7 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"> The most recent and authoritative statement was issued by the Royal Australasian College of Physicians in October 2010. This document states clearly: “After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.” The policy also points out that routine circumcision is under strong attack from bioethics and human rights advocates, “because it is recognised that the foreskin has a functional role, the operation is non-therapeutic and the infant is unable to consent.” Summing up the pros and cons, the statement continues: “The decision to circumcise or not to circumcise involves weighing up potential harms and potential benefits. The potential benefits include connectedness for particular socio-cultural groups and decreased risk of some diseases. The potential harms include contravention of individual rights, loss of choice, loss of function, procedural and psychological complications.” That being the case, it would appear that the potential harms outweigh the potential benefits, meaning that the circumcision decision is one that can properly be made only by the person who must bear the consequences. The new statement leaves this issue open, but does point out that leaving the circumcision decision to be made by the boy when he is old enough to understand the issues and make an informed choice has the merit of respecting individual autonomy and preserving all the options: “The option of leaving circumcision until later, when the boy is old enough to make a decision for himself does need to be raised with parents and considered. This option has recently been recommended by the Royal Dutch Medical Association. The ethical merit of this option is that it seeks to respect the child’s physical integrity, and capacity for autonomy by leaving the options open for him to make his own autonomous choice in the future.” The policy concludes by noting that its recommendation not to cut is consistent with policies on circumcision released by the <a href="http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp">British Medical Association</a>, the <a href="http://www.cirp.org/library/statements/">Canada Pediatric Society</a>, the <a href="http://www.cirp.org/library/statements/">American Academy of Pediatrics</a>, the <a href="http://www.rcseng.ac.uk/new_rcseng/content/publications/docs/male_circumcision.html">Royal College of Surgeons</a> of England and the <a href="https://www.circinfo.org/Dutch_circumcision_policy.html">Royal Dutch Medical Association</a>. <a href="https://www.racp.edu.au/" rel="noopener" target="_blank">The full statement may be downloaded from the RACP website as a PDF: use search function.</a> NOTE: RACP tends to reorganise its website rather frequently and changes the address of documents. If you can't find what you are looking for, go to their main page and usethe search function: https://www.racp.edu.au <h2>Doctors reject call for more circumcision: New RACP policy defends rights of child</h2> Australian and New Zealand doctors have decisively rejected a proposal that near-universal circumcision of baby boys be introduced as a strategy against heterosexually transmitted HIV infection. The call, published in the Medical Journal of Australia, came from a small group of well-known circumcision enthusiasts who based their suggestion on evidence from three clinical trials in Africa that circumcision of adult men can reduce the risk of a male’s acquiring HIV during unprotected sexual intercourse with an infected female partner. But this suggestion has been firmly knocked back by the Royal Australasian College of Physicians, which points out that Australia is not Africa, that infants and children are not at risk of sexually transmitted diseases, and that more circumcision would do nothing to reduce or contain the risk of HIV infection in the Australian and New Zealand context. They also point out that the recommendation by the World Health Organisation, that circumcision be offered as an option for AIDS control in areas of high HIV prevalence, applied to sexually active adult men, not to infants or children, and was not intended to apply to the developed world. Dr Gervase Chaney, President of the Paediatric and Child Health Division of the RACP, said that he and his colleagues did not agree with the new proposal. <a href="https://www.abc.net.au/listen/programs/worldtoday/sydney-doctors-re-ignite-circumcision-debate/2267568" rel="noopener" target="_blank">Speaking on the ABC’s “World Today” program on 20 September</a>, Dr Chaney said: “We believe that the evidence currently would not support that in Australia. It might be supported in other countries, particularly in Africa where there are much higher rates of HIV transmitted heterosexually. But at this stage that is not something that we would support; we disagree with that group.” Also commenting was the President of the Australian Medical Association, Dr Andrew Pesce, who said that he found it “difficult to believe that a foreskin, evolved over billions of years of human evolution, needed to be chopped off as soon as the baby was born.” “What we are talking about”, Dr Pesce continued, “is that otherwise healthy boys have an operation because of a feeling that it’s good for them in the future, even though there is nothing wrong now. That requires a lot of rigorous data collection, a really good understanding of what the potential benefits over the lifetime of the operation are, and balancing them up against the immediate surgical risks of a procedure which can have a low but a measurable complication rate of bleeding, infection, scarring things like that.” The RACP’s new policy on routine circumcision of male infants and boys, released a fortnight later, states firmly that it does not recommend circumcision as a “routine” or medically unnecessary procedure: “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.” The policy also points out that routine circumcision is under strong attack from bioethics and human rights advocates, “because it is recognised that the foreskin has a functional role, the operation is non-therapeutic and the infant is unable to consent.” Summing up the pros and cons, the statement continues: “The decision to circumcise or not to circumcise involves weighing up potential harms and potential benefits. The potential benefits include connectedness for particular socio-cultural groups and decreased risk of some diseases. The potential harms include contravention of individual rights, loss of choice, loss of function, procedural and psychological complications.” That being the case, it would appear that the potential harms outweigh the potential benefits, meaning that the circumcision decision is one that can properly be made only by the person who must bear the consequences. The new statement leaves this issue open, but does point out that leaving the circumcision decision to be made by the boy when he is old enough to understand the issues and make an informed choice has the merit of respecting individual autonomy and preserving all the options: “The option of leaving circumcision until later, when the boy is old enough to make a decision for himself does need to be raised with parents and considered. This option has recently been recommended by the Royal Dutch Medical Association. The ethical merit of this option is that it seeks to respect the child’s physical integrity, and capacity for autonomy by leaving the options open for him to make his own autonomous choice in the future.” That would surely also be the attitude of all parents who genuinely respected the body and mind of their children. The policy concludes by noting that its recommendation not to cut is consistent with policies on circumcision released by the <a href="http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp">British Medical Association</a>, the <a href="http://www.cirp.org/library/statements/">Canada Pediatric Society</a>, the <a href="http://www.cirp.org/library/statements/">American Academy of Pediatrics</a>, the <a href="http://www.rcseng.ac.uk/new_rcseng/content/publications/docs/male_circumcision.html">Royal College of Surgeons</a> of England and the <a href="https://www.circinfo.org/Dutch_circumcision_policy.html">Royal Dutch Medical Association</a>. <div class="indent"> <h2> <a id="prev" name="prev"></a>Previous statements by Australian medical authorities</h2> <blockquote> The Australian Pediatric Association recommends that newborn male infants should not, as a routine, be circumcised. — Australian Pediatric Association, 24 April 1971 The ACP should continue to discourage the practice of circumcision in the newborn male infant. — Australian College of Paediatrics, Official statement, 1983 The Australasian Association of Paediatric Surgeons does not support the routine circumcision of male neonates, infants or children in Australia. It is considered to be inappropriate and unnecessary as a routine to remove the prepuce, based on the current evidence available. We do not support the removal of a normal part of the body, unless there are definite indications to justify the complications and risks which may arise. In particular, we are opposed to male children being subjected to a procedure, which had they been old enough to consider the advantages and disadvantages, may well have opted to reject the operation and retain their prepuce. — The Australasian Association of Paediatric Surgeons, “Guidelines for circumcision”, 1996 A more detailed statement was issued by the Royal Australasian College of Physicians in 2002 an reissued 2004. The document summary states: The Division of Paediatrics and Child Health, Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of infants and boys assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that there is no medical indication for routine male circumcision. Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure. The policy statement represents the consensus position of the Australasian Association of Paediatric Surgeons, the New Zealand Society of Paediatric Surgeons, the Urological Society of Australasia, the Royal Australasian College of Surgeons and the Paediatric Society of New Zealand. Royal Australasian College of Physicians, 2002 and 2004 A further statement, reiterating these points, was issued in August 2009 When considering routine infant circumcision, ethical concerns have focused on recognition of the functional role of the foreskin, the non-therapeutic nature of the operation, and the psychological distress felt by some adult males circumcised as infants. The possibility that routine circumcision contravenes human rights has been raised because circumcision is performed on a minor for non-clinical reasons, and is potentially without net clinical benefit for the child. Recently there has been renewed debate regarding both the possible health benefits and the ethical concerns relating to routine male circumcision. The most important conditions where some benefit may result from circumcision are urinary tract infections, and in adults HIV infection and cancer of the penis. The frequency of these conditions, the level of protection offered by circumcision and complication rate of circumcision do not warrant a recommendation of universal circumcision for newborn and infant males in an Australian and New Zealand context. After extensive review of the literature the RACP does not recommend that routine circumcision in infancy be performed, but accepts that parents should be able to make this decision with their doctors. One reasonable option is for routine circumcision to be delayed until males are old enough to make an informed choice. In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarising the evidence should be widely available to parents. In the absence of evidence of substantial harm, parental choice should be respected. Royal Australasian College of Physicians, August 2009 </blockquote> </div> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Royal Australasian College of Physicians: circumcision not recommended 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>Response to RACP's 2002 circumcision policy statement</h1> <h3>New policy statement by Australian and New Zealand doctors rejects circumcision</h3> The new policy statement on routine male circumcision issued by the Paediatric and Child Health Division of the Royal Australasian College of Physicians should be welcomed by all those concerned with the welfare and happiness of Australian and New Zealand boys. Although it does not go as far as it could towards discouraging this unnecessary and harmful surgery, it has many positive features. Its message is clearly that boys should be left as nature made them. The new statement is one of the most authoritative policies on circumcision ever issued by a medical organisation. It has been endorsed by six Australian and New Zealand medical bodies. After a thorough review of the medical literature, including recent claims about the supposed protective effect of circumcision against STDs, AIDS, penile cancer, urinary tract infections and cervical cancer in female partners, the working party concluded that there was "no medical indication for routine male circumcision" and that there was "no evidence of benefit outweighing harm for circumcision as a routine procedure". The statement, which includes links to many of the articles in medical and other journals cited by the statement, accompanied by some critical comment <a href="http://www.nocirc.org/position/">is available here</a>. Another copy of the statement with a critical commentary and evaluation, and links to further information and many of the articles cited, <a href="http://www.circumstitions.com/RACP.html">is available at Circumstitions</a>. <img alt="" class="image-center" height="119" src="https://www.circinfo.org/images/billboard2_000.gif" width="402"/> <h2>MEDIA RELEASE by Circumcision Information Australia, 28 September 2002</h2> Human Rights Groups Welcome Statement on Male Circumcision Australasian human rights groups welcome the release of the new Position Statement on Circumcision by the Paediatric and Child Health Division of the Royal Australasian College of Physicians. "This is a victory for good sense and the spirit of Anzac cooperation" said Shane Peterson for Circumcision Information Australia and NORM New Zealand. The new policy states: "there is no medical indication for routine male circumcision." It also warns against risks and complications more strongly than previous statements, and raises serious legal and ethical issues. "The new statement sends a clear message to doctors that they should warn parents against choosing circumcision for their sons. The few old GPs and cranky professors who get up in the media to preach the medical benefits of circumcision are now exposed as quacks." The new statement has been endorsed by six Australian and New Zealand medical bodies. After a thorough review of the medical literature, including recent claims that circumcision is protective against STDs, AIDS, urinary tract infections and cervical cancer in female partners, the working party concluded that there is "no evidence of benefit outweighing harm for circumcision as a routine procedure". The new policy is based on a narrow evaluation of the medical benefit and harm of circumcision. Mr Peterson said, that despite this narrow view, the College still concluded that the risks of harm and injury outweigh the claimed benefits. "When additional factors are considered, the case against routine circumcision becomes overwhelming." A surprising omission from the statement is a discussion of the sensory and mechanical roles of the foreskin in male sexual function, and its contribution to sexual pleasure and self-esteem for both the man and his partner. "The penis is a fragile sensory organ. Removal of the foreskin and frenulum by circumcision is similar in effect to surgically injuring the retina of the eye in a way that causes tunnel vision and colour-blindness." The working party also paid little attention to important issues in human rights and medical ethics. A person has the right to an intact body and to refuse unnecessary medical treatment. It is doubtful if it can ever be ethical to amputate healthy tissue from a non-consenting minor in the absence of acute medical necessity. Mr Peterson said it is now time to address the disturbingly high rate of infant circumcision in some states compared to others. In 2001-2002, Medicare funded the circumcision of approximately 14% of male infants born in South Australia and New South Wales, and over 20% of male infants born in Queensland. During this same period, about 5% of male infants were circumcised in Victoria, Western Australia, Tasmania and the ACT. The incidence of circumcision in New Zealand has been less than 5% for over a decade. "Doctors now insist that medical interventions must be based on evidence of benefit exceeding the risk of harm. There is no evidence based rationale for this significant difference in the incidence of circumcision between states and countries", said Mr Peterson. "It is now time to remove routine circumcision from the Medical Benefits Schedule." In his ground breaking article "<a href="http://www.cirp.org/library/general/gairdner">The fate of the foreskin</a>" in 1949, Douglas Gairdner, consultant paediatrician to United Cambridge Hospitals, advised that routine circumcision was harmful and recommended against it. As a result of Gairdner's research and the policy of the National Health Service, the rate of routine circumcision in Britain fell from about 30% in the 1940s to less than 5% in the 1950s. Gairdner debunked the myth of phimosis and showed that it was normal for the foreskin not to be retractable in early childhood. He also concluded that circumcision did not provide meaningful protection against STDs or cancer. He documented injuries and side effects, including the death of around 16 boys under five each year in the UK from 1942 to 1947. Deaths still occur regularly from circumcision. The recent death of an infant following circumcision in British Columbia during August made national news. In response, several Canadian state medical bodies have cautioned doctors against performing unnecessary circumcisions. <a href="http://www.courtchallenge.com/">For further information</a> . Mr Peterson said the new RACP statement is a very positive step towards protecting children. "Doctors should be required to give a copy of the new statement to all parents who enquire about circumcision. Parents should then have a week's cooling off period to think about it. The written consent of both parents should also be mandatory." <h2>Review of RACP policy 2002 by Circumcision Information Australia</h2> The recent policy statement on routine male circumcision issued by the Paediatric and Child Health Division of the Royal Australasian College of Physicians should be welcomed by all those concerned with the welfare and happiness of Australian and New Zealand boys. Although it does not go as far as it could towards discouraging this unnecessary and harmful surgery, it has many positive features. Its message is clearly that boys should be left as nature intended. In reaffirming earlier statements against routine circumcision dating back to 1971, the RACP has issued strong advice to parents that circumcision of their baby boys is neither necessary nor desirable. It has also sent an unmistakeable message to doctors that they should warn parents against the operation. The statement is one of the most authoritative policies on circumcision ever issued by a medical organisation. It has been endorsed by six Australian and New Zealand medical bodies. After a thorough review of the medical literature, including recent claims about the supposed protective effect of circumcision against STDs, AIDS, penile cancer, urinary tract infections and cervical cancer in female partners, the working party concluded that there was "no medical indication for routine male circumcision" and that there was "no evidence of benefit outweighing harm for circumcision as a routine procedure". This is a significant victory for good sense. The working party has carefully considered the clamour of those urging universal circumcision as a strategy against problem diseases and has rejected their scenarios as alarmist and their prescriptions as scientifically unsound. Doctors are now obliged to tell parents seeking advice about circumcision that there is no medical benefit from the operation and a significant risk of harm. In other words, the Australian and New Zealand medical profession is saying "Don't do it". Perhaps the greatest value of the new statement is that it reaches its conclusions on the basis of a narrow calculus of medical benefit and harm, and still finds that the risk of harm outweighs the possibility of benefit. The working party did not pay much attention to the important areas of human rights (e.g. a person's right to a non-disfigured body and to refuse unwanted medical treatment), or to medical ethics (e.g. whether it can ever be ethical for a doctor to amputate healthy tissue from a non-consenting minor in the absence of acute medical necessity). But the statement did acknowledge that even if it were true that circumcision reduced the incidence of UTIs, "this should not be the only consideration": in other words, retention of the foreskin for whatever reason could in itself be more important than reducing the risk of disease. The most serious omission from the statement is any discussion or acknowledgement of the value of the foreskin as a natural and prominent part of the male genitals and a significant contributor to normal sexual function, partners' pleasure and a person's happiness and self-esteem. When these and similar factors are added to the equation, the case against routine circumcision becomes overwhelming. There is now no basis for claims made by maverick GPs and misguided professors that there are sound scientific reasons to circumcise male infants. The medical aspect of the long-running debate has now been settled. The few old GPs and cranky professors who get up in the media to preach the medical benefits of circumcision no longer have a leg to stand on. They are now exposed as the quacks they have been all along, more reminiscent of a top-hatted Victorian, issuing dire warnings against the perils of masturbation, than a modern medical practitioner concerned about the quality of life of those under his care. The statement opens the way for a consideration of whether routine circumcision should be deleted from the Medicare benefits schedule. Now that male circumcision has authoritatively been declared an unnecessary and non-therapeutic procedure, there is no reason why taxpayers should fund it through the health care budget. In the rare instances where circumcision is medically required it should of course be publicly funded, but where it is performed for non-medical reasons it should be categorised as a cosmetic procedure and paid for by the individuals who want it done. <h3>The weaknesses of the position statement may be summarised under eight headings:</h3> <ol> <li>The statement does not recognise that the foreskin itself is a normal part of the body and a prominent part of the penis, with value in its own right, and which makes a significant contribution to sexual functioning, self-esteem, body image and personal happiness. There is a vast medical literature on the significance of the foreskin, from Hippocrates, Galen and the classical Greeks, who devised procedures to lengthen inadequate prepuces, right down to the modern Canadian researchers who have investigated the unique innervation of the penis and identified the ridged bands and frenular delta. <a href="http://www.circinfo.org/quote.html">Further details</a>.</li> <li>It does not recognise that the removal of an excessive quantity of tissue, resulting in a tight circumcision and uncomfortable erections, is very common. Tearing and bleeding of the penile skin after puberty is less common, but not rare.</li> <li>It does not discuss the risks of general anaesthesia, nor indicate that sucrose and EMLA are not effective analgesics, when used separately or together.</li> <li>It does not consider less invasive surgical methods to treat pathological phimosis which retain the foreskin, such as the dorsal slit.</li> <li>It does not propose a method to ensure that each state/territory health department prints an accurate and up-to-date information booklet, based on the recommendations of this statement, to be distributed to all parents expecting a child. Doctors should be required to give parents requesting circumcision a copy of the leaflet (and ideally the full statement) before they can perform the procedure.</li> <li>The statement does not warn doctors that there is a real and increasing danger of litigation on the part of individuals who, without necessarily suffering complications or serous injury, grow up and wish that they had not been circumcised. (<a href="http://www.circinfo.org/doctors.html#canadian">See comments on Canadian situation below</a>.)</li> <li>It does not pay sufficient attention to human rights and ethical issues. It has long been accepted than an individual has the right to refuse medical treatment, and it is increasingly argued by legal and ethics experts that male circumcision is little different from female genital mutilation and should be governed by similar rules. More people are asking whether it can ever be ethical for a doctor to amputate healthy tissue from a non-consenting minor in the absence of acute medical necessity.</li> <li>It does not adequately address the issue of parental consent for medically unnecessary circumcision. (<a href="http://www.circinfo.org/doctors.html#rights">See comments below</a>.)</li> </ol> In a recent case in Bundaberg, Queensland, a non-practising Moslem father, who did not have legal custody of children by his former partner, arranged for the circumcision of his two sons during an access visit, against the mother's express wishes and in breach of a specific order by the Family Court. (<a href="http://www.circinfo.org/ethics.html">See details on this site</a>). Stricter rules governing consent for non-therapeutic circumcision could have prevented this sad and all too common occurrence. A high proportion of marriages in Australia are between men and women of different ethnic/cultural backgrounds, and the children of such unions cannot be said to belong strictly to one or the other group; this is all the more true in the many cases where marriages end in separation while the children are still young. Children in such situations will eventually decide which (if any) of the parental cultures they wish to identify with, or whether they wish to choose a cultural identity of their own, and we recognize their right to make a free choice. In a multicultural society , freedom of religion means that each individual must have the freedom to adopt his or her own religion and not have it imposed on them. In order to ensure that this right is real, their bodies must be protected from tell-tale alterations as much as their minds from indoctrination. Individual determination has a physical as well as a mental dimension. In the <a href="http://www.cirp.org/library/legal/Re_J/">United Kingdom</a> and <a href="http://www.circumstitions.com/Sweden.html">Sweden</a> the judicial systems have intervened in instances where Moslem fathers have sought or arranged for the circumcision of boys without maternal consent. In two cases the fathers were convicted, and in one of these cases the father was gaoled for three months. The practitioner who performed the circumcision was also charged with an offence, though acquitted, by the National Board of Health and Welfare. The rights of mothers and boys would have better protection if the following conditions had to be met before a practitioner agreed to perform medically unnecessary circumcision: <ol> <li> Check bona fides: The medical practitioner should establish that the persons requesting the circumcision do in fact have legal custody of the children. In the Queensland case the father was separated from the mother and was not the legal guardian of the children. The mother had sole custody; his consent was probably invalid in law. </li> <li> Written consent of both parents: Where circumcision has been requested in the absence of medical indications or for cultural reasons, doctors should obtain the written consent of both parents before performing the procedure. If the written consent of both parents or guardians cannot be obtained, the practitioner should advise that he cannot perform the circumcision. Physicians should provide a complete copy of the new RACP statement to all parents who inquire about the procedure. Parents should then have a "cooling off" period of a week to consider their decision. </li> <li> Check that the boys do not object: If the boys are old enough (e.g. over 5 years old), before proceeding the practitioner should explain honestly to the boys what he is going to do to them and ascertain that they are willing to go through with it. If they do not understand what is proposed or if they show hesitation or objection, the practitioner should decline to carry out the surgery. </li> </ol> Legal risk In Canada, where the recent death of a baby after circumcision in British Columbia has made national news, several state medical bodies have cautioned doctors against performing unnecessary circumcisions. The College of Physicians and Surgeons of Saskatchewan has asked doctors to consider the physical risk to the patient and the legal risk to the physician before becoming involved in the routine circumcision of infants. It warns that circumcision poses a greater risk of harm than benefit and could form the basis of lawsuits by circumcised adults. The college registrar, Dr Dennis Kendel, says the threat of litigation is now producing "a great deal of sober second thought" among physicians. "It could have what we call 'long-tail liability' if this societal movement takes on more steam and more men become angry because they think they ought not to have been circumcised". <a href="http://www.cmaj.ca/cgi/content/full/167/5/532-a">Link to full details here</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 Royal Australasian College of Physicians: review of 2002 policy 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>Submissions to RACP before its 2002 policy</h3> <h2> <a id="williams" name="williams"></a>1. Shane Peterson and Dr George Williams for Circumcision Information Australia</h2> We are aware that the College has created a Taskforce to review the Australian College of Paediatrics/Royal Australian College of Physicians 1996 policy on routine neonatal circumcision of infants and young boys (RNC). We understand that the College has not invited submissions on this topic and we appreciate your approval of our request to make a submission to the review. Circumcision Information Australia (formerly NOCIRC Australia) was established by the Sydney paediatrician Dr George Williams in 1992 to increase public awareness of the detrimental effects of routine circumcision. We appreciate that ACP disapproval of RNC since 1971, (1) and particularly since 1983,(2) has played an important role in the decline of the practice in Australia. We are concerned that there has been recent pressure by RNC advocates to revive the procedure as a public health measure, (3, 4, 5) despite legitimate criticism of such advocates' claims in the medical literature. (6, 7, 8, 9, 10, 11) We do not advocate the circumcision of infants or young boys in the absence of definite and health threatening medical indications for three important reasons. <img alt="" class="image-center" height="119" src="https://www.circinfo.org/images/billboard1_000.gif" width="402"/> 1. The penis is a delicate sensory organ which is permanently damaged by RNC, especially if performed before the natural separation of the glans and foreskin. Circumcision is associated with bodily disfigurement, an unacceptable incidence of complications, and long-term detrimental effects on sexual function which have been under-reported in the medical literature. (12, 13) 2. Circumcision is not an effective method for the prevention of sexually transmitted diseases or exposure to the human papilloma viruses, which are implicated in the development of penile and cervical cancer.(11) Only condoms are an effective method to prevent exposure to infectious pathogens during sexual intercourse. However, with a reduction in sensitivity of the penis and a false belief that they are immune to sexually transmitted infections, circumcised men seem less likely to adopt safer sex practices. (14) 3. Australian and other societies have recognised that parents and other adults do not have the right to use surgery to impose their sexual, cosmetic or religious preferences on children. (15, 16 ,17, 18, 19) Although he is dependent and voiceless, the child is the end consumer or client of RNC. Regardless of the impact on his body, his sexuality, and his personal beliefs, he has no choice but to live with the results of the procedure for the remainder of his life. Children should be given the right to make such decisions about irreversible and non-therapeutic procedures on their bodies after they reach the legal age of consent. We would appreciate your consideration of the above points and enclosed references. We hope that your revised policy will further strengthen your existing stance on RNC to achieve the following objectives: <ol> <li>Provide further protection of the rights of the child in accordance with United Nations (17) and other recommendations.</li> <li>Create a stronger directive for physicians to provide parents with accurate and up-to-date information about the risks of RNC, and its detrimental and irreversible effects on men's health and sexuality.</li> </ol> We draw your attention to action by the College of Physicians and Surgeons of Saskatchewan in their recent memo <a href="http://www.courtchallenge.com/letters/skcoll2.html">Caution Against Routine Circumcision of Newborn Male Infants</a>. (20) Yours faithfully Shane Peterson BSc (Hons) George Williams (MB ChB, FRACP) Circumcision Information Australia REFERENCES 1. Australian Pediatric Association, resolution passed a meeting on 24 April 1971, letter to Medical Journal of Australia, 22 May 1971, p. 1148 2. Australian College of Paediatrics (1983) Position Statement on Male Circumcision, Parkville, Victoria. College of Paediatrics (1996) Position Statement: Routine Circumcision of Normal Male Infants and Boys, Parkville, Victoria. 3. Castellsague, X., Bosch, F. X., Munoz, N., Meijer, C. J., Shah, K. V., de Sanjose, S., Eluf-Neto, J., Ngelangel, C. A., Chichareon, S., Smith, J. S., Herrero, R., Moreno, V., and Franceschi, S. (2002) Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners, N Engl J Med, 346(15), 1105-12. 4. Szabo, R., and Short, R. V. (2000) How does male circumcision protect against HIV infection?, BMJ, 320(7249), 1592-1594. Full text with critical comments at: <a href="http://www.circumstitions.com/Short-HIV.html">www.circumstitions.com/Short-HIV.html</a> email responses in BMJ available at <a href="http://bmj.com/cgi/eletters/320/7249/1592">http://bmj.com/cgi/eletters/320/7249/1592</a> 5. Morris, B. (1999) In favour of circumcision, New South Wales University Press, Sydney. Critique available at: <a href="http://www.circumstitions.com/Morris.html">www.circumstitions.com/Morris.html</a> 6. Milos, M. F. (2002) <a href="http://bmj.com/cgi/eletters/324/7344/994/a#21707">NEJM Cervical Cancer Study Has Fatal Flaws, BMJ, Electronic Responses</a>. 7. American Cancer Society (2001). <a href="http://www.cancer.org/eprise/main/docroot/CRI/CRI_2x?sitearea=CRI&dt=35">Cancer Reference Information: What is Penile Cancer?</a> 8. Bailey, R. C., Plummer, F. A., and Moses, S. (2001) Male circumcision and HIV prevention: current knowledge and future research directions, Lancet Infect Dis, 1(4), 223-31. 9. Bonner, K. (2001) Male circumcision as an HIV control strategy: not a "natural condom", Reprod Health Matters, 9(18), 143-55. 10. Donovan, B. (1999) Review of Morris, In favour of circumcision, Venereology, 12(2), 68-69. 11. Donovan, B., Bassett, I., and Bodsworth, N. J. (1994) Male Circumcision and Common Sexually Transmissible Diseases in a Developed Nation Setting, Genitourinary Medicine, 70(5), 317-320. 12. Peterson, S. E. (2001) Assaulted and Mutilated: A Personal Account of Circumcision Trauma, in Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem, G.C. Denniston, Hodges, F.M., Milos, M.F., (eds), Kluwer Academic / Plenum Publishers, New York, 271-289. (<a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=93&Itemid=50">Text now available at History of Circumcision</a>) 13. Williams, N., and Kapila, L. (1993) <a href="http://www.cirp.org/library/complications/williams-kapila/">Complications of circumcision, Br J Surg, 80 </a>(10), 1231-6. 14. Richters, J., Gerofi, J., and Donovan, B. (1995) Why do condoms break or slip off in use? An exploratory study, Inernationalt Jnl STD AIDS, 6(1), 11-8. 15. Family Law Council report to the Attorney-General (1994) <a href="http://law.gov.au/flc/reports/sterilisation.html">Sterilisation and Other Medical Procedures on Children, Commonwealth of Australia</a>. 16. World Medical Association (1993) <a href="http://www.wma.net/e/policy/10-24_e.html">Statement on Condemnation of Female Genital Mutilation, Budapest, Hungary</a>. 17. United Nations General Assembly (1989) <a href="http://www1.umn.edu/humanrts/instree/k2crc.htm">Convention on the Rights of the Child, Document A/RES/44/25 (12 December 1989)</a>. 18. Goldman, R. (1998) Questioning Circumcision: A Jewish Perspective, Vanguard Publications, Boston. (Synopsis and review at: <a href="http://www.cirp.org/pages/reviews/goldman/jp.html">www.cirp.org/pages/reviews/goldman/jp.html</a>) 19. Queensland Law Reform Commission (1993) <a href="http://www.cirp.org/library/legal/QLRC">Circumcision of Male Infants: Research Paper, Brisbane</a>. 20. College of Physicians and Surgeons of Saskatchewan (2002) <a href="http://www.courtchallenge.com/letters/skcoll2.html">Caution Against Routine Circumcision of Newborn Male Infants, Saskatchewan, Canada</a>. <h2> <a id="darby" name="darby"></a>Submission from Dr Robert Darby, Canberra</h2> I enclose my submission to the ACP/RACP's current review of the policy on the routine circumcision of normal male infants and boys. To explain my interest in this issue, I should let you know that I am not a medical doctor but a historian, currently engaged in writing a social history of the rise and decline of routine neonatal (male) circumcision (RNC) in Britain and Australia. My researches over the past few years into the origins and nature of the practice have provided me with a perspective on the issue which, I believe, will be different from that of most paediatricians, but which I hope will be found enlightening and perhaps challenging. My historical knowledge is thus one of the bases on which I feel I am entitled to speak out on this issue. The second reason for my interest in the matter arises from my personal history as the target of an unwanted routine circumcision. Like most males born in Australia in the 1950s, I was circumcised at birth, and I have no reason to think that I was handled any more severely or traumatically than anybody else at that time. When, at around the age of ten years, I discovered that some boys had a moveable sleeve of soft, ticklish skin covering their penises, and realised what must have been done to mine, I was very upset and bitterly angry with my parents for allowing me to suffer such a loss. It has never been my wish to cultivate a victim mentality, but many discussions with contemporaries over the years have convinced me that, even if most circumcised men accept their status without complaint, the majority would have declined the procedure had they been offered a choice. That, it seems to me, is the strongest argument of all against the continuation of RNC. My submission takes the form of series of comments on selected paragraphs of the existing Position Statement (1996). I have largely confined my observations to matters on which I feel I have sufficient expertise to make a useful contribution: the history of both ritual and medically rationalised circumcision, and some of the logical and ethical aspects of today's debates on the legitimacy of RNC. I have also included five attachments expanding on some of these points. I am aware that the most welcome decline in the incidence of RNC in Australia since the 1960s has been largely a consequence of the lead shown by the paediatric community, and in particular a response to the resolution of the Australian Pediatric Association in 1971 that "newborn male infants should not, as a rule, be circumcised", and the rather stronger statement issued by the Australian College of Paediatrics in 1983. I am also conscious that the position statement issued in 1996 represents a slight weakening of the stand adopted then, no doubt in response to the scare over AIDS and UTIs. I hope it is now possible to view those problems in proper perspective, and to see that the alarmist scenarios and dire predictions of circumcision advocates in the USA and Australia have not been fulfilled. The current review offers the ACP/RACP another opportunity to show leadership on this issue by taking a public stand which will reduce the incidence of such unnecessary and harmful surgery in Australia to an even lower level than it has already attained - for which the boys and girls of the future will thank you. Yours sincerely (Dr) Robert Darby BA (La Trobe), B Litt (ANU), Ph D (UNSW) Comments on the current position statement, 1996 Paragraph 1 Circumcision of males has been undertaken for religious and cultural reasons for many thousands of years. It probably originated as a hygiene measure in communities living in hot and dry environments. It remains a very important ritual in some religious/cultural groups. 1. There is no evidence that ritual or religious circumcision first arose as a hygiene measure. Many ancient and tribal cultures carried out a great variety of mutilating procedures on the genitals of both boys and girls at different ages, but the origins and rationale of these practices are obscure and contested, as are the environmental conditions prevailing at the time when such customs emerged. It is an illusion of Marxist anthropology to assume that ancient religious rituals must have a materialist and rational explanation; modern anthropology recognises that such customs have a ritual origin in the belief structure of the cultures which produced them and do not necessarily have any practical significance. Many conflicting theories have been advanced to account for the rise of ritual operations on the male and female genitals, among which are the following: <ul> <li> a propitiatory sacrifice, probably a milder form of a ritual which began as outright human sacrifice; </li> <li> a mark of tribal identification; </li> <li> a rite of passage from childhood to adult responsibility; </li> <li> (in the case of boys circumcised at puberty) the imposition of adult and tribal authority at a time when youthful rebellion might be expected; </li> <li> a fertility rite, aimed at giving men the power of procreation by making them shed blood from their genitals like women; </li> <li> an attempt to emphasise feminine or masculine characteristics in girls and boys by removing the parts of the genitals (clitoris and foreskin) believed to resemble the genitals of the other sex; </li> <li> a punishment for slaves which did not prevent them from reproducing; </li> <li> a way of humiliating and marking defeated enemies. </li> </ul> The only point of agreement among the proponents of the various theories is that a rational issue like hygiene had nothing to do with it. In the days before aseptic surgery, any cutting of the skin was fraught with risk, and dangerous operations of this kind must have led to many fatal infections and haemorrhage. It is quite wrong to project a 20th century concern with moral and physical cleanliness onto stone age or other ancient cultures which had no such concepts. (See Attachment 1.) For a summary of current theories on the origin of ritual circumcision, see Gollaher (2000) chs. 1 and 3; see also de Meo (1997); Dunsmuir and Gordon (1999). 2. The opening paragraph as a whole creates a mood favourable to routine circumcision: an ancient practice; promotes hygiene; a valued ritual among respected ethnic groups today. It also gives the impression that there is something inherently unhygienic about the normal penis, or at the very least that it is significantly more difficult to keep clean than the simplified variety. This could be regarded as propaganda rather than an objective assessment of the position. It should also be pointed out that many of the cultures which practise male circumcision also prescribe the circumcision of women (and other forms of female genital mutilation), but that modern societies like Australia do not countenance such rituals, however important they may be to the cultures in question, and have in fact made them illegal. Paragraph 2 During the last 50-100 years, routine neonatal male circumcision became widespread in English-speaking countries. 1. This is imprecise. Widespread circumcision was introduced in Britain and the USA in the late 19th century for several reasons, prominent among which was the belief that it would discourage masturbation, particularly among boys before puberty. From Britain the practice spread to British colonies like Australia, New Zealand and Canada - but not to Quebec, where the French-speaking inhabitants regarded the idea as an English fad, not a valid medical procedure, and wanted nothing to do with it. Circumcision always remained a controversial procedure in Britain and had critics from the outset, with the result that it remained concentrated among the rich and upper classes and never became as common as in Australia and the USA: at its peak in the 1920s it probably affected no more than a third of British males (Hyam 1990, p. 78). The incidence of the procedure began to decline in the late 1930s and all but disappeared in the early 1950s, following the well known critique by Gairdner (1949). The same pattern was followed in New Zealand. In Australia RNC continued at a considerably higher incidence than ever attained in Britain until the early 1970s, when the practice fell into disfavour, a tendency accelerated in the 1980s. The only countries today where RNC remains common is the USA, where the rate reached almost universal coverage in the 1950s and 60s, but which now stands at between 50 and 60 per cent; and in South Korea, where the procedure was introduced as a consequence of the US occupation following the Korean War. The inescapable conclusions from this quick survey are: <ul> <li> routine infant circumcision was a 19th century invention; </li> <li> it has always been a controversial procedure; </li> <li> on a world scale it has never been supported by more than minority of the world's medical profession; </li> <li> its restriction to English-speaking countries, and especially those within the sphere of influence of great powers like Britain and the USA, suggests that it is more like a cultural ritual than a medical procedure with objectively defined and universally agreed therapeutic benefits. </li> </ul> 2. The proposition that circumcision, both in girls and boys, was first introduced largely to prevent or discourage masturbation (then regarded as a serious disease in itself and as the cause of many more) is an embarrassment to contemporary advocates of RNC, and one which they attempt to deny (Morris 1999, p. 57). The reality of the connection has, however, been recognised by scholars since the 1950s, and recent research by historians of medicine has proved just how important this link was, even until quite recent times. 3. It is of course true that, merely because circumcision was originally introduced to discourage masturbation, it does not necessarily follow that it has no health benefits today, but this sort of historical background does enable one to view such assertions in perspective. What then becomes apparent is that claims for the health benefits of circumcision have shrunk dramatically over the last hundred years: in the 1890s it was guaranteed to cure, prevent or at least reduce the risk of tuberculosis, rickets, cancer, syphilis, polio, convulsions, epilepsy, bed-wetting, nervousness, brass poisoning (and almost anything you cared to name). Today we are left with no more than some infantile UTIs, usually minor; possibly cancer of the penis (though only a few extremists continue to believe it); and maybe AIDS, which has taken the place of syphilis as the spectre haunting our liberated sex-lives, though the claim is highly controversial and unproven. As scientific understanding of diseases has increased, so the folklore that they could be defeated by sacrificing part of the body has been discredited (though of course that may be necessary in the case of seriously diseased or infected structures); in a century's time the belief that circumcision could protect a man against AIDS is likely to look as ridiculous as the claim that it could save him from TB or "paralysis" does today. The much misunderstood issue of phimosis is covered by Hodges (1999). Paragraph 3 There have been increasing claims over recent years of health benefits from routine male circumcision. 1. Contrary to the implication of this sentence, there is nothing new in the claim that circumcision may reduce the risk of a man's becoming infected with the AIDS virus - and I note that the alleged benefit is confined to cases where he engages in vaginal intercourse, or takes the active role in anal intercourse, with a HIV-positive partner, without using a condom. 2. The decline of RNC in Australia and the USA has probably been arrested or slowed by the AIDS scare, which has proved as great a boon to long-time advocates of routine circumcision as it has been a godsend to haters of homosexuals. In each case the response has been the same: AIDS is such a serious disease that it demands both the resumption of mass amputation of foreskins and an end to tolerance of sexual deviants whose vile practices spread the virus. As soon as AIDS became a visible problem in the USA, existing enthusiasts for the operation immediately hailed circumcision as a protection (Fink 1986, 1990), a claim which required some gall, considering that the only country with an AIDS epidemic at that time was the very one in which the vast majority of sexually active men were already circumcised. To its great credit, the medical profession in western countries rejected calls to resume persecution of homosexuals as a "strategy" against AIDS, with the result that the disease has been contained in response to the "safe sex" message. The profession should also resist calls to resume persecution of the foreskin as yet another mystical approach to what remains a serious problem. (See Attachment 2.) 3. But the assertion that circumcision could provide protection against AIDS goes back much further than Fink: it is really a revival of discredited claims that it could lower the risk of contracting other STDs. The AIDS of the 19th century was syphilis, a similarly incurable disease with a long incubation period, hideous symptoms, caused by a blood-borne micro-organism, transmitted by sexual contact; it will come as no surprise that one of the major selling points for RNC in the late 19th century was the proposition that it provided significant protection against syphilis. This claim was first put forward by Jonathan Hutchinson (1855) on the basis of his impressions of the Jewish community in east London, and it was repeated in many articles favouring routine circumcision over the next half century (Freeland 1900), some of which added the novel point that the operation also lowered the incidence of gonorrhoea, despite Hutchinson's original observation that Jewish men actually presented a higher incidence of gonorrhoea than his gentile clientele. Only a few extremists today claim that circumcision provides meaningful protection against STDs, and serious doubts have been thrown on their views (van Howe, 1999). 4. From a paediatric perspective, it is hard to see the relevance of any argument for circumcision relating to STDs acquired through sexual contact with another, since children are not sexually active with others. While paediatricians must take account of the long term as well as the immediate health interests of the child, their direct responsibility ends roughly with the onset of puberty; the average age of first intercourse for boys in Australia is about 17, by which time they are old enough to make their own decisions about their health. Even if it were true that circumcision provided a significant degree of protection against AIDS, it does not follow that all boys should be circumcised at birth. The most you could logically and ethically conclude is that if the uncut faced a greater risk, the danger should be explained to them when they are old enough to understand, and advice provided on the options for minimising it. The boy himself is the one who should decide how he wishes to manage that risk; it is not a decision which should be pre-empted by irreversible actions performed by others. 5. Advocates of RNC are fond of likening circumcision to immunisation (Moses et al 1998, p. 372), a comparison which first emerged in the 1890s, but a moment's thought will reveal that it is a false analogy. Successful vaccination does make a person completely resistant to a disease, but merely to reduce the risk of contracting it is not to confer immunity; vaccination boosts the body's natural antibody system, but circumcision removes healthy and normal tissue; immunisation adds to what is already there, but circumcision injures and mutilates a sensitive and psychologically important part of the male body. It could more accurately be characterised as pre-emptive amputation. It is easy enough to protect the body against future diseases by deleting the organs that are expected to suffer: removal of the testicles or prostate will certainly guarantee immunity to testicular or prostate cancer. Most people would not, however, regard it as appropriate for a doctor to do the work of the disease as though on its behalf; and in relation to all body parts except the foreskin this principle is taken for granted. Paragraph 4 The possibility that routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven medical benefit. Whether these legal concerns are valid will probably only be known if the matter is determined in a court of law. 1. The human rights question is broader than this, crucially involving principles of medical ethics and matters of consent: the limits of surrogate consent, the validity of consent where the child cannot know what is going on or give valid consent, the child's right not to be subjected to irreversible procedures that he or she may later regret. Nor is it correct to imply that the issue of human rights can be ignored until the matter is settled by a court: the problem will be there whether it ever comes to court or not. Even so, damages are increasingly being awarded for injury caused by circumcision, and this trend is likely to strengthen as more men become aware of and indignant about the harm that was done to them. 2. But it is just as much a medical ethics as a human rights or legal issue: in the normal course of events, no part of the body is ever amputated except in cases of desperate necessity (gangrene, infection, incurable damage, cancer) and only after all attempts to save it have failed. If a parent asked a doctor to cut off a baby's finger or toe, he or she would not perform the operation because there is obviously no health advantage, and surrogate consent is valid only if the procedure is of proven medical benefit to the child. Many doctors will not perform even such a mild and relatively harmless procedure as an ear-piercing for the same reason: but if they have scruples there, how much more scrupulous and conservative should they be in relation to procedures on a boy's most prized possession? It is hard to see why the rules governing the amputation of the foreskin should be different from the rules governing the amputation of any other non-diseased body part. The ethical issues are complex, involving both the parents' expectations and the child's rights, and the doctor's obligation to act in the best interests of the child. Paragraph 8 In the majority of cases, parents will decide for or against a routine male circumcision on family, social, aesthetic and religious grounds rather than medical ones. In all cases the medical attendant should avoid exaggeration of either risks or benefits of the procedure. 1. The ACP/RACP may be realistic in acknowledging that family tradition, social pressure, aesthetic taste and religious affiliation may be more important than medical considerations in most parents' decision on this issue. But having recognised that, what is the duty of the medical attendant? I would suggest that his or her overriding priority should be the health and happiness of the child: that he or she should advise the parents as to the boy's best interests from a health point of view, without regard to such considerations. I am sure that most paediatricians feel this way and act so in their practice. But if the decision regarding circumcision is not a medical one at all, but something as subjective as an aesthetic or social preference, it is surely the prerogative of the boy himself (who will have to live with the result for the rest of his life), and not of any other parties, no matter how much power they may have over him at that time, or how little capacity he has to make his will known at that tender age. If so, the appropriate stance is to recommend caution and restraint, pointing out that the decision regarding circumcision should really be made by the one who must carry the consequences. 2. In this context, it is not enough for the medical attendant to exaggerate neither the benefits of circumcision nor the risks of the procedure. There is a third and vital point left out here: the disadvantages of being without a foreskin. Much of the argument as to the health benefits of circumcision has rested on the assumption that the foreskin was useless flap of skin, with the result that the loss of this tissue was never factored into such cost-benefit analyses of the procedure as have been attempted. The negative aspects of having a partially flayed penis have not been properly assessed; indeed, there has been great reluctance to admit that any damage at all is done, let alone anything as severe as a partial flaying or mutilation. If the foreskin performs valuable functions, or even if it is no more than a desirable adornment, the equation changes sharply, and even if circumcision offered real health benefits, they must be set against the disadvantages of losing that part of the body. 3. Before the 19th century nobody doubted that the foreskin was both central to male sexuality and relevant to female sexual pleasure (Hodges 1999, Wolper 1982), and that perspective is now being rediscovered in countries which took up RNC and consequently lost this knowledge (Cold and Taylor 1999, Cold and McGrath 1999, O'Hara 2001, Taylor et al 1996). Another of the obligations of the medical attendant should be to explain to parents, particularly in cases where the father is circumcised, the functions of the foreskin and the many delights of having a normal penis. As the US physician Robert J. Valentine (1974, p. 42), in an article wildly in favour of circumcision, conceded: "If it [the foreskin] does have a function, its routine removal in newborns cannot be justified. Perhaps the foreskin does have a rationale that has been ignored or not recognised." Or as Thomas Szasz (1996, p. 145) has argued: "The practice of RNC rests on the absurd premise that the only mammal in creation born in a condition that requires immediate surgical correction is the human male. If the penile foreskin is not merely non-functional but a biological disadvantage so severe as to justify its immediate ablation, then, surely, it might have atrophied by now." Attachment 1 Explanations for circumcision among the Jewish people Many fanciful ideas about the origins of Jewish circumcision were proposed in the 19th century as part of the process by which English doctors came to accept and advocate the procedure as a legitimate one on British boys, including the notion that it arose out of concern with cleanliness or to gain other health benefits. These ideas were elaborated at great length in the late nineteenth century by British and American doctors who were keen to get routine circumcision accepted by their own societies, and by Jewish modernisers who wanted to preserve their ancient ritual by finding sanitary justifications for it and thus defending it against the more radical reformers who wanted to abolish it along with many other outdated observances (Glick 2001). The most elaborate presentation of the hygienic value of circumcision was made by the notorious American doctor and snake oil salesman, P.C. Remondino, author of History of circumcision from the earliest times to the present: Moral and physical reasons for its performance (1891), a feverish diatribe against the foreskin. The orthodox position had been put long before by Moses ben Maimon, who insisted that for Jews circumcision was strictly a test of faith, carried out not to correct a defect but to injure and chasten the penis, thus curbing sexual desire. Until this step was abolished in the late nineteenth century, Jewish circumcision also required the Mohel to suck the bleeding penis after he had cut the foreskin the metsitsah phase); far from being a hygienic measure, this operation was a significant vector for the transmission of fatal diseases, including tuberculosis and syphilis, as even Hutchinson and Abraham Wolbarst, both outspoken enthusiasts for universal circumcision, acknowledged. ben Maimon (12th century) wrote as follows: "With regard to circumcision, one of the reasons for it is, in my opinion, the wish to bring about a decrease in sexual intercourse and a weakening of the organ in question, so that this activity be diminished and the organ be in as quiet a state as possible. It has been thought that circumcision perfects what is defective congenitally. This gave the possibility for everyone to raise an objection and to say: How can natural things be defective so that they need to be perfected from outside, all the more because we know how useful the foreskin is for the member? In fact this commandment has not been prescribed with a view to perfecting what is defective congenitally, but to perfecting what is defective morally. "The bodily pain caused to that member is the real purpose of circumcision. None of the activities necessary for the preservation of the individual is harmed thereby, nor is procreation rendered impossible, but violent concupiscence and lust that goes beyond what is needed are diminished. The fact that circumcision weakens the faculty of sexual excitement and sometimes perhaps diminishes the pleasure is indubitable. For if at birth this member has been made to bleed and has had its covering taken away from it, it must indubitably be weakened." (Moses ben Maimon, Guide of the Perplexed, Part III, Chapter 49) Despite such explicit texts, is interesting to observe how readily some contemporary advocates of RNC still fall for the sort of stories told by Remondino and other propagandists. Brian Morris writes: "The Bible records that Abraham circumcised himself at age 99, along with his 13 year-old son Ishmael. Not long afterwards his wife Sarah, after many barren years, became pregnant and bore Isaac. Weiss speculates that Abraham had a foreskin problem, possibly exacerbated by the desert environment, and that this problem interfered with his sexual activity. The difficulties were solved by having a circumcision" (Morris 1999, p. 60, citing G.N. Weiss, "Prophylactic neonatal surgery and infectious diseases", Medical Journal, 1997). It is surprising to see modern scientists treating the Old Testament as though it was literal history. No serious scholars of ancient biblical studies today believes that the books of the Old Testament have any historicity; it is now generally accepted that they are a collection of myths assembled by Jewish religious leaders in the 6th century BCE. It follows that Abraham et al are as much mythical figures as Hercules or Oedipus, and that Weiss's "speculations" are on a par with Archbishop Ussher's calculations of the age of the earth, according to the genealogies of Genesis, back in the 17th century. Recent research also suggests that Jewish ritual circumcision did not become routine and privileged as a sign of the Covenant until the Babylonian exile of the 6th century (at about the same time as the first five books of the Old Testament - the Torah - were compiled), when the rationale would most likely have been the maintenance of cultural identity and racial purity in a hostile social environment by the enforcement of physical distinctiveness, and would have had nothing to do with foreskin problems, protection against disease or the irritation caused by desert sands (Hoffman 1996, Glick 2001). The foreskin was far more likely a protection against such irritation than a source of it, as Valentine and Remondino admit. Allowing the myth for a moment, if it was Abraham who had the foreskin problem, why did he also circumcise Ishmael? And if this "problem" prevented him from begetting children, how come he already had a son? <h3>REFERENCES</h3> Cold, C.J. and J.R. Taylor, (1999), "The prepuce", BJU International, Vol. 83, Supplement 1, January, pp. 34-44 Cold, C.J. and K.A. McGrath (1999), "Anatomy and histology of the penile and clitoral prepuce in primates: Evolutionary perspective of specialised sensory tissue of the external genitalia", in George C. Denniston, Frederick Hodges and Marilyn Milos (eds), Male and female circumcision: Medical, legal and ethical considerations in pediatric practice, New York, Kluwer Academic/Plenum Publishers de Meo, James (1997), "The geography of male and female genital mutilations", in George C. Denniston and Marilyn Fayre Milos (eds), Sexual mutilations: A human tragedy, New York, Plenum Press Dunsmuir, W.D. and E.M. Gordon (1999), "The history of circumcision", BJU International, Vol. 83, Supplement 1, January, pp. 1-12 Fink, A.J. (1986), "A possible explanation for heterosexual male infection with AIDS", New England Journal of Medicine, Vol. 315, p. 1167 Fink, A.J. (1990), "Newborn circumcision: A long-term strategy for AIDS prevention", Journal of the Royal Society of Medicine, Vol. 83, p. 673 Freeland, E. Harding (1900), "Circumcision as a preventive of syphilis and other disorders", Lancet, Vol. 2, (29 December), pp. 1869-70 Glick, Leonard (2001), "Jewish circumcision: An enigma in historical perspective", in Marilyn Milos, George C. Denniston and Frederick Hodges (eds), Understanding circumcision: A multi-disciplinary approach to a multi-dimensional problem, London and New York, Kluwer Academic and Plenum Press Gairdner, Douglas (1949), "The fate of the foreskin: A study of circumcision", British Medical Journal, Vol. 2, (24 December), pp. 1433-37 Gollaher, David L. (2000), Circumcision: A history of the world's most controversial surgery, New York, Basic Books Hodges, Frederick (1997), "A short history of the institutionalization of involuntary sexual mutilation in the United States", in George C. Denniston and Marilyn Fayre Milos (eds), Sexual mutilations: A human tragedy, New York, Plenum Press Hodges, Frederick (1999), "The history of phimosis from antiquity to the present", in George C. Denniston, Frederick Hodges and Marilyn Milos (eds), Male and female circumcision: Medical, legal and ethical considerations in pediatric practice, New York, Kluwer Academic/Plenum Publishers Hoffman, Lawrence W. (1996), Covenant of blood: Circumcision and gender in rabbinic Judaism, University of Chicago Press Hutchinson, Jonathan (1855), "On the influence of circumcision in preventing syphilis", Medical Times and Gazette, Vol. 2, p. 542 Hyam, Ronald (1990), Empire and sexuality: The British experience, Manchester University Press Morris, Brian (1999), In favour of circumcision, Sydney, New South Wales University Press Moses, Stephen et al (1998), "Male circumcision: Assessment of health benefits and risks", Sexually Transmitted Infections, Vol. 74, pp. 368-73 O'Hara, Kristen (2001), Sex as nature intended it, Hudson, Mass., Turning Point Publications Remondino, P.C. (1891), History of circumcision from the earliest times to the present: Moral and physical reasons for its performance, Philadelphia and London, F.A. Davis Szasz, Thomas (1996), "Routine neonatal circumcision: Symbol of the birth of the therapeutic state", Journal of Medicine and Philosophy, Vol 21, pp. 137-48 Taylor, J.R. et al (1996), "The prepuce: Specialised mucosa of the penis and its loss to circumcision", British Journal of Urology, Vol. 77, pp. 291-5 Valentine, Robert J. (1974), "Adult circumcision: A personal report", Medical Aspects of Human Sexuality, Vol. 8, January 1974, pp. 31-42, 48 Van Howe, R.S. (1999), "Does circumcision influence sexually transmitted diseases? A literature review", BJU International, Vol. 83, Supplement 1 (January), pp. 52-62 Wolper, Roy S. (1982), "Circumcision as polemic in the Jew Bill of 1753: The cutter cut?", Eighteenth Century Life, Vol. VII, pp. 24-3 <h2> <a id="arc" name="arc"></a>Attorneys for the Rights of the Child</h2> I understand that the RACP will be considering the issue of male circumcision at its next Policy Committee Meeting. As I understand things, the Australian College of Paediatrics has been absorbed into the RACP, and the RACP now has adopted and has under review the 1996 Australian College of Paediatrics' (ACP's) Position Statement on Routine Circumcision of Normal Male Infants(2). I am writing to point out a few pertinent principles for your consideration and to provide you with copies of some materials which may be of assistance in your review of this important issue. I have enclosed two articles I co-authored, from the Journal of Law and Medicine and the Journal of Contemporary Health Law and Policy. The average male circumcision removes at least half of the skin of the penis and also does significant other damage(3). The Australian Association of Paediatric Surgeons has unambiguously rejected the practice, declaring that it "does not support the routine circumcision of male neonates, infants or children in Australia. It is considered to be inappropriate and unnecessary as a routine to remove the prepuce, based on the current evidence available(4)." The Australian Medical Association has concurred, stating its determination to "discourage circumcision of baby boys in line with the Australian College of Paediatrics' Position Statement on Routine Circumcision of Normal Male Infants and Boys."(5) All national medical associations worldwide which have addressed the issue have uniformly failed to find justification for male circumcision as a routine therapeutic procedure(6). The Queensland Law Reform Commission concluded, "The circumcision procedure is invasive, irreversible and major. It involves the removal of an otherwise healthy organ part. It has serious attendant risks."(7) Parental consent is invalid except under certain limited circumstances not met by routine infant circumcision.(8) According to the Queensland Law Reform Commission: "The common law operating in Queensland appears to be that if the young person is unable, through lack of maturity or other disability, to give effective consent to a proposed procedure and if the nature of the proposed treatment is invasive, irreversible and major surgery and for non-therapeutic purposes, then court approval is required before such treatment can proceed. The court will not approve the treatment unless it is necessary and in the young person's best interests. The basis of this attitude is the respect which must be paid to an individual's bodily integrity."(9) The legal status quo, whereby circumcisions are not punished either criminally or civilly as long as they are done "competently" and with "consent" of the parents, must be unstable. Paragraph 4 of the ACP's 1996 position statement states: "The possibility that routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven medical benefit."(10) Indeed, a number of human rights documents - whether ratified or applicable under principles of customary international law - forbid routine infant male circumcision based on such important principles as the rights of the child, the right to freedom of religion, and the right to the highest attainable standard of health. These include the United Nations Charter, the International Covenant on Civil and Political Rights, the International Covenant on Economic, Social and Cultural Rights, and the Convention on the Rights of the Child, now ratified by all but two of the world's nations.(11) Each of these documents has been ratified by Australia.(12) The right of freedom of religion does not justify and conflicts with male circumcision. Children bear their own right to freedom of religion, independent of the wishes of their parents or guardians. Under Article 14.1 of the Convention on the Rights of the Child, children have the right to demand that states parties respect their right to freedom of thought, conscience, and religion. No infant is capable of consenting to a surgical procedure based on his own religion. Where the procedure is one based on religion, it is therefore the parents' religion which motivates the procedure and not the religion of the person whose genitals are being surgically altered. A parent's consent is therefore again clearly insufficient.(13) Precisely due to the necessity of preserving freedom of religion, governments must prevent ritual male circumcision and, for that matter, ritual female genital mutilation. A ritual mutilation permanently takes away the person's right to his bodily integrity and his right to choose whether to permit the alteration of his body under the precepts of a particular religion. Thank you for your time and attention. If you have any questions regarding any matters raised in this letter or in the attached articles, please feel free to contact me as indicated above. Very truly yours J Steven Svoboda Executive Director <h3>References</h3> <ol> <li>Boyle GJ, Svoboda JS, Price CP, Turner JN. Circumcision of healthy boys: criminal assault? J Law & Med 2000; 7:301-310.</li> <li>Position Statement: Routine Circumcision of Normal Male Infants and Boys. Parkville, Victoria: Australian College of Paediatrics; 1996.</li> <li>Taylor JR, Lockwood AP and Taylor AJ. The Prepuce: Specialized Mucosa of the Penis and its Loss to Circumcision. British Journal of Urology 1996; 77:291-295.</li> <li>Guidelines for Circumcision. Australasian Association of Paediatric Surgeons. Herston, QLD: 1996.</li> <li>Circumcision Deterred. Australian Medicine 1997 (6-20 January):5.</li> <li>See <a href="http://www.cirp.org/library/statements/">www.cirp.org/library/statements/</a>, downloaded 26 September 2001.</li> <li>Circumcision of Male Infants Research Paper. Queensland Law Reform Commission. Brisbane 1993, p. 39</li> <li>Svoboda JS, Van Howe RS, Dwyer JG. Informed consent for neonatal circumcision: an ethical and legal conundrum. J Contemp Health Law Policy 2000; 17(1): 60-134.</li> <li>Circumcision of Male Infants Research Paper. Queensland Law Reform Commission. Brisbane 1993, p. 38</li> <li>Position Statement: Routine Circumcision of Normal Male Infants and Boys. Parkville, Victoria: Australian College of Paediatrics; 1996.</li> <li>Boyle GJ, Svoboda JS, Price CP, Turner JN. Circumcision of healthy boys: criminal assault? J Law & Med 2000; 7:301-310.</li> <li>The United Nations. The United Nations and Human Rights, 1945-1995. New York: United Nations Department of Public Information; 1995, p. 504.</li> <li>Svoboda JS, Van Howe RS, Dwyer JG. Informed consent for neonatal circumcision: an ethical and legal conundrum. J Contemp Health Law Policy 2000; 17 (1): 60-134.</li> </ol> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Royal Australasian College of Physicians: submissions before its 2002 policy 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"> It is interesting to trace the evolution of the statements and policies on circumcision issued by Australian medical authorities, from the one-line announcement in 1971 that circumcision was not recommended to the 100-page thesis published in 2002. Interestingly, the need to elaborate on the policy was not felt until the mid-1990s, when medical conservatives and others committed to circumcision as a cultural practice became alarmed that the United Nations Convention on the Rights of the Child (1989) threatened to make circumcision a recognised human rights violation and hence impossible in countries that professed respect for human rights. Their response was to revive the most credible of the old rationalisations for circumcision (prevention of phimosis, cancer, syphilis and other sexually transmitted infections, and to look for new ones. HIV-AIDS seemed tailor-made for this purpose. As a consequence of the agitation of this committed band of circumcision promoters in the medical research industry (mainly in the U.S.A.), circumcision has today become a controversial question, and not a forgotten medical fad like mercury or frontal lobotomy <h3>Australian Pediatric Association, 24 April 1971</h3> The Australian Pediatric Association recommends that newborn male infants should not, as a routine, be circumcised. Medical Journal of Australia, 22 May 1971, p. 1148 <h3> Australian College of Paediatrics, 1983</h3> <ol> <li>The ACP should continue to discourage the practice of circumcision in the newborn male infant.</li> <li>Educational material on the topic of circumcision should be available to parents before the birth of their baby and also in maternity hospitals. This will facilitate informed discussion with their medical attendant.</li> <li>Some parents after considering medical, social, religious and family factors will opt for circumcision of their infant. It is then the responsibility of the medical attendant to recommend that this circumcision be performed at an age and under medical circumstances that reduce the hazards to a minimum.</li> </ol> This statement was reviewed and reissued by the ACP on 28 May 1991. <h3><img alt="" class="image-center" height="388" src="https://www.circinfo.org/images/Dont.jpg" width="500"/></h3> <h3> </h3> <h3>Australian College of Paediatrics , 1996</h3> The Australian College of Paediatrics has prepared the following statement on routine circumcision of infants and boys to assist parents who are considering having this procedure undertaken in their male children and for doctors who are asked to advise on or undertake it. Routine circumcision of normal male infants and boys Circumcision of males has been undertaken for religious and cultural reasons for many thousands of years. It probably originated as a hygiene measure in communities living in hot and dry environments. It remains a very important ritual in some religious/cultural groups. During the last 50-100 years, neonatal male circumcision became widespread in English-speaking countries. Until the late 1960s or early 1970s, it was generally performed without any form of anaesthesia. In Australia, the circumcision rate has fallen very considerably in recent years and it is estimated that currently only 10 percent of male infants are routinely circumcised. It is now generally performed with some form of local or general anesthesia. There have been increasing claims of health benefits from routine male circumcision. There are, however, also risks associated with the procedure from infection, bleeding and damage to the glans penis. The College has recently reviewed evidence in relation to risks and benefits and has concluded that it is not possible to be dogmatic on the exact risk/benefit ratio. There are suggestions of reductions in the risk of urinary tract infections, of local inflammatory conditions of the penis and later cancer of the penis. It has also been claimed that there is a reduction in the risk of sexually transmitted disease (especially HIV) and of cancer of the cervix in partners of circumcised males. However, studies claiming these benefits do have methodological problems which could influence findings and these problems will be difficult to overcome. Therefore, at the present time it would be wrong either to claim that there are definite health benefits or to deny that they exist. The possibility that routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven medical benefit. Whether these legal concerns are valid will probably only be known if the matter is determined in a court of law. The Australasian Association of Paediatric Surgeons has informed the College that it is its view that routine male circumcision should not be performed prior to the age of 6 months. It considers that "Neonatal male circumcision has no medical indication. It is a traumatic procedure performed without anaesthesia to remove a normal and healthy prepuce." The College believes informed discussion with parents regarding the possible health benefits of routine male circumcision and the risks associated with the operation are essential. Up-to-date, unbiased written material summarising the evidence in plain English should be widely available to parents. If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthetic techniques and under medical conditions that minimise the hazards. In the majority of cases, parents will decide for or against a routine male circumcision on family, social, aesthetic and religious grounds rather than on medical ones. In all cases the medical attendant should avoid exaggeration of either benefits or risks of this procedure. Issued 27 May 1996 NOTE: There are many problems and dubious claims in this policy statement. These were the subject of critical comment in 2001-02, when the Royal Australasian College of Physicians was reviewing the policy and a number of individuals sent comments and submissions in. <a href="https://www.circinfo.org/whatwesay.html">Read these comments here on "Whatwesay" page.</a> <h3>The Australasian Association of Paediatric Surgeons, 1996</h3> Guidelines for circumcision Preamble The Australasian Association of Paediatric Surgeons does not support the routine circumcision of male neonates, infants or children in Australia. It is considered to be inappropriate and unnecessary as a routine to remove the prepuce, based on the current evidence available. Due to religious beliefs, Jewish children are circumcised by the seventh day of life, as a mark of dedication to God. Children born into the Muslim faith will likewise be circumcised for religious reasons, although the timing for the procedure is less clearly defined. There are Christian groups in other parts of the world, who insist on ritual religious circumcision, as well as tribal or cultural customs promoting male circumcision. We do not support the removal of a normal part of the body, unless there are definite indications to justify the complications and risks which may arise. In particular, we are opposed to male children being subjected to a procedure, which had they been old enough to consider the advantages and disadvantages, may well have opted to reject the operation and retain their prepuce. Indications for male circumcision Balanitis Xerotica Obliterans Recurrent Balanoposthitis Phimosis resistant to steroid cream Contraindications to male circumcision Hypospadias and other congenital anomalies of the penis, e.g. epispadias, chordee Sick and unstable infants Family history of a bleeding disorder or an actual bleeding disorder Timing of surgery Neonatal male circumcision has no medical indication. It is a traumatic procedure performed without anaesthesia to remove a normal functional and protective prepuce. At birth, the prepuce has not separated from the underlying glans and must be forcibly torn apart to deliver the glans, prior to removal of the prepuce distal to the coronal groove. Balanitis Xerotica Obliterans, when diagnosed, should be treated by circumcision. Timing of circumcision for recurrent balanoposthitis is difficult to define. Many infants and children will have an episode of preputial inflammation. If successive occurrences of dysuria with associated redness and purulent discharge from beneath the prepuce have been treated and the previously fully or partially retractable prepuce is less readily retractable after the subsidence of the inflammation, circumcision should be considered. The physiological phimosis will normally resolve by the age of 3-4 years. If it fails to respond to steroid cream/ointment applied several times daily for 4-6 weeks, there is a reasonable probability that these boys will have problems in the future. Infants and children who have a proven urinary tract infection and, on investigation, are found to have a significant urinary tract anomaly, e.g. posterior urethral valves or significant vesico-ureteric reflux, may benefit from circumcision. This will reduce the normal bacterial flora resident under the prepuce, which in the presence of a urinary tract anomaly may be associated with an increased risk of further upper tract infections with possible local and systemic damage. The risk of carcinoma of the penis developing in the uncircumcised is very low. Lifetime penile hygiene is the key to penile health and a reduction in the incidence of carcinoma of the penis. Personal sexual behaviour patterns will determine whether sexually transmitted infections with human papilloma virus, herpes simplex virus and the human immune deficiency virus are contracted. Routine or infant male circumcision is not justified in Australia to protect males from contracting diseases that some may acquire through their ignoring the recognized precautions to be taken during their sexually active life. Consent for surgery Parents requesting circumcision of their male children should have the complications both general and local, explained to them. These complications are usually minor but can be severe and may result in the death of the child. Time should also be spent discussing the advantages and disadvantages of the operation, both in the short and long term, as is currently applicable in Australia. There are many adults in the community who hold a very strong opinion as to the place of circumcision. This may be for religious reasons or for family "custom" or a claim of "cleanliness" or other reasons. In this event the procedure should be performed electively after six months of age. When performed, it should be carried out by a surgeon performing circumcisions on children on a regular basis with an anaesthetist using appropriate techniques. This would imply that the anaesthetist is fully trained in the art of paediatric anaesthesia, including the ability to perform caudal and penile regional or local anaesthesia. The operation should be carried out in a paediatrically orientated environment, designed to reduce the risk to the child and providing support to the parents or caregivers. Points of interest Marshall in 1960, reporting to the Society of Pediatric Urologists in Philadelphia and quoted by John Duckett, a distinguished pediatric urologist in Philadelphia, calculated that 140 boys a week for 24 weeks would need to be circumcised to prevent one case of carcinoma of the penis. The Jewish Talmud stated that "the third child was excused from circumcision if the first two had died as a result of the circumcision". Dr. Derek Llewellyn Jones in his book Everywoman (1971), stated: "Mothers demand it, doctors profit by it and babies cannot complain about it". The 1989 United Nations Convention on the Rights of the Child states: "State parties should take all effective and appropriate measures with a view to abolishing traditional practices prejudical to the health of children." Circumcision of male infants was addressed in a research paper published by the <a href="http://www.cirp.org/library/legal/QLRC">Queensland Law Reform Commission</a> in December 1993. The preface addresses the problem when it states: "From the Commission's research to date, it is apparent that there are two quite vocal sides of the debate on routine male circumcision. One side advocates the practice, primarily on a preventative health basis or on religious grounds. The other side opposes the practice, primarily on human rights and preservation of bodily integrity grounds. Both sides rely on medical evidence and opinion to support their respective views". Having considered all the information the paper concludes with "The Commission has yet to decide what, if any reform of the law should be recommended in relation to infant male circumcision." <h3>Australian Medical Association, 1997</h3> The AMA will discourage circumcision of baby boys in line with the Australian College of Paediatrics "Position Statement on Routine Circumcision of Normal Male Infants and Boys". The statement, released in June and supported by the AMA's November Federal Council meeting, includes: <ul> <li> The Australian College of Paediatrics should continue to discourage the practice of circumcision in newborns. </li> <li> Educational material should be available to parents before the birth of their baby and in maternity hospitals. </li> <li> Some parents after considering medical, social, religious and family factors will opt for circumcision. It is then the responsibility of the doctor to recommend this is performed at an age and under circumstances which reduce hazards to a minimum. </li> </ul> Australian Medicine, 6-20 January 1997, p. 5 <h3>Royal Australasian College of Physicians, 2002 and 2004</h3> Routine Circumcision Of Normal Male Infants And Boys - Summary Statement The Paediatrics & Child Health Division, Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of infants and boys assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that there is no medical indication for routine male circumcision. Circumcision of males has been undertaken for religious and cultural reasons for many thousands of years. It remains an important ritual in some religious and cultural groups. In Australia and New Zealand, the circumcision rate has fallen considerably in recent years and it is estimated that currently only 10 percent of male infants are routinely circumcised. It is now generally performed with some form of local or general anaesthesia, and usually outside the neonatal period. The best recognised indication for circumcision is phimosis. There have been increasing claims over recent years of health benefits from routine male circumcision. The most important other conditions where some benefit may result from circumcision are urinary tract infections, HIV and later cancer of the penis. <ul> <li>Urinary tract infections in boys are uncommon, affecting at most 1%-2%, and may be about 5 times less frequent in circumcised boys, whilst circumcision has a complication rate of 1% to 5%. Routine neonatal circumcision can not be supported as a public health measure on this basis.</li> <li>While there is some evidence, particularly from sub-Saharan Africa, that male circumcision reduces the risk of acquisition of HIV, evidence is conflicting and clearly this can not be seen as an argument in favour of universal neonatal circumcision in countries with a low prevalence of HIV.</li> <li>Penile cancer is a rare disease with an incidence of around 1 per 100,000 in developed countries. Even though the evidence suggests neonatal circumcision may reduce the risk 10-fold, the rarity of the condition is such that universal circumcision is clearly not justified on these grounds.</li> </ul> The complication rate of neonatal circumcision is reported to be around 1% to 5% and includes local infection, bleeding and damage to the penis. Serious complications such as bleeding, septicaemia and meningitis may occasionally cause death. The possibility that routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven medical benefit. Whether these legal concerns are valid will be known only if the matter is determined in a court of law. If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment. In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarising the evidence should be widely available to parents. Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure. The full statement, with critical comment, are available at <a href="http://www.nocirc.org/position/racp2002.php">Nocirc USA</a> and <a href="http://www.circumstitions.com/RACP.html">Circumstitions</a> (New Zealand) COMMENT While this statement is clearly an improvement on that of 1996 it nonetheless falls short in several important areas: (1) It fails to consider the anatomy and physiology of the foreskin itself and its functions as a sexual organ. (2) It confuses ethical and human rights issues with legal issues; whether circumcision without consent is a violation of human rights or medical ethics is independent of the question as to whether it is legal. (3) It fails to acknowledge the right of the individual to choose whether he prefers to have a foreskin or not. (4) It accepts the conclusions of a number of flawed or questionable studies. </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 Previous statements by Australian medical authorities darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>Sexism and double standards alive and well, as girls get full protection</h3> <h3>while boys are thrown to the wolves</h3> The new policy on female genital mutilation released by the Royal Australasian College of Physician in April 2012 takes a firm stand in defence of the bodily integrity and human rights of girls and women. According to the policy, FGM is an injury to the external genitals; it is usually performed on girls between infancy and 15 years of age; it causes harm; it violates the human rights of the victims; it is wrong because it is performed on minors without consent; it is illegal in all Australian states; and, although it is a practice authorized and recommended by some cultural and religious minorities, it is unacceptable in Australia. Doctors should vigorously oppose any form of FGM and become advocates for girls who are threatened with it, even against their parents and culture of origin. These are very fine sentiments, and one wonders why the same principles have not been adopted in the RACP’s policy on circumcision of boys. Every one of the above objections to FGM also applies to male genital mutilation: circumcision is also an injury to the external genitals (usually more severe than mild forms of FGM, such as a nick); it is usually performed between infancy and 15 years of age; it causes harm; it violates the human rights of the victims; and it is performed on minors without consent. But at this point some striking differences emerge: despite injuring the genitals, causing bodily harm and violating a boy’s human rights, circumcision is apparently OK if a boy’s parents prefer him to be circumcised; the practice is not illegal or even regulated anywhere in Australia; and doctors are not urged to oppose the practice and become advocates for the victims. One can only feels that the RACP is suffering from a certain schizophrenia. If any form of female genital mutilation is a violation of a girl’s human rights, it follows that the right must also apply to boys. A human right is a right that applies to all humans, regardless of gender or age, simply by virtue of their humanity; it has nothing to do with the culture of their parents. For the RACP’s position to be logically consistent there are only two possibilities here: either a girl’s right not to have any part of her genitals injured by FGM is a not a human right at all, but gender-specific right, applicable only to females; or boys are not human. Neither possibility seems very likely, and the shabby truth appears simply to be that the RACP is in the grip of the usual sexist double standard on genital mutilation, whereby the slightest nick to the female genitals is an outrage that must be abhorred and opposed, while the most ruthless and brutal circumcision of a boy is a harmless snip that must be allowed and may be applauded. The RACP’s full policy on female genital mutilation is reproduced below, preceded by the media release that announced it. We urge readers to add the words and male or and boys or and men whenever they see the word female, girls or women. The result will be a non-discriminatory policy statement that shows equal respect for the bodily integrity and human rights of all children, not merely those fortunate enough to have been born without a penis. Why isn’t circumcision also “a child protection issue”? <h2>Media release: Female genital mutilation an unacceptable practice in Australia and New Zealand</h2> Physicians (RACP) today launched the Female Genital Mutilation/Cutting (FGMC) Policy. With increasing numbers of immigrants arriving in Australia and New Zealand, paediatricians may encounter in their practice, girls or women who have undergone FGMC, or are at risk of it, according to Professor David Forbes, Chair of the Policy and Advocacy Committee of the Paediatric and Child Health Division (P&HCD). FGMC is defined as an injury of the external female genitalia undertaken for cultural or non-therapeutic reasons. FGMC is usually carried out on young girls between infancy and 15 years of age. With cultural migration, the practice has moved to Western countries. “FGMC is recognised internationally as a violation of the human rights of girls and women,” Professor Forbes said. “FGMC exposes children and women to significant health risks and has no measurable health benefit. The RACP believes that it is not an acceptable practice.” The P&CHD, through the launch of the policy, is calling for all paediatricians to be aware of the practice and the associated risks, and to seek opportunities for prevention and child protection. “It is important for paediatricians practising in Australia and New Zealand to understand both the cultural context in which FGMC occurs and the clinical implications for patients who have undergone the procedure. Girls and adolescent women may be exposed to the risk of FGMC either in Australia or New Zealand or on return visits to their country of origin. Girls and adolescent women migrating to Australia and New Zealand may already have undergone FGMC or may be at risk of undergoing FGMC on return visits to their country of origin.” All forms of FGMC are condemned by leading health professional organisations. It is illegal in Australia and New Zealand for cosmetic genital surgery of any form to be undertaken on minors. FGMC causes significant short and long-term health risks for girls and women, including acute and chronic infection, infertility, childbirth difficulties, sexual relationship difficulties and significant short and long-term psychological trauma. United Nations organisations report that 140,000,000 women have undergone FGMC and 3,000,000 girls are at risk of the procedure every year. “Paediatricians need to develop the skills to be able to recognise families where FGMC may be practiced and girls are at highest risk, and to discuss FGMC with these families,” according to Professor Forbes. Children and adolescent girls who have experienced FGMC may require long-term care that that necessitates the involvement of a range of different services including mental health and gynecological services. Royal Australasian College of Physicians, 24 April 2012 The full RACP policy on female genital mutilation follows <h2>FEMALE GENITAL MUTILATION/CUTTING</h2> Definition Female genital mutilation/cutting (FGMC) is defined as an injury of the external female genitalia undertaken for cultural or non-therapeutic reasons. The term FGMC is now in use by UNICEF and some other international agencies [1]. FGMC comprises all procedures that involve partial or total removal of the external female genitalia, or other deliberate injury to the female genital organs for non-medical reasons[1]. This includes so-called “nicking” of the external genitalia. Key Points <ul> <li>FGMC is recognised internationally as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women.</li> <li>All forms of FGMC including so-called “nicking” of the clitoral hood are condemned by leading health professional organisations [11, 12]. It is illegal in Australia and New Zealand for cosmetic genital surgery of any form to be undertaken on minors.</li> <li>FGMC violates basic human rights, exposes children and women to significant health risks and has no measurable health benefit. The RACP believes that it is not an acceptable practice.</li> </ul> Background FGMC is a cultural, but not religious, practice of groups from Saharan Africa, parts of East Africa, Asia and South America. It is believed to have arisen in Africa and to pre-date Islam. It is not restricted to Islamic populations, is not supported by Islamic doctrine and has been condemned as an unacceptable practice by Islamic groups [1, 14]. United Nations organisations report that 140,000,000 women have undergone FGMC, and 3,000,000 girls are at risk of the procedure every year [1]. Traditionally FGMC was performed to safeguard family honour and social position, and to prevent female promiscuity and rape [3]. FGMC is sustained by the belief that it is in the best interest of the child and that failure to participate may place the child at risk [1, 4], although this justification is no longer considered valid. FGMC is usually carried out on young girls between infancy and 15 years of age [2]. It is typically carried out by traditional circumcisers, but is now performed by health care providers in some countries. With cultural migration the practice has moved to Western countries and has been documented in North America and a number of European countries [5, 6]. It is not clear that FGMC is practiced in Australia and New Zealand [7], although press and legal reports suggest that it is being undertaken in these countries. [8] FGMC causes significant short and long-term health risks for girls and women, including acute and chronic infection, infertility, childbirth difficulties, sexual relationship difficulties and significant short and long term psychological trauma. There are higher rates of Caesarean section for women who have undergone FGMC, and increased infant death rates [9], 10]. FGMC is illegal in Australia and New Zealand and in most other western countries. [8] It is also illegal to send girls and young women overseas for the purpose of genital surgery. In some Australian and New Zealand jurisdictions it is a requirement that children who are perceived to be at risk of FGMC or have ever experienced FGMC are to be notified to child protection services. Western custom and practice appears inconsistent in relation to genital surgery, by tolerating and even facilitating cosmetic genital surgery that includes piercing and labioplasty. Key differences are that genital cosmetic surgery is usually performed on consenting adults, while FGMC is performed without consent on minors. Paediatricians and FGMC FGMC is relevant to paediatricians in Australian and New Zealand, and it is important that paediatricians are aware of the practice and the risks associated with it, and the opportunities for prevention and child protection: Girls may be exposed to the risk of FGMC either in Australia and New Zealand or on return visits to their country of origin. Girls immigrating to Australia and New Zealand may already have undergone FGMC or may be at risk of undergoing FGMC on return visits to their country of origin. Paediatricians need to develop the skills to be able to recognise families where FGMC may be practiced and girls are at highest risk, and to discuss FGMC with these families (See Royal College of Nursing educational resource [13]). The RACP has a role in ensuring trainees and practising paediatricians have access to training regarding cultural awareness and specific aspects of recognition and management of FGMC. In clinical settings with potential high prevalence of FGMC this should be routinely, but respectfully, inquired about in order to avoid missing girls at risk. Care must be taken to avoid stigmatizing particular ethnic groups. Paediatricians working with communities that traditionally practice FGMC should seek opportunities, in conjunction with other health and child protection services to raise awareness that FGMC is not an acceptable practice in Australia, and to educate community leaders regarding healthy attitudes to female sexuality and to the dangers of FGMC. FGMC is a child protection issue, and paediatricians need to be prepared to advocate for girls and young women with their families and communities, and if necessary with the agencies charged with child protection. Paediatricians may be required to collaborate with other health and non-health professionals to advocate for and protect girls at risk. Service providers need to be aware that in protecting girls from FGMC they may expose them to risk of becoming ostracized within their families and communities through not participating in cultural rituals, and they may need special intervention to minimise this risk. Children and adolescent girls who have experienced FGMC are at risk of a range of serious, long-term physical and psychological problems. They will require long-term care that may require the involvement of a range of different services including mental health and gynaecological services. Royal Australasian College of Physicians, April 2012 References 1. OHCR, et al., Eliminating female genital mutilation: An interagency statement, 2008, World Health Organization: Geneva. 2. World Health Organisation, Female Genital Mutilation: Fact Sheet, 2012, World Health Organisation: Geneva. 3. Shell-Duncan, B., et al., Dynamics of change in the practice of female genital cutting in Senegambia: Testing predictions of social convention theory. Social Science & Medicine, 2011. 73: p. 1275-83. 4. Alo, O.A. and B. Gbadebo, Intergenerational Attitude Change Regarding Female Genital Cutting in a Yoruba-Speaking Ethnic Group of Southwest Nigeria. J Womens Health (Larchmt), 2011. 20: p. 1655-61. 5. Davis, D.S., Ritual genital cutting of female minors. Pediatrics, 2010. 125(5): p. 1088-93. 6. Jaeger, F., M. Caflisch, and P. Hohlfeld, Female genital mutilation and its prevention: a challenge for paediatricians. Eur J Pediatr, 2009. 168(1): p. 27-33. 7. Grover, S., Female genital mutilation. J Paediatr Child Health, 2009. 45(10): p. 614-5. 8. Matthews, B., Female genital mutilation: Australian law policy and practice challenges for doctors. Med J Aust, 2011. 194: p. 139-41. 9. Chibber, R., E. El-Saleh, and J. El Harmi, Female circumcision: obstetrical and psychological sequelae continues unabated in the 21st century. J Matern Fetal Neonatal Med, 2011. 24(6): p. 833-6. 10. Merritt, D.F., Genital trauma in children and adolescents. Clin Obstet Gynecol, 2008. 51(2): p. 237-48. 11. American Academy of Pediatrics, Policy Statement- Ritual cutting of female minors. Pediatrics, 2010. 12. Royal College of Obstetricians and Gynaecologists Joint RCOG/RCPCH statement on the AAP policy statement on FGM. 2010. 13. Royal College of Nursing, Female genital mutilation. An RCN educational resource for nursing and midwifery staff, 2006, Royal College of Nursing,: London. 14. WISE Muslim Women’s Shura Council, Female Genital Cutting: Harmful and Un-Islamic. 2010. Accessed 5 March 2012: http://www.wisemuslimwomen.org/images/uploads/WISE_Shura_Council_FGC_DigestStatement.pdf_.pdf </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource RACP's policy on female genital mutilation darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Netherlands medical authorities condemn circumcision</h1> In a hard-hitting statement issued on 27 May 2010, the Royal Dutch Medical Association (KNMG) has condemned non-therapeutic circumcision of male minors and urged its members to discourage the practice. The statement points out that prophylactic or preventive circumcision of normal male infants and boys confers no health benefit; carries many risks of harm and damage; has an adverse effect on sexual function and bodily appearance; and is a violation of the child’s right to physical integrity. The press release issued by KNMG and a summary of the policy statement is printed below. <h3>Violation of physical integrity</h3> <h2>Royal Dutch Medical Association (KNMG) to discourage non-therapeutic circumcision of male minors</h2> Utrecht, 27 May 2010 – The official standpoint of KNMG and other related medical/scientific organisations is that non-therapeutic circumcision of male minors is a violation of children’s rights to autonomy and physical integrity. KNMG is urging a strong policy of deterrence. The reason for the adoption of an official standpoint regarding this matter is the increasing emphasis on the protection of children’s rights. Contrary to popular belief, circumcision can also cause complications – bleeding, infection, urethral stricture and panic attacks are particularly common. Full or partial penile amputations have also been reported as a consequence of complications. KNMG is calling upon doctors to actively and insistently inform parents who are considering the procedure of the absence of medical benefits and the danger of complications. “The rule is: do not operate on healthy children”, says Arie Nieuwenhuijzen Kruseman, chairman of the KNMG. “It is an unfortunate fact that any surgical procedure can cause complications. Doctors accept this to a certain extent because there are medical reasons for the procedure. However, no complications can be justified that occur as the result of an operation that is medically unnecessary.” <h3>Children’s rights</h3> KNMG regards the non-therapeutic circumcision of male minors as a violation of physical integrity, a constitutional right that protects individuals against unwanted internal or external physical modifications. According to the KNMG, minors should only be subjected to medical procedures in the event of illness or abnormalities, or if a convincing case can be made that the procedure is in the interests of the child (such as vaccination). <h3>Dialogue</h3> The KNMG sees good reasons for the statutory prohibition of non-therapeutic circumcision of male minors, but fears that the procedure will then be driven underground, leading to an increase in the number of complications. The Medical Association is aware that the practice of circumcision of male minors has deep religious, symbolic and cultural meaning for some ethnic and religious groups. The KNMG respects this, and is calling for dialogue among medical associations, experts and the relevant religious groups. <h3>Wide support</h3> The following medical and scientific organisations officially support the standpoint of the KNMG: the Dutch Urological Association (Nederlandse Vereniging voor Urologie), the Dutch College of General Practitioners (Het Nederlands Huisartsengenootschap), the Dutch Paediatric Surgery Association (Nederlandse Vereniging voor Kinderchirurgie), the Dutch Plastic Surgery Association (Nederlandse Vereniging voor Plastische Chirurgie), the Association of Surgeons of the Netherlands (Nederlandse Vereniging voor Heelkunde) and the Dutch Paediatric Association (Nederlandse Vereniging voor Kindergeneeskunde). Royal Dutch Medical Association, Policy statement, May 2010 <h2>Non-therapeutic circumcision of male minors</h2> <h3>Preamble</h3> Non-therapeutic circumcision of male minors is a practice that has been carried out for centuries by a variety of different cultures for a variety of different reasons. It is estimated that 13 million boys around the world are circumcised each year. In the Netherlands, the annual figure is between ten and fifteen thousand. Following on from other medical organisations, the Royal Dutch Medical Association (KNMG) has adopted an official viewpoint with regard to this issue. This viewpoint was formulated following consultation with relevant scientific organisations, who also support this stance. This ensures that this viewpoint has a broad basis of support from the relevant professional associations. The reason for our adoption of an official viewpoint regarding this matter is the increasing emphasis on children’s rights. It is particularly relevant for doctors that children must not be subjected to medical proceedings that have no therapeutic or preventative value. In addition to this, there is growing concern regarding complications, both minor and serious, which can occur as a result of circumcising a child. A third reason for this viewpoint is the growing sentiment that there is a discrepancy between the KNMG’s firm stance with regard to female genital mutilation and the lack of a stance with regard to the non-therapeutic circumcision of male minors, as the two have a number of similarities. The initial objective of this viewpoint is to initiate public discussion of this issue. The ultimate aim is to minimise non-therapeutic circumcision of male minors. The KNMG realises that this particular practice has deep religious, symbolic and cultural meaning. For this reason, it is unrealistic to expect that this practice can be eradicated, even if it was prohibited by law. However, the KNMG does believe that a powerful policy of deterrence should be established. As long as this practice takes place, the KNMG aims to reduce the number of complications as much as possible. The KNMG therefore emphasises that circumcision is a surgical procedure covered by the Individual Healthcare Professions Act. This means that circumcision may only be performed by qualified professional practitioners, in this case, doctors. Doctors who perform circumcisions must also follow all applicable scientific guidelines. This entails, amongst other matters, that circumcisions can only be carried out under local or general anaesthetic, after thorough and precise advice and information has been given to the child’s parents. The fact that this practice is not medically necessary and entails a genuine risk of complications means that extra-stringent requirements must be established with regard to this type of information and advice. 27 May 2010 Prof. Dr. Arie Nieuwenhuijzen Kruseman, Chairman of KNMG <h3>Summary</h3> There is no convincing evidence that circumcision is useful or necessary in terms of prevention or hygiene. Partly in the light of the complications which can arise during or after circumcision, circumcision is not justifiable except on medical/therapeutic grounds. Insofar as there are medical benefits, such as a possibly reduced risk of HIV infection, it is reasonable to put off circumcision until the age at which such a risk is relevant and the boy himself can decide about the intervention, or can opt for any available alternatives. Contrary to what is often thought, circumcision entails the risk of medical and psychological complications. The most common complications are bleeding, infections, meatus stenosis (narrowing of the urethra) and panic attacks. Partial or complete penis amputations as a result of complications following circumcisions have also been reported, as have psychological problems as a result of the circumcision. Non-therapeutic circumcision of male minors is contrary to the rule that minors may only be exposed to medical treatments if illness or abnormalities are present, or if it can be convincingly demonstrated that the medical intervention is in the interest of the child, as in the case of vaccinations. Non-therapeutic circumcision of male minors conflicts with the child’s right to autonomy and physical integrity. The KNMG calls on (referring) doctors to explicitly inform parents/carers who are considering non-therapeutic circumcision for male minors of the risk of complications and the lack of convincing medical benefits. The fact that this is a medically non-essential intervention with a real risk of complications makes the quality of this advice particularly important. The doctor must then record the informed consent in the medical file. The KNMG respects the deep religious, symbolic and cultural feelings that surround the practice of non-therapeutic circumcision. The KNMG calls for a dialogue between doctors’ organisations, experts and the religious groups concerned in order to put the issue of non-therapeutic circumcision of male minors on the agenda and ultimately restrict it as much as possible. There are good reasons for a legal prohibition of non-therapeutic circumcision of male minors, as exists for female genital mutilation. However, the KNMG fears that a legal prohibition would result in the intervention being performed by non-medically qualified individuals in circumstances in which the quality of the intervention could not be sufficiently guaranteed. This could lead to more serious complications than is currently the case. The full policy in English can be downloaded as a PDF from the <a href="http://knmg.artsennet.nl/Diensten/knmgpublicaties/KNMGpublicatie/Nontherapeutic-circumcision-of-male-minors-2010.htm">Royal Dutch Medical Society website</a> <h2>British Medical Journal supports Dutch circumcision policy</h2> Dutch medical alliance moves to change thinking on male circumcision by Tony Sheldon A broad alliance of medical organisations in the Netherlands has officially adopted the view that circumcision of underage boys without a medical reason violates children’s human rights and contravenes the Dutch constitution. The Dutch Medical Association has spearheaded the move, arguing that the medical benefits of circumcision are unproved whereas complications are underestimated, and urging “a strong policy of deterrence.” Doctors should "actively and insistently" inform parents seeking to have their child circumcised about the association’s stance. It is estimated that up to15,000 circumcisions of boys under 16 years of age are carried out each year in the Netherlands — largely for religious or cultural reasons — among Jewish, Muslim, and African Christian communities. [Or more precisely, on account of the cultural, ethnic or religious adherence of the parents; the boys, now living in a secular and multicultural society, may well have other ideas.] The association thinks there are good reasons to ban the practice — female circumcision was outlawed in 2004 — but fears that this might force it underground, leading to a greater number of complications. Instead, it calls for a dialogue between doctors and religious leaders in recognition of the “deep religious, symbolic, and cultural sensitivity” surrounding circumcision. The Dutch Medical Association’s stance was taken on the basis of the argument that “non-therapeutic circumcision” of underage boys amounts to a violation of a child’s physical integrity, and so contravenes Article 8 of the European Convention on Human Rights and Article 11 of the Dutch constitution. It believes circumcision can lead to complications, including haemorrhage, infection, urethral stricture, and panic attacks. There are also reported cases of amputation of part, or all, of the penis as a result of complications involving necrosis. <h3>50 cases with complications per year at one hospital</h3> Dr Tom de Jong, head of paediatric urology at Wilhelmina Children’s Hospital, Utrecht, sees around 50 cases of complications after circumcision every year. Although there is no systematic registration of complications in the Netherlands, his belief, on the basis of published research, is that long term complications can occur in between 8% to 20% of cases, whereas complications arise in 3% to 5% of cases immediately after surgery The association believes that studies that suggest that circumcision reduces the risk of urinary tract infections or HIV/AIDS are inconclusive. Any preventive benefits should be balanced against less invasive forms of prevention, such as good personal hygiene, antibiotics, condom use, and information on safer sex, it argues. The possible medical advantages are “insufficient to justify circumcision on grounds of prevention.” The Dutch Medical Association’s chair, Dr Arie Nieuwenhuijzen Kruseman, said: “With every surgical procedure there is a risk of complications. The rule is not to operate on a healthy child. Children should only be exposed to medical intervention if there is an illness, abnormality, or it can be shown that it is in the interests of the child, such as vaccination.” A survey by the association, carried out to coincide with the new stance, found that two thirds (65%) of a representative sample of 1500 members believe that non-therapeutic circumcision violates physical integrity. The Dutch associations of paediatric medicine, paediatric surgery, surgery, and the college of general practitioners are backing the Dutch Medical Association’s stance. British Medical Journal, 7 June 2010 <a href="http://www.bmj.com/cgi/content/extract/340/jun07_2/c2987" rel="noopener" target="_blank">BMJ 2010;340:c2987</a> <h3>Response: Non-therapeutic Excision of the Foreskin</h3> Antony D. Lempert, GP Principal and Co-ordinator of the Secular Medical Forum Wylcwm Street Surgery, Knighton, Powys LD7 1AD I welcome the principled statement by the Dutch Medical Association and their colleagues advocating an end to ritual circumcision. Without the caveat of religious privilege, a debate about whether or not to surgically interfere with the normal genitalia of little children would be largely unnecessary. There is no reason for gender discrimination when considering child protection. Clinically unnecessary surgical excision of normal genital skin violates a child's human right to an intact body and to be protected from harm [1] In 2007, Sorrells et al [2] demonstrated that circumcision ablates the most sensitive parts of the male penis. There is a risk of further harm [3] when the operation goes wrong. This is sad enough when the circumcision was considered clinically necessary; it is tragic when the operation was done for reasons of conforming to the parents’ religious or cultural views. Many children do not later share their parents’ beliefs or even their cultural values. The bodies of children must be protected from those who would brand them when they are too young to either consent or object. This protection must extend to their genitalia or it is no protection at all. All intervention carries a degree of risk. This is why surgery should only be contemplated where there is a potential for greater good than harm, particularly on non-consenting infants to whom society owes a duty of care and protection. This basic principle ordinarily guides our day to day practice. Were it not for the demands of traditional religious privilege it would not be up for discussion. In January 2010, The SMF approached the doctors’ regulatory body in the UK, the General Medical Council (GMC), asking for them to reconsider their stated non-position on Ritual male circumcision [4] and [5]. The first principle of GMC guidance is “Make the care of your patient your first concern”. With regard to ritual non-therapeutic circumcision, we were advised by the GMC that they had no immediate plans to amend their current guidance. It is time that both the GMC and the BMA followed the Dutch Medical Association’s excellent example of putting patient welfare ahead of the varied chosen beliefs of their parents. Legislation should accompany this to prevent all non-therapeutic surgery on non-consenting children. And let’s call it what it is: Non-therapeutic excision of the foreskin. [1] <a href="http://www.arclaw.org/arc_human_rights_table/">UN Convention on the Rights of the Child 1989</a> [2] Morris L Sorrells et al, <a href="http://www.cirp.org/library/anatomy/sorrells_2007/">Fine-touch pressure thresholds in the adult penis</a>, BJUI 2007; 99: 864-869. (3) Williams N, Kapila L. <a href="http://www.cirp.org/library/complications/williams-kapila/">Complications of circumcision</a>. Brit J Surg 1993;80:1231-6. [4] <a href="http://www.gmc-uk.org/guidance/ethical_guidance/personal_beliefs.asp">Circumcision of Male Children for Religious or cultural reasons</a> [5] <a href="http://www.secularmedicalforum.org.uk/index.php?subject=resources">Ritual Circumcision</a>, Letter to the GMC March 2010 Competing interests: I co-ordinate the <a href="http://www.secularmedicalforum.org.uk/">Secular Medical Forum</a> (SMF) in the UK. We campaign for equality of care for all patients irrespective of their own or their doctors’ own personal beliefs. <a href="http://www.bmj.com/cgi/eletters/340/jun07_2/c2987#237392" rel="noopener" target="_blank">BMJ, 16 June 2010</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 Dutch Medical Association: condemns non-therapeutic circumcision darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>Canadian urologists reject routine circumcision</h3> In a major statement based on a comprehensive survey of the medical literature in January 2018, the Canadian Urological Association has concluded that routine prophylactic circumcision of male infants and boys is not justified as a preventive health measure. The statement is of particular interest because it reaches this conclusion on the basis of a very narrow calculation of medical benefits, costs and risks, pays little attention to the harms of circumcision (such as effect on male sexuality, moral harm of denying choice etc) and largely ignores bioethical and human rights issues. The statement emphasises that the results of clinical studies in underdeveloped regions with acute health and social problems cannot be mapped onto developed nations with quite different epidemiological and social environments, and point out that “The effect of MC has to be analyzed at the individual and societal level.” The statement is at pains to point out that the evidence as to the benefits and risks of circumcision is contradictory and inconclusive, and that much of it is of poor quality, especially studies claiming to show that circumcision has little impact on sexual sensation and function. The final conclusion is that while circumcision does offer some advantages, they are small, can be achieved by other, non-surgical means, and are outweighed by the risks and harms. This being the case, routine circumcision is not justified as a health measure and cannot be recommended. INTRODUCTION “Circumcision is the oldest planned operative procedure in the history of the human civilization but there continues to be a lack of consensus and strong opposing views on whether universal neonatal circumcision should be adopted as a public health measure. … A review of the literature on MC shows evidence of a vehement debate, often clouded by strong personal biases and lack of high quality evidence. Creation of a guideline specific to the need of Canadian infant males is therefore difficult given the level of evidence provided for each potential benefit, the lack of data directly applicable to the Canadian population, the inability to quantify the true complication rate of routine circumcisions accurately, uncertainty about the health benefits of a circumcision compared with other health interventions, the ethical issues and acceptability of a surgical procedure done by parental consent for future benefits, and the costs of training and implementation of any universal neonatal circumcision policy in Canada.” In its conclusion the statement emphasises that the results of clinical studies in underdeveloped regions with acute health and social problems cannot be mapped onto developed nations with quite different epidemiological and social environments, and point out that “The effect of MC has to be analyzed at the individual and societal level. For the individual Canadian neonate, there are definite advantages of a circumcision, but the exact estimates of the effect are unknown, the protection provided is not comprehensive, accrue over a life-time and can be achieved by other preventive health measures. … There are also clear risks associated with this surgical procedure and parents will continue to have to weigh the potential benefits and risks of neonatal circumcision. In an overall societal perspective, given our health care system and the socio-economic and educational status of our population, universal neonatal circumcision is not justified based on the evidence available." Source: Sumit Dave, Kourosh Afshar, Luis H. Braga, Peter Anderson. <a href="http://www.cuaj.ca/index.php/journal/article/view/5033/3371" rel="noopener" target="_blank">CUA guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants</a>. Canadian Urological Association Journal 2017 Dec. 1; Epub ahead of print. http://dx.doi.org/10.5489/cuaj.5033. Earlier policies and policies issued by the various provincial medical bodies and the Canadian Pediatric Society <a href="http://www.cirp.org/library/statements/">are available from CIRP</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 Canadian Urological Association: routine circumcision "not justified" 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>Canadian doctors reject circumcision</h2> In a statement released on 9 September the Canadian Pediatric Society confirmed its long-standing opposition to routine circumcision of male infants and boys. The new policy states clearly that the recommendation of the CPS is against circumcision because the benefits are small and outweighed by the risks. This outcome has surprised some observers, who were expecting the CPS to follow the American Academy of Pediatrics to conclude, while not recommending circumcision, that the benefits exceeded the risks, and that circumcision was a matter of “parental preference”. In rejecting this assessment as scientifically unsound, the new CPS policy aligns itself with those of the Royal Australasian College of Physicians and child health experts in Britain and all European countries. Their position leaves the Americans more isolated than ever as the only medical organisation in the world to think that there is anything worthwhile in routine circumcision. <a href="https://www.academia.edu/12035421/Risks_benefits_complications_and_harms_Neglected_factors_in_the_debate_on_non-therapeutic_circumcision" rel="noopener" target="_blank">Scholars have criticised</a> the risk/benefit calculus as inadequate for the “circumcision decision”, as it fails to consider the value of the foreskin and the likely future wishes of the boy, or to give adequate weight to bioethical and human rights principles. It is nonetheless significant that the CPS could recommend against circumcision after a narrow calculation of the strictly medical issues considered pretty much on their own. Once you add the functions of the foreskin and bioethical issues to the equation, the case against circumcision becomes overwhelming. <a href="http://www.cps.ca/en/media/release-communique/canadian-paediatricians-revisit-newborn-male-circumcision-recommendations" rel="noopener" target="_blank">Media release by Canadian Pediatric Society</a> <a href="http://www.arclaw.org/resources/press-releases/arc-press-release-praising-canadian-pediatrics-position-statement-circumcis" rel="noopener" target="_blank">Media release by Attorneys for the Rights of the Child</a> <h2>Strengths and weaknesses in the 2015 Canadian Pediatric Society statement on newborn male circumcision</h2> <a href="http://blog.practicalethics.ox.ac.uk/author/brian-earp/" rel="noopener" target="_blank">Brian Earp, University of Oxford</a> The following critique by Brian Earp, research fellow at the University of Oxford is forthcoming in the Canadian Journal of Pediatrics and is available at his <a href="https://www.academia.edu/15746362/Strengths_and_weaknesses_in_the_2015_Canadian_Paediatric_Society_statement_on_newborn_male_circumcision" rel="noopener" target="_blank">Academia.edu page</a>. The latest statement from the Canadian Pediatric Society (CPS) on newborn male circumcision exhibits both strengths and weaknesses. Strengths include (1) acknowledgement that the foreskin is not redundant skin; that it “serves to cover the glans penis and has an abundance of sensory nerves” (p. 4); that it is adherent at birth and may take several years to become fully retractile; that this is normal and should not be pathologized as phimosis; that true phimosis can be treated non-surgically; (2) acknowledgement that the absolute risk for UTIs in boys is low; that it would take 100+ circumcisions to prevent 1 case; that UTIs may be over-diagnosed in genitally intact boys; that UTIs can be treated non-surgically; that “UTIs in children with normal kidneys do not result in long-term sequelae” (p. 2); (3) acknowledgement that the absolute risk of female-to-male heterosexual transmission of HIV in countries such as Canada and the USA is low; that findings from African trials concerning adult men may not translate to newborn boys in developed countries; that circumcision does not reduce male-to-female transmission of HIV; that safe sex practices must continue to be emphasized; (4) acknowledgement that penile cancer is rare in developed countries; that its association with intact male genitalia is primarily explained by the presence of phimosis; that HPV vaccines are expected to “dramatically decrease the incidence rate of cervical cancer” (p. 3), thereby obviating a role for circumcision; (5) acknowledgement that circumcision is painful; that this pain may have long-term adverse sequelae; that circumcision is a procedure with “lifelong consequences … performed on a [healthy] child who cannot give [his] consent” (p. 4); that the “authority of substitute decision makers is … usually limited [to] interventions deemed to be medically necessary” (p. 4); that newborn male circumcision does not satisfy this condition. Weaknesses include (1) failure to engage seriously with the literature on negative sexual effects of circumcision.[1][2][3] This includes a recent analytic review by Bossio et al.[4] as well as several published critiques of the studies by Kigozi et al. and Krieger et al.,[5][6] the latter of which did not use validated instruments. The CPS authors also conflate adult circumcision and infant circumcision in this section.[5] (2) failure to state that the cited cost-effectiveness estimate concerning lifetime risk of HIV acquisition did not demonstrate cost savings for circumcision in the majority population of white males; (3) failure to explain the inclusion of a brochure by an Australian pro-circumcision lobbying group with no official status[7] as one of three “Selected resources” (p. 5), rather than the official brochure of the Royal Australasian College of Physicians (RACP),[8] which advocates against neonatal circumcision; (4) failure to consider analogous interventions in girls.[9] The non-therapeutic removal of any amount tissue from the female genitalia prior to an age of consent, including procedures that are less invasive than male circumcision, is a crime in Canada, notwithstanding any health benefits that might or might not ensue.[10] References [1] Frisch M, Lindholm M, Grønbæk M. Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. Int J Epidemiol 2011;40(5):1367-1381. [2] Bronselaer GA, Schober JM, Meyer‐Bahlburg H F, et al. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int 2013;111(5):820-827. [3] Dias J, Freitas R, Amorim R, et al. Adult circumcision and male sexual health: a retrospective analysis. Andrologia 2014;46(5):459-464. [4] Bossio JA, Pukall CF, Steele S. A review of the current state of the male circumcision literature. J Sex Med 2014;11(12):2847-2864. [5] Earp BD. Sex and circumcision. Am J Bioeth 2015; 15(2):43-45. [6] Frisch M. Author's response to: Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect? Int J Epidemiol 2012;41(1):312-314. [7] Earp BD, Darby RJ. <a href="https://www.academia.edu/9872471/Does_science_support_infant_circumcision" rel="noopener" target="_blank">Does science support infant circumcision? A skeptical reply to Brian Morris</a>. Skeptic 2015;25(3)23-30. [8] Royal Australasian College of Physicians. <a href="https://members.racp.edu.au/page/paed-policy" rel="noopener" target="_blank">Policy statement and brochure for parents</a>. [9] Earp BD. <a href="https://www.academia.edu/10270196/Female_genital_mutilation_and_male_circumcision_Toward_an_autonomy-based_ethical_framework" rel="noopener" target="_blank">Female genital mutilation and male circumcision: Toward an autonomy-based ethical framework</a>. [10] Earp BD. Do the benefits of male circumcision outweigh the risks? A critique of the proposed CDC guidelines. Front Pediatr 2015;3(18):1-6. <h3>Canadian circumcision policy criticised by children’s health and human rights group</h3> “On right track, but could do better” VICTORIA, BRITISH COLUMBIA – (Sept. 9, 2015) – A just released policy on infant male circumcision by the Canadian Paediatric Society (CPS) was judged today by the Children’s Health & Human Rights Partnership (CHHRP) to be a step in the right direction, but was “nevertheless ‘predictably inadequate’ with respect to several specific issues." CHHRP Medical Director Dr. Christopher Guest, MD, FRCPC, said the new policy is consistent with international paediatric associations that affirm infant boys should not have their healthy foreskins routinely removed. Citing the position of the CPS that recognizes the unique sensory functions of the male foreskin, Dr. Guest asserted that, “A growing number of medical associations now recognize that an intact penis with a foreskin contributes to sexual pleasure for the male and his partner.” According to Guest, in 2010 the Royal Dutch Medical Association concluded, “the foreskin is a complex erotogenic structure that plays an important role in the mechanical function of the penis during sexual acts.” “Circumcision alters the structure of the penis, which inevitably alters function. Long term harm to men from infant circumcision has never been studied” Guest said. Despite this, Guest says men are reporting long-term adverse consequences at the Canadian-based online Global Survey of Circumcision Harm. Although the CPS failed to include it, Guest says scientific evidence has emerged that supports these men’s claims. In 2011, Dr. Morten Frisch published findings in the International Journal of Epidemiology showing that in Denmark, where circumcision is rare, ‘circumcision was associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in their female partners, notably orgasm difficulties, dyspareunia [difficult or painful sexual intercourse] and a sense of incomplete needs fulfilment.’ Guest faulted the CPS for inclusion of “convenient untruths,” most notably a discussion of HIV being lower in circumcised men. He says such claims are based on methodologically weak African trials, which contradict global HIV trends, for example the United States, which has a high circumcision rate, yet a significantly higher rate of HIV infection than Sweden and Japan where circumcision is rare. “Even if the African trials were scientifically valid, they cannot be used to justify infant circumcision because infants are not sexually active persons,” he said. “Soap and water and safer sex practices, including condoms, can prevent disease.” According to Guest, the CPS failed to include crucial information from a 2012 report by the International NGO Council on Violence Against Children, which CHHRP sent to the CPS in 2014. The report stated that “non-consensual, non-therapeutic circumcision of boys, whatever the circumstances, constitutes a gross violation of their rights, including the right to physical integrity, to freedom of thought and religion and to protection from physical and mental violence.” “Medical associations in the Netherlands, Finland, Sweden, Norway, Denmark, Germany, and others confirm that there is no justification for circumcising infants in the absence of medical urgency,” Guest stated. “The CPS is out of step with those medical associations, who also urge an end to the practice due to ethical and human rights concerns.” Although the CPS concluded that routine infant circumcision is not recommended, and that the benefits of the surgery do not outweigh the risks (contrary to a 2012 claim by the American Academy of Pediatrics), Guest contends that the position statement is still insufficient due to its ambiguity in leaving the decision up to parents. “Parents are not physicians. They do not have the medical knowledge to decide if surgery is medically indicated for their child,” Guest asserted. He went on to say that, “Leaving a decision about medically unnecessary surgery up to parents is an ethical failure on the CPS’ part. Where else in medicine do physicians place this burden on parents, in order to obviate their own professional responsibility?” “Preservation of bodily integrity is a basic and universal human right that the CPS must articulate clearly in future statements,” Guest said. “We Canadians, as well as our institutions and government, have an obligation to protect that right for all citizens, regardless of gender or age.” <a href="http://chhrp.org/" rel="noopener" target="_blank">The Children’s Health & Human Rights Partnership</a> was established in 2012 as a partnership of professionals in the fields of medicine, ethics, and law to further public education regarding non-therapeutic genital surgery on Canadian children. <a href="http://chhrp.org/index.php/news/canadian-childrens-rights-group-questions-new-circumcision-policy/" rel="noopener" target="_blank">The CHHRP statement is available here</a>. <h2>Revised circumcision policy issued by British Columbia, 2009</h2> Like Australia, Canada has a past history of widespread circumcision, but a dramatically falling incidence over the past couple of decades. Also as in Australia, it has been the medical profession itself, led by paediatric health authorities, that has taken the initiative to discourage the practice. In recent times Canadian medical authorities have been among the most outspoken opponents of routine (prophylactic) circumcision, and they have issued several <a href="http://www.cirp.org/library/statements/sask2002/">cautions against the practice</a>. Parallel with this attitude, State health authorities in the Canadian provinces (Manitoba partially excepted) do not pay for medically unnecessary circumcision operations, nor reimburse parents through the Canadian equivalent of Medicare unless the procedure is essential to correct a problem. Among the Canadian health authorities that have issued policies that recommend against circumcision is the College of Physicians and Surgeons of British Columbia, which released a revised policy in September 2009. The following points are highlights of the statement. “Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western counties. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention.” The new policy states clearly that “routine removal of normal tissue in a healthy infant is not recommended.” It also points out that: <ul> <li>proxy consent by parents is now being questioned. Many believe it should be limited to consent for diagnosis and treatment of medical conditions, and that it is not relevant for non-therapeutic procedures;</li> <li>an infant has rights that include security of person, life, freedom and bodily integrity.</li> </ul> The policy recommends that doctors should: <ul> <li>Advise parents that the current medical consensus is that routine infant male circumcision is not a recommended procedure; it is non-therapeutic and has no medical prophylactic basis; it is a cosmetic surgical procedure; current evidence indicates that previously-thought prophylactic public health benefits do not outweigh the potential risks.</li> <li>Provide objective medical information about the risk of complications and potential harm in infant male circumcision.</li> <li>Discuss the new ethical considerations of infant's rights and proxy consent in a non-therapeutic procedure.</li> </ul> The full text of the policy appears below. <h3>The College of Physicians and Surgeons of British Columbia</h3> <h2>Circumcision (Infant Male)</h2> Until recently, only public health and religious views were taken into consideration in the debate over infant male circumcision. However, our understanding of medical practice must change as research findings become available. The College is issuing this guide for physicians regarding routine infant male circumcision in light of evidence-based medicine and contemporary principles in ethics, law and human rights. Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention. From a religious standpoint, infant male circumcision is acknowledged to be an important ritual and an integral part of Jewish and Islamic religions. Male circumcision is also practiced in other parts of the world as a rite of puberty. A wider societal discussion on infant male circumcision is warranted based on a current understanding of bioethics that takes into account the non-therapeutic nature of the procedure as well as the high importance it plays in religious and traditional customs. This paper provides a discussion on current medical perspectives as well as relevant legal, human rights, and ethical considerations. Medical Perspectives Circumcision removes the prepuce that covers and protects the head or the glans of the penis. The prepuce is composed of an outer skin and an inner mucosa that is rich in specialized sensory nerve endings and erogenous tissue. Circumcision is painful, and puts the patient at risk for complications ranging from minor, as in mild local infections, to more serious such as injury to the penis, meatal stenosis, urinary retention, urinary tract infection and, rarely, even haemorrhage leading to death. The benefits of infant male circumcision that have been promoted over time include the prevention of urinary tract infections and sexually transmitted diseases, and the reduction in risk of penile and cervical cancer. Current consensus of medical opinion, including that of the Canadian and American Paediatric Societies and the American Urological Society, is that there is insufficient evidence that these benefits outweigh the potential risks. That is, routine infant male circumcision, i.e. routine removal of normal tissue in a healthy infant, is not recommended. Legal Considerations To date, the legality of infant male circumcision has not been tested in the Courts. It is thus assumed to be legal if it is performed competently, in the child’s best interest, and after valid consent has been obtained. At all times the physician must perform the procedure with competence and at all times, the parent and physician must act in the best interests of the child. Signed parental consent for any treatment is assumed to be valid if the parent understands the nature of the procedure and its associated risks and benefits. However, proxy consent by parents is now being questioned. Many believe it should be limited to consent for diagnosis and treatment of medical conditions, and that it is not relevant for non-therapeutic procedures. Human Rights Considerations The matter of infant male circumcision is particularly difficult in regards to human rights, as it involves consideration of the rights of the infant as well as the rights of the parents. Under the Canadian Charter of Rights and Freedoms and the United Nations Universal Declaration of Human Rights, an infant has rights that include security of person, life, freedom and bodily integrity. Routine infant male circumcision is an unnecessary and irreversible procedure. Therefore, many consider it to be “unwarranted mutilating surgery”. Many adult men are increasingly concerned about whether their parents had the right to give consent for infant male circumcision. They claim that an infant’s rights should take priority over any parental rights to make such a decision. This procedure should be delayed to a later date when the child can make his own informed decision. Parental preference alone does not justify a non-therapeutic procedure. Others argue that this stance violates the parents’ right to religious or cultural expression, and that adherence to their religious and cultural practices would be in the best interests of the infant. Ethical Considerations Ethical considerations regarding infant male circumcision centre on the welfare (or “best interests”) of the infant and the potential benefit and harm associated with the procedure. Ethics points us to corrective vision, i.e. to question practices that have become routine, or which we take for granted. Therefore, each request for the procedure should be carefully evaluated, and an agreement to perform the procedure should take into consideration the ethical principles of beneficence (duty to benefit); non-maleficence (do no harm); veracity (accurate information); autonomy (consent); and justice (fairness). These principles are articulated in specific responsibility statements in the CMA Code of Ethics. Also included below are items relating to physicians rights and care of the patient. <h3>Canada Medical Association Code of Ethics</h3> Beneficence (duty to benefit) 1. Consider first the well-being of the patient. 14. Recommend only those diagnostic and therapeutic procedures that you consider to be beneficial to your patient and not others. For consideration Medical evidence is that the benefits of routine infant male circumcision do not outweigh the risks of complications from the procedure. Best interests also take into account the infant’s social circumstances. Non-maleficence (do no harm) 33. Refuse to participate in or support practices that violate basic human rights. For consideration Routine infant male circumcision does cause pain and permanent loss of healthy tissue. Veracity (adequate information) 13. Make every reasonable effort to communicate with your patients in such way that information exchanged is understood. For consideration Discussion should include the new understanding that there is a lack of evidence of a real medical benefit in routine infant male circumcision, that it is non-therapeutic, and that only in rare situations is there any clinical indication for the procedure. Specifics of potential risks and complications should also be explained. It is important to ensure a meaningful discussion between physician and parents, and that the information provided is understood. Autonomy (informed consent) 12. Provide your patients with the information they need to make informed decisions about their medical care, and answer their questions to the best of your ability. For consideration Parents must be given accurate and impartial information to assist them in making an informed decision. The infant, the actual patient, is unable to give consent. Proxy consent by parents for a non-therapeutic procedure is debatable. Justice (fairness) 29. Recognize that community, society and the environment are important factors in the health of individual patients. For consideration Physicians should understand the basis for the request and consider the infant’s social and cultural circumstances and what might be in the infant’s best interest. Physicians’ Rights 8. Inform your patient when your personal morality would influence the recommendation or practice of any medical procedure that the patient needs or wants. For Consideration If your personal beliefs dictate against infant male circumcision, this should be made known to your patients, with an offer of referral to another physician competent in performing the procedure. Care of the Patient 3. Provide for appropriate care for your patient, including physical comfort and spiritual and psychosocial support. 4. Practice the art and science of medicine competently and without impairment. 6. Recognize your limitations and the competence of others, and, when indicated, recommend that additional opinions and services be sought. For consideration As with any medical procedure, if for religious or cultural reasons you decide to perform an infant male circumcision, ensure that your skills are current. Expertise can be maintained only if a sufficient number of such circumcisions are performed. Recommendation Best medical practice includes the following standards of practice for doctors who are asked to circumcise male infants: <ul> <li>Keep up-to-date on the issues surrounding infant male circumcision, including the therapeutic medical indications and legal and ethical issues.</li> <li>Advise parents that the current medical consensus is that routine infant male circumcision is not a recommended procedure; it is non-therapeutic and has no medical prophylactic basis; it is a cosmetic surgical procedure; current evidence indicates that previously-thought prophylactic public health benefits do not outweigh the potential risks.</li> <li>Provide objective medical information about the risk of complications and potential harm in infant male circumcision.</li> <li>Discuss the new ethical considerations of infant’s rights and proxy consent in a non-therapeutic procedure.</li> <li>Listen to parents and consider the basis of their request, which may be based on religious or cultural practices.</li> </ul> [Conclusion] This paper is intended to help physicians use their professional judgement when a request is made for routine infant male circumcision. While parental preference is important, factors like the best available evidence regarding potential benefits and complications, alternatives to this intervention, the infant’s best interest, and current understanding of bioethics should be taken into consideration. You are not obliged to act upon a request to circumcise an infant, but you must discuss the medical evidence and the current thoughts in bioethics that dissuade you from performing this procedure. You must also inform the parents that they have the right to see another doctor. If you decide to perform the procedure for religious, cultural or other reasons: <ul> <li>Ensure that you have the necessary skills and experience, or ensure that the parents and child are referred to a physician who has these skills.</li> <li>Obtain valid consent from both parents and ensure that both parents sign a consent form.</li> <li>Provide the procedure under hygienic conditions with appropriate analgesia and aftercare.</li> </ul> RESOURCES CITED American Academy of Pediatrics. Task force on Circumcision. Circumcision Policy Statement. Pediatrics 1999; 103: 686-693 British Medical Association Committee on Medical Ethics: <a href="http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp">The Law and Ethics of Male Circumcision: guidance for doctors</a>, March 2003 Canadian Medical Association. Code of Ethics. Can Med Assoc J 1996; 155: 1176A-B Canadian Paediatric Society. <a href="http://www.cps.ca/english/statements/FN/fn96-01.htm">Neonatal circumcision revisited</a>. Can Med Assoc J 1996: 154(6): 769-780 College of Physicians and Surgeons of BC. Code of Ethics. Policy Manual. College of Physicians and Surgeons of Manitoba. Neonatal Circumcision. Winnipeg: College of Physicians and Surgeons of Manitoba 1997 College of Physicians and Surgeons of Saskatchewan. Caution against Circumcision of Newborn Male Infants. Feb 2002 Christakis DA, Harvey E, Zerr DM et al. A Trade-off Analysis of Routine Newborn Circumcision. Pediatrics 2000. 105: 246-249 Goodman J. <a href="http://www.cirp.org/library/cultural/goodman1999/">Jewish Circumcision: an alternative perspective</a>. BJU International 1999. 83: Suppl. 1, 22-27 Paton M. The Ethics of Circumcising Male Babies. The Bioethics Bulletin (June 1992). Edmonton, University of Alberta. Richards D. <a href="http://www.cirp.org/library/legal/richards/">Male Circumcision: Medical or Ritual?</a> Journal of Law and Medicine 1996. 3:371-376 Somerville M. <a href="http://www.intact.ca/canary.htm">Altering Baby Boys’ Bodies: the ethics of male circumcision</a>. The Ethical Canary: Science, Society and Human Spirit. Toronto: Viking, 2000:202-219 Szasz T. <a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=70&Itemid=0">Routine Neonatal Circumcision: Symbol of the Birth of the Therapeutic State</a>. Journal of Medicine and Philosophy 1996:21:137-14, 8 September 2009 </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 Canadian Pediatric Society: recommends against 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>The foreskin: Guide for carers and owners</h1> The following guide to foreskin management, including treatment options for foreskin problems, was prepared by the British Association of Paediatric Urologists. Although it is aimed at medical professionals, it includes much sensible advice that will be of interest and value to parents and foreskin owners. <h2>MANAGEMENT of FORESKIN CONDITIONS</h2> Statement from the British Association of Paediatric Urologists on behalf of the British Association of Paediatric Surgeons and the Association of Paediatric Anaesthetists. <h2>Table of contents</h2> Executive Summary Recommendations 1. Natural History of the foreskin 2. Common conditions and diseases associated with the presence of a foreskin 3. Treatment of conditions of the foreskin 4. Circumcision (a) British Medical Association (BMA) Guidelines (b) Anaesthesia and analgesia for circumcision (c) Complications of circumcision (d) Governance issues References Addenda (a) Comments by Doctors Opposing Circumcision (b) Comment from NORM-UK (c) Comments from a Muslim male religious circumcision practitioner (d) Response from the Association of Reform & Liberal Mohelim Working Party members and contact address <h2> <a id="exec" name="exec"></a>EXECUTIVE SUMMARY</h2> <h3>Strategic context</h3> The management of foreskin conditions varies amongst medical practitioners from observation to circumcision. Therapeutic circumcision is performed in the U.K for specific indications. There is as yet no policy for non-therapeutic or religious/cultural circumcision in the U.K., although a position statement was issued by the British Association of Paediatric Surgeons (BAPS) in 2001 [34]. <h3>Background</h3> 1. The natural history of the foreskin Almost all boys have a non-retractile foreskin at birth [1]. The inner foreskin is attached to the glans. Foreskin adhesions break down and form smegma pearls, white cysts under the foreskin, which are then extruded. The foreskin does not retract before the age of 2 years, after which it “pouts like a flower” -- physiological phimosis. The process of retractility is spontaneous and does not require manipulation. The majority of boys will have a retractile foreskin by 10 years of age and 95% by 16-17 years of age [2-4]. 2. Common foreskin conditions and diseases associated with presence of a foreskin A. Common foreskin conditions: Definitions (a) Balanoposthitis: inflammation of the glans and foreskin [5, 6]. (b) Balanitis: inflammation of the glans that often spreads along the shaft and may occur in the circumcised population [7]. (c) Posthitis: inflammation restricted to the foreskin itself. (d) Balanitis Xerotica Obliterans (BXO): a lesion akin to lichen sclerosus et atrophicus, is the cause of true scarring of the foreskin -- pathological phimosis -- the shutter type foreskin with no pouting of the inner foreskin on gentle retraction [8]. It is rare before the age of 5 years [9] and presents with discomfort on voiding and white firm scarring of the foreskin tip. The aetiology is unknown but may be of viral origin. This condition may also affect the glans and urethra. (e) Paraphimosis: results when the narrow tip of the foreskin is retracted behind the glans at the coronal sulcus causing oedema of the glans and foreskin and inability to manipulate the foreskin back over the glans. (f) Hooded foreskin: is an abnormal dorsal hemiforeskin (the penis is anatomically described in the erect position) which is deficient ventrally and is usually associated with hypospadias. B. Diseases associated with presence of a foreskin There is no current evidence to support an increased risk of penile cancer [10-14], human immunodeficiency virus infection [15] or cervical cancer [16, 17] in uncircumcised males. Circumcision to prevent urinary tract infection (UTI) is unproven except in boys with abnormal renal tracts [18]. 3. Treatment of conditions of the foreskin (a) Inflammatory conditions: Balanoposthitis, Balanitis, Posthitis: Simple bathing, topical steroids and antibiotics. (b) Non retractile healthy foreskin (physiological phimosis): No intervention, topical steroids, preputioplasty infrequently [19-25]. (c) BXO: Circumcision. There are no randomised trials that can ascertain the efficacy of other techniques and their long term outcome [26-30]. (d) Paraphimosis: Reduction with or without anaesthetic [31, 32]. (e) Hooded foreskin: Without hypospadias: no treatment, modified circumcision, foreskin reconstruction. With hypospadias: no treatment, circumcision or foreskin reconstruction with hypospadias repair. 4. Circumcision Background Male circumcision is the most common surgical procedure in the world. It may be performed for clinical reasons or to comply with religious/cultural practice -- "non-therapeutic circumcision". Non therapeutic circumcisions are not uniformly available on the NHS (where they are performed by medical practitioners and nurse practitioners ) and are also performed in the community by general practitioners and non clinicians. 4 (a) British Medical Association guidelines Reproduced in part from the BMA document: The law and ethics of male circumcision, London, 2006 [35]. (i) Ethics and the Law Male circumcision is generally assumed to be lawful provided that: <ul> <li>it is performed competently;</li> <li>it is believed to be in the child's best interests;</li> <li>there is valid consent.</li> </ul> (ii) Consent and refusal <ul> <li>Competent children may decide for themselves.</li> <li>The wishes that children express must be taken into account.</li> <li>If parents disagree, non-therapeutic circumcision must not be carried out without the leave of a court.</li> <li>Consent should be confirmed in writing.</li> </ul> (iii) Best interests <ul> <li>Doctors must act in the best interests of the patient.</li> <li>The views that children express are important in determining what is in their best interests.</li> <li>Parental preference must be weighed in terms of the child's interests.</li> <li>The child's lifestyle and likely upbringing are relevant factors to take into account.</li> <li>Parents must explain and justify requests for circumcision, in terms of the child's interests.</li> </ul> (iv) Health issues Parents seeking circumcision for their son for reasons of hygiene or health benefits must be fully informed of the lack of consensus amongst the profession over such benefits. The BMA considers there is insufficient evidence concerning health benefit from non-therapeutic circumcision. (v) Standards The General Medical Council advises that doctors must have the necessary skills and experience both to perform the operation and use appropriate measures, including anaesthesia, to minimise pain and discomfort. There is no legal requirement for non-therapeutic circumcisions to be undertaken by registered health professionals. (vi) Facilities Doctors must ensure that the premises in which they are carrying out circumcision are suitable for the purpose. In particular, if general anaesthesia is used, full resuscitation facilities must be available. (vii) Charging patients Although non-therapeutic circumcision is not a service which is provided free of charge, some doctors and hospitals have been willing to provide non-therapeutic circumcision without charge rather than risk the procedure being carried out in unhygienic conditions. In such cases doctors must still be able to justify any decision to circumcise a child based on the considerations above. (viii) Conscientious objection Health care professionals are under no obligation to comply with a request to circumcise a child. Where the procedure is not therapeutic but a matter of patient or parental choice, there is no ethical obligation to refer on. 4 (b) Anaesthesia and Analgesia for circumcision (i) Anaesthesia There is an increased risk from general anaesthesia in the neonatal period [36, 37]. According to the Royal College of Anaesthetists handbook, any general anaesthetic should be administered by an appropriately trained anaesthetist with ongoing relevant paediatric experience (38). (ii) Analgesia It is essential that adequate analgesia be provided when undertaking male circumcision. Dorsal nerve block and ring block are equally effective [45, 70]. Adequate time needs to elapse after the block before surgery is started. Eutectic mixture of local anaesthetics (EMLA), contraindicated on open wounds and mucous membranes, should be allowed 1 hour to take effect [40].This can be tested by picking up the foreskin in forceps before commencing the procedure. Non-pharmacological methods (non-nutritive suckling, rocking, massaging, cuddling) or systemic analgesia with paracetamol are inadequate in isolation for analgesia [49-59]. Caudal analgesia is effective in anaesthetised boys but has not been studied in neonatal awake circumcisions [62, 64]. 4 (c) Complications of circumcision Bleeding (1.5%), local sepsis (8.5%), oozing (36%), discomfort > 7 days (26%), meatal scabbing or stenosis, removal of too much or too little skin, urethral injury ,amputation of the glans and inclusion cyst are recorded complications [81-85]. There is conflicting evidence with respect to penile sensation, sexual function and satisfaction in adult men following circumcision [86-89]. 4 (d). Governance Issues Clinical Governance applies to all professionals i.e. clinicians including medical and nurse practitioners [90]. Non clinical practitioners performing circumcisions in the community may apply similar governance principles. <h2> <a id="recommendations" name="recommendations"></a>RECOMMENDATIONS</h2> <h3>A. Treatment of conditions of the foreskin</h3> 1. Inflammatory conditions: Balanoposthitis, Balanitis, Posthitis Simple bathing, topical steroids and antibiotics. 2. Non retractile healthy foreskin ( physiological phimosis ) No intervention, topical steroids, preputioplasty -- infrequently. 3. BXO Circumcision: There are no randomised trials that can ascertain the efficacy of other techniques and their long term outcome. 4. Paraphimosis Reduction with or without anaesthetic. 5. Hooded foreskin Without hypospadias: no treatment, modified circumcision, foreskin reconstruction. With hypospadias: no treatment, circumcision or foreskin reconstruction with hypospadias repair. <h3>B. Circumcision</h3> 1. Indications for circumcision 2. The operator 3. Standards of care 1. Indications for circumcision (a) Absolute (i) Penile malignancy (ii) Traumatic foreskin injury where it cannot be salvaged. (b) Medical (i) Balanitis Xerotica Obliterans. (ii) Severe recurrent attacks of balanoposthitis. (iii) Recurrent febrile UTIs with an abnormal urinary tract. (c) Non-therapeutic ritual circumcision 2. The operator (a) The person performing the procedure should be experienced and competent to do so. Written consent should be obtained from both parents. (b) The operator should be able to identify co-morbidity and deal with it appropriately. (c) The operator should have a full understanding of the risks and complications of the procedure and their management. (d) The operator should be familiar with various modes of analgesia for the procedure. (e) The operator should keep thorough records and regularly audit his/her practice. 3. Standards of Care (a) The operation should be undertaken in an environment capable of fulfilling guidelines for surgical procedures in children. (b) Adequate analgesia is essential. This involves systemic (oral) paracetamol and an adequate local anaesthetic. Sufficient time for the local infiltration to provide analgesia is crucial and this should be tested prior to conducting the circumcision. (c) There should be close links with the community, GP and hospital services for ongoing care and ease of referral if complications arise. (d) Regular audit of practice at individual level, trust level and in the community is essential. <h2> <a id="natural" name="natural"></a>1. The NATURAL HISTORY of the FORESKIN</h2> The fate of the foreskin has been well documented after the initial description by Gairdner in 1949 [1]. There is developmental variability in the appearance of the normal foreskin throughout childhood and puberty. The inner foreskin is attached to the glans. Foreskin adhesions break down and form smegma pearls -- white cysts under the foreskin -- which are then extruded. The foreskin does not retract before the age of 2 years. The process of retractility is spontaneous and does not require manipulation. The majority of boys will have a retractile foreskin by 10 years of age and 95% by 16-17 years of age [2-4]. Since 1996, there has been a decline in the number of children aged 0-14 treated by general surgeons with more children being seen by paediatric surgeons and paediatric urologists. Figures from the Department of Health demonstrate a reduction in paediatric surgical procedures from 30,000 per annum to nearer 20,000 per annum over a period of 10 years (Prof. D.F.M. Thomas, unpublished data). This may partly be secondary to a decrease in the number of circumcisions due to the recognition that physiological phimosis -- a healthy non-retractile foreskin which pouts like a flower on gentle retraction is normal. <h2> <a id="common" name="common"></a>2. COMMON FORESKIN CONDITIONS and DISEASES ASSOCIATED with the PRESENCE of a FORESKIN</h2> <h3>Common foreskin conditions</h3> Balanoposthitis (Balanos Greek for acorn, posthos, Greek for foreskin) is the term used for inflammation of both the glans and foreskin. It may present with dramatic swelling and erythema of the distal penis and foreskin associated with discharge, bleeding from the prepuce, dysuria, and occasionally urinary retention. It occurs in about 4% of uncircumcised boys between 2-5 years of age [5]. The aetiology is unclear although infection, contact allergy and contact irritation have been described [6]. Although balanoposthitis may be recurrent, the episodes decrease in frequency in older boys and reflect foreskin maturation. Balanitis refers to inflammation of the glans that often spreads along the shaft and may occur in the circumcised population [7]. Posthitis refers to inflammation restricted to the foreskin itself. Balanitis Xerotica Obliterans (BXO), a lesion akin to lichen sclerosus et atrophicus is the cause of true scarring of the foreskin i.e. pathological phimosis and the shutter type foreskin [8] -- no pouting of the inner foreskin on gentle retraction. It is rare before the age of 5 years [9] and presents with discomfort on voiding and a white firm scarring of the foreskin tip. The aetiology is unknown but may be of viral origin. This condition may also affect the glans and urethra. Whereas there is a strong association between BXO in adults and penile carcinoma, there is no such evidence to link it as a precancerous condition in children because the majority of children with BXO have historically undergone a circumcision. Paraphimosis results when the narrow tip of the foreskin is retracted behind the glans at the coronal sulcus causing oedema of the glans and foreskin and inability to manipulate the foreskin back over the glans. A hooded foreskin is an abnormal dorsal hemiforeskin (the penis is anatomically described in the erect position ) which is deficient ventrally and may or may not be associated with hypospadias. <h3>Diseases associated with presence of a foreskin</h3> Penile cancer Cancer of the penis is extremely rare and was previously not documented in circumcised men. Several recently reported cases question the protective effect of circumcision on the development of penile cancer as an adult [10-13]. Poor personal hygiene, smoking and exposure to wart virus (human papilloma virus) increase the risk of developing penile cancer at least as much as being uncircumcised [12-13]. Circumcised men are more at risk from penile warts than uncircumcised men [14], and the risk of developing penile cancer is now almost equal in the two groups. Routine circumcision in children cannot be recommended to prevent penile cancer. Human immunodeficiency virus (HIV) infection The results from existing observational studies showed a strong epidemiological association between male circumcision and prevention of HIV. These observational studies however were done in specific high risk groups. Randomised controlled trials are currently under way and the results are awaited. A Cochrane review [15] found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men. [CIA note: Since this document was prepared the World Health Organisation has recommended that in African countries with a high prevalence of HIV and a high rate of female-to-male infection, circumcision be offered as an option to sexually active adult males. Contrary to the propaganda of circumcision promoters, it has not recommended circumcision of children or proposed that adult circumcision programs be introduced in developed nations. For a full discussion of why the African data and WHO policies are not applicable to countries such as Australia, <a href="https://www.circinfo.org/hiv.html">see the HIV page on this site</a>.] Cervical cancer Several studies have shown an association between an increased incidence of human papilloma virus infection in heterosexual uncircumcised men with high risk activity (multiple sexual partners, avoidance of condoms) and cervical cancer [16-17]. These studies are retrospective observational studies from different geographical areas with a variable incidence of cervical cancer. The current evidence is inadequate to recommend routine male circumcision as a preventive measure against cervical cancer. Urinary tract infection (UTI) Recent meta analysis [18] data on 402,908 children were identified from 12 studies (one randomized controlled trial, four cohort studies, and seven case-control studies). Circumcision was associated with a significantly reduced risk of UTI for all three types of study design. This study concluded that circumcision reduces the risk of UTI. Given a risk in normal boys of about 1%, the number-needed-to treat to prevent one UTI is 111. In boys with recurrent UTI or high grade vesicoureteric reflux, the risk of UTI recurrence is 10% and 30% and the numbers-needed-to-treat are 11 and 4, respectively. <h2> <a id="treatment" name="treatment"></a>3. TREATMENT of CONDITIONS of the FORESKIN</h2> Inflammatory conditions: Balanitis, Balanoposthitis, Posthitis Simple bathing, topical steroids and antibiotics. Circumcision may very rarely be considered if recurrent severe episodes of inflammation occur. Physiological phimosis No intervention is necessary. Topical steroid application to the preputial ring to treat ?phimosis? has reported success rates between 33% and 95% in various series [19-24] but frequently authors fail to define the difference between a healthy non retractile foreskin and true BXO. A preputioplasty technique has been described with good results [25] for the non-retractile foreskin though the authors gave no significant reason for intervention. Pathological phimosis (BXO) Intralesional steroid injection [26], long term antibiotics [27], carbon dioxide laser therapy [28], a radial preputioplasty alone [29] or with intralesional injection of steroid [30] have all been described. There are no randomised trials to ascertain the efficacy and the long term outcome of these techniques. Most paediatric urologists circumcise the foreskin for BXO. Once the range of treatment options are presented, the surgeon should express his or her own preference. If a surgeon is faced with a parent who refuses a conventional circumcision for BXO, but wishes for an alternative option, the surgeon is at liberty to decline to treat. The surgeon then has a duty to offer a second opinion, although there is no obligation to find a colleague who is likely to advocate the alternative option. Paraphimosis Gentle compression with a saline soaked swab [31] followed by reduction of the prepuce over the glans is usually successful. Alternatives include multiple punctures in the oedematous foreskin [32] or injection of hyaluronidase [31] prior to compression reduction. General anaesthesia may be required. Paraphimosis is not an indication for circumcision as after reduction, the foreskin continues to develop normally. Hooded foreskin A hooded foreskin without hypospadias is a cosmetic abnormality. Any therapeutic intervention should be undertaken after full discussion with both parents and may be a modified circumcision or foreskin reconstruction. Hooded foreskin with hypospadias needs treatment with correction of the hypospadias. <h2> <a id="circum" name="circum"></a>4. CIRCUMCISION</h2> Circumcision is a surgical procedure that involves partial or complete removal of the foreskin (prepuce) of the penis. Circumcision may be performed for therapeutic or non therapeutic reasons and both are accepted practices within the U.K. provided certain standards are met [33, 91]. There is as yet no policy for non-therapeutic or religious circumcision in the U.K., although a position statement was published by BAPS in 2001 [34]. <h3> <a id="bma" name="bma"></a>4 (a) British Medical Association (BMA) Guidelines 2003</h3> The BMA have set out guidelines with respect to both therapeutic and non therapeutic circumcision [35]. These guidelines discuss the issues mentioned below. <ul> <li>Ethics and the law</li> <li>Consent and refusal</li> <li>Best interests</li> <li>Health issues</li> <li>Standards</li> <li>Facilities</li> <li>Charging patients</li> <li>Conscientious objection</li> </ul> A full discussion of the guidelines is beyond the scope of this document. The 2003 guidelines (The law and ethics of male circumcision - Guidance for doctors) can be obtained from the BMA website. [CIA NOTE: This statement was <a href="http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp">updated in November 2007</a>.] With respect to consent the working party point out that having both parents consent for a therapeutic circumcision is not necessary. The legal purpose of consent is to provide the clinician with a defence against negligence and battery, so a single consent is valid. In non-therapeutic circumcision, the purpose of the second consent is to protect the second parent from having a procedure performed on their son of which they disapprove. At present case law is clear: <a href="http://www.cirp.org/library/legal/Re_J/">Re J (Child's religious upbringing and circumcision)</a> COURT OF APPEAL (CIVIL DIVISION) 25 November 1999. Permission from both parents is required for non-therapeutic circumcision. Currently, the only way for the clinician to show that they have conformed to this is to get both parents to sign the consent form. However, legal advice has suggested that this position is open to challenge. In discussion with the wider membership of BAPU there was widespread support for the requirement for both parents' signatures, but this was not unanimous. Paediatric patient information documents for circumcision (ref. PSO2) are available from EIDO Healthcare at www.eidohealthcare.com. <h3> <a id="anaesthesia" name="anaesthesia"></a>4 (b) Anaesthesia and analgesia for circumcision</h3> (i) Anaesthesia Modern general anaesthesia is extremely safe. However the risk of general anaesthesia will never be zero and is increased in infants. In two large series [36-37] the risk of complications was significantly higher in infants than in children. Adequate analgesia must always be provided whether a general anaesthetic is being administered or not. There is an increased risk from general anaesthesia in the neonatal period. According to the Royal College of Anaesthetists handbook [38], any general anaesthetic should be administered by an appropriately trained anaesthetist with ongoing relevant paediatric experience. (ii) Analgesia INTRODUCTION Adequate analgesia for male circumcision is required and is the subject of two Cochrane reviews [39-40]. In non-anaesthetised neonates who underwent circumcision a rise in adrenal corticoids [41-42], skin flushing, vomiting and cyanosis43, increases in crying [41-44], apnoea and choking [45] and a pneumothorax [46] have all been described. Increases in heart rate and respiratory rate with decreases in oxygen saturation [47] have been recorded with inadequate analgesia. Infants who undergo circumcision show exaggerated pain behaviour to their routine immunisations during the ensuing six months when compared to uncircumcised control infants [48] suggesting that they develop a "pain memory" from an early age. INTERVENTIONS Non-pharmacological In neonates, rocking, massage, tucking and cuddling reduce pain responses to invasive procedures [49-51]. Music and heartbeat sounds have been shown to modulate pain perception [52]. None of these seem adequate as stand alone methods of providing analgesia for neonatal circumcision and cannot be endorsed as such. These and similar methods may well have a role to play as adjunctive therapies. Non-nutritive suckling There are several trials comparing sugar solutions to water and or no treatment in neonatal circumcisions without general anaesthesia [53-59]. Since a large range of concentrations (24-50%) and volumes (1.5 to 10 ml) were used across these studies it is hard to draw any firm conclusions. Heterogeneous outcome measures were used but, cry times and heart rate changes were not significantly different in the treatment groups when compared to the controls in the context of circumcision. This is not to say that non-nutritive suckling does not have a role to play as an adjunctive therapy. Systemic analgesia Paracetamol has been compared to placebo in two trials [60-61]. Macke [61] found a benefit from Paracetamol compared to placebo but Howard [61] found no difference between placebo and paracetamol as judged by a 20-point comfort score. Parenteral opioids have been compared to caudal anaesthetics in older children having general anaesthetics for circumcision. Intramuscular codeine62, fentanyl and paracetamol [63], intramuscular morphine [64], intravenous diamorphine65 and intramuscular buprenorphine [66] have all been compared with caudal analgesia. In summary, parenteral opioids lead to a greater need for rescue analgesia than caudals and result in a higher incidence of nausea and vomiting. Post-procedural analgesia should always be provided. The paracetamol dose should not exceed 60mg/kg/24 hours for neonates and 90mg/kg/24 hours for older children. Dorsal Penile Nerve Block (DPNB) The results of DPNB when used against active treatment controls are shown in the table below. Penile block is recommended as an effective means of providing analgesia. It should be noted that performance of this block requires training, and that it is generally best performed in the anaesthetized infant. TABLE: Comparison of active treatments versus DPNB in neonatal circumcision [Not shown here: <a href="http://baps.org.uk/page14/page14.html">Available in PDF at BAPS website</a>.] Bicarbonate solution Although there are theoretical advantages to adding bicarbonate to the local anaesthetic solution in any block in terms of decreasing the pain on injection and increasing the speed of onset of the block Stang et al [56] showed no advantage in doing this as judged by any of the outcome measures of heart rate, cry time, behavioural distress score or serum cortisol levels. Ring Block There are two trials comparing ring block to no treatment [45, 71] the latter showing significantly lower heart rates in the treatment group and the former showing no difference in respiratory rate and oxygen saturation. When compared to EMLA there was no advantage versus ring block as judged by heart rate and cry time [45]. A test of the adequacy of the block such as gently picking up the foreskin with forceps should always be undertaken prior to surgery and the operator should be satisfied that there is no pain response to this test. Caudal Epidural Block There is a reduced requirement for early post-operative rescue analgesia and less post-operative nausea and vomiting if a caudal is used. Urinary retention and leg weakness are known complications of caudal block. All studies [62, 64] comparing caudal block against other modes of analgesia for circumcision were in anaesthetized children. Topical Analgesia EMLA cream Six studies compare EMLA (Eutectic Mixture of Local Anaesthetic) to placebo as cited in the Cochrane review by Brady-Fryer and colleagues [40]. EMLA significantly reduced pain behaviour scores in most studies. Heart rate was significantly reduced in the EMLA groups whereas respiratory rate and blood pressure were not. There is risk of methaemoglobinaemia with the use of prilocaine (a constituent of EMLA) especially in neonates. Indeed the BNF for children 2005 does not recommend its use in neonates. It has been safely used for heel lancing in neonates on neonatal units. EMLA should not be used on open wounds or mucous membranes. EMLA cream should be allowed adequate time to take effect and one hour is regarded as the minimum. Amethocaine (tetracaine 4%) gel Like EMLA the BNF for children 2005 does not recommend the use of amethocaine gel in neonates although it is commonly used in this population. Repeated applications should be avoided. Amethocaine only takes 30 minutes to become clinically effective and is thus twice as fast in onset as EMLA [72]. A common practice is to apply topical local anaesthetic such as amethocaine gel half an hour before performing a deeper block such as DNPB or ring block thus helping to minimise the pain of injection of the deeper block. Lidocaine Three trials compare topical lidocaine to placebo [73-75]. Cry time is significantly reduced by lidocaine. Oxygen saturations tend to be higher in the treatment groups but not statistically so. SUMMARY It is essential to provide adequate analgesia when undertaking male circumcision. Dorsal nerve block and ring block are easy to perform and are effective. Adequate time needs to elapse after the block before surgery is started. Non-pharmacological methods and optimum treatment with systemic analgesics should also be employed. <h3> <a id="complications" name="complications"></a>4 (c) Complications of circumcision</h3> Numerous techniques have been described for circumcision. This is achieved either by the freehand or sleeve technique [76], using a clamp [77, 78] or a plastibell device [79]. Circumcisions performed in hospitals have a statistically lower complication rate than those in the community [80-82]. These include bleeding, local sepsis, meatal scabbing or stenosis, removal of too much skin or too little skin, urethral injury ,amputation of the glans and inclusion cyst. Engorgement of the glans as a result of failure of the plastibell ring to fall off is well recognized [83] and necessitates removal of the ring. An inappropriate circumcision in the presence of a penile abnormality such as a hypospadias can lead to long term morbidity. Griffiths et al [84] in a prospective survey of hospital circumcision recorded the following complications: oozing in 36%, discomfort >7 days 26%, infection needing antibiotics 8.5% and haemorrhage in 1.5%. Kaplan [85] noted the effect of the exposed glans to wet diapers causing meatitis and meatal ulcers. There is conflicting evidence with respect to penile sensation, sexual function and satisfaction in adult men following circumcision [86-89]. <h3> <a id="governance" name="governance"></a>4 (d) Governance issues</h3> In 1999 the Department of Health set out a white paper defining clinical governance in the NHS [90].This is maintained by regular audit, evidence based practice, Continuing Professional Development (CPD) and Research, risk management and clinical effectiveness. All medically qualified practitioners fall under this umbrella and are answerable to their peers. The role of nurse practitioners in performing circumcision depends on their contractual position and consultant supervision. It is anticipated that liability would be shared between the employing trust and the operator, and only with the supervisor if it is "just and reasonable" that they should share liability. Non medical personnel performing circumcisions in the community must obtain valid consent and have appropriate experience. There is a need for personal audit in these circumstances. <a id="refs" name="refs"></a><a href="https://www.circinfo.org/baps_refs.html">References</a><a href="https://www.circinfo.org/baps_refs.html">: On separate page</a> <h2> <a id="addenda" name="addenda"></a>ADDENDA</h2> <h3>Addendum A: Comment by Doctors Opposing Circumcision</h3> This statement, Management of Foreskin Conditions, is a progressive move to reform the treatment of foreskin conditions. The statement favours conservative treatment over radical circumcision and should do much to promote genital integrity. We urge its speedy adoption. Our comments are small ones. Lawfulness. The lawfulness of non-therapeutic male circumcision is questionable under British law. Law professors Fox and Thomson recently argued that non-therapeutic male circumcision is unlawful under the Offences Against the Person Act 1861 after the House of Lords decision of R v Brown (1993). Fox and Thomson argue that consent cannot excuse the practice of non-therapeutic circumcision because no one can consent to a criminal act [1]. No court has ruled on this matter so this question remains unsettled. Complications. Death is a possible outcome of male circumcision [2]. Natural history and development of retractile foreskin. This section provides newer and more accurate data. These data should greatly reduce the incidence of erroneous diagnosis of pathological phimosis in boys and adolescents. Diagnosis and Treatment of Inflammation (Balanitis, Posthitis, and Balanoposthitis). We would like to see greater emphasis placed on the importance of careful diagnosis, since these conditions have varied etiology, which require varied treatment [3]. Careful diagnosis is necessary to find the cause and select the appropriate treatment. The British Guidelines provide excellent information [4]. Diagnosis may include a patient history, physical examination, swab and culture, and biopsy [3, 4]. The presence of infection with Candida Albicans should cause suspicion of diabetes mellitus. Recurrent mycotic infection may indicate a compromised immune system and dictate further investigation [5]. References 1. Fox M, Thomson M. <a href="http://www.cirp.org/library/legal/UKlaw/fox-thomson2005/">A covenant with the status quo? Male circumcision and the new BMA guidance to doctors</a>. J Med Ethics 2005;31:463-9. 2. Williams N, Kapila L. <a href="http://www.cirp.org/library/complications/williams-kapila/">Complications of circumcision</a>. Brit J Surg 1993;80:1231-6. 3. Edwards S. <a href="http://www.ncbi.nlm.nih.gov/pmc/issues/120947/">Balanitis and balanoposthitis: a review</a>. Genitourin Med 1996;72(3):155-9. 4. Edwards S. (for the Clinical Effectiveness Group) National guideline on the management of balanitis. Association for Genitourinary Medicine (U.K.) and the Medical Society for the Study of Venereal Diseases (U.K.). (2001) [CIA Note: Balanitis is a generic term covering a wide range of conditions that may affect the glans of the penis and the foreskin. Posthitis merely means an "itis" of the "posthe", or in English an inflammation of the foreskin. The various conditions called balanitis may be caused by any one or more of a dozen different agents, which may be bacterial, viral, fungal, or the result of injury. For full details on the identification and treatment of such inflammations, see the <a href="http://www.bashh.org/guidelines">guidelines issued by the British Association for Sexual Health and HIV</a>. BAHSH points out that balanitis is one of the most common conditions encountered at sexual health clinics, and that it is nearly always easy to treat. The guidelines do not recommend circumcision as either a treatment or preventive for these mild and easily-curable problems.] 5. Mayser P. Mycotic infections of the penis. Andrologia 1999;31 Suppl 1:13-6. <a href="http://www.doctorsopposingcircumcision.org/" rel="noopener" target="_blank">Doctors Opposing Circumcision</a> Suite 42, 2442 NW Market Street Seattle, Washington 98107-4137 USA <h3>Addendum B: Comment from Norm-UK</h3> On the whole NORM-UK do not consider that this is a balanced view of the management of foreskin conditions, since they are looking at circumcision rather than the management of foreskin conditions. It is pleasing to see that conservative management is stressed in the cases of balanitis/balanoposthitis, non-retractile foreskin and paraphimosis. With regard to circumcision, a realistic view of complication rates is mentioned. We also welcome your sensible, up to date view of the natural history of the foreskin. It is also pleasing that the authors of report are not impressed by supposed prevention of penile cancer by circumcision. It is interesting, however, that they note increased risk of penile warts in circumcised men as compared with intact. With regard to BXO, we would urge you to state that this is lichen sclerosus, rather than merely being akin to lichen sclerosus. We also believe that there is RCT evidence to support the efficacy of topical steroids for the treatment of lichen sclerosus. Lindhagen presented a prospective, randomised, double-blind study, although it is admittedly unclear as to whether those who were effectively treated actually had lichen sclerosus [1]. Kiss and colleagues also presented a randomised, placebo controlled double blind study to show the effective treatment of "BXO" histopathology by mometasone furoate [2]. At the very least this would seem to merit a recommendation for further research. It is also pleasing that they are not impressed by claims that circumcision prevents cervical cancer in female partners. Unfortunately in this connection they have not questioned the ethics of performing surgery on a healthy child with a view to preventing disease in a third party at some distant time in the future on the assumption that the individual will go on to have a partner of the opposite sex. Setting aside that this is outside the scope of managing actual disease of the foreskin, it is surely an example of where a choice for circumcision could be made by a consenting adult rather than being imposed on an un-consenting child? In the case of prevention of UTIs the fact that it is necessary to operate on 111 infants to prevent one case of UTI is pretty clear evidence that circumcision should not be undertaken for this reason, particularly in view of the complication rates, which they report. However, they have not pressed that conclusion clearly enough. It is also noteworthy that the one RCT to examine circumcision for the prevention of UTI in boys found that circumcision was not effective at reducing recurrences of UTI [3]. While this was a study solely of boys having anti-reflux surgery for VUR, this is to the best of our knowledge the only published RCT to consider circumcision for prevention of UTI. It seems disingenuous to recommend circumcision in boys with VUR when the only RCT to have considered the matter shows that it does not work. References 1. Lindhagen T. Topical clobetasol propionate compared with placebo in the treatment of the unretractable foreskin. Eur J Surg. 1996; 162:969. 2. Kiss A, Csontai A, Pirot L, Nyirady P,Merksz M, Kiraly L. The response of balanitis xerotica obliterans to local steroid application compared with placebo in children. J Urol. 2001; 165(1):219-20. 3. Kwak C, Oh SJ, Lee A, Choi H. Effect of circumcision on urinary tract infection after successful antireflux surgery. BJU Int. 2004; 94(4):627-629 We note that in their discussion of the management of Hooded Foreskin, a congenital defect of cosmetic but not functional significance, the authors do not propose a course of management of waiting for the patient to be mature enough to express an opinion as to whether he wants surgical correction or not, which might be a suitable plan in some cases. We consider this to be an illustration of the wider question as to why male circumcision should be construed as a matter of personal (parental) choice as opposed a choice to be made by the individual affected when he is of sufficient age and maturity to make the choice for himself. We urge you to bear this in mind when you go on to consider religious circumcision. Dr J Warren Chairman <a href="http://www.norm-uk.org/" rel="noopener" target="_blank">Norm UK</a> <h3>ADDENDUM C: Comments from a Muslim male religious circumcision practitioner</h3> In my capacity as a General Practitioner who also serves my community with such a service, my comments will only concern "non-therapeutic ritual/religious" circumcision. I would like to make mention, again, that I do NOT ascribe to the view that a child should be circumcised simply to "look like his dad" -- the main reason for circumcision in the United States and elsewhere! I think this is a deplorable state of affairs! I have had to turn many parents away who come to me to have it done "because his dad is circumcised"! Circumcision been an irreversible procedure with attendant surgical/anaesthetic risks. Specifically I would like to raise certain pertinent points under the headings Non Therapeutic "Ritual" circumcision and Standards of Care of the associations draft statement. "The operator should have a full understanding of the risks and complications of the procedure and their management." I assume this means the operator must be aware of the different management decision making processes when he/she encounters complications, as opposed to actually been able, skilled, and qualified to deal/handle any complications that may arise. Whereas some us may at the very least be "trained to" o perform circumcisions, most us are necessarily not trained to handle the more than simple, albeit uncommon, complications of circumcisions e.g., significant bleeder, significant infection, concealed penis, denuded penis, meatal stenosis, revision of circumcisions, urethrocutaneous fistula, etc. There was a G.M.C. case recently where it was felt that it was inappropropriate and beyond the professionalism of the G.P. to manage a post-operative bleeder. The child should have been referred to hospital instead. This is in keeping with the very useful and almost pragmatic B.A.P.S guidelines and G.M.C guidelines on offering "appropriate after care" A lot of us who seek support or training have been either turned down (no PCT funding etc) or have had very "unsupportive" letters back. There is a lot of noise about protecting children and the welfare of children being paramount, but in reality, training/support is never forthcoming for those G.P.s who want to offer a circumcision service for the children amongst the 3,000,000 Muslims who live in the UK. Even if help is offered, the conditions under which one will be trained would be that of a motionless, unconscious child with a low blood pressure: i.e. general anaesthetic. One should not underestimate the singular advantage this gives the operator. Community practitioners are faced with the singular hurdle of operating on a person with local anaesthesia with all its limitations, including a moving, slippery target. A lot of Paediatric surgeons/urologists have stated how difficult it is to operate on a moving target, and that they view with disbelief and awe how we manage to perform circumcision under L.A. (personal e-mail communications with >10 paediatric surgeons, including a professor of paediatric surgery). It would therefore not be unreasonable to form an opinion that community practitioners would legitimately have intra-/post operative outcomes not as favorable as those performed in hospitals. Who then decides what an acceptable outcome in the community setting is? Throw in certain confounding variables: assent NOT consent, unlicensed usage of local anaethesia, operators not been surgeons NOR trained properly, a contentious surgical technique, suboptimal anaesthetic conditions e.g. the child been awake! In medical malpractice litigation the standard of care is that degree of care which a reasonably prudent person in similar circumstances would be expected to exercise [1-2]. In view of the recent statement on Medical Expert Witness from the Academy of Medical Royal Colleges, it would be very difficult for a hospital paediatric surgeon to claim to pronounce on a case carried out by a community practitioner [3]. There being a difference between, reasonable, acceptable practice and the Gold standard, as explained by Bolam and Bolitho. In terms of drawing up guidelines around religious circumcision it is unclear what benefit can be derived from such publications when such a position does not reflect the diversity of opinion and practice in the profession itself [4]. "The operation should be undertaken in an environment capable of fulfilling guidelines for surgical procedures in children". At a single stroke you will stop all qualified Jewish doctors, who are also Mohels, from performing home ceremonial religious circumcision on babies! It has been shown time and again that Jewish religious neonatal male circumcision can be carried out under aseptic technique, with minimal morbidity and mortality and primary healing [5-7]. The singular advantage of neonatal circumcision is the reduced infective and technical burden. I am somewhat embarrassed to say the Muslim community, as far as I am aware, has no such internal system of training and accreditation and hence benchmarking. There is ample work done to show that paediatric circumcision is a safe office procedure and not requiring an "environment capable of fulfilling guidelines for surgical procedure in children" This is neither necessary nor cost-effective.The bare minimum appears to be it must take place under hygienic conditions [8-17]. There is not much good research published to determine complications rates, especially when those done in the community are not often reported - BMJ Best Treatment. A commonly quoted range is 2-10% [18]. Looking at the international experience, complications rates are indeed quite high [19] . But a casual review indicates that the operators are mainly non medics with no ideas of surgical technique or infection control The procedure itself is relatively straightforward [20]: when this is done in hospital and so under general anaesthetic .To help prevent complications four principal factors have to be adhered to attention to aseptic conditions, adequate but not excessive excision of inner and outer preputial layers, meticulous haemostasis, and protection of glans and urethra [21]. References 1. Brian Hurwitz. How does evidence based guidelines influence determinations of medical negligence? BMJ 2004;329:1024-1028 2. American Academy of Pediatrics, Policy Statement, Committee on Medical Liability: Guidelines for Expert Witness Testimony in Medical Malpractice Litigation Pediatrics 2002;109:974-979 3. Medical Expert Witnesses, Guidance from the Academy of Medical Royal Colleges, July 2005. 4. R Mussell, Ethics department B.M.A. The development of professional guidelines on the law and ethics of male circumcision. Journal of Medical Ethics, 2004; 30:254-25. 5. Dr J Spitzer, The Surgery of Bris Milah. Published under the auspices of The Initation Society, London .1996 6. Ben-Chaim-Jacob et al. The Israel Medical Association Journal, June 2005;7:368-70 7. Samuel Menahem. Complications arising from ritual circumcision: pathogenesis and possible prevention. Israel Journal of Medical Science, January 1981;17:45-48 8. General Medical Council, Guidance for Doctors asked to circumcise male children: (procedure must take place in ?hygienic? conditions), September 1997. 9. Heart of Birmingham N.H.S religious circumcision service protocols, 2005. 10. Iftikhar Ahmad, Circumcision in babies and children with the Plastibell technique: an easy procedure with minimal complications. Pakistan Journal of Medical Sciences, 2004;20:175-180 11. John Krieger et al. Adult male circumcision: results of a standardized procedure in Kisumu District, Kenya. Reconstructive Urology, BJU international, 2005;96:1109-1113 12. Jayanthi et al. Post-neonatal circumcision with local anaesthesia: a cost effective alternative: NHS Economic and Evaluation Database, The centre for Reviews and Dissemination, University of York. Journal of Urology, 1999:161: 1301-1303 13. Schmitz RF et al. Good results from circumcisions of Muslim boys performed outside the hospital. Ned Tijdschr Geneeskd. 1999; 143: 627-30. 14. Metcalf et al, Circumcision: a study of Current Practices. Clinical Pediatrics, August 1983; 22:575-579 15. Smith C et al. Office pediatric urologic procedures from a parental perspective. Feb 2000. Urology: 2:272-6 16. Clair DLet al. Pediatric office procedures. Urol Clin North Am, Nov 1988:15, 715-23 17. Personal reply from the Department of Health to an e-mail, 7 June 2006. 18. Williams and Kapila. Complications of circumcision. British Journal of Surgery, 1993;80:1231-1236 19. Ozdemir. Significantly increased complications risks with mass circumcisions. British Journal of Urology, July 1997;80;136-139 20. R Wheeler. Legal challenges in Paediatric Surgery. New law Journal ,November 2001 21. Gerharz et al. Medicolegal aspects of male circumcision. British Journal of Urology, International. August 2000:86.3 Dr Noor Ahmad June 2006 <h3>Addendum D: Response from the Association of Reform & Liberal Mohelim</h3> The ARLM is a group of doctors who perform religious, ritual and non-therapeutic circumcisions, mostly for the Jewish Reform & Liberal communities, but extending to other communities (non-Jewish) as well. We start from the premise that circumcision is required by our religion, is not illegal in this country, and therefore must be allowed. However, our particular association dictates that we must all be doctors, all trained to an appropriate level, and we all agree to abide by certain standards of performance and conduct in relation to circumcision. All of the standards we agree to are encompassed in the GMC guidelines, and in particular we agree that the interest of the child are paramount, safe medical practice must be observed, and religious requirements must never override medical requirement when the safety of the child is at risk. We believe that circumcision in the home is a safe procedure (having taken appropriate steps to ensure sterility of instruments etc) and analgesia is necessary, though can be provided by a variety of conventional medical approaches. Pre-op assessment, consent, method of circumcision, post-op care and note keeping must follow standard medical guidelines. We disagree with the complication rates quoted in the position paper: home circumcision in the neonatal period does not produce the level of complications quoted, and we have yearly internal audits which can demonstrate this. The complication rate is only at the level quoted when older children, hospital circumcisions, medical (therapeutic) circumcisions and adult circumcisions are all mixed in the figures. We therefore believe that circumcisions in the community can and should be a safe procedure, although would agree that standards (such as those drawn up by our association) should apply to all doctors performing circumcisions in the community. Those standards are more akin to minor surgery in General Practice that the standards that apply to hospital surgical procedures. Nigel Zoltie, MB, ChB, FRCS, FCEM Chairman, ARLM <h2> <a id="working" name="working"></a>Working Party Members</h2> Mr Prasad Godbole, Consultant Paediatric Urologist, Sheffield, Chairperson Mr Patrick Duffy, Consultant Paediatric Urologist, London Miss Su-Anna Boddy, Consultant Paediatric Urologist, London Mr Ewen MacKinnon, Consultant Paediatric Urologist, Sheffield Mr Alan Bailie, Consultant Paediatric Urologist, Belfast Mr Rob Wheeler, Consultant Paediatric Surgeon, Southampton Dr Mark Thomas, Consultant Paediatric Anaesthetist, London Miss Kalpana Patil, Consultant Paediatric Urologist, London Addresses for correspondence Miss Su-Anna Boddy Mr Prasad Godbole <a class="__cf_email__" data-cfemail="0f6760617c6a6c4f6d6e7f7c21607d68217a64" href="/cdn-cgi/l/email-protection">[email protected]</a> St George's Hospital Dept of Paediatric Surgery LONDON Sheffield Children's Hospital SHEFFIELD This statement refers to management of foreskin conditions and circumcision in male children. Female circumcision is prohibited by law: LASSL (2004)4: Female Genital Mutilation Act 2003, DoH, published 27.2.2004 Statement from the Royal College of Paediatricians and Child Health: This document addresses an important clinical area for which there are no existing guidelines or practise statements. Whilst this statement is not evidence based on a consensus, it provides information of relevance to paediatricians SOURCE: The full statement can be <a href="http://baps.org.uk/page14/page14.html">downloaded from the BAPS website</a> as a PDF. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource British Association of Paediatric Urologists: foreskin care and management 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>AAP waves white flag as Vikings storm fortress circumcision</h1> The case for circumcision has been dealt a final, fatal blow. Danish research showing that the vast majority of normal (uncircumcised) boys never experience any “foreskin problems”, and that only a tiny minority of boys with a problem require circumcision to fix it, has forced the American Academy of Pediatrics to admit that the case for routine (prophylactic) circumcision is empty and bankrupt. The key facts from the paper by Ida Sneppen and Jorgen Thorup, are as follows: <ul> <li>5% of boys (aged 0-18) experienced a foreskin-related problem (mainly phimosis, BXO and frenulum breve).</li> <li>1.7% of boys required surgery to correct the problem.</li> <li>0.4% of boys required circumcision to correct the problem.</li> </ul> <h2>95 per cent of uncircumcised boys will never experience a foreskin problem</h2> What this really means is that: <ul> <li>95% of boys will never experience a foreskin problem.</li> <li>More than 98% of boys will not need foreskin-related surgery (mainly because most foreskin problems, especially phimosis, can be addressed by non-surgical means, such as topical medication).</li> <li>Only a tiny minority of boys (less than half a per cent) will need to be circumcised because their particular foreskin problems are not amenable, or did not respond, to medical treatment.</li> </ul> The paper also noted that meatal stenosis (narrowing of the urethral opening) is 3 times more common in circumcised boys. This website <a href="https://www.circinfo.org/news_2012.html#au93" rel="noopener" target="_blank">pointed out</a> some years ago that 93% of Aussie boys would never experience a foreskin problem, and thus that routine circumcision makes no medical sense at all. This latest, comprehensive Danish study confirms this assessment, and further shows that only a small minority of the unlucky few who do experience problems will require surgery. The case for precautionary circumcision in advance is now well and truly dead and buried. Source: Ida Sneppen and Jorgen Thorup, <a href="http://pediatrics.aappublications.org/content/early/2016/04/04/peds.2015-4340" rel="noopener" target="_blank">Foreskin morbidity in uncircumcised males</a>, Pediatrics 137 (5), May 2016. Advance access 6 April 2016 <h3>Waving the white flag:</h3> <h2>Astonishing admissions from American Academy of Pediatrics</h2> In response to this devastating avalanche of scientific evidence, the AAP has more or less conceded that its 2012 circumcision policy was not really concerned with the medical case for circumcision at all, but with cultural and religious issues. In an editorial accompanying the Sneppen/Thorup paper, Andrew Freedman, a member of the circumcision policy taskforce, makes the following amazing admissions: <ul> <li>Circumcision is basically and usually a religious or cultural preference on the part of the parents, not a medical decision.</li> <li>Parents and medical advisers use medical evidence selectively to bolster their prior ideological positions on circumcision.</li> <li>We did not recommend circumcision.</li> <li>Circumcision is not necessary for optimum health.</li> <li>Underlying aim of 2012 circumcision policy was to counter proposals to prohibit non-therapeutic circumcision of minors.</li> <li>“Given the role of the phallus in our culture”, it is legitimate to consider non-medical factors in the circumcision decision.</li> <li>Not all penises have to look the same.</li> <li>The risk/benefit equation we devised (“benefits outweigh risks”) is applicable and relevant only to those who have non-medical (cultural, religious, social) reasons for circumcision.</li> </ul> Source: Andrew Freedman, <a href="http://pediatrics.aappublications.org/content/early/2016/04/04/peds.2016-0594" rel="noopener" target="_blank">The circumcision debate: Beyond benefits and risks</a>. Pediatrics 137 (5), May 2016. Advance access 6 April 2016. The obvious questions arising from Dr Freedman's admissions are: 1. If circumcision is not a medical procedure, is not recommended and is not necessary for health, and if it is primarily a religious, cultural or social ritual, how can the AAP justify its recommendation that it is legitimate for health insurance providers to fund it? 2. Given the above, plus the acknowledged non-medical significance of the penis in our culture, how can the AAP justify its assumption that it is the parents, rather than the owner of the penis, who are the appropriate parties to make the circumcision decision? We must point out that it was Freedman who, when the <a href="https://www.circinfo.org/United_States_circumcision_policy.html" rel="noopener" target="_blank">AAP policy was under attack</a> back in 2012, notoriously stated that he did not circumcise his own boys for medical reasons, but because he felt the weight of centuries of ancestors breathing down his neck. It is evidence of his continuing commitment to circumcision as a cultural/religious rite that he makes no mention of bioethical or human rights issues, such as the <a href="https://www.academia.edu/17264543/" rel="noopener" target="_blank">child’s right to an open future</a>; nor does he acknowledge that the AAP’s risk/benefit calculation <a href="https://www.academia.edu/12035421/" rel="noopener" target="_blank">has been criticised</a> as empirically false, conceptually misconceived and inadequate to the complexity of the “circumcision decision”. Despite the title of his editorial, Freedman has not gone far enough beyond “benefits and risks”. The key point is that those who have sought to advocate or defend circumcision (whether for cultural or medical reasons) on the basis that the AAP had guaranteed the soundness of the health case in its favour now find that the cheque has bounced. The fact is that the AAP bank account is empty. The last remaining bastion of respectable circumcision advocacy has been the American Academy of Pediatrics; now that their fortress has been stormed by a devastating Viking raid, the case for circumcision is well and truly on its last legs. </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 American Academy of Pediatrics: admits 2012 circumcision policy dictated by cultural and political concerns darby