their core and of little practical value. The CDC has made its draft guidelines available for public comment; as the early critiques published below suggest, it is likely to receive a lot of flak over the next few weeks. What is it with these Americans? <h2>Harm of circumcision and value of foreskin ignored</h2> Comment by Brian Earp on the proposed guidelines concerning male circumcision to be issued by the United States Centers for Disease Control Several people have asked for my take on the provisional CDC guidelines announced today suggesting that the benefits of male circumcision outweigh the risks. What follows is a brief, preliminary comment, in which I highlight just a few of the key issues: (1) The Centers for Disease Control (CDC) is largely following the American Academy of Pediatrics (AAP), whose statement I have already criticized here. Note that I have included some other professional critiques of the AAP documents in my post: the upshot is that the findings of the AAP were not taken seriously by the majority of its peer organizations in Europe, whose assessment of the AAP was that it exhibited cultural bias in favor of circumcision due to the status of circumcision as a routinized norm in this country. (Circumcision was absorbed into the medical establishment of the United States in the late 1800s in an effort to combat masturbation, among other dubious reasons, and then became preserved over time as a rationalized habit -- long past the time it was effectively abandoned by other developed nations). The CDC appears to be making the same mistakes, in part by misapplying the same - or similar - data to incommensurate epidemiological environments (i.e., by relying on studies carried out on adults in Sub-Saharan Africa to make recommendations concerning infant circumcision in the United States). It also falls flat in its (meager) ethical analysis in much the same way as the AAP did in 2012. For more on the AAP, the science of circumcision, and the attendant ethical issues, see my discussion here. See this recent paper well. (2) The CDC is using the wrong formulation for assessing the prudence of circumcision, namely benefit vs. risk. Benefit vs. risk was designed for therapeutic procedures (sometimes referred to as "medically necessary" surgeries), where it must be shown that the benefits to the patient outweigh the risk of surgical complications. In the case of circumcision performed on healthy individuals who cannot—if they are minors—consent, however, the appropriate test is not benefit vs. risk, but rather benefit vs. harm. Here, “harm” includes not only the risk of surgical complications (an elusive figure, due to the poor quality of the existing data), but also the inherent harm of having a functional, erotogenic genital structure removed in the absence of either disease or deformity. In legal theory, at least, unnecessary surgeries that amputate healthy tissue are considered to be harmful per se. On this view, the loss of the tissue is in itself a harm, unless the tissue can be shown either to have no value or to serve no functions, neither of which can plausibly be demonstrated in this case. Since there is no disease present, and since any future diseases to which the tissue may one day fall prey can be avoided and/or treated through non-surgical means, an additional harm concerns the loss of choice, in light of alternative risk-management options, concerning an extremely personal part of one's anatomy. The CDC glosses over all of this, however, and appeals (again) to an entirely inappropriate heuristic for non-therapeutic surgeries, according to which “surgical risk” is deemed to be the only morally-relevant cost to circumcision. (In its technical report, the CDC does point out that one advantage of adult circumcision, compared to infant circumcision, is that the former can be done autonomously, while the latter is always done without consent -- and may therefore lead to later resentment. This observation has not received much attention in the ongoing flurry of media coverage.) (3) Let me make one last point by way of a thought experiment. Suppose it could be shown that removing the labia majora of infant girls reduced their risk of getting urinary tract infections (since there would be fewer folds of moist genital tissue in which bacteria could find a home), as well as cancers of the vulva (since there would be less tissue in which such cancers could develop). It's not implausible, and in fact in countries in which female genital cutting is culturally normative, it is easy to find “medical” support for these views: female circumcision is often thought to be “more hygienic” and well as more aesthetically pleasing: therefore, it is often said, it is in the best interests of the girl child to be circumcised so that she can attain these benefits. Remember, female circumcision falls on a spectrum, and some forms of it are less invasive than male circumcision, may not involve modification of the clitoris, and are sometimes done for reasons other than (attempted) control of sexuality. Nevertheless, it is actually illegal in Western countries to conduct the very research by which such "health benefits" could be discovered. Non-therapeutic, non-consensual surgeries carried out on the genitals of healthy girls—no matter how slight or under what material conditions—are defined as impermissible mutilations in Western law. This is because it is presumed that girls are entitled to grow up with their genitals intact, and to decide, at an age of understanding, whether they would like to undergo permanent alterations to their private parts, and if so, for what reasons, and what kind. Whether a minor reduction in the risk of certain infections or diseases (whose prevalence is determined by socio-behavioral factors much more than anatomical-biological factors, and whose occurrence can typically be prevented and/or treated in much more conservatives ways) is worth the trade-off of losing one's labia (let’s say) -- or indeed one’s foreskin -- is a complex question, and one whose answer is likely to be highly subjective. Therefore, it should be up to the affected person to decide about permanent genital-modification surgeries at such a time as he or she can factor in his or her own preferences and values. Circumcision (of boys or girls) is not an effective health-promotion strategy, given less ethically problematic alternatives. Brian D. Earp, University of Oxford, 2 December 2014 Brian D. Earp is a <a href="http://blog.practicalethics.ox.ac.uk/author/brian-earp/" rel="noopener" target="_blank">Research Fellow in Ethics</a> at the University of Oxford. He holds degrees from Yale, Oxford, and Cambridge universities, including an M.Phil. degree in the history, philosophy, and sociology of science and medicine, focusing on male and female genital surgeries. Brian has served as a Guest Editor for the Journal of Medical Ethics, editing a <a href="https://www.circinfo.org/Journal_of_medical_ethics_July13.html" rel="noopener" target="_blank">special issue on the topic of childhood circumcision</a>, and has published widely in the leading journals in his field. <a href="https://www.academia.edu/9603843/Brief_comment_on_the_proposed_guidelines_concerning_male_circumcision_to_be_issued_by_the_CDC" rel="noopener" target="_blank">Proposed CDC guidelines on male circumcision: A critique (with links)</a> Circumcision risks and harms outweigh benefits: Now published as Brian Earp. <a href="http://journal.frontiersin.org/article/10.3389/fped.2015.00018/abstract" rel="noopener" target="_blank">Do the benefits of male circumcision outweigh the risks? A critique of the proposed CDC guidelines</a>. Frontiers in Pediatrics 3 (18), 21 February 2015 <h2>Why the Centers for Disease Control can’t get their facts straight</h2> <h3>Statement by Intact America</h3> Intact America, an organization that opposes the forced genital cutting of babies and children, sharply criticizes the recent Centers for Disease Control (CDC) proposed guidelines for circumcision. The CDC is calling for doctors to tell the parents of male infants, children and adolescents that circumcision has been found to reduce the transmission to men of HIV and other sexually transmitted infections (STIs). The guidelines were released on December 2, 2014, opening a public comment period that will end on January 16, 2015. “Beyond stating and restating its support for medically unnecessary circumcision, the Centers for Disease Control fails to provide any solid evidence to bolster the case for circumcision as a valid measure for disease prevention,” said Georganne Chapin, an attorney and executive director of Intact America. “The studies cited by the CDC purporting to show that circumcision reduces transmission of STIs were conducted in poor rural areas of sub-Saharan Africa over eight years ago. These studies have never been replicated elsewhere—let alone in the United States—and have no relevance to children or men in the developed world.” “There have been no systematic studies conducted anywhere about the short-or long-term adverse consequences resulting from circumcision," says director Chapin. "Through thousands of personal stories from boys, men and their parents we know that circumcision causes myriad complications, some requiring surgical correction. Adult consequences include poor body image, painful sex, psychological problems, and erectile dysfunction. The CDC's continued persistence in recommending what they know to be an unnecessary surgery is questionable. It is happening in the face of increased public awareness about circumcision’s harms, declining U.S. circumcision rates, and the growing reluctance of states and insurers to pay for this medically unnecessary surgery.” Intact America notes that the CDC’s proposed guidelines make no mention of the spontaneous and growing protests around the U.S. and Canada by men who are speaking out angrily about having been forced as children to undergo circumcision. “As a public health organization, the CDC should be calling for a study of the true risks and complications from circumcision that occur over the lifetime of boys and men,” says Chapin, “before it promotes its evidence-free claim that the benefits of newborn circumcision outweigh its harms.” The American Academy of Pediatrics released a statement in 2012 promoting the benefits of infant circumcision and calling for insurers and state Medicaid programs to pay for the surgery, performed in the U.S. often without anesthesia. This report is at sharp odds with the ethical and medical stance taken by physicians here and in Europe concerning the removal of healthy sexual tissue from children who cannot consent. In early 2013 in the journal Pediatrics, a large group of physicians, medical organizations, and ethicists from European, Scandinavian, and Commonwealth countries issued <a href="http://pediatrics.aappublications.org/content/early/2013/03/12/peds.2012-2896" rel="noopener" target="_blank">a strongly-worded statement</a>, calling American medicine’s support for infant circumcision “culturally biased,” and “different from [the conclusions] reached by physicians in other parts of the Western world, including Europe, Canada and Australia." In October 2014, Britain’s National Health Service affirmed its previous position stating that, “most healthcare professionals now agree that the risks associated with routine circumcision, such as infection and excessive bleeding, outweigh any potential benefits.” <h2>Centers for Disease Control ignoring the medical evidence</h2> <h3>Statement by Attorneys for the Rights of the Child</h3> The human rights organization <a href="http://www.arclaw.org/" rel="noopener" target="_blank">Attorneys for the Rights of the Child</a> (ARC) is preparing a response to the Centers for Disease Control and Prevention (CDC) regarding its release on December 2, 2014 of a draft of proposed circumcision guidelines. J. Steven Svoboda, ARC’s Executive Director, commented today, “Sadly, the CDC has chosen to ignore the medical evidence to try to justify an outmoded and painful cultural—not medical—practice. In these days of constantly mounting medical costs and ever scarcer resources, we simply cannot afford to continue supporting and performing a harmful and antiquated procedure.” Regarding the CDC’s claim that circumcision’s benefits outweigh the risks, Svoboda commented, “The CDC omitted the functions of the amputated tissue. If the CDC advocates for cutting off a body part, shouldn’t we know what that body part does?” Svoboda commented, “If circumcision is as desirable as the CDC suggests, why are European countries moving towards banning it, why are their males healthier than Americans, and why does the CDC not come out and recommend it?” By the CDC’s own admission, Americans are increasingly choosing to leave their sons intact, as circumcision rates have plunged in recent years. Svoboda added, “A recent study by Bossio et al in the Journal of Sexual Medicine, concluded that the literature favoring circumcision contains considerable gaps, lacks rigor and is largely not applicable to North America.” Studies of HIV in adult males in Africa suffer from methodological and statistical errors and even if valid, given vast differences in health conditions and modes of transmission, the results can hardly be applied to justify infant male circumcision in the United States. “Doctors cannot ethically remove tissue from babies without consent, based on speculation about their possible sexual behavior decades later,” Svoboda added. “Male circumcision,” Svoboda said, “violates a child’s right to bodily integrity, not to mention numerous civil and criminal statutes.” Malpractice awards are mounting up; a list of seventy such cases were released by ARC, the largest amounts to 22.8 million dollars (Antonio Willis v. Northside Hospital Atlanta, March 1991) <h2>Legal and child health experts criticise new circumcision guidelines</h2> Last Tuesday, the Centers for Disease Control and Prevention (CDC) released its proposed guidelines on male circumcision for public comment. The new federal guidelines would recommend male circumcision as a healthy choice that doctors should offer for parents to make for their sons and for teenagers and adults to consider. The CDC background report claims that circumcision has been shown to prevent HIV, HPV and other infections. The new CDC report mimics the 2012 American Academy of Pediatrics Circumcision Policy Statement which drew widespread criticism for its claim that circumcision benefits outweigh the risks. IntactNews asked the CDC for comment about the risks for an average American male in acquiring HIV. “It’s hard to establish one, single figure for risk of HIV acquisition by a heterosexual male,” the CDC responded in an email to IntactNews today, saying the risks are not well documented. <a href="http://www.hivlawandpolicy.org/resources/heterosexual-risk-hiv-1-infection-sexual-act-systematic-review-and-meta-analysis" rel="noopener" target="_blank">One study estimates</a> the chance of an American male acquiring HIV through a single unprotected sex act with a known HIV+ female partner is less than 0.04%. That adds up to a 6% risk per year, with an estimated total of 620 new HIV infections per year for white, heterosexual males with known HIV+ or high-risk female partners. What these numbers show is that the average American man has a comparably low risk of getting HIV through unprotected sex. In fact, the number of average American men getting infected with HIV per year is so low that the CDC does not have data on this demographic. As one legal expert comments, “It is ludicrous and scientifically unsound to recommend the removal of a normal body part from all males to reduce the incidence of sexually transmitted diseases that can be prevented by ABC—practicing abstinence, being faithful and using condoms,” says David Llewellyn, an Atlanta-based attorney whose practice focuses on botched and wrongful circumcisions. “The idea that doctors should counsel teenage boys to get circumcised rather than teaching them ABC is equally absurd. “Furthermore, the CDC recommendations completely ignore the known functions of the foreskin, how circumcision changes the penis, and the hidden but well recognized common injuries that happen every day as a direct result of neonatal circumcision. In my practice, I see the devastating results of circumcision every day. In particular, the high rate of the narrowing of the urinary opening (meatal stenosis) which occurs to tens of thousands of circumcised boys every year. This is not sufficiently addressed by the CDC, even though it is a well-known complication of circumcision. The CDC needs to be paying more than lip service to the devastating effects of these injuries. ” Pediatric urologist warns on high incidence of circumcision complications and other harm “It is regrettable that the CDC has chosen to position itself on the wrong side of scientific evidence with its endorsement of circumcision for male newborns and heterosexual adult males,” says Dr. Alexandre T. Rotta, Chief of Pediatric Critical Care at University Hospitals in Cleveland, Ohio. “By cherry-picking data that, at best, have marginal relevance (if any) in parts of Africa with high heterosexual HIV transmission, the CDC recommendation is empty, counterintuitive, and irrelevant to the health of the very Americans it aims to protect. As a pediatrician, I am deeply troubled by this form of government-endorsed mutilation of children, fragile human beings who will forever be robbed of the right to make an informed decision on such a deeply personal matter carrying irreversible consequences. This is an egregious violation of personal autonomy and medical ethics.” Source: Experts denounce CDC’s “blind promotion” of circumcision in proposed guidelines, <a href="http://intactnews.org/" rel="noopener" target="_blank">Intact News, 4 December 2014</a> Further critical comment at the <a href="http://chhrp.org/index.php/news/chhrp-responds-to-the-cdc/" rel="noopener" target="_blank">Canadian Children's Health and Human Rights Partnership</a> <h2>Centers for Disease circumcision guidelines unethical and medically unsound</h2> The following comment on the draft guidelines for circumcision issued by the United States Centers for Disease Control was released by <a href="http://arclaw.org/" rel="noopener" target="_blank">Attorneys for the Rights of the Child</a> and <a href="http://www.intactamerica.org/" rel="noopener" target="_blank">Intact America</a>. In compiling its proposed recommendations, the CDC has ignored the considerable and reputable literature from the fields of medicine, medical ethics, law, and human rights that calls into question the legitimacy of foreskin removal (circumcision) as a health care measure. Recommendation 1 acknowledges that routine circumcision in the United States, though performed “medically,” is primarily a religious, social, cultural and cosmetic procedure. As such, and in the absence of a diagnosable pathology, the circumcision of infants and children, and the circumcision of any individual in the absence of truly informed consent by physicians who understand the normal male genitalia and the function and benefits of the foreskin, is unethical. The CDC fails to mention that numerous medical organizations, legislatures, physicians and ethicists from European and Commonwealth countries with sophisticated medical systems and lower rates of sexually transmitted infections (STIs), including HIV, have criticized the American medical establishment for its cultural bias toward circumcision, for exaggerating the procedure’s benefits, and for ignoring and understating its risks and harms. The CDC also fails to acknowledge that even the merest pin prick of a minor girl’s genitals – whether motivated by religion, culture or aesthetic preference – violates federal laws against “female genital mutilation.” The United States Constitution guarantees equal treatment of females and males, and thus the circumcision of non-consenting male minors combined with the protection of female minors constitutes illegal discrimination. It also may constitute establishment of a religion in violation of the United States Constitution. Recommendation 2 states that all sexually active adolescent and adult males need to use “other” (i.e., other than circumcision) “proven HIV and STI risk-reduction strategies.” The question must then be asked: Why perform surgery at all, especially considering that no benefit whatsoever is obtained for the (circumcised) male’s sexual partners? Recommendation 3 fails to mention that there has been no systematic longitudinal study of the long-term harms and complications from neonatal circumcision – many of which doctors are not taught to recognize and some of which do not appear until later in life. Nor do the recommendations acknowledge that unnecessary surgery in itself causes harm. As a California Appeals Court has stated, “Even if a surgery is executed flawlessly, if the surgery were unnecessary, the surgery in and of itself constitutes harm. (Tortorella v. Castro, 140 Cal. App.4th 1, 43 Cal. Rptr.3d 853, Cal.App. 2 Dist. (2006)) Recommendation 4 fails to mention: <ul> <li>Urinary tract infections can be treated in boys, as in girls, with simple antibiotics rather than the surgical removal of a normal healthy body part.</li> <li>Balanitis and balanoposthitis are easily treatable with topical creams.</li> <li>Penile cancer is extremely rare, and no medical organization (including the American Cancer Society) recommends circumcision as a preventive measure. The CDC’s reference to a “possibility” that circumcised males are less likely to experience prostate cancer is speculative and unproven and therefore its mention by the CDC as an argument for circumcision is inappropriate.</li> <li>The CDC acknowledges that “the risk [of HIV and STIs] for any individual neonate, child or adolescent cannot be definitively defined at the time that a circumcision decision is made.” The CDC also shockingly fails to examine and weigh the immunological, protective, erogenous, and other functions of the tissue that is to be removed. Unknown risks and omitted harms cannot be meaningfully weighed against asserted benefits.</li> <li>Surrogate (i.e., parental) permission for a procedure on a child is valid only in the case of a serious or life-threatening disease or illness. The American Academy of Pediatrics (AAP) states that the surrogate is limited to providing “informed permission for diagnosis and treatment of children.” (American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995;95(2):314–7.) Non-therapeutic child circumcision is neither diagnosis nor treatment and thus falls outside parental power to consent. A normal boy with a normal foreskin should never be a candidate for circumcision surgery.</li> <li>Regarding “the timing of male circumcision,” the recommendations inexplicably dismiss the important fact that infants are not at risk of STIs. The recommendations also mention the lower cost of neonatal circumcision as justification. This claim is irrelevant, as any surgery is too expensive if it is unnecessary.</li> <li>Regarding “complications,” mounting evidence indicates that both circumcised men and their partners experience sexual problems as a result of the male having had his foreskin permanently removed.</li> </ul> The AAP’s 2012 technical report on circumcision has been roundly criticized for reasons also applicable to the CDC recommendations: cultural bias, cherry-picking of evidence, repeatedly stating that benefits of circumcision outweigh its risks without providing evidence of the harms, and omitting information about the functions of the foreskin. In sum, the CDC exaggerates the benefits of circumcision, minimizes its risks, utterly ignores the function and benefits of the foreskin, and blithely disregards critical ethical and legal questions regarding the rights of all children to enjoy their normal, natural sex organs. <h3>US media scent winds of change</h3> Even the mainstream United States media, usually avid in their promotion of circumcision have been forced to recognise that Americans are now “telling Uncle Sam to leave the foreskin alone” Cheryl Wetzstein, <a href="http://www.washingtontimes.com/news/2014/dec/9/cdc-circumsion-proposal-getting-thumbs-down/" rel="noopener" target="_blank">Americians push back against CDC recommendation on circumcision</a>, Washington Times, 9 December 2014 Victoria Colliver, <a href="http://www.sfchronicle.com/health/article/Federal-circumcision-guidelines-meet-with-5944107.php?t=7a6651e708&cmpid=twitter-tablet#/0" rel="noopener" target="_blank">Federal circumcision guidelines meet with opposition</a>, San Francisco Chronicle, 10 December 2014 <h2>Superficial, inadequate and ideological: Child health expert’s scathing review of CDC circumcision guidelines</h2> Unscholarly, selective and biased are a few of the more complimentary terms applied by paediatrician Robert Van Howe to the draft guidelines on male circumcision issued for public comment by the United States Centers for Disease Control in December 2014. Appointed as an official peer reviewer for the guidelines, Dr Van Howe, Professor of Paediatrics at Michigan Central University, did not muck about. In a 200-page review, with over 1300 references, he subjected every statement in the CDC’s draft to a withering critique and found nearly all its facts to be wrong, its claims dubious, its conclusions invalid, and its recommendations dangerous. The most striking features of the document were the glaring gaps in its research, the lack of logic in its arguments, and its irresponsible resort to scare tactics, particularly its attempt to use fear of AIDS in sub-Saharan Africa as a means of driving Americans to embrace circumcision. As Professor Van Howe asks, if the CDC guidelines are meant to assist Americans, how come it is so obsessed with Africa? More specifically, Van Howe identifies seven major flaws in the CDC’s report. (1) It lacks scientific rigour. (2) It is thin on details. (3) It disregards much of the medical evidence. (4) It ignores the anatomy, physiology and functions of the foreskin. (5) It is out of step with world opinion on non-therapeutic circumcision. (6) Despite massive consultation, the document is not significantly different from the draft issued in 2007 – eight years ago. (7) It urges health providers to supply the public with misleading, irrelevant and out of date information. The introductory paragraphs of Professor Van Howe’s peer review are given below. The full document may be <a href="https://cmich.academia.edu/RobertVanHowe" rel="noopener" target="_blank">seen at his Academia.edu page.</a> A CDC-requested, Evidence-based Critique of the Centers for Disease Control and Prevention 2014 Draft on Male Circumcision: How Ideology and Selective Science Lead to Superficial, Culturally-biased Recommendations by the CDC Several things are remarkable about this draft. First, is the obvious lack of scientific and scholarly rigor that went into preparing this draft. While it is stated that the writers of the draft performed a search of the medical literature, the evidence (in the form of the draft itself) indicates that their search was far from complete. Instead of collecting and analyzing data, they relied on review articles to do the work for them. One review article was published in 1983 — a bit dated to say the least. In some sections, the draft relied on opinion pieces as their sources of information. In areas where review articles were not available, the information provided was far from complete. For example, in reviewing the medical literature on the impact of male circumcision in North America, which is a major thrust of the draft, only two of the eight available studies are mentioned. Similarly, no serious attempt was made to review the harms, risks, complications, or pain associated with circumcision. The draft has only 255 references, some of which are redundant, which are only a small sampling of the material available in the literature. A PUBMED search using the search word “circumcision” on January 12, 2015 identified 6338 publications. The draft also ignores basic epidemiological principles. It fails to apply the standards that are needed to identify when an intervention should be applied. Throughout the draft, it is assumed that circumcision will be successful as a primary prevention for HIV, when the data clearly demonstrate that it is ineffective as primary prevention. Even its role as a secondary preventive measure has only been evaluated in one study in the United States, which included a very small, limited population. For this very small population, modeling by the CDC has estimated that circumcision’s impact on infection risk is nearly inconsequential. Policy should be based on more than one small subset of patients from a single study when several other studies fail to support this conclusion. It is clear that both the investigators of the randomized clinical trials and the CDC draft authors do not understand the epidemiological difference between efficacy (a positive finding in a research setting) and effectiveness (positive results in the real world). The draft fails to adequately scrutinize the validity of the few studies it identified. It assumed the randomized clinical trials could not harbor any bias (the draft actually states this!) and did not question the methodology of these studies, although their methodology has been questioned extensively. Instead of accepting the study results at face value, the expectation of scholarly rigor would demand that these studies be carefully scrutinized, and a determination made as to whether the studies generated valid results and/or if the criticisms raised about these studies were convincing. The writers of the draft made no effort to question or analyze these studies. If a student were to submit these drafts for consideration as a senior undergraduate or master’s thesis, they would fail based on their lack of scholarship. It appears the CDC was only going through the motions in preparing this draft. If the CDC had performed an adequate search of the medical literature and applied the expected level of scholarly rigor, their conclusions and recommendations would have been different. Perhaps that was the point. Perhaps the hope was, by releasing the draft with a selective bibliography, no one would recognize the lack of scholarly effort or call the CDC out on doing a subpar job. It worked for the American Academy of Pediatrics, and they seemed to get away with it. The difference is that CDC documents are open for public comment because it is a government agency. One would think that, after all of the embarrassment the CDC has endured in the recent past, they would want to put their best foot forward by publishing a rigorous, balanced, evidence-based assessment of male circumcision. That obviously did not happen. Second, is the lack of attention to detail. Many of the citations given have the authors and journals incorrectly listed. Several of the citations require updating, while several of the citations were redundant. There are several misspellings in the manuscript. This indicates the CDC did not expend sufficient effort putting forth this piece of work, which is consistent with its lack of scholarly rigor. Third, is the wanton disregard for the medical evidence. It is clear throughout that the writers of the CDC draft believe absolutely in the presumption that infant male circumcision can reduce HIV and sexually transmitted infections beyond a shadow of a doubt. As a consequence, the draft goes about finding evidence to support their presumption and primarily presents evidence supportive of this presumption, despite evidence to the contrary. The quality of the evidence supporting the presumption is never questioned. Any evidence that does not support their presumption is either ignored, criticized, or dismissed. As a consequence, the draft is laughably biased and reflects the expectation bias of its writers. Fourth, is the lack of a thorough discussion of the foreskin and its anatomy, histology, physiology, and function. It is standard procedure for review articles of this type to review these topics to provide a basic science foundation. How can the CDC discuss the biological plausibility of sexually transmitted infections without a knowledge of the basic anatomy, histology, physiology, and function? This information must be included since health care providers must understand what is lost by removing the normal foreskin/prepuce. How else can they explain the impact of its removal to patients? This information is also an essential element of the disclosure given during the informed consent process. Fifth, is how out of step the CDC is with the rest of the world. National medical organizations and human rights groups throughout the world, including the Council of Europe, are, in increasing numbers, denouncing infant circumcision as being medically unnecessary and a blatant human rights violation. At this point in time, the CDC and the American Academy of Pediatrics are the last stronghold in the defense of infant circumcision. Remarkably, the draft fails to mention all the medical organizations outside of the United States who have weighed in with an opposing opinion on male circumcision. Is there some source of special knowledge the CDC has in its possession that allowed them to reach conclusions that are diametrically opposed to every other national medical organization (other than the American Academy of Pediatrics)? If it exists, why is it missing from the draft? Please provide enlightenment. If the CDC has a clue, they could at least share it. Sixth, it took over seven years for the CDC to produce a substandard, scientifically unacceptable product, nearly identical in content to what was presented at the 2007 consultation. Finally, the most remarkable thing is that the CDC is recommending clinicians and health care providers relay information that is counterfactual, incomplete, and biased to medical decision makers. In essence, they are deliberately encouraging health care providers to misinform their patients and thus commit medical malpractice. The CDC needs to throw out this draft and start again from scratch, this time without a preconceived conclusion in mind. They need to review the entire medical literature, thoroughly scrutinize the studies in the literature, and properly apply basic epidemiological principles. When they have done so, they need to consult with experts from around the world to make sure their findings are not culturally biased. They also need to focus on the United States, not Africa. Source: Robert Van Howe, MD, MS, FAAP. A CDC-requested, Evidence-based Critique of the Centers for Disease Control and Prevention 2014 Draft on Male Circumcision: How Ideology and Selective Science Lead to Superficial, Culturally-biased Recommendations by the CDC. January 2015. <a href="https://www.academia.edu/10553782" rel="noopener" target="_blank">Full text available at Academia.edu</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 Centers for Disease Control and male circumcision: Americans out of touch and living in the past 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>Circumcised men at equal risk of HPV infection</h2> A large-scale study at the University of Washington has found no difference in the incidence of HPV infection between circumcised and uncircumcised male college students. HPV (Human Papilloma Virus) is a large group of viruses that may cause genital warts, and are implicated in the genesis of genital cancers. HPV is very common among the sexually active population. but most people never show any symptoms. The risk factors for the development of cancer have been shown to be numerous different sexual partners and smoking. The new study confirmed previous research which showed that the location of the virus differed between circumcised and uncircumcised men: circumcised men tend to carry the virus on the shaft skin of the penis, while intact men are more likely to carry it on the glans. The study also also found that circumcised men have more sexual partners. In a previous study the researchers found found that for college females the circumcision status of their partner was NOT a risk factor for HPV infection in women. The authors comment that the African Random Clinical Trials, which seemed to show that uncircumcised men were more likely to carry the HPV virus, were seriously flawed because they took samples only from the glans (not from the shaft skin, where the virus is concentrated in the circumcised). ABSTRACT Background: The role of circumcision in male HPV acquisition is not clear. Methods: Male university students (aged 18–20 years) were recruited from 2003 to 2009 and followed up triannually. Shaft/scrotum, glans, and urine samples were tested for 37 human papillomavirus (HPV) genotypes. Cox proportional hazards methods were used to evaluate the association between circumcision and HPV acquisition. Logistic regression was used to assess whether the number of genital sites infected at incident HPV detection or site of incident detection varied by circumcision status. Results: In 477 men, rates of acquiring clinically relevant HPV types (high-risk types plus types 6 and 11) did not differ significantly by circumcision status (hazard ratio for uncircumcised relative to circumcised subjects: 0.9 [95% confidence interval{CI}: 0.7–1.2]). However, compared with circumcised men, uncircumcised men were 10.1 (95% CI: 2.9 –35.6) times more likely to have the same HPV type detected in all 3 genital specimens than in a single genital specimen and were 2.7 (95% CI: 1.6–4.5) times more likely to have an HPV-positive urine or glans specimen at first detection. Conclusion: We found no differences by circumcision status in overall HPV acquisition or in number of HPV types acquired. Findings held for all clinically relevant HPV types, as well as for the subgroups of high-risk types, high-risk -9 types, and HPV-16. This observation is consistent with findings from other longitudinal studies. Bottom line: Circumcision does not lower the risk of infection with Human Papilloma Virus. People who claim that uncircumcised men are more likely to develop or communicate genital cancers are ignoring the facts and spreading misleading information. Source: Kelley Van Buskirk et al, Circumcision and Acquisition of Human Papillomavirus Infection in Young Men, Sexually Transmitted Diseases 38 (12), December 2011. Journal homepage: http://journals.lww.com/stdjournal/pages/default.aspx Abstract available at journal - Published ahead of print: http://journals.lww.com/stdjournal/toc/publishahead <h2>Circumcision, human papilloma virus (HPV) and cervical cancer in women</h2> A review (2015) of the literature by a statistical and epidemiological experts shows there is no evidence that uncircumcised men are more likely to harbour HPV. Abstract: Genital infections with human papillomavirus (HPV) may be the most common sexually transmitted infections, but most infections with HPV are transient. While HPV infections may cause cervical cancer, only a handful of the hundred or so types of HPV are carcinogenic. Some have claimed, using a selective bibliography, that circumcision in males reduces the risk of HPV infections and the risk of cervical cancer in female sexual partners. The breadth and the quality of the epidemiological research regarding any association between male circumcision and HPV infections in general, and carcinogenic HPV in particular, will be considered. It will also be explored whether associations found in some studies can be attributed to other factors. Conclusion: The big lie To get to the truth, one needs to look beyond just the tip of the penis to get the full picture of the impact of circumcision on the risk for genital HPV infections. For all the hyperbole surrounding the propaganda of repeating the lie that circumcision reduces the risk of genital HPV infections in both men and women, the medical evidence simply does not support this claim. Anyone who makes these claims should be called out as a fraud. Source: Dr Robert Van Howe. <a href="https://www.academia.edu/13846777/Human_Papillomavirus_and_Circumcision_The_Story_Beyond_the_Tip" rel="noopener" target="_blank">Human Papillomavirus and Circumcision: The Story Beyond the Tip</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 Cervical cancer, HPV 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"> <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"> <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"> <h3>American Academy of Pediatrics experts fail to defend circumcision</h3> The Twentieth Pitts Lectureship in Medical Ethics at the Medical University of South Carolina in Charleston, South Carolina, held on 18-19 October 2013, was the scene of an epoch-making confrontation between advocates of genital integrity and supporters of routine infant circumcision. On the pro-circumcision side were Drs Michael Brady and Douglas Diekema, members of the American Academy of Pediatrics (AAP) <a href="https://www.circinfo.org/United_States_circumcision_policy.html">Task Force on Circumcision</a>. Arguing for genital integrity were J. Steven Svoboda from <a href="http://www.arclaw.org/">Attorneys for the Rights of the Child</a>, supported by ARC Legal Advisor Peter Adler, community activist Aubrey Taylor, and her husband, Angel Alonso Terron. In the following personal report, Steven Svoboda takes up the story. Brady was my opponent in the debate about whether circumcision is legal and ethical. Diekema, despite initial claims of objectivity, joined with Brady as a proponent of circumcision. Brady gave a presentation on Friday, October 18, 2013 that closely tracked his PowerPoint. My response followed. Our PowerPoint was by that point persuasive enough that, as they each personally told me later, two of the five physician presenters who are not AAP Task Force members were completely convinced by our arguments and went from being pretty strongly pro-circumcision prior to the event to coming to oppose the procedure based on our arguments. (This also is a good testament to the open-mindedness and objectivity of these doctors.) Following my presentation was a scheduled 45-minute debate between Dr. Brady and me. We each got our blows in, but it quickly became clear that Brady was unaware of recent political developments and pertinent medical studies. On Saturday, we were each allowed five minutes to summarize our views. After I spoke for the full five minutes, Dr. Brady was unable to effectively rebut any of my points, speaking for just over a minute in an effective concession of defeat. Brady referred to me in his short talk as “Dr, er excuse me, Mr Svoboda.” On Friday, Dr. Brady had audibly complained about how the organizers had allowed “non-physician presenters” to speak, of which I was the only one. On Saturday, October 19, after each presenter spoke, an open discussion ensued amongst all eight panelists for about 2.5 hours, the last half of which was focused on male circumcision. Peter, Aubrey, and Angel each made very powerful and effective points that helped move the discussion further in our direction. Aubrey and Angel also videotaped, as I had arranged with the conference organizers, all conference proceedings on Friday, and were supposed to record Saturday as well but some presenters asked that no recording be done on Saturday and this was agreed to without informing me of the change. Peter, Aubrey, Angel and I were able to drive home over quite a few key points, such as uncertainty about the effectiveness of circumcision in reducing the risk of heterosexually acquired HIV. Even the AAP is calling for further studies regarding the connection (if any) between male circumcision and HIV, and eminent scholar Michel Garenne says you need a condom even if you are circumcised. In that case, what’s the point of circumcision. Aubrey offered a great analysis of how Dr. Brady was treating a healthy body part as if it were a tumor, thus pathologizing normal, functional tissue. Dr. Brady said in his PowerPoint: If the benefits can’t be clearly shown to outweigh problems, then circumcision should not be done. I argued, does not the fact that 38 eminent physicians (37 of whom are in Europe) say in the AAP’s own journal that we should not do it in itself cast sufficient doubt that the practice should be stopped? As I asked near the end of the event, “If circumcision is so great why doesn’t the AAP recommend it? I would think the AAP would be taking out ads in the New York Times to say that everybody should get circumcised. Why the weird balancing act in which the AAP says that circumcision is not recommended but that Medicaid should cover it?” Angel asked if people present could explain the functions of the foreskin and no one answered it, including Brady and Diekema. Brady said, “I don't think anybody knows the functions of the foreskin,” then reiterated, in nearly identical words, “Nobody knows the functions of the foreskin.” I noted that there was not a word about the functions of the foreskin in the 2012 AAP report, and asked, shouldn’t we know something about the functions of the healthy body part that is being removed? One amusing aspect: Diekema criticized me on Friday for allegedly being unfair in emphasizing a sentence where the AAP admits that circumcision complication rates are unknown. So the next day, in my five minutes, I read three sentences from that same passage in full, quoting directly from the AAP report, and pointing out several other interesting points contained therein. Here's what I read: “The true incidence of complications after newborn circumcision is unknown, in part due to differing definitions of ‘complication’ and differing standards for determining the timing of when a complication has occurred (ie, early or late). Adding to the confusion is the commingling of ‘early’ complications, such as bleeding or infection, with ‘late’ complications such as adhesions and meatal stenosis. Also, complication rates after an in-hospital procedure with trained personnel may be far different from those of the developing world and/or by untrained ritual providers.” I then pointed out all the doubt and uncertainty contained therein: Confusion, complication rates differing, differing definitions, differing standards, unknown incidence. After all this, Diekema alleged in his five minutes that I was still quoting selectively. The audience saw through all of this eventually. An African woman was smiling at Aubrey toward the end and the whole row of audience members were clearly on her side. Angel and Aubrey and Peter each was awesome. Aubrey had this brilliant time in the sun where she was allowed to speak for over five minutes and through the whole issue into a new light in a brilliant way by developing the detailed analysis I mentioned of the pathologization of healthy tissue. Angel talked about his own experience being an intact man and no one could argue with that. The circumcision advocates tried to blame female genital cutting on patriarchy and argued that if male circumcision was bad, men who have all the power under patriarchy, would have stopped it long ago. In reply to this, Angel talked about male denial and about Sparta, an extremely patriarchal society where men faced extreme oppression, proving that society-wide male oppression can and does exist, even under patriarchy. [In patriarchal societies, it is the young men and boys who are oppressed by the old men, and who must typically endure painful initiation rituals in order to be able to graduate to adult status and enjoy adult privileges, such as access to women. It is not adult men who are subjected to circumcision in patriarchal societies, but infants or boys.] I was able to cite those “well-known anti-circumcision groups” the United Nations, the Council of Europe, and the other European organizations that I didn’t fit into my PowerPoint on Friday. The circumcision advocates could not say much about that, except to offer the response that I was just citing individuals, not all of Europe. Diekema accused me of oversimplifying, and I responded that no, these issues are incredibly complex and I wasn’t oversimplifying anything. Rather, I used the word “Europe” to describe the location of several countries that have recently found non-therapeutic circumcision of children to be illegal. Then Diekema said that those are only physicians’ groups, and hence not all physicians, and that I was oversimplifying again. This weak argument essentially refuted itself. After we effectively prevailed in Saturday’s panel, Brady responded by claiming that he had inside information that both “Australia” (presumably the Royal Australasian College of Physicians) and Canada are about to issue position statements echoing that of the AAP. No evidence was presented, however, and one may be forgiven for suspecting that perhaps no such evidence exists. Overall, this debate was personally perhaps the single most gratifying experience I have had in my nearly two decades as a promoter of genital integrity. Papers arising from the conference will be published in a special issue of the Journal of Law, Ethics and Medicine next year. </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 Charleston bioethics debate highlights harm 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"> The policy statement on circumcision (i.e. non-therapeutic circumcision of normal male infants and boys) released in September 2012 by the American (i.e. United States) Academy of Pediatrics is meeting a growing chorus of disapproval, rejection and ridicule. Child health experts in Europe and Canada; paediatricians and human rights lawyers in the United States; and a medical historian in Australia have all recently condemned the policy statement for failing to respect the bodies and advance the best interests of the very group that the AAP is (supposedly) dedicated to protecting - that is, children. If the AAP is not there to promote the best interests of children, what is it there for? <h3>European child health experts</h3> In an article published in the AAP house journal Pediatrics, child health experts from Austria, Britain, Denmark, Estonia, Finland, Germany, Iceland, Latvia, Lithuania, Norway, Sweden, the Netherlands, Canada, the Czech Republic, France and Poland have condemned the statement as unbalanced, tunnel-visioned, ignorant, wrong on many medical issues, and grossly inadequate in the all-important areas of medical ethics and human rights. The abstract of the article states: The American Academy of Pediatrics (AAP) recently released its new technical report and policy statement on male circumcision, concluding that current evidence indicates that the health benefits of newborn male circumcision outweigh the risks. The technical report is based on the scrutiny of a large number of complex scientific articles. Therefore, while striving for objectivity, the conclusions drawn by the eight task force members reflect what these individual doctors perceived as trustworthy evidence. Seen from the outside, cultural bias reflecting the normality of non-therapeutic male circumcision in the US seems obvious, and the report’s conclusions are different from those reached by doctors in other parts of the Western world, including Europe, Canada, and Australia. In this commentary, a quite different view is presented by non-US-based doctors and representatives of general medical associations and societies for pediatrics, pediatric surgery and pediatric urology in Northern Europe. To these authors, there is but one of the arguments put forward by the AAP that has some theoretical relevance in relation to infant male circumcision, namely the possible protection against urinary tract infections in infant boys, which can be easily treated with antibiotics without tissue loss. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts and penile cancer, are questionable, weak and likely to have little public health relevance in a Western context, and do not represent compelling reasons for surgery before boys are old enough to decide for themselves. Source: Morten Frisch et al, Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision. Pediatrics 131, April 2013 <a href="http://www.circumstitions.com/Docs/aap-12-europe.pdf" rel="noopener" target="_blank">Full text may be downloaded as a PDF from Circumstitions.com</a> See also the analysis by High Young, <a href="http://www.circumstitions.com/news/news55.html#aap-europe2">AAP task force reveals cultural bias while denying it</a> <h3>Dissent in the United States</h3> In the United States itself, a clinical professor in pediatrics and a human rights lawyer have condemned the policy as culturally biased and invalidated by its neglect of such crucial issues as the anatomy, physiology and functions of the foreskin, the harm and complications of circumcision, and whether the removal of body parts from healthy children can be justified within accepted principles of medical ethics and human rights. Writing in the Journal of Medical Ethics, pediatrician Robert Van Howe and lawyer J. Steven Svoboda argue that the AAP ignores so many important topics that it is hard to know where to begin the critique. Svoboda says: “For example, the anatomy and function of the foreskin are not mentioned. The AAP’s circumcision recommendations contradict its own bioethics policy statement, which requires pediatric care to be based only on the needs of the patient. Non-therapeutic circumcision is incompatible with widely accepted ground rules for surgical intervention in minors. When physicians decide whether to do a procedure, they must, and normally do, exclude from their medical decisions non-medical factors regarding the parents’ culture. Contrary to what the AAP suggests, doctors are not cultural brokers. Their duty is promoting and protecting the health of their patients, not following practices lacking a solid ethical and medical foundation.” Van Howe and Svoboda accuse the AAP of cherry-picking articles that support circumcision, and of taking passages out of context from within articles that do not support it. They conclude that male circumcision should be neither recommended to parents nor funded by government insurance systems. Abstract: The American Academy of Pediatrics recently released a policy statement and technical report on circumcision, in both of which the organisation suggests that the health benefits conferred by the surgical removal of the foreskin in infancy definitively outweigh the risks and complications associated with the procedure. While these new documents do not positively recommend neonatal circumcision, they do paradoxically conclude that its purported benefits “justify access to this procedure for families who choose it,” claiming that whenever and for whatever reason it is performed, it should be covered by government health insurance. The policy statement and technical report suffer from several troubling deficiencies, ultimately undermining their credibility. These deficiencies include the exclusion of important topics and discussions, an incomplete and apparently partisan excursion through the medical literature, improper analysis of the available information, poorly documented and often inaccurate presentation of relevant findings, and conclusions that are not supported by the evidence given. Source: J. Steven Svoboda and Robert Van Howe, Out of step: Fatal flaws in the latest AAP policy report on neonatal circumcision. Journal of Medical Ethics, online first, 18 March 2013 <a href="http://www.circumstitions.com/Docs/aap-12-svobodavanhowejme.pdf" rel="noopener" target="_blank">The full article may be downloaded as a PDF from Circumstitions.com</a> See also the analysis by Hugh Young, <a href="http://www.circumstitions.com/news/news55.html#aap-jme">AAP Circumcision Task Force fails again</a>, 24 March 2013 <h3>Australian medical historian finds United States circumcision obsession puzzling and rather ridiculous</h3> Viewing the controversy from Australia, medical historian Dr Robert Darby considers the flaws of the new AAP policy in a updated version of The Sorcerer’s Apprentice –– his analysis of the United States obsession with circumcision, published as an e-book on Amazon. Dr Darby notes that the AAP has never released a policy on guns or firearms, and wonders how many American boys are killed or injured each year in firearms accidents. Does the AAP think that foreskins are a greater risk to child health than firearms? If not, why have a policy on circumcision but nothing on gun control or firearm safety? He writes in the preface: This short book is a revised and much expanded version of an article originally published in Contexts, magazine of the American Sociological Association, invited to coincide with the publication of my history of the rise and fall of circumcision in Britain (A Surgical Temptation) in 2005. An expanded version was published on my website (www.historyofcircumcision.net). Apart from a few references, that book did not cover the rise of circumcision in the United States, though it was the persistence of the practice there and its rather slow decline in Australia that led me to study the British experience in the first place. For this version I have further revised the essay and expanded it to include an explanation for the efforts to revive claims as to the “health benefits” of routine circumcision that began to appear in the early 1990s, and an examination of the climax of this trend in the latest policy statement on circumcision issued by the American Academy of Pediatrics in September 2012. Non-therapeutic (routine) circumcision of male infants and boys has always been an anomalous practice, defying all the normal rules of evidence-based medicine, biomedical ethics and surgery. Although evidence-based medicine requires that treatments be based on proof of the intervention having a direct net benefit (in the promise-of-benefit/risk-of-harm calculus) for the recipients, most of the evidence for the prophylactic (disease-preventing) effects of circumcision are applicable to adult men and even adult women, not to the male infants undergoing the surgery. Recognised authorities on biomedical ethics hold that no treatment is permissible without the informed consent of the subject; that treatments must always observe the principles of autonomy, non-maleficence, beneficence, proportionality and justice; and that surrogate consent (for incapable subjects, such as infants and the disabled) is valid only when clearly in the subject’s best interests or – when it involves amputation of body parts – in life-threatening situations. In the normal course of events, surgery is regarded as appropriate only when there is a pathological condition requiring surgical treatment; unnecessary surgery is rightly regarded as cosmetic (or even bad) surgery, and prophylactic removal of healthy tissue and body parts has never become part of the medical mainstream – except in relation to tonsils (briefly) and foreskins. Because tonsils have no psychological, sexual or cultural significance, it proved far easier to drop routine tonsillectomy than to abandon circumcision. On a world scale, routine circumcision has never attracted widespread support; it has always been a controversial and contested operation, with a vast and inconclusive literature, as enthusiasts and advocates endeavoured to make a convincing case against the foreskin. As I write this preface, the polarisation of opinion has reached a new pitch, further demonstrating that there is no consensus on this issue. In the United States medical authorities have just overturned forty years of disapproval by announcing that although the “health benefits” of circumcision are not great enough to recommend it as a routine, they are sufficient to allow parents to decide for their children and for medical insurance schemes to pay for it. In the Netherlands, by contrast, the Royal Dutch Medical Association has issued a powerful statement rejecting circumcision, warning that it is not merely of no medical value to children, but that it infringes their right to bodily integrity. In Germany a court has found that non-therapeutic circumcision constitutes bodily harm and is thus unlawful. In Australia the Tasmania Law Reform Institute has recommended that it be legally prohibited in most cases, with limited exemptions for religious practice. In Helsinki an international conference heard many speakers defend the right of all children to bodily integrity, and criticize unnecessary genital surgeries of all types, whether performed for medical or cultural reasons, and whether on boys, girls or intersex children. Never before have American health officials been so out of step with world opinion – and indeed, with informed opinion even in their own country. Within a few days of the publication of the latest circumcision statement, vigorous, well-argued critiques had appeared on numerous websites and blogs. Even the New York Times, usually the most rabidly pro-circumcision newspaper on earth, greeted the statement with the headline “Benefits of circumcision SAID to outweigh the risks”, suggesting that it was not entirely convinced. To give a flavour of the debate, I have included the commentary from the Seattle-based group, Doctors Opposing Circumcision, as an appendix. European rejection of the practice reminds us that routine circumcision was a strictly Anglophone phenomenon, generated in the late Victorian period when understanding of disease processes was primitive, there were few effective treatments, medical ethics were non-existent, masturbation (i.e. any pleasurable touching of the genitals) was regarded as both a disease and a moral crime, and children were not considered to have any rights at all. Times have changed, but less so in the United States than elsewhere. While Britain gave up circumcision in the 1950s, New Zealand in the 1960s, Australia in the 1970s-80s and Canada in the 1990s, the practice remained entrenched in the United States and probably did not reach its peak until the 1960s. Statements against the practice regularly issued by the American Academy of Pediatrics as from 1971 had little impact. It was one of those sad situations, like the mess caused by the sorcerer’s apprentice, where it proved easier to start a habit than to give it up it, and surprising, when so many other pre-modern shibboleths have gone by the board, even the taboo against homosexual behaviour. Americans today seem more comfortable with the idea of gay men having sex together and even marrying each other than with the prospect of uncircumcised heterosexual men having sex with their wives and girlfriends. How has it come about that Americans are more afraid of foreskins than of homosexuals? Why does a nation that prides itself on its individualism and love of freedom remain so keen on this mark of uniformity and submission? In this short essay I cannot provide a comprehensive answer to these question, but I hope at least to raise the principal headings under which an explanation may be found. We shall see that it has far more to do with culture, religion, tradition, power and economics – in short, the desires of adults – than with the health and happiness of American children. </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 ridicule American circumcision policy statement 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"> An editorial in the January edition of the (Australian) Journal of Paediatrics and Child Health calls circumcision a “bizarre mutilation” and dismisses claims that it contributes to hygiene or improves child health. The editorial, by the editor in chief, David Isaacs, covers several aspects of both ritual and “health” circumcision, runs through the origins of circumcision as a religious/cultural rite in the region bordering the Red Sea, and comments that “there seem to be insufficient health benefits for circumcision to have evolved through natural selection”. He also devotes some attention to the rise of medically-rationalised circumcision of infants in nineteenth century Britain and the USA, and although the discussion is brief, he correctly notes that at that time the principle selling point for the operation was that it would discourage masturbation in infants and boys. Professor Isaacs concludes with a question that deserves greater debate – “Should the autonomy of an infant to choose when he is older outweigh his parents’ right to choose to have their infant son circumcised?” – but does not explore this issue. His remark that circumcision is no laughing matter seems undermined by the rather flippant style in which the editorial is written. Overall its message is that circumcision is primarily a cultural ritual and from a medical point of view too trivial a matter to be discussed in medical journals. The editorial, followed by our comments, appears below. <h2>Editorial: Circumcision</h2> What is the name of the useless bit at the end of a penis? A man of course, but circumcision is no joke. If you crave controversy, choose a topic concerned with sex or religion. The ancient ritual of circumcision meets both criteria. In the second century BC, tribes on the Red Sea, now Egypt, practised both female and male circumcision. One possible explanation relates to the belief that gods were bisexual and humans, like gods, had both a female and a male soul. The man’s female soul which resided in the prepuce and the woman’s male soul which resided in the clitoris had to be removed for healthy gender development. [1] An alternative theory is that female circumcision was a means for men to control women’s sexuality. Islam is opposed to female circumcision and Muslims attribute its continued practice in some Africa countries to traditional custom, not to religion. The modern re-naming of female circumcision as female genital mutilation is a clear ethical statement opposing this practice. Male circumcision, unlike female circumcision, is incorporated into major religions. Neonatal circumcision is practised routinely by Jews, Muslims and some African Christians while adolescent circumcision is a common tribal manhood initiation ceremony. The World Health Organization estimates that 650 million or 30% of all males aged over 14 are circumcised, 70% of whom are Muslims. [1] That the bizarre mutilation of ritual male circumcision is so customary suggests some deep significance. There seem to be insufficient health benefits for circumcision to have evolved through natural selection. Freud suggested that circumcision represented a metaphorical ritual castration of the son by his father to control the son’s Oedipal rivalry. Whatever the veracity of psychological explanations for male circumcision, its historic and geographic spread is intriguing. The ancient Greeks hated circumcision and the practice consequently declined under Greek rule. From about 1900, however, male circumcision became common in the United States, Australia and other English-speaking countries. In the UK there was a clear social gradient. It was purportedly impossible for a boy to attend Eton with either his foreskin or his tonsils intact. Neonatal circumcision, whether religious or cultural, was often performed without either analgesia or anaesthetic. This further example of our barbaric denial of neonatal pain, following neonatal surgery for pyloric stenosis and other conditions, is now unconscionable. A Cochrane meta-analysis shows that dorsal penile nerve block and, to a lesser extent local anaesthetic cream, is markedly superior to placebo. [2] Inadequate pain relief for circumcision persisted into the 1990s but is no longer tenable. What happens to the foreskin after circumcision? Many are discarded but intriguing uses include incorporation into face creams and anti-ageing cosmetics, skin grafts, and as the foreskin fibroblast cell lines to feed stem cells, grow viruses and produce beta-interferon. In Africa, the foreskin may be dipped in brandy and eaten by the patient or the circumciser. [1] There are some controversial medical benefits of male circumcision. In Africa, male circumcision halves the risk of a man acquiring HIV heterosexually. [3] Infant male circumcision reduces the risk of urinary tract infection (UTI) significantly, but because only 1% of normal boys has a UTI, 111 boys need to be circumcised to prevent one UTI. Since 2% of circumcisions are complicated by infection or haemorrhage, therapeutic circumcision should be reserved for boys with recurrent UTI or severe vesicoureteric reflux. [4] There is no evidence that circumcision improves hygiene, although this and the fond belief that it prevented masturbation were the main motivating factors in twentieth-century Western countries. Circumcision is a rich ethical topic. Should the autonomy of an infant to choose when he is older outweigh his parents’ right to choose to have their infant son circumcised? Who should pay? Non-therapeutic circumcision is rarely publicly funded. The RACP is revising its recommendations on circumcision, but previously did not recommend routine male circumcision, while acknowledging that informed parental choice should be respected. Circumcision is a topic for endless debate. But no laughing matter. Professor David Isaacs Editor-in-Chief, Journal of Paediatrics and Child Health Children’s Hospital at Westmead (Sydney) <a class="__cf_email__" data-cfemail="3c58554f5d5d5f4f7c5f544b12595849125d49" href="/cdn-cgi/l/email-protection">[email protected]</a> References 1. Wikipedia. Circumcision. Available from: http://en.wikipedia.org/wiki/Circumcision [Accessed March 2010]. 2. Brady-Fryer B, Wiebe N, Lander JA. Pain relief for neonatal circumcision. Cochrane Database Syst. Rev. 2004; 3: CD004217. DOI: 10.1002/14651858.CD004217.pub2. 3. Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database Syst. Rev. 2009; 2: CD003362. DOI: 10.1002/14651858.CD003362.pub2. 4. Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch. Dis. Child. 2005; 90: 853–8. <h3>Comments from CIA</h3> Although we welcome Professor Isaacs' description of circumcision as a “bizarre mutilation” and his dismissal of the many claims for its “health benefits” in children, there are a few aspects of his editorial that demand comment. 1. It is very unlikely that the persistence and spread of circumcision have anything to do with any supposed “deep significance” of the rite. The persistence arises simply from the fact that it is usually performed by powerful adults on infants or children who have no capacity to say No; it is more like a bad habit, handed down thoughtlessly from father to son, not so different from smoking. As to the spread of circumcision, this is explained by the comment that 70 per cent of the world’s circumcised men are Muslims; in other words, the large number of circumcised men simply reflects the wide distribution of Islam, the armies of which conquered vast swathes of central and southern Asia, northern Africa, south-east Asia and eastern Europe from the 8th to the 17th centuries. In India, Hinduism, and in south-east Europe, including Greece, Christianity resisted mass conversion, but in Africa, central Asia and south-east Asia the new religion wiped out the indigenous cultures and imposed circumcision on the conquered populations. 2. Muslims do not traditionally practise neonatal circumcision. The canonical age for circumcision in Islam is eight years, though in places such as Turkey it is usually done at any time between the ages of 6 and 9, in an elaborate ceremony with much dancing and drinking, and a certain amount of kicking and screaming from the central figure. As circumcision is medicalised, however, more parents are doing it in the manner of the Jews and modern Americans, soon or very soon after birth, in a coldly clinical rather than a warmly celebratory setting. Once medicalised in this way, circumcision loses whatever cultural significance it might have had. 3. It is not true, as Isaacs states, that “Islam is opposed to female circumcision and Muslims attribute its continued practice in some Africa countries to traditional custom, not to religion.” For one thing, unlike the major Christian denominations, Islam has no central authority determining doctrine. This means that every local preacher is free to interpret the sacred writings in pretty much any way he chooses, issue rulings and fatwas, call for the murder of blasphemers such as Salman Rushdie, and generally make up his own rules. Many Muslim authorities are strongly in favour of female circumcision, which is widely practised in north Africa, parts of the Middle East and among Muslims in Malaysia and Indonesia. Criminalisation of female genital mutilation in countries such as Egypt has had very little impact on local practice. Much the same comment as that quoted could as truthfully be made about male circumcision. There is no mention of circumcision in the Koran, and but the prophet Mohammed is reported to have stated that “Circumcision is a sunnah for the men and a makrumah for the women”. (Note the reference to men and women: nothing about boys and girls.) The term sunnah means customary or traditional; the term makrumah means meritorious. The most you could conclude is that circumcision was customary for men and meritorious for women, and thus desirable for both but obligatory for neither. In these respects Islam is quite different from Judaism, which requires the head of the household not only to circumcise his baby sons at eight days, but also his male servants and employees, which makes no mention of women in this context, and in which the rule of circumcision is stated prominently in the first book of the Jewish bible. Mohammed further laid down five rules for Muslim men: shaving the pubic hair; circumcision; trimming the moustache; plucking the hairs from the armpits; and clipping the nails. These constitute the fitrah, or laws of personal deportment, to which a pious man in pursuit of perfection must conform. According to Dr Sami Aldeeb, “They are not compulsory, but simply advisable”. The vital point about this list is that circumcision is a recommendation for adult men, perhaps no more important than trimming their moustache or shaving their pubic hair. It is thus less obligatory than the rule of prayer five times a day, the pilgrimage to Mecca, fasting at Ramadan or abstention from alcohol and pork. There is certainly nothing in the fitrah which requires parents to circumcise their children. Sami A. Aldeeb Abu-Sahlieh, <a href="http://www.nocirc.org/symposia/fourth/aldeeb.html">Jehovah, his cousin Allah and sexual mutilations</a>, in George C. Denniston and Marilyn Milos (eds), Sexual mutilations: A human tragedy (New York: Plenum Press, 1997) Sami Aldeeb, <a href="http://www.cirp.org/library/cultural/aldeeb1/">To mutilate in the name of Allah or Jehovah: The legitimation of male and female circumcision</a>, Medicine and Law, Vol 13, No 7-8, 1994, pp. 575-622 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) 4. It is true that non-therapeutic (medically unnecessary) circumcision is rarely publicly funded, but one of the few places where it is funded by the taxpayer out of the health budget is Australia. Medicare provides a no-questions-asked rebate for medically unnecessary circumcision, even though <a href="http://www.medicareaustralia.gov.au/public/claims/what-cover.jsp">its own guidelines state</a> that rebates are not available for “medical services which are not clinically necessary” or “surgery solely for cosmetic reasons”. 5. It is odd that Professor Isaacs writes that the Royal Australasian College of Physicians “is revising its recommendations on circumcision” when in fact the new policy was issued in October 2010, several months before the editorial was published. In the new statement the RACP maintained the opposition to routine circumcision of male infants and boys that Australian paediatric authorities had first formulated in 1971. The most recent statement is quite clear: “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.” Other medical bodies, such as the British Medical Association and the Royal Dutch Medical Association, have issued policies even more strongly opposed to the practice. Only in backward and impoverished places such as the United States and some regions of darkest Africa does faith in the health-giving powers of this mutilation linger. (For details, see <a href="https://www.circinfo.org/doctors.html">statements from medical authorities</a> on this site.) 6. Finally, we are surprised that a professor should cite the Wikipedia as an authority for anything, let alone a topic as controversial as circumcision. This would not have been acceptable in an assignment written by one of his students, and it should not be regarded as acceptable for somebody in a senior academic position. Why go to the Wikipedia, when scholarly texts by David Gollaher, Leonard Glick and Robert Darby are readily available? David Gollaher, Circumcision: A History of the World’s Most Controversial Surgery (New York: Basic Books, 2000) Leonard Glick, Circumcision from Ancient Judaea to Modern America (New York: Oxford University Press, 2005) Robert Darby, A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain (Chicago University Press, 2005) Robert Darby, “‘A source of serious mischief’: The demonisation of the foreskin and the rise of preventive circumcision in Australia”, in George C. Denniston, Frederick Hodges and Marylin Milos (eds), Understanding circumcision: A multi-disciplinary approach to a multi-dimensional problem (London and New York: Kluwer Academic and Plenum Press, 2001) <a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=category&sectionid=6&id=71&Itemid=50">Available at History of Circumcision</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 journal calls circumcision "bizarre mutilation" darby