4 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"> <h3>Genital cutting without consent ruled a grave offence</h3> The New South Wales doctor who excised a woman’s genitalia “for her health” has had his gaol sentence increased by a further 18 months. In March 2011 former south coast gynaecologist Graeme Reeves was convicted of inflicting grievous bodily harm on a patient, Carolyn DeWaegeneire, and sentenced to two and a half years gaol. Both he and the prosecution then appealed, Reeves because he claimed the jury had been wrongly directed, the prosecution because the sentence was “manifestly inadequate” to the gravity of the offence. On 21 February 2013 the Court of Criminal Appeal rejected Reeves’ appeal and increased his sentence by a further 18 months. The case goes back to 2002, when Mrs DeWaegeneire sought treatment for a small, discoloured (possibly pre-cancerous) patch on her labia. Instead of treating it medically or delicately cutting it out with minimal tissue loss, Reeves performed an operation under general anaesthetic during which he excised most of the woman’s external genitalia – much to her horror and dismay. Mrs DeWaegeneire then faced enormous difficulties and obstruction, and showed amazing fortitude and persistence, before the authorities took action, but eventually Reeves was charged under Section 45 of the NSW Crimes Act, covering female genital mutilation. At his trial in 2010 he claimed that the radical surgery he had performed was necessary to stop the cancer from spreading and thus essential for the woman’s health. In this case the jury was unable to agree on a verdict because Section 45 (3) (a) permits a defence to the cutting of the female genitals if it is “necessary for the health of the person on whom it is performed and is performed by a medical practitioner”. Although Reeves provided no evidence that the lesion was cancerous or likely to spread, sufficient numbers of the jury were evidently persuaded to give him the benefit of the doubt, and a new trial was ordered. For those who are surprised at the absence of a third condition that must be met for a defence against genital cutting, namely, the consent of the subject, it must remembered that Section 45 does not allow consent as a defence against female genital mutilation. This is to ensure that young women are not coerced by their family into giving a consent they do not really feel; although this is a necessary safeguard, it prevents competent adult women from electing genital modification surgery even if they desire it. Without reducing the protection given to the young, it would be possible and a sensible precaution to add “informed consent of the patient” to the relevant sub-section. At his second trial in March 2011 Reeves was charged under a different section of the Crimes Act – Section 33, covering wounding with intent to inflict grievous bodily harm. In this case the defence of “medical necessity” was not available, and although he tried it on, the jury was not convinced and duly found him guilty, largely on the basis that consent had not been given and the accused knew it had not been given. Announcing his appeal, however, Reeves was still trying to rely on “professional judgement” as the excuse for his actions. His barrister even tried to argue that the case should not have come to a criminal trial at all, since he “believed” that what he was doing was for the benefit of his patient. This defence will not hold, however, as doctors can believe (or say they believe) all kinds of cock and bull; the justification for surgical removal of functional body parts is not that a doctor “believes” such an excision to be in a person’s best interests, but if the operation is generally accepted by the medical profession as necessary in the circumstances and the patient has given explicit consent. Without such consent, any interference with another person’s body is assault – as the prosecution correctly argued in its recent appeal. This point was emphasized in the court judgment, which rejected as totally spurious Reeves’ attempt to argue that a patient’s consent meant merely a general authorization for the doctor to do whatever he thought desirable or necessary. On the contrary, Bathurst CJ reiterated the understanding of consent that has prevailed in Australian law since the High Court decision in Rogers v Whitaker (1992) and confirmed the trial court’s verdict that Reeves knew he did not have the patient’s consent for what he did to her. On the question of the sentence, the Chief Justice stated that in view of: <ul> <li>The radical and extensive nature of the surgery undertaken in circumstances in which the respondent knew that he did not have the consent of the complainant;</li> <li>The extensive harm inflicted on the complainant in consequence of the surgery involving the removal effectively of all the external genitalia, including the labia majora, labia minora, clitoris and perineum;</li> <li>The associated physical and emotional suffering resulting from the unauthorised surgery; and</li> <li>The respondent’s action in undertaking the surgery in circumstances involving a significant breach of the trust relationship between himself, as a medical practitioner, and the complainant, as his patient -</li> </ul> the offence committed was an objectively serious offence of a high order. The respondent did not, as he was bound to do, provide a clear explanation of the extensive and radical surgical procedure that he intended to carry out and did subsequently carry out. His failure to provide a proper explanation to the complainant, and his undertaking surgery without obtaining her consent, constituted a gross departure from accepted standards of surgical practice amounting to a grave offence. Accordingly, the sentence was increased to 4 years with a minimum parole period of 2 years. Implications for non-therapeutic circumcision This saga may have implications for medical law in general and for doctors who perform surgery on the genitals in particular. It confirms the old legal principle that any interference with a person’s body without consent is a criminal assault, punishable by imprisonment. It establishes that deliberate wounding of the genitals constitutes grievous bodily harm. It makes clear that doctors may not rely merely on their professional opinion, but must produce evidence for the value of and necessity for any proposed treatment. And it drives home the point that no treatment is permissible without the informed consent of the patient. Because Reeves’ conviction was under gender-neutral provisions of the Crimes Act, these principles apply just as strongly to males as to females, with possible implications for non-therapeutic circumcision of male minors. For there is something eerily familiar about Reeves defence that he was “only trying to save the woman’s life”, and “honestly believed” that the surgery was necessary for her health. We hear it every time enthusiasts for routine circumcision tries to justify the amputation of part of a boy’s external genitalia. “You may not like circumcision”, they say, “but it is necessary for your future health; and if you refuse to accept it voluntarily, it must be imposed on you by force, for your own good.” There is no difference between Reeves’ defence and the arguments of circumcision advocates, both in Australia and overseas. They, too, “honestly believe” that removal of part of a boy’s genitals is necessary to save his life, and they regard issues such as informed consent, medical ethics, human rights and personal preference as tedious, humanistic scruples that merely get in their way. Increasingly, however, it is recognised that the double standard that allows female genital mutilation to be condemned and punished but male circumcision to be tolerated and even promoted as “necessary for health” (as Reeves claimed with respect to Mrs DeWaegeneire) cannot be sustained. If it is wrong to remove a female’s genitals without her fully informed consent, how can it be acceptable to remove part of a male’s genitals without his fully informed consent? In this age of gender equality, this is one form of discrimination that will come under ever-sharpening scrutiny. <h3>What Does “Informed Consent” Mean?</h3> The following definition was given by Justice Woods at Reeves' trial in 2011 As a matter of law, any person has a right to his or her bodily integrity. In the context of this case, the law says that medical surgery cannot be performed on an adult person except with the voluntary and informed consent of the patient. “Consent” means “agreement”. Consent may be in writing, or spoken, so long as it is voluntarily given. To be valid, consent must be “informed”. This means that the medical practitioner must at least explain to the patient the purpose of the operation, the part or parts of the body to be cut or removed, the possible major consequences of the operation, and any options or alternative treatments which may be reasonably available. The explanation must be given at a time when the patient is conscious. If the patient is affected by drugs or anaesthesia, a purported consent at that time may be invalid if the patient cannot understand it. An explanation given in merely technical medical language may also fail to lead to valid consent, because the patient does not understand it or is misled by it. The purpose of the consent procedure is to inform the patient and to obtain the patient’s agreement to what is performed. If the explanation is not communicated adequately, by clear writing and/or words, the meaning of which she can grasp, the patient may not understand the explanation, or a vital part of it. If so, it cannot be said that there is “informed consent.” <a href="http://www.caselaw.nsw.gov.au/action/PJUDG?jgmtid=163170" rel="noopener" target="_blank">Full judgement available at Caselaw New South Wales</a> <h3>Earlier report:</h3> <h2>Genital mutilation doctor guilty of assault</h2> A former New South Wales doctor who excised a woman’s external genitals during an operation to remove a small patch of discoloured tissue on her labia has been found guilty of assault occasioning grievous bodily harm. His victim, aged 58 at the time of the operation, told the court that the doctor had informed her that he was going to remove a lesion, but never mentioned removing anything else. If he had, she said “I would never have walked through that hospital door to start with”. The doctor’s defence, that the complete removal of the woman’s external genitalia was necessary to stop a cancerous growth from spreading, was rejected as spurious. The doctor’s name has been suppressed by the court, though will presumably be revealed when he comes up for sentencing at a later date. The case outcome has been reported in most of the Australian news media and the ABC. The following report is from the Sydney Daily Telegraph. A FORMER NSW doctor has been found guilty of maliciously inflicting grievous bodily harm on a patient whose genitals he removed without her consent. The doctor had told a nurse that the patient's husband was dead “so it did not matter anyway” that he had taken her clitoris during the operation, the Sydney jury heard. The doctor, who cannot be named for legal reasons, denied maliciously inflicting grievous bodily harm (GBH) on Carolyn DeWaegeneire with intent to cause her GBH in 2002. But late this afternoon, the NSW District Court jury found him guilty after another jury failed to reach a verdict last year. Ms DeWaegeneire, 58 at the time of the operation, told the jury the doctor had informed her he was going to remove a lesion but never mentioned taking anything else, including her clitoris. If he had, “I would never have walked through that hospital door to start with”, she said, adding she “never, never, never, never” would have consented to the removal of her genitals. She had sought treatment for a small patch of discoloured skin on her labia, later identified as a form of pre-cancer. Ms DeWaegeneire said the doctor told her of his intention when she was about to pass out from anaesthesia on the operating table. “He leaned over me and, for my ears only, he said: ‘I’m going to take your clitoris too’,” she said. She told the jury there was “nothing” left of her genital region. It was “all gone”. Theatre nurse Sharon Demmery said she remembered the operation because of the large size of the tissue which was taken from the patient. “I said, ‘That is fairly radical’, and (the doctor) said, ‘Yes, if I didn’t take that much, the cancer would spread’,” Ms Demmery said. She said something came up about the clitoris, and she told the doctor, “You wouldn’t be taking my clitoris, no matter what.” He then said that “the patient’s husband was dead so it did not matter anyway.” The doctor had maintained that, far from having an intention to inflict harm on the woman, he was “trying to save her life”. He said he honestly believed the surgery was needed for her health. Judge Greg Woods will sentence him at a later date. Margaret Scheikowski, Former doctor guilty of removing Carolyn DeWaegeneire's genitals without consent, Daily Telegraph (Sydney), 11 March 2011 <h2>Comment by CIA</h2> <h3>Double standard on genital mutilation must be questioned</h3> While we will all be shocked at this appalling example of medical mayhem, and will applaud the fortitude of Ms DeWaegeneire in facing public humiliation to bring this butcher to justice, we should also spare a thought for the many other victims of genital mutilation whose cases do not reach the courts or the newspapers. We refer, of course, to the thousands of unnecessary circumcision operations performed each year on male infants and boys in New South Wales, all of whom would also have fled from the hospital if they had known what was being done to them and if they had the power to resist or run away. Circumcision may not be as radical or as crippling a surgery as the excisions performed on Ms DeWaegeneire, but it is just as gross an affront of a person’s bodily integrity and human dignity, just as gross a violation of the principles of medical ethics, and just as unnecessary. Without wishing in any way to minimise the enormity of this case, we suggest that in, some ways, routine circumcision of infants and boys is even worse than what was done to Ms DeWaegeneire. She really did have a pre-cancerous lesion on her genitals that needed limited surgery; none of the infants and boys routinely circumcised have anything wrong with their genitals, and did not need any kind of surgery at all. She gave limited consent to a minimal procedure; the infants and boys gave no consent at all. She had already experienced a full life with a complete body and a normal set of genital organs; circumcised infants and boys will never know what it is like to have a complete body and a normal set of natural genitals. The doctor’s defence also demands analysis. He was, he claims, “only trying to save her life”, and “honestly believed” that the surgery was necessary for the woman's health. We have heard this defence somewhere before, namely, in every justification for routine circumcision that has ever been attempted. “You may not like circumcision”, say the circumcision promoters, “but it is necessary for your future health; and if you refuse to accept it voluntarily, it must be imposed on you by force, for your own good.” There is no difference at all between Dr X’s defence here and the arguments put forward by circumcision promoters, both in Australia and overseas. They, too, “honestly believe” that removal of part of a boy’s genitals is necessary to save his life, and they they regard issues such as informed consent, medical ethics, human rights and personal preference as tedious humanistic scruples that merely get in the way of their knives. We wonder whether this doctor was as fond of circumcising male infants and boys as he was of performing mutilating operations on women, and if so, why one of these hobbies is regarded as a monstrous crime and the other as medical treatment. Increasingly, however, it is recognised that the double standard that allows female genital mutilation to be condemned and punished but male circumcision to be tolerated and even promoted as “necessary for health” (as this Dr X claimed with respect to Ms DeWaegeneire) cannot be sustained. If it is wrong to remove a woman’s genitals without her fully informed consent, how can it be acceptable to remove part of a man’s genitals without his fully informed consent? In this age of sexual equality, this is one form of discrimination that cannot be allowed to continue. NOTE: We find it strange and unfair that the name of the doctor has been suppressed, while his victim must face the glare of publicity. We do not know his name, and so cannot reveal it, but we suspect that entering the term “Butcher of Bega” into Google will bring up much relevant and interesting information about somebody who appears rather similar. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Gaol sentence increased for FGM doctor darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>Updated January 2013</h3> People often talk about the “rate” of circumcision but this can confuse two different ideas: incidence and prevalence. Incidence refers to the number of persons in a particular group who are circumcised each year; prevalence means how many in that group are currently circumcised. The prevalence of circumcision for newborn boys is zero, because none is born circumcised, but incidence is about 13% in the first year of life. On the other hand, annual incidence of circumcision for intact men in their 20s is about 0.07%, but prevalence in 2012 was estimated at 26%. Below we provide the most accurate estimates of circumcision incidence and prevalence for Australia available either on the Web or in print. The vast majority of circumcisions in Australia have always been performed routinely on infants. By routine we mean surgery performed without medical indication. The opposite of routine is therapeutic, which means for the treatment of a disease or to correct an anatomical defect. Routine circumcision reached a peak of more than 80% in the 1950s, with most procedures performed on neonates before the birth discharge from hospital. Incidence has fallen steadily since the 1960s, so that today about 85% of boys start primary school still in possession of their foreskins. Further, only 25% of circumcisions for this age group are now performed in a hospital setting; the rest are done in doctors’ rooms, mainly by profit-oriented GPs rather than qualified surgeons working with anaesthetists in theatre. <h2>Incidence</h2> <h2>Children</h2> The number of circumcisions for boys is the sum of Medicare rebates plus procedures performed on public patients in public hospitals. The latter is an important qualification because public hospitals progressively stopped offering this “elective procedure” from the 1990s, and from November 2007 none did (with very partial exceptions in Queensland and the Northern Territory). This is the main reason many people, looking only at Medicare rebates, have claimed that the “circumcision rate” has been going up, when in fact incidence has been very stable over the past decade and has recently begun a renewed decline. Table 1 <img alt="" height="262" src="https://www.circinfo.org/images/0clip_image002.gif" width="435"/> A reader asks if we can obtain a more recent picture of circumcision incidence that includes a State breakdown. There is at least a 2-year lag for release of the relevant hospital data, which are national only. But happily public hospital circumcisions have been of decreasing importance for preschool boys as elective procedures have been phased out. Since Medicare rebates were claimed for 94% of circumcisions in this age group in 2010, Medicare statistics – which are published at monthly intervals – can provide a more current snapshot of incidence, as well as allowing a State breakdown, with only a small loss of accuracy. In order to obtain a more sensitive measure for comparative purposes we can calculate a true rate: rebates per 1000 person-years in this case. The distinction between rate and risk is subtle but important: rate is what actually happened that year for all boys aged 0-4; risk is a prediction of what would happen for boys born that year were the rate to stay the same over the ensuing 4 years. Table 2 <img alt="" height="249" src="https://www.circinfo.org/images/0clip_image004.gif" width="551"/> There are several points to note about this table. First, to obtain a total risk value comparable to that in Table 1, we must add 1 percentage point (based on 2010 data) to the national Medicare estimate. So the total national risk should be 15% in 2011-12, barring unforeseen changes in public hospital practices (for individual States and Territories the equivalent increments vary in ways that are difficult to measure precisely but fall in the range 0.5-1.5%). Second, Victorian and South Australian public hospitals still offered elective circumcision in 2007-08, so the small rate rises in Medicare rebates for these States largely reflected a move from publicly insured to fee-for-service rather than an increase in the actual number of procedures. Third, and most important, it is now clear that after more than a decade of stability the incidence of infant circumcision started a renewed decline from 2008 in Queensland and NSW, the States with the highest incidence. This is not surprising given the falling prevalence among first-time fathers (see below). Finally, religious (ritual) circumcision is increasing in importance and now accounts for the majority of procedures in Victoria; as with Europe, being circumcised in Australia is becoming a marker of religious identity, with fewer than 10% of boys circumcised for secular reasons by the time they start school. <h2>Incidence</h2> <h2>Adults</h2> Since Australian adults are only circumcised in a full surgical setting (public or private hospital, or private free-standing day surgery), we can ignore Medicare data and just use hospital Procedures data for estimates. However, we cannot use total population to calculate a rate, since only intact men can be circumcised. For this we need to know the circumcision prevalence, which was 58% in 2005 for males aged 15-64. Table 3 <img alt="" height="142" src="https://www.circinfo.org/images/0clip_image006.gif" width="208"/> The table indicates that 96% of the 15-year-olds who were intact in 2005 will not be circumcised by their 65th birthday for any reason, if incidence remains the same. But will it? And what are the main reasons for adults being circumcised, anyway? We can use the Principal Diagnosis fields of the same hospital records to answer these questions for phimosis and routine (i.e. elective) circumcision, which combined constitute the reasons for more than 95% of all adult procedures. Table 4 shows the results for men in their 20s, who have seen the most dramatic decline in circumcision prevalence over the past two decades (see Prevalence below). Three-year averages were calculated to “smooth” any random variations in population estimates or case numbers. Table 4 <img align="left" alt="" height="192" src="https://www.circinfo.org/images/0clip_image008.gif" width="334"/> The most striking feature of this table is that as intact men move from being a minority to a large majority in their peer group, they are much less likely to opt for circumcision. This means that the already small risk of adult circumcision (incidence) is actually falling as circumcision prevalence falls. <h2>Prevalence</h2> <h3>Who has been circumcised?</h3> The primary source for prevalence data is the Australian Studies of Health and Relationships, which has conducted large-scale scientific surveys of sexual health issues since 2001. Stratifying this information by birth year and place provides an excellent picture of the changing circumcision status of the adult population, including a breakdown into its Australian-born and overseas-born components (the latter now constituting 30% of the total male population). Figure 1 <img alt="" height="346" src="https://www.circinfo.org/images/0clip_image010.gif" width="415"/> The 2005 intake of this survey confirmed these data and found that prevalence for those born in 1987-89 was 27%, which would indicate that the decline in incidence had started to “flatten out” at that time. It is important for a correct interpretation of this graph to understand that while the measured prevalence for all residents (the red line) born in the 1950s was 70% in 2001-02, it would have been higher in, say, 1960. That’s because net migration depresses total prevalence over time, as long as the blue line (Australian-born) is higher than the green line (overseas-born). Analysis of the latest Census data by country of origin indicates the circumcision rate of recent arrivals is about 15%, which means immigration continues to exert downward pressure on adult circumcision prevalence. Prevalence for Australian-born men closely approximates incidence for each birth year, given the relative rarity of adult circumcision. Another way of looking at the same dataset is to plot the prevalence for an age group over time. Again, it is men in their 20s who are of most interest, since it follows that whatever has happened to them will be the case for men in their 30s ten years later; that is, the circumcision prevalence of men aged 20-29 years in 2002 will closely correspond to that of those aged 30-39 in 2012, since they are largely the same people! Figure 2 <img alt="" height="253" src="https://www.circinfo.org/images/0clip_image012.gif" width="414"/> The fact that in 2005, for instance, 64% of these men were intact means that in 2015 about two-thirds of first-time fathers will also be intact, creating a demographic feedback loop that increasingly protects the next generation, since the biggest risk factor for infant circumcision is circumcised fathers. The trend (red line) shows a steady fall over 20 years of 2.1% a year. One important implication is that even with the active discouragement of routine circumcision by most of the medical profession, it still took two decades to effect a reversal of incidence (roughly from 70:30 to 30:70). This makes calls for “boosting” RIC as an alleged prophylaxis for certain adult sexual health issues particularly quixotic, since in addition to the lead time for the measure to be relevant (median ages of 34 and 69 years for HIV and penile cancer, respectively), one has to factor in the two or three decades it would take to reverse infant circumcision incidence from its current low level (assuming that were even possible, never mind desirable). The final question many people ask about prevalence is: how many living males are currently circumcised? This inevitably involves a little more guess-work than the other calculations offered above, particularly for elderly males (born before WWII), but the last table offers a conservative estimate based on population data for 2011. Table 5 <img alt="" height="103" src="https://www.circinfo.org/images/0clip_image014.gif" width="253"/> Note that even if incidence did not change, total prevalence would continue to fall as older males leave the population, largely intact birth cohorts enter, and younger males age. <h2>Technical notes</h2> <ul> <li>All years are financial years, ending June 30.</li> <li>Percentages and rates are variously rounded to reflect the error levels of the data represented.</li> <li> Sources: Medicare data are from the Health Insurance Commission. Hospital figures are from the National Hospital Morbidity Database, maintained by the Australian Institute of Health and Welfare, and populated by separation data provided by State and Territory health departments. Prevalence data are from the Australian Study of Health and Relationships. Population data are from the Australian Bureau of Statistics. </li> <li class="style2"> Error margins: These apply to prevalence estimates and are inversely proportional to the square root of the sample size. For Figure 1 these average ±4.5% for each 5-year cohort. For Figure 2 these average ±3% for each data point. The 58% estimate for circumcision prevalence in 2005 has a margin of ±1.5%, so the risk calculation in Table 5 is ±0.13%. These margins are calculated at a 95% confidence level. Population data are ABS estimates and should not be considered accurate beyond the third decimal place (i.e. 100s). </li> <li>Incidence data only cover circumcisions performed in a medical setting, thus excluding boys circumcised by mohelim without a Medicare provider number and tribal circumcisions by Aboriginal people. These are unlikely to be statistically significant.</li> <li>Also excluded are persons who did not claim a Medicare rebate for which they were eligible. The number of such cases is unknown but, given the financial incentive to claim, it is probably quite small.</li> <li>There are two possible sources of double-counting, which would inflate incidence figures. The first is circumcised individuals who undergo a “circumcision revision”, which would be recorded simply as a new circumcision in the hospital or Medicare data; the second involves public patients who are nonetheless charged for surgical services (but not the hospital stay) and subsequently claim a rebate. The combined effect of these two factors is also difficult to quantify but probably equals or outweighs sources of under-counting identified in points 5 and 6.</li> </ul> © John Cozijn, 2013 This page is copyright. Any reproduction of this information, in whole or in part, must credit Circumcision Information Australia and/or provide a link to this page. Questions or suggestions should be directed to the author at <a class="__cf_email__" data-cfemail="2c54494940494919196c4b414d4540024f4341" href="/cdn-cgi/l/email-protection">[email protected]</a> <h2> <a id="decline" name="decline"></a>Update 2017: Sharp fall in Australian circumcision incidence</h2> Figures from Medicare show that circumcision incidence in Australia continues to decline and is now at the lowest rate since records were kept. Between Financial Year 2009/10 and 2015/16 the number of circumcisions of boys under 6 months of age fell from 20,246 to 14,880 – a decline of about 30%. The fall was particularly dramatic in New South Wales (down from 8750 to 5923) and Queensland (down from 5611 to 3145). There were small falls in South Australia, the Northern Territory and the Australian Capital Territory, and slight rises in Victoria and Western Australia – where, however, the figures remain well below NSW and Qld (2943 and 1361 cases respectively). See Table 1 for details. These figures are based on claims under Medicare item 30653, circumcision of a male under 6 months of age, and may not include all circumcision operations performed in Australia – those carried out as part of a childbirth “package”, for example, or by community operators, such as Mohels servicing the Jewish community. On the other hand, it is not likely that parents who arrange circumcisions with GPs and so-called specialist clinics would fail to claim the rebate, so it is likely that the figures give a reasonable approximation of the true picture. Even if they understate the incidence, the declining trend is obvious. Although the majority of circumcision procedures are performed on baby boys under 6 months of age, significant numbers are also circumcised at later ages, and a few (very few) adults seek circumcision for their own personal reasons. Table 2 shows national figures for Medicare item 30656 (circumcision of a male between 6 months and 10 years of age); 30659 (circumcision of a male 10 years or over by a GP); and 30660 (circumcision of male 10 years or over by a specialist). From these it appears that while fewer boys between 6 months and 10 years are being circumcised, there is a slight increase in circumcision incidence among males 10 years or older. Some of these are likely to be boys circumcised on the basis of a mistaken or spurious diagnosis of phimosis. <a href="https://www.circinfo.org/phimosiscomment.html">Doctors warned</a> some years ago that too many older boys were being circumcised for phimosis (foreskin tightness or non-retractability), without efforts having been made to treat the problem medically, such as with topical steroids. They further point out that this condition is usually a normal developmental stage that will usually resolve itself without treatment as the boy matures. Even where there is pain or discomfort, most <a href="https://www.circinfo.org/phimosis.html">cases of phimosis</a> can be cured by application of topical steroids. Other reasons given for circumcision, such as balanitis (inflammation of the foreskin or glans) are equally suspect, as most of these conditions can be cured by application of appropriate medications or other non-surgical treatment. <a href="https://www.circinfo.org/AAP_in_retreat.html">Research in Denmark</a> has established that only a tiny percentage of boys need circumcision for medical reasons. It is also likely that a further (but unknown) proportion circumcision procedures in the 10-years-plus category are competent adults (aged 18 years and above) who elect circumcision for themselves, but since Medicare does not provide a more detailed breakdown by age it is not possible to reach a definite conclusion on this point. Since Australian male births are currently running at nearly 160,000 per year, it is clear that the proportion of competent males seeking circumcision for themselves is extremely small. The good news is that the incidence of circumcision among infants and young boys unable to give informed consent is declining steadily, and quite dramatically in the two “problem” states, New South Wales and Queensland. In calendar year 2015, the number of circumcision procedures performed on boys under 6 months of age was 15,176; in the same year, there were 157,088 male births, giving a circumcision incidence of 9.66%. In other words, the current incidence of circumcision in Australia is at its lowest level since records began. Table 2: Claims for circumcision for boys aged over 6 months by Medicare item number <table border="1" width="308"> <tbody> <tr> <td class="grey" width="100">Item No</td> <td class="grey" width="100">Financial year</td> <td class="grey" width="100">Financial year</td> </tr> <tr> <td> </td> <td>2009-2010</td> <td>2015-2016</td> </tr> <tr> <td class="grey">30656</td> <td class="grey">4274</td> <td class="grey">3039</td> </tr> <tr> <td>30659</td> <td>694</td> <td>897</td> </tr> <tr> <td class="grey">30660</td> <td class="grey">2523</td> <td class="grey">3205</td> </tr> </tbody> </table> Table 1: Claims for circumcision of boys aged 6 months and under, by financial year and state <table border="1" width="818"> <tbody> <tr> <td width="100">Year</td> <td width="100">NSW</td> <td width="100">Vic</td> <td width="100">Qld</td> <td width="100">SA</td> <td width="100">WA</td> <td width="100">Tas</td> <td width="100">ACT</td> </tr> <tr> <td class="grey">2009/10</td> <td class="grey">8750</td> <td class="grey">2919</td> <td class="grey">5611</td> <td class="grey">1566</td> <td class="grey">1117</td> <td class="grey">50</td> <td class="grey">178</td> </tr> <tr> <td>2010/11</td> <td>8521</td> <td>2992</td> <td>4036</td> <td>1563</td> <td>1104</td> <td>43</td> <td>197</td> </tr> <tr> <td class="grey">2011/12</td> <td class="grey">8524</td> <td class="grey">3170</td> <td class="grey">3936</td> <td class="grey">1523</td> <td class="grey">1168</td> <td class="grey">44</td> <td class="grey">208</td> </tr> <tr> <td>2102/13</td> <td>7758</td> <td>3007</td> <td>3710</td> <td>1536</td> <td>1268</td> <td>47</td> <td>208</td> </tr> <tr> <td class="grey">2013/14</td> <td class="grey">7288</td> <td class="grey">3019</td> <td class="grey">3478</td> <td class="grey">1487</td> <td class="grey">1283</td> <td class="grey">47</td> <td class="grey">230</td> </tr> <tr> <td>2014/15</td> <td>6841</td> <td>3097</td> <td>3140</td> <td>1275</td> <td>1277</td> <td>56</td> <td>151</td> </tr> <tr> <td class="grey">2015/16</td> <td class="grey">5923</td> <td class="grey">2934</td> <td class="grey">3145</td> <td class="grey">1304</td> <td class="grey">1361</td> <td class="grey">61</td> <td class="grey">112</td> </tr> </tbody> </table> Table 1 (Continued) <table border="1" width="308"> <tbody> <tr> <td width="100">Year</td> <td width="100">NT</td> <td width="100">Total Aust</td> </tr> <tr> <td class="grey">2009/10</td> <td class="grey">55</td> <td class="grey">20246</td> </tr> <tr> <td>2010/11</td> <td>47</td> <td>18503</td> </tr> <tr> <td class="grey">2011/12</td> <td class="grey">43</td> <td class="grey">18616</td> </tr> <tr> <td>2012/13</td> <td>44</td> <td>17578</td> </tr> <tr> <td class="grey">2013/14</td> <td class="grey">47</td> <td class="grey">16897</td> </tr> <tr> <td>2014/15</td> <td>52</td> <td>15889</td> </tr> <tr> <td class="grey">2015/16</td> <td class="grey">40</td> <td class="grey">14880</td> </tr> </tbody> </table> Figures derived from statistics kept by Medicare at http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Incidence and prevalence of circumcision in Australia darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Gaol sentence increased for genital mutilation doctor:</h1> <h3>Genital cutting without consent ruled a grave offence</h3> The New South Wales doctor who excised a woman’s genitalia “for her health” has had his gaol sentence increased by a further 18 months. In March 2011 former south coast gynecologist Graeme Reeves was convicted of inflicting grievous bodily harm on a patient, Carolyn DeWaegeneire, and sentenced to two and a half years gaol. Both he and the prosecution then appealed, Reeves because he claimed the jury had been wrongly directed, the prosecution because the sentence was “manifestly inadequate” to the gravity of the offence. On 21 February 2013 the Court of Criminal Appeal rejected Reeves’ appeal and increased his sentence by a further 18 months. The case goes back to 2002, when Mrs DeWaegeneire sought treatment for a small, discoloured (possibly pre-cancerous) patch on her labia. Instead of treating it medically or delicately cutting it out with minimal tissue loss, Reeves performed an operation under general anaesthetic during which he excised most of the woman’s external genitalia – much to her horror and dismay. Mrs DeWaegeneire then faced enormous difficulties and obstruction, and showed amazing fortitude and persistence, before the authorities took action, but eventually Reeves was charged under Section 45 of the NSW Crimes Act, covering female genital mutilation. At his trial in 2010 he claimed that the radical surgery he had performed was necessary to stop the cancer from spreading and thus essential for the woman’s health. In this case the jury was unable to agree on a verdict because Section 45 (3) (a) permits a defence to the cutting of the female genitals if it is “necessary for the health of the person on whom it is performed and is performed by a medical practitioner”. Although Reeves provided no evidence that the lesion was cancerous or likely to spread, sufficient numbers of the jury were evidently persuaded to give him the benefit of the doubt, and a new trial was ordered. For those who are surprised at the absence of a third condition that must be met for a defence against genital cutting, namely, the consent of the subject, it must remembered that Section 45 does not allow consent as a defence against female genital mutilation. This is to ensure that young women are not coerced by their family into giving a consent they do not really feel; although this is a necessary safeguard, it prevents competent adult women from electing genital modification surgery even if they desire it. Without reducing the protection given to the young, it would be possible and a sensible precaution to add “informed consent of the patient” to the relevant sub-section. At his second trial in March 2011 Reeves was charged under a different section of the Crimes Act – Section 33, covering wounding with intent to inflict grievous bodily harm. In this case the defence of “medical necessity” was not available, and although he tried it on, the jury was not convinced and duly found him guilty, largely on the basis that consent had not been given and the accused knew it had not been given. Announcing his appeal, however, Reeves was still trying to rely on “professional judgement” as the excuse for his actions. His barrister even tried to argue that the case should not have come to a criminal trial at all, since he “believed” that what he was doing was for the benefit of his patient. This defence will not hold, however, as doctors can believe (or say they believe) all kinds of cock and bull; the justification for surgical removal of functional body parts is not that a doctor “believes” such an excision to be in a person’s best interests, but if the operation is generally accepted by the medical profession as necessary in the circumstances and the patient has given explicit consent. Without such consent, any interference with another person’s body is assault – as the prosecution correctly argued in its recent appeal. This point was emphasized in the court judgment, which rejected as totally spurious Reeves’ attempt to argue that a patient’s consent meant merely a general authorization for the doctor to do whatever he thought desirable or necessary. On the contrary, Bathurst CJ reiterated the understanding of consent that has prevailed in Australian law since the High Court decision in Rogers v Whitaker (1992) and confirmed the trial court’s verdict that Reeves knew he did not have the patient’s consent for what he did to her. On the question of the sentence, the Chief Justice stated that in view of: <ul> <li>The radical and extensive nature of the surgery undertaken in circumstances in which the respondent knew that he did not have the consent of the complainant;</li> <li>The extensive harm inflicted on the complainant in consequence of the surgery involving the removal effectively of all the external genitalia, including the labia majora, labia minora, clitoris and perineum;</li> <li>The associated physical and emotional suffering resulting from the unauthorised surgery; and</li> <li>The respondent’s action in undertaking the surgery in circumstances involving a significant breach of the trust relationship between himself, as a medical practitioner, and the complainant, as his patient -</li> </ul> the offence committed was an objectively serious offence of a high order. The respondent did not, as he was bound to do, provide a clear explanation of the extensive and radical surgical procedure that he intended to carry out and did subsequently carry out. His failure to provide a proper explanation to the complainant, and his undertaking surgery without obtaining her consent, constituted a gross departure from accepted standards of surgical practice amounting to a grave offence. Accordingly, the sentence was increased to 4 years with a minimum parole period of 2 years. Implications for non-therapeutic circumcision This saga may have implications for medical law in general and for doctors who perform surgery on the genitals in particular. It confirms the old legal principle that any interference with a person’s body without consent is a criminal assault, punishable by imprisonment. It establishes that deliberate wounding of the genitals constitutes grievous bodily harm. It makes clear that doctors may not rely merely on their professional opinion, but must produce evidence for the value of and necessity for any proposed treatment. And it drives home the point that no treatment is permissible without the informed consent of the patient. Because Reeves’ conviction was under gender-neutral provisions of the Crimes Act, these principles apply just as strongly to males as to females, with possible implications for non-therapeutic circumcision of male minors. For there is something eerily familiar about Reeves defence that he was “only trying to save the woman’s life”, and “honestly believed” that the surgery was necessary for her health. We hear it every time enthusiasts for routine circumcision tries to justify the amputation of part of a boy’s external genitalia. “You may not like circumcision”, they say, “but it is necessary for your future health; and if you refuse to accept it voluntarily, it must be imposed on you by force, for your own good.” There is no difference between Reeves’ defence and the arguments of circumcision advocates, both in Australia and overseas. They, too, “honestly believe” that removal of part of a boy’s genitals is necessary to save his life, and they regard issues such as informed consent, medical ethics, human rights and personal preference as tedious, humanistic scruples that merely get in their way. Increasingly, however, it is recognised that the double standard that allows female genital mutilation to be condemned and punished but male circumcision to be tolerated and even promoted as “necessary for health” (as Reeves claimed with respect to Mrs DeWaegeneire) cannot be sustained. If it is wrong to remove a female’s genitals without her fully informed consent, how can it be acceptable to remove part of a male’s genitals without his fully informed consent? In this age of gender equality, this is one form of discrimination that will come under ever-sharpening scrutiny. <h3>What Does “Informed Consent” Mean?</h3> The following definition was given by Justice Woods at Reeves' trial in 2011 As a matter of law, any person has a right to his or her bodily integrity. In the context of this case, the law says that medical surgery cannot be performed on an adult person except with the voluntary and informed consent of the patient. “Consent” means “agreement”. Consent may be in writing, or spoken, so long as it is voluntarily given. To be valid, consent must be “informed”. This means that the medical practitioner must at least explain to the patient the purpose of the operation, the part or parts of the body to be cut or removed, the possible major consequences of the operation, and any options or alternative treatments which may be reasonably available. The explanation must be given at a time when the patient is conscious. If the patient is affected by drugs or anaesthesia, a purported consent at that time may be invalid if the patient cannot understand it. An explanation given in merely technical medical language may also fail to lead to valid consent, because the patient does not understand it or is misled by it. The purpose of the consent procedure is to inform the patient and to obtain the patient’s agreement to what is performed. If the explanation is not communicated adequately, by clear writing and/or words, the meaning of which she can grasp, the patient may not understand the explanation, or a vital part of it. If so, it cannot be said that there is “informed consent.” <a href="http://www.caselaw.nsw.gov.au/action/PJUDG?jgmtid=163170" rel="noopener" target="_blank">Full judgement available at Caselaw New South Wales</a> <h3>Earlier report:</h3> <h2>Genital mutilation doctor guilty of assault</h2> A former New South Wales doctor who excised a woman’s external genitals during an operation to remove a small patch of discoloured tissue on her labia has been found guilty of assault occasioning grievous bodily harm. His victim, aged 58 at the time of the operation, told the court that the doctor had informed her that he was going to remove a lesion, but never mentioned removing anything else. If he had, she said “I would never have walked through that hospital door to start with”. The doctor’s defence, that the complete removal of the woman’s external genitalia was necessary to stop a cancerous growth from spreading, was rejected as spurious. The doctor’s name has been suppressed by the court, though will presumably be revealed when he comes up for sentencing at a later date. The case outcome has been reported in most of the Australian news media and the ABC. The following report is from the Sydney Daily Telegraph. A FORMER NSW doctor has been found guilty of maliciously inflicting grievous bodily harm on a patient whose genitals he removed without her consent. The doctor had told a nurse that the patient's husband was dead “so it did not matter anyway” that he had taken her clitoris during the operation, the Sydney jury heard. The doctor, who cannot be named for legal reasons, denied maliciously inflicting grievous bodily harm (GBH) on Carolyn DeWaegeneire with intent to cause her GBH in 2002. But late this afternoon, the NSW District Court jury found him guilty after another jury failed to reach a verdict last year. Ms DeWaegeneire, 58 at the time of the operation, told the jury the doctor had informed her he was going to remove a lesion but never mentioned taking anything else, including her clitoris. If he had, “I would never have walked through that hospital door to start with”, she said, adding she “never, never, never, never” would have consented to the removal of her genitals. She had sought treatment for a small patch of discoloured skin on her labia, later identified as a form of pre-cancer. Ms DeWaegeneire said the doctor told her of his intention when she was about to pass out from anaesthesia on the operating table. “He leaned over me and, for my ears only, he said: ‘I’m going to take your clitoris too’,” she said. She told the jury there was “nothing” left of her genital region. It was “all gone”. Theatre nurse Sharon Demmery said she remembered the operation because of the large size of the tissue which was taken from the patient. “I said, ‘That is fairly radical’, and (the doctor) said, ‘Yes, if I didn’t take that much, the cancer would spread’,” Ms Demmery said. She said something came up about the clitoris, and she told the doctor, “You wouldn’t be taking my clitoris, no matter what.” He then said that “the patient’s husband was dead so it did not matter anyway.” The doctor had maintained that, far from having an intention to inflict harm on the woman, he was “trying to save her life”. He said he honestly believed the surgery was needed for her health. Judge Greg Woods will sentence him at a later date. Margaret Scheikowski, Former doctor guilty of removing Carolyn DeWaegeneire's genitals without consent, <a href="http://www.dailytelegraph.com.au/news/former-doctor-guilty-of-removing-carolyn-dewaegeneires-genitals-without-consent/story-e6freuy9-1226019237310">Daily Telegraph</a> (Sydney), 11 March 2011 <h2>Comment by CIA</h2> <h3>Double standard on genital mutilation must be questioned</h3> While we will all be shocked at this appalling example of medical mayhem, and will applaud the fortitude of Ms DeWaegeneire in facing public humiliation to bring this butcher to justice, we should also spare a thought for the many other victims of genital mutilation whose cases do not reach the courts or the newspapers. We refer, of course, to the thousands of unnecessary circumcision operations performed each year on male infants and boys in New South Wales, all of whom would also have fled from the hospital if they had known what was being done to them and if they had the power to resist or run away. Circumcision may not be as radical or as crippling a surgery as the excisions performed on Ms DeWaegeneire, but it is just as gross an affront of a person’s bodily integrity and human dignity, just as gross a violation of the principles of medical ethics, and just as unnecessary. Without wishing in any way to minimise the enormity of this case, we suggest that in, some ways, routine circumcision of infants and boys is even worse than what was done to Ms DeWaegeneire. She really did have a pre-cancerous lesion on her genitals that needed limited surgery; none of the infants and boys routinely circumcised have anything wrong with their genitals, and did not need any kind of surgery at all. She gave limited consent to a minimal procedure; the infants and boys gave no consent at all. She had already experienced a full life with a complete body and a normal set of genital organs; circumcised infants and boys will never know what it is like to have a complete body and a normal set of natural genitals. The doctor’s defence also demands analysis. He was, he claims, “only trying to save her life”, and “honestly believed” that the surgery was necessary for the woman's health. We have heard this defence somewhere before, namely, in every justification for routine circumcision that has ever been attempted. “You may not like circumcision”, say the circumcision promoters, “but it is necessary for your future health; and if you refuse to accept it voluntarily, it must be imposed on you by force, for your own good.” There is no difference at all between Dr X’s defence here and the arguments put forward by circumcision promoters, both in Australia and overseas. They, too, “honestly believe” that removal of part of a boy’s genitals is necessary to save his life, and they they regard issues such as informed consent, medical ethics, human rights and personal preference as tedious humanistic scruples that merely get in the way of their knives. We wonder whether this doctor was as fond of circumcising male infants and boys as he was of performing mutilating operations on women, and if so, why one of these hobbies is regarded as a monstrous crime and the other as medical treatment. Increasingly, however, it is recognised that the double standard that allows female genital mutilation to be condemned and punished but male circumcision to be tolerated and even promoted as “necessary for health” (as this Dr X claimed with respect to Ms DeWaegeneire) cannot be sustained. If it is wrong to remove a woman’s genitals without her fully informed consent, how can it be acceptable to remove part of a man’s genitals without his fully informed consent? In this age of sexual equality, this is one form of discrimination that cannot be allowed to continue. NOTE: We find it strange and unfair that the name of the doctor has been suppressed, while his victim must face the glare of publicity. We do not know his name, and so cannot reveal it, but we suspect that entering the term “Butcher of Bega” into Google will bring up much relevant and interesting information about somebody who appears rather similar. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource New South Wales doctor guilty of genital mutilation darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> Circumcision is not appropriate for 21st Century Aussie boys. A definitive article in Australia’s leading child health journal confirms the judgement of Australian paediatricians since 1971 that boys should not be routinely circumcised as a health precaution. In a rebuff to the <a href="https://www.darboninstitute.org/child_health_experts_ridicule_american_circumcision_policy_statement" rel="noopener" target="_blank">American Academy of Pediatrics</a> (and by extension the <a href="https://www.darboninstitute.org/centers_for_disease_control_and_male_circumcision_americans_out_of_touch_and_living_in_the_past" rel="noopener" target="_blank">Centers for Disease Control</a>, which repeats its errors) the article endorses the conclusion of the circumcision policy statement issued by the Royal Australasian College of Physicians in 2010, namely, that there is no medical warrant for routine circumcision in the Australian and New Zealand context. The paper, by leading Australian child health authorities, runs through the reasons traditionally cited for non-therapeutic circumcision of infants and finds none of them convincing or sufficient. They particularly reject the common argument that circumcision should be performed in order to reduce the risk of HIV infection. Although there is evidence that circumcision can reduce the risk of disease transmission during unprotected intercourse with an infected female partner, all of it comes from studies of adult circumcision in under-developed African countries with both very high HIV prevalence and social and epidemiological conditions quite different from those in Australia. As the authors point out “Although most of the research on circumcision have sound scientific basis, its findings are usually only applicable to the specific socio-cultural context in which the study was conducted”, and they warn that too many authors “tend to prematurely extrapolate the data in an attempt to set national and international standards.” (Brian Morris: are you listening?) The authors also raise important questions of bioethics and human rights, pointing out that while adult males can give autonomous consent to circumcision for any reason, “it is difficult to argue the same ethical principles for infants.” While parents have “legal rights to consent for a medical procedure if it is in the child’s best interest,” it is difficult to justify circumcision “as being in the best interest of the infant when most uncircumcised Australian adult males themselves … are reluctant to undergo adult circumcision?” In other words, circumcision fails the imputed judgement test and violates the child’s right to a open future. The upshot is that paediatricians should seek to discourage parents from having their boys circumcised, as was the case back in the 1980s. Very few boys are circumcised these days, and the incidence is declining, meaning that the old, silly argument about “looking like his father” is no longer relevant. Quite the contrary: “as fewer children are being circumcised, parents’ priorities might have changed from making the boy to look like his father to allowing the boy to look more like the other uncircumcised boys at school.” The authors conclude that “although there is a benefit of circumcision in those with urogenital tract anomalies, in a healthy newborn, the disease in the foreskin is non-existent.” Taking into account the lack of significant medical benefits, risk of complications, the harms of foreskin loss, and the financial cost, routine circumcision in Australia “cannot be justified. From medical point of view, the ‘price’ is still too high.” Source: Angelika F. Na, Sharman P.T. Tanny and John M. Hutson. <a href="http://onlinelibrary.wiley.com/doi/10.1111/jpc.12825/full" rel="noopener" target="_blank">Circumcision: Is it worth it for 21st-century Australian boys?</a> Journal of Paediatrics and Child Health. Advance access, 12 February 2015. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Circumcision “not worth it” for Aussie boys darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Submission to Medical Benefits Schedule Review, October 2015</h2> <h2>Summary</h2> 1. Medicare guidelines state that benefits are payable only for procedures that are clinically necessary and are not payable for cosmetic procedures. 2. Australian and most world medical authorities have determined that non-therapeutic circumcision is not clinically necessary and is not recommended. 3. Despite this, Medicare pays a benefit for non-therapeutic (clinically unnecessary) circumcision of males at any age. 4. There are strong objections to non-therapeutic circumcision of male minors for medical, bioethical, human rights and financial reasons. 5. In view of Medicare rules and these objections, non-therapeutic circumcision should be deleted from the Medical Benefits Schedule. 6. This objective is most easily and equitably achieved by adding the words “where medically necessary” to each of the circumcision codes. <h2>Background</h2> In 1985, on the recommendation of the National Health and Medical Research Council, circumcision was removed from the Medical Benefits Schedule. For reasons explained below, the decision was soon reversed and the rebate restored. The lesson of the episode is that when Medicare was established in 1984-85 the government’s intention was that it would not cover non-therapeutic circumcision. A review of Medicare in 2011 found evidence that between 2 and 3 billion dollars are spent inappropriately each year. The review, by Dr Tony Webber, noted that Medicare’s no-questions-asked policy led to serious financial abuses and failed to take account of the medical business environment: “The MBS [Medical Benefits Schedule] is riddled with misdirected incentives for practitioners … and has many examples of good public policy being thwarted by the MBS rules”. Among the abuses, he mentions cases where “the Safety Net was used in effect to subsidise cosmetic procedures such as surgery for designer vaginas at $5000-$6000 each”. In a related study, Elshaug et al (2012) identified 150 low value medical procedures whose presence on the MBS demanded scrutiny. Among these (listed in the appendix to their paper) was neonatal circumcision, with the comment “Current evidence fails to recommend widespread neonatal circumcision for the prevention of sexually transmitted infections, urinary tract infections and penile cancer”, citing Perera et al 2010. At the same time a planned review of specifically paediatric surgery was established by the Department of Health and Ageing (2013) with a view to assessing the justification for Medicare coverage of a range of paediatric surgical procedures, including “the safety, effectiveness, cost effectiveness, and appropriate clinical use of excision of pre-auricular sinus (MBS item 30104), repair of tongue tie (MBS items 30278 and 30281), circumcision (MBS items 30653, 30656 and 30660).” In May 2012 a poll in the Sydney Morning Herald found that 67 per cent of respondents were in favour of dropping circumcision from the MBS, and in August a survey in Australian Doctor showed that 51 per cent believed that circumcision was child abuse and should not be done at all, while a further 23 per cent believed that it was an individual choice that should neither be available in public hospitals nor funded by Medicare (Hartley 2012). It is thus evident that there is widespread concern both within the medical community and among the public at large that Medicare continues to subsidise a cosmetic procedure that is increasingly regarded as analogous to designer vaginas, namely, surgery for “designer penises” – that is to say, non-therapeutic (medically unnecessary) circumcision of male infants and boys. This is despite the fact that no medical organisation in the world recommends circumcision as a routine procedure, and that Australian health authorities have consistently recommended against the procedure since 1971. There is no reason why the over-stretched health budget should continue to waste taxpayers’ money by paying for an operation, usually on non-consenting children, that medical authorities judge to be medically unnecessary, risky, potentially harmful, and contrary to accepted principles of medical ethics and human rights. <h2>Introduction</h2> Although Australian medical authorities do not recommend circumcision as a routine or prophylactic procedure, Medicare continues to provide an automatic rebate for such operations, whether medically required or not. The medical validity, appropriateness, ethics and even the lawfulness of this policy have been questioned in recent years. In this submission I argue that for reasons of consistent public policy, financial prudence and respect for established principles of bioethics, human rights, gender equity and law the rebate should be abolished except for cases of proven medical need. The Australian government is under pressure to balance budgets, give more recognition to individual human rights, promote gender equity and protect children from harm. One simple way to make progress on all these fronts is to drop non-therapeutic circumcision from the Medical Benefits Schedule. I follow the definition of non-therapeutic given by the Tasmania Law Reform Institute (2009, p. 7): “A circumcision is non-therapeutic if it is performed for any reason other than remedying or treating an existing disease, illness or deformity of the body. … A circumcision performed for the purpose of preventing or reducing the likelihood of possible future disease, illness or deformity of the body (a prophylactic circumcision) is a non-therapeutic circumcision.” Medicare currently provides an automatic, no-questions-asked rebate for circumcision, despite the fact that the vast majority of these operations have no medical indication, and in defiance of Medicare’s own guidelines. These state that benefits are not payable for “medical services which are not clinically necessary”, nor “surgery for cosmetic reasons”. A medical procedure is clinically necessary only if it is essential to correct a diagnosed disease, injury, deformity or other pathological condition that has not responded to conservative (non-surgical) treatment. Surgery for any other reason, particularly cultural or social reasons, is essentially cosmetic surgery, intended to alter the appearance of the body part in question. As the Royal Australasian College of Surgeons (2008) points out, “male non-therapeutic circumcision is not clinically necessary as it does not treat an underlying pathological process.” <h2>Opinions of medical authorities</h2> Australian medical authorities have sought to discourage routine (medically unnecessary) circumcision since the early 1970s. In fact, the government did drop circumcision from the MBS in 1985, only to restore it a few weeks later, for reasons explained below. Nonetheless, Australian medical authorities have maintained their opposition to the practice, with the result that the incidence of circumcision in Australia continues to decline (Cozijn 2013). The most recent statement (October 2010) by the Royal Australasian College of Physicians states clearly: “After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.” Stronger statements against routine circumcision have been issued by the British Medical Association (2007), the Canadian Pediatric Society (2015), the Royal Dutch Medical Association (2010), the South African Medical Association, and medical authorities in Germany, Denmark, Finland, Norway and Sweden. Even in the United States, where routine circumcision is deeply entrenched as a medicalised cultural ritual, the American Academy of Pediatrics, although stating in its 2012 policy that the benefits exceed the risks, does not recommend the operation or regard it as medically necessary. Even this moderate position has been heavily criticised by child health experts (Frisch et al 2013) and bioethicists (Svoboda and Van Howe 2013; Darby 2015), and it has been rejected by health authorities in Australia. (Na et al 2015; Forbes 2015). In any case, the opinions of the AAP have no weight in Australia, where the relevant authority is the RACP. There are six other reasons why non-therapeutic circumcision should be dropped from the MBS. These relate to the absence of a convincing health case; conformity with international practice; principles of ethics and human rights; gender equity; legal issues; and financial prudence. <h2>1. No health case for routine circumcision</h2> It is not only the authorities mentioned above that have examined the medical literature and concluded that there is no health case for routine circumcision of infants or boys. Studies by Malone and Steinbrecher (2007) and Perera et al (2010) subjected the claims of circumcision advocates to an exhaustive review, and concluded that its value for child health was insignificant. When the medical literature is considered as a whole there is no proof that circumcision provides any significant protection against urinary tract infections, sexually transmitted infections or cancer of the penis. The only evidence for prophylactic efficacy came from Africa, where there was evidence that adult males who got themselves circumcised had a slightly lower risk of contracting HIV through unprotected intercourse with an infected female partner. As Perera et al comment, however, Africa has unique health problems. The circumcision trials were on adult men and can no more be applied to children than the World Health Organisation recommendations for the underdeveloped world can be transferred to a developed country like Australia. In Australia, unlike in Africa, HIV-AIDS is not a heterosexual epidemic, but a relatively rare disease confined to specific sub-cultures – homosexual men and injecting drug users. It is well established that these groups can derive no protection from circumcision at all. In any case, because it is a disease of promiscuous adults, children are not at risk of infection – unless by surgery. When they become sexually active boys are old enough to understand the issues and make their own decisions about how to manage the risks of sexual activity with others. The Australian Federation of AIDS Organisations (2007) has stated that circumcision has no relevance to Australia’s HIV problem, and their conclusion has been endorsed in a paper by Darby and Van Howe (2011) which argues that circumcision is not a surgical vaccine and is not appropriate as an HIV control tactic in developed countries such as Australia. These conclusions have been confirmed by Bossio et al (2014), which points out that the evidence for circumcision having a protective effect against heterosexually transmitted HIV is not applicable to developed countries such as the United States or Australia. <h2>2. International practice</h2> Australia is the only country in the world that provides automatic coverage of circumcision through the health budget. This policy is despite the fact that most State governments (Victoria, Western Australia, Tasmania, New South Wales and South Australia) do not provide free coverage of circumcision in public hospitals, and it is in sharp contrast with the practice of comparable developed nations. • In Britain the National Health Service has never included routine circumcision among its free procedures, and covers it only as a therapeutic procedure in cases of medical necessity. The same is true of New Zealand. • In Canada, where medical insurance is the responsibility of the provinces, the only province to include circumcision in its cover is Manitoba; and even there many doctors refuse to charge the state but bill the parents. • In the United States, the federal government provides the funds for public health insurance to the states, which make their own decisions as to which services they cover. When the program was introduced in 1965 all states covered circumcision, but since then 18 of the 50 states have ceased to fund it, and more are likely to do so as budgetary constraints intensify (Craig and Bollinger 2006). • The Dutch national health insurance service withdrew coverage of non-therapeutic circumcision in 2004 when it was realised that 90 per cent of the procedures were done for religious/cultural rather than for health-related reasons. • Circumcision is not funded by the Israeli government, but remains the responsibility of and a charge to each Jewish family. • Circumcision is not funded by the governments of Israel, Turkey, Indonesia, Iran or any other predominantly Islamic country where the procedure is widely practised as a cultural/religious ritual, not even when the operation is performed in hospitals rather than (as is traditional) in the boy’s home. Further details and references are provided in Darby (2011). <h2>3. Ethics and human rights</h2> For a surgical intervention to be ethically permissible the fundamental requirement is that the person must give informed consent. An adult male can consent to having himself circumcised, but the question becomes difficult when parents wish to circumcise their children because minors can no more consent to surgery than to sexual relations with adults. Circumcision of children thus deprives them of choice and amounts to coercion. The problem is especially relevant to Medicare, since the vast majority of the circumcision procedures that it covers involve children. In FY 2010-11, of 25,842 circumcision procedures funded by Medicare, 22,491 (88%) were on boys aged under 10 years, and of these 18,503 (71% of the total) were aged less than 6 months. Very few of these operations could be regarded as therapeutic or clinically necessary. An additional 2641 procedures were on males aged 10 years or more, but Medicare provides no breakdown as to how many of these are adults and how many are still minors, though it is clear enough that very few adult males elect to have themselves circumcised. Surrogate consent for surgery on minors is valid only for life-saving medical treatment, or where the procedure is manifestly and uncontroversially in the best interests of the child and passes the imputed judgement test – that is, it is an operation the child would choose for himself if he were competent. It has been strongly argued that, in the absence of a life-threatening disorder, surrogate consent for non-therapeutic surgery such as circumcision is ethically problematic and may not be legally valid. When there is no urgency to intervene, it is best to wait until the child can make his own choice. In addition to informed consent, leading bioethicists propose five conditions that must be met in order for a medical procedure to be ethically permissible. Beneficence — Does the proposed procedure provide a net therapeutic benefit to the patient, considering the risk, pain, and loss of normal function? Non-maleficence — Does the procedure avoid permanently diminishing the patient in any way that could be avoided? Proportionality — Will the final result provide a significant net benefit to the patient in proportion to the risk undertaken and the losses sustained? Justice — Will the patient be treated as fairly as we would all wish to be treated? Autonomy — Lacking life-threatening urgency, will the procedure honour the patient’s right to his or her own likely choice? Could it wait for the patient’s assent? Non-therapeutic circumcision of minors fails all these tests. It is not beneficent because it does not provide a therapeutic benefit (nor even a relevant prophylactic benefit, since a child is at zero risk of sexually transmitted infections ). It is malefic because it diminishes the genitals. It is disproportional because the net gain (if any) is out of proportion to the loss, harm and risk of complications. It is unjust because adult preferences show clearly that if he had a choice in the matter the boy would refuse the operation. Finally, and most importantly circumcision fails to respect the boy’s autonomy and preserve his future options as an adult individual (Sarajlic 2014). The British Medical Association and the Royal Dutch Medical Association have issued particularly strong warnings that non-therapeutic circumcision of minors is likely to breach accepted principles of bioethics and potentially of the law. In its policy statement (May 2010) the latter states: “Non-therapeutic circumcision of male minors is contrary to the rule that minors may only be exposed to medical treatments if illness or abnormalities are present, or if it can be convincingly demonstrated that the medical intervention is in the interest of the child, as in the case of vaccinations”; and further that such interventions violate “the child’s right to autonomy and physical integrity.” The RACP agrees: “The option of leaving circumcision until later, when the boy is old enough to make a decision for himself does need to be raised with parents and considered. … The ethical merit of this option is that it seeks to respect the child’s physical integrity, and capacity for autonomy by leaving the options open for him to make his own autonomous choice in the future.” International instruments are also relevant. Article 8 of the UNESCO Declaration on Human Rights and Bioethics (2005) states that “In applying and advancing scientific knowledge, medical practice and associated technologies, human vulnerability should be taken into account. Individuals and groups of special vulnerability should be protected and the personal integrity of such individuals respected.” Children certainly fall into this category. Given the government’s commitment to enhancing Australia’s commitment to individual human rights, it is highly anomalous that it allows Medicare to subsidise and thus encourage a disfiguring operation that denies them to so many children. The ethical status of non-therapeutic circumcision of minors has been under a cloud for the last couple of decades (Svoboda et al 2000) and has been the subject of so many critiques that it must now be regarded as highly controversial; while there is no consensus on the issue, it is clear that the majority view from the bioethical and human rights community is that the procedure is not significantly different from female genital mutilation and should be subject to similar restrictions (Earp 2015). For a summary of current opinion, see the special issue of the Journal of Medical Ethics, July 2013. <h2>4. Gender equity</h2> Australia’s obligations under the Sex Discrimination Act 1984 and as a signatory to the United Nations Convention on the Rights of the Child require the national and State governments to treat males and females equally and without discrimination on the basis of sex, and to take action to eradicate traditional practices harmful to children. Article 24 (3) of the Convention requires parties to take “all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children.” In pursuance of this development several States passed laws to prohibit any form of female circumcision, and in 1995 the Commonwealth specifically excluded such procedures from the Medical Benefits Schedule. Although there was nothing in the wording of the Convention to suggest that it did not include male children, no action has yet been taken to protect boys. This failure is increasingly recognized, in Ranipal Narulla’s (2007) words, as “a hidden human rights violation”. The Commonwealth Sex Discrimination Act, Section 3 (b), states that the Act applies to the administration of Commonwealth laws and programs, while Section 22 (b) makes it illegal to discriminate on the basis of sex in the provision of goods, services and facilities. It could be argued that the exclusion of female circumcision from the MBS is a breach of this provision, since it denies to women a benefit given to men. Whether or not circumcision is regarded as a benefit or a deprivation, it is certainly anomalous and inconsistent that the MBS specifically denies coverage for cutting procedures on the female genitals while providing a no-questions-asked rebate for comparable procedures on the genitals of boys. The simplest way to remove such discrimination and restore the principle of equal treatment is to limit coverage of male circumcision to cases of proven medical necessity. <h2>5. Legal issues</h2> In recent times it is not merely the ethics but even the legality of circumcision that has been questioned. In 1993 the Queensland Law Reform Commission observed that non-therapeutic circumcision of minors was probably unlawful under the common law of assault, as well as specific provisions of the Queensland criminal code covering assault, injury and sexual assault. More recently an exhaustive review of the ethical and legal status of non-therapeutic circumcision by the the Tasmania Law Reform Institute (2012) concluded that there was no medical justification for the operation, that it was dangerously unregulated, and recommended a range of legal reforms, including partial prohibition in the case of incompetent minors. Given the controversial status of non-therapeutic circumcision of minors and the lack of proof as to medical need or even significant benefit, doubts have been raised as to the legality of health insurance payments. A study by a United States legal expert (Adler 2011) argues that payments for non-therapeutic (medically unnecessary) circumcision by the US health insurance scheme Medicaid violate the protocols for benefits under this program and are thus unlawful. The article shows that the federal and state Medicaid acts stipulate that physicians and patients can use Medicaid to pay for medical services only when they are clinically necessary. This provision clearly excludes non-essential medical services, and some states expressly exclude cosmetic surgery from the list of covered treatments. In addition, federal and state Medicaid law require diagnosis of a medical condition and recommendation of an effective treatment before any benefit is payable. Medicare has not been the subject of such a study, but it is quite possible (given the guidelines) that its own payments for non-therapeutic circumcision are not authorised by Parliament and are thus unlawful. <h2>6. Economy and financial prudence</h2> All government welfare programs should be targeted at genuine need and be administered with prudence and economy. An open-slather approach to funding a medically unnecessary procedure is wasteful and invites over-servicing. It also acts as a signal that circumcision is a socially acceptable and even medically recommended operation, thus encouraging more parents to seek to have it done. Assuming 15,000 unnecessary circumcision procedures per year at a cost of between $100 and $1600 each, Katrina Spilsbury and colleagues (2003) have estimated that the removal of medically unnecessary circumcision from the MBS would save between $1.5 million and $24 million per year. They state that “the potential savings to the public purse would be considerable if elective and discretionary circumcision was removed from the Medicare schedule in line with other cosmetic surgeries, leaving rebates for the genuine medically indicated circumcision.” According to figures available on the Medicare website, the total cost of the rebate for all circumcision procedures in FY 2010-11 was $1,577,754, nearly half of which went to subsidise operations on infants less than 6 months old, almost none of whom could have had a genuine medical indication. This is not a large sum in the overall budget context, but the real cost to the government will be considerably higher, given that this figure does not include the cost of treating complications and long-term adverse effects, which may not become apparent until adolescence. A cost-utility analysis of neonatal circumcision by American researcher Robert Van Howe (2004) found that even if the extreme claims of circumcision advocates were true, the associated complications and adverse outcomes would cancel out and exceed the benefit to health by a considerable margin. On top of this there may be losses to revenue arising from tax rebates that parents are able to claim under the Medicare safety net for expenses related to child-bearing. These may not substantial sums in the context of today’s billion-dollar budgets, but when every effort is being made to rein in public expenditure, especially the ever-expanding health budget, every million saved can help to make a difference. If the rebate had been abolished in 1985 as intended, the accumulated savings would have been quite significant. And there are other reasons to predict that if the subsidy is retained expenditure will rise. 1. The high birthrate in Australia’s increasing Muslim community. Muslims traditionally circumcise boys and tend to prefer a clinical operation by a doctor rather than a traditional circumciser, unlike the Jewish people’s use of a mohel. Muslim doctors in Sydney are distributing advertising material which ignores the recommendations of the RACP and instead stresses the “medical benefits” of circumcision, suggesting that they seek to attract paying customers not merely from their co-religionists, but from the public at large. The presence of a financial rebate will make the procedure more attractive to parents and is likely to increase demand. 2. Irresponsible media commentary on the role of circumcision in controlling HIV and other STIs, as well as the efforts of circumcision promoters such as the “Circumcision Academy of Australia” and entrepreneurial circumcision practitioners, aim to generate a mood of alarm. The demand for circumcision could increase if parents are misled by their advocacy and become fearful of the alleged risks of not getting it done. It is thus possible that the cost of the circumcision subsidy will increase unless entitlement is restricted. Economists have shown that price signals are the most effective means of encouraging or discouraging consumer behaviour. This is highly relevant to subsidies for circumcision, as Craig and Bollinger (2006) found that the single most important factor governing the incidence of circumcision in the United States was whether the state provided a rebate under Medicaid. Removal of non-therapeutic circumcision from the MBS will send a clear signal to Australian parents that routine circumcision is not a medically recommended procedure and is not necessary for the health and well-being of their child. The main argument for dropping non-therapeutic circumcision from the MBS is not the cost-saving, however, but the principles of prudent and targeted assistance to those in need; of adherence to stated entitlement guidelines and lawful program administration; of respecting current expert medical advice; of observing accepted principles of ethics and human rights; and of avoiding discrimination on the basis of sex. Allowing Medicare to provide a rebate for non-therapeutic circumcision sends the wrong signals to parents, suggesting that it is a socially and medically approved procedure, and thereby encouraging the practice. <h2>Cultural and religiously motivated circumcision not affected</h2> There is nothing in this proposal that will limit the right of parents to circumcise their children if they feel they have a compelling cultural or religious reason, merely that they will not receive a public subsidy for doing so. There is no intent to restrict the right of Jewish, Aboriginal or Muslim parents to circumcise their children in accordance with their respective traditions; but equally there is no reason why such cultural/religious rites and practices should be funded by the Australian taxpayer through the health budget. It is true that when the Hawke government dropped circumcision from the MBS in 1985 it faced protests from Jewish community leaders and soon backed down, leading to the development of the myth that there was a “community backlash” and discouraging further attempts. This myth has been disproved in my study of the incident, published in the international journal Hygiea (Darby 2011). My conclusions are that the decision was justified on medical and public policy grounds; that there was no wide public outcry and, indeed, that the decision was widely approved; and that the rapid reversal of the decision was the result of inept implementation, failure to consult, and a fortuitous combination of subsequent factors, including, vigorous lobbying by the groups who felt most deeply affected. The main objection of Jewish community leaders was not to the dropping of the rebate in itself, but the fact that it was dropped only from the code for circumcision of boys under 6 months, leaving the rebate in place for operations at later ages. Since Jewish people traditionally circumcise at 8 days, they justifiably felt that this was unreasonable discrimination. It is not clear why the government, rather than abjectly restoring the rebate, did not resolve the problem by requiring a medical indication at all ages, as would have been the simplest, most economical and most equitable course of action. The government now has the opportunity to rectify this mistake. If a proven medical requirement is attached to each of the codes for circumcision, there is no reason why the sensibilities of the Moslem and Jewish communities should be affronted, since the new rules would apply to everybody in the community, without discrimination. The lesson of 1985 is that a controversial procedure such as circumcision must be approached with tact and sensitivity to cultural sensibilities. It may be necessary to consult with Jewish and Muslim community organisations, and it is vital not to repeat the mistakes made in 1985, and especially the deadly mistake of limiting removal of the rebate to a specific age-group. Nobody likes having to pay more for a good or service, but so long as all age groups and cultural identities are treated equally there should be no valid grounds for complaint. <h2>Conclusion</h2> There is no reason why Medicare, and thus the Australian taxpayer, should continue to fund operations that medical authorities have defined as unnecessary and potentially harmful, and which many people regard as an violation of the rights of the child, or even genital mutilation. The government must face up to its responsibilities, bite the bullet, rectify the mistakes it made in 1985, and delete non-therapeutic circumcision from the Medical Benefits Schedule. <h3>Appendix: Relevant MBS codes and payments (as at 1 January 2012)</h3> 30653: Circumcision of a male under 6 months of age Scheduled fee: $45.65; Benefit: $34.25 (75%); $38.85 (85%) 30656: Circumcision of a male under 10 years of age but not less than 6 months of age Scheduled fee: $106.15; Benefit: $79.65 (75%); $90.25 (85%) 30659: Circumcision of a male 10 years of age or over by a GP Scheduled fee: $146.95; Benefit $110.25 (75%); $124.95 (85%) 30660: Circumcision of a male 10 years of age or over by a specialist Scheduled fee: $182.15; Benefit $136.65 (75%); $154.85 (85%) 30663: Haemorrhage, arrest of, following circumcision requiring general anaesthesia Scheduled fee: $141.65; Benefit $106.25 (75%); $120.45 (85%) Until 1995 these codes were unisex and read “circumcision of a person”, thus authorising a benefit for circumcision of females as well as of males. In order to protect girls from genital mutilation as part of the general development of laws and policies against FGM that followed the passage of the UN Convention on the Rights of the Child, “person” was changed to “male”, thus introducing two elements of discrimination: females were denied a service that remained available to males; but males were denied the protection that was accorded to females. The deletion of non-therapeutic circumcision from the schedule can be effected by simply by adding the phrase “where medically indicated” to each of the codes above. “Medically indicated” means a case where (1) there is a medical problem that has not responded to conservative (non-surgical) treatment after reasonable efforts; and (2) this is certified by two qualified medical practitioners, one of whom must be an appropriate specialist, and neither of whom may be the surgeon or other operator who is to perform the surgery. <h2>Selected references</h2> Adler, Peter. 2011. Is it lawful to use Medicaid to pay for circumcision? Journal of Law and Medicine, Vol. 19, December 2011: 335-353. Australian Federation of AIDS Organisations. 2007. Male circumcision has no role in the Australian HIV epidemic. Briefing paper, 23 July 2007. Beauchamp TL, Childress JF. 2009 Principles of Biomedical Ethics (6th edn). Oxford University Press: 2009. Bossio JA, Pukall CF, Steele S. 2014. A review of the current state of the male circumcision literature. J Sex Med. 2014 Dec;11(12):2847-64. doi: 10.1111/jsm.12703 British Medical Association. 2007. <a href="https://www.circinfo.org/doctors.html" rel="noopener" target="_blank">The Law and Ethics of Male Circumcision: Guidance for Doctors</a> (November 2007). Cozijn. J. 2013. <a href="https://www.circinfo.org/statistics.html" rel="noopener" target="_blank">Incidence and prevalence of circumcision in Australia</a>. Craig A. and Bollinger D. 2006. Of waste and want: A nationwide survey of Medicaid funding for medically unnecessary, non-therapeutic circumcision. In George C. Denniston et al (eds.), Bodily Integrity and the Politics of Circumcision: Culture, Controversy and Change (New York, Springer, 2006). Darby, Robert. 2011. “Scientific advice, traditional practices and the politics of health-care: The Australian debate over public funding of non-therapeutic circumcision, 1985.” Hygiea Internationalis: An Interdisciplinary Journal for the History of Public Health, Vol. 10, December 2011. <a href="https://www.academia.edu/7028494/Scientific_advice_traditional_practices_and_the_politics_of_health-care_The_Australian_debate_over_public_funding_of_non-therapeutic_circumcision_1985" rel="noopener" target="_blank">Available at Dr Darby's Academia.edu page</a>. Darby, Robert and Robert Van Howe. 2011. Not a surgical vaccine: There is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia. Australian And New Zealand Journal of Public Health, Vol. 35, October 2011: 459-465. Darby, Robert. 2015. Risks, benefits, complications and harms: Neglected factors in the current debate on non-therapeutic circumcision. Kennedy Institute of Ethics Journal, Vol. 25 (1), March 2015: 1-34. Department of Health and Ageing. 2013. MBS Reviews, Paediatric Surgery – Scope. Discussion paper draft (February). Earp, Brian. 2015. <a href="https://www.dovepress.com/articles.php?article_id=23974" rel="noopener" target="_blank">Female genital mutilation and male circumcision: Toward an autonomy-based ethical framework</a>. MedicoLegal and Bioethics 2015; 5 (3 Oct): 89-104. Elshaug AG, Watt AM, Mundy L, Willis CD. 2012. Over 150 potentially low-value health care practices: an Australian study. Med J Aust 2012; 197: 556-560. doi: 10.5694/mja12.11083. Forbes, David. 2009. <a href="http://www.smh.com.au/national/letters/no-evidence-to-support-routine-circumcision-20090911-fkna.html" rel="noopener" target="_blank">No evidence to support routine circumcision</a>. Sydney Morning Herald, 12 September 2009. Forbes D. 2015. Circumcision and the best interests of the child. J Paediatr Child Health. 2015 Mar;51(3):263-5. doi: 10.1111/jpc.12853. Frisch, Morten, et al. 2013. Cultural bias in the AAP’s 2012 Technical Report and Policy Statement on male circumcision. Pediatrics 131 (4): 796-800. Hartley, Jo. 2012. <a href="https://www.australiandoctor.com.au/news/latest-news/strong-opposition-to-newborn-circumcision" rel="noopener" target="_blank">Strong opposition to newborn circumcision</a>, Australian Doctor, 9 August 2012. See also: <a href="https://www.circinfo.org/news_2012.html#flop" rel="noopener" target="_blank">Morris, Wodak circumcision campaign falls flat</a> <a href="https://www.circinfo.org/news_2012.html#poll" rel="noopener" target="_blank">Aussies give thumbs down to circumcision</a> Malone, Padraig, and Steinbrecher H. 2007. Medical aspects of male circumcision. British Medical Journal 2007; 335: 1206-1209. Na AF, Tanny SP, Hutson JM. 2015. Circumcision: Is it worth it for 21st-century Australian boys? J Paediatr Child Health. 2015 Jun;51(6):580-3. doi: 10.1111/jpc.12825. Narulla, Ranipal. 2007. Circumscribing circumcision: Traversing the moral and legal ground around a hidden human rights violation. Australian Journal of Human Rights, Vol. 12, 2007, 89-118. Perera, C.L, F.H. Bridgewater, et al. 2010. Safety and efficacy of nontherapeutic male circumcision: a systematic review. Ann Fam Med 8(1): 64-72. Royal Australasian College of Physicians. <a href="http://www.racp.edu.au/page/policy-and-advocacy/paediatrics-and-child-health" rel="noopener" target="_blank">Circumcision of Infant Males [Policy statement]</a>. Sydney: October 2010. Available at Royal Australasian College of Surgeons. 2008. Australian Safety and Efficacy Registry of New Interventional Procedures – Surgical. Report No. 65: Male non-therapeutic circumcision. Adelaide: RACS, 2008. Royal Dutch Medical Association. 2010. <a href="https://www.circinfo.org/Dutch_circumcision_policy.html" rel="noopener" target="_blank">Non-therapeutic Circumcision of Male Minors</a> (May 2010). Sarajlic, Eldar. 2014. Can Culture Justify Infant Circumcision? Res Publica 20 (4). November 2014, 327-343. DOI 10.1007/s11158-014-9254-x Spilsbury K, Semmons JB, Wisniewski ZS, Holman CD. 2003. <a href="http://www.cirp.org/library/procedure/spilsbury1/" rel="noopener" target="_blank">Routine circumcision practice in Western Australia 1981–1999</a>. ANZ Journal of Surgery 2003;73(8):610-4. Svoboda JS, Van Howe RS, Dwyer JG. 2000. <a href="http://www.cirp.org/library/legal/conundrum/" rel="noopener" target="_blank">Informed consent for neonatal circumcision: An ethical and legal conundrum</a>. Journal of Contemporary Health Law and Policy 2000;17:61-133. Svoboda, J. Steven and Robert Van Howe. 2013. Out of step: Fatal flaws in the latest AAP policy report on neonatal circumcision. Journal of Medical Ethics 39 (7): 434-41. Sydney Morning Herald 12 May 2012, <a href="https://www.circinfo.org/news_2012.html#poll" rel="noopener" target="_blank">The Question: Should elective circumcision continue to be covered by Medicare?</a> Tasmania Law Reform Institute. 2009: Non-therapeutic Male Circumcision. Issues Paper No. 14. Tasmania Law Reform Institute. 2012. Non-Therapeutic Male Circumcision. Report No 17, August. University of Tasmania. Van Howe RS. 2004. <a href="http://www.cirp.org/library/procedure/vanhowe2004/" rel="noopener" target="_blank">A cost-utility analysis of neonatal circumcision</a>. Medical Decision Making 2004;24:584-601. Webber, T. 2012. What is wrong with Medicare?. Medical Journal of Australia 2012; 196 (1): 18-19. NOTE: This submission was prepared by Dr Robert Darby, Canberra. Australia. <a href="https://independent.academia.edu/RobertDarby" rel="noopener" target="_blank">Also available at his Academia.edu page.</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Medicare should not cover non-therapeutic circumcision darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Puzzling changes to Medicare coverage of circumcision</h1> <h3>Incidence of infant circumcision obscured, circumcision of girls now funded</h3> Despite several reviews and inquiries into medically unnecessary and low-value procedures, Medicare continues to provide a rebate for non-therapeutic circumcision of male infants and boys. Under changes to the codes that became effective in June 2016, however, it is now impossible find out how many circumcision procedures are performed on boys aged under 6 months. Even more alarming, it appears that Medicare is also paying for circumcision of girls – otherwise known as female genital mutilation (FGM). <h2>Background</h2> A <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/26CEC8388EE86854CA2580210016EF82/%24File/MBS-Review-Interim-report-Final-%204%20Oct.pdf" rel="noopener" target="_blank">report to the Minister for Health</a> arising from these inquiries did not pay much attention to circumcision (one of the low-value procedures identified in the reviews), but it did contain the following paragraph: “Less commonly mentioned was unnecessary surgical intervention. However, when this issue did arise, the implications in terms of unnecessary patient risk were often more serious. Commonly cited examples included inductions of labour and caesareans for no medical reason, knee arthroscopy for patients with osteoarthritis, and circumcision in healthy male infants. A number of respondents to the survey indicated that surgery should not be considered unless conservative treatments had been undertaken — for example, physiotherapy for incontinence or prolapse, or physiotherapy for back pain rather than spinal surgery.” Although <a href="https://www.circinfo.org/Medicare_coverage_for_circumcision.html" rel="noopener" target="_blank">several public submissions</a> urged that the rebate for non-therapeutic circumcision be entirely scrapped (as the government intended when Medicare was introduced in 1985), the only major change arising from the inquiries was the replacement of the relevant codes. The old codes were: 30653: Circumcision of a male under 6 months of age 30656: Circumcision of a male under 10 years of age but not less than 6 months of age 30659: Circumcision of a male 10 years of age or over by a GP 30660: Circumcision of a male 10 years of age or over by a specialist 30663: Haemorrhage, arrest of, following circumcision requiring general anaesthesia The new codes, operative since June 2016, are as follows: 30649 HAEMORRHAGE, arrest of, following circumcision requiring general anaesthesia on a person under 10 years of age 30654 Circumcision of the penis (other than a service to which item 30658 applies) 30658 Circumcision of the penis, when performed in conjunction with a service to which an item in Group T7 or Group T10 applies 30663 HAEMORRHAGE, arrest of, following circumcision requiring general anaesthesia on a person 10 years of age or over. <a href="http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Home" rel="noopener" target="_blank">Medicare codes may be searched here</a>. As a <a href="http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/news-2016-11-01-latest-news-Nov">Department of Health news item</a> (November 2016) stated: “The four circumcision items (30653, 30656, 30659 and 30660) have been removed and replaced with two new items (30654 and 30658). Item 30658 is for circumcision procedures performed under anaesthesia and item 30654 is for all other circumcision procedures.” It is not clear from the information readily available whether “under anaesthesia” means with a general anaesthetic (not possible with young babies), or whether “all other circumcision procedures” are performed without any anaesthetic at all. <h2>What is happening? The brute facts</h2> According to figures that can be searched at the <a href="http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp" rel="noopener" target="_blank">Medicare statistics portal</a> of the Department of Health, the number of circumcisions performed under item 30654 (all other procedures) in June 2017 was 854. Following the link to find the ages of these patients reveals the astonishing information that 15 of these procedures were performed on females, with an age breakdown as follows: 0-4 years 5 25-34 years 6 35-44 years 4 Of the 839 males circumcised: 0-4 years 798 5-14 years 20 15-24 years 6 – and the remainder at older ages. Figures for item 30658 (circumcision with anaesthesia) are even more alarming. In the second quarter of 2017 (March-May) 2328 circumcision procedures were performed, including 21 on females and 2307 on males. The age break down for the females was: 1-4 years 7 5-14 years 2 25-34 1 Of the 2307 males circumcised: 0-4 years 1262 5-14 years 399 15-24 years 185 <h2>So what is really happening?</h2> Until 1995 the Medicare circumcision codes were unisex and read “circumcision of a person”, thus authorising a benefit for circumcision of females as well as of males. In order to protect girls from genital mutilation as part of the general development of laws and policies against FGM that followed the passage of the UN Convention on the Rights of the Child “person” was changed to “male”. At the same time the Crimes Acts of all states were amended to make female genital cutting a criminal offence. The new provisions made no exception for culturally or religiously motivated circumcision, but they do allow a defence of medical necessity – that is, if the operation is judged to be necessary for the girl’s or woman’s health, it is then permissible. It is certainly possible that the procedures recorded here were deemed to be medically necessary, and thus not illegal, but it is still surprising to see female infants exhibiting such serious genital pathologies as would require circumcision. On top of that, we wonder who is making the judgement about medical need, and whether there is any safeguard against spurious or fraudulent claims. It also seems rather bizarre that a code described as “circumcision of the penis” can be used to fund circumcision of girls. A similar comment about medical need applies to the large number of baby boys still being circumcised and attracting a Medicare rebate. It does not seem credible that so many boys aged 1 to 4 years (over 1200 in only 3 months) had such serious foreskin problems that circumcision was really necessary, and one suspects that the real reason was cultural or religious, dressed up as medical need for the purpose of attracting the rebate. The report to the Minister noted that people were questioning why healthy boys should be circumcised at the expense of Medicare. In response, it would appear that the Government has changed the presentation of statistics in a way that makes it more difficult to work out how many juvenile circumcisions are taking place and impossible to determine how many neonatal circumcisions (i.e., circumcisions under the age of 6 months or one year) are being performed. Even more surprising, despite the new wording of the codes specifically referring to penises, it appears that little girls are also being subjected to circumcision procedures. <h2>Female genital mutilation: Hiding in plain sight under Medicare</h2> Further investigations by Mr Michael Glass, of Sydney, and Circumcision Information Australia have revealed the astonishing fact that Medicare began to provide a rebate for circumcision of females in 2013, wen the relevant codes were defined as “circumcision of a male”– a phenomenon that continued and increased when the new codes were introduced in 2016. Over the 20 years since Medicare statistics became available (1993-2003) there were more than 450,000 rebates for male circumcision. Although there were some cases where the gender of the patient was not specified, no case was recorded where Medicare paid for the circumcision of a patient classed as female. Starting in July 2013, Medicare began to subsidise the circumcision of women and girls. 4 years of female circumcision under Medicare In the 4 years from 1 July 2013 to 30 June 2017 Medicare paid for the circumcision of 256 girls under the age of 6 months. In the same period, Medicare also paid for the circumcision of 72 girls over the age of 6 months but less than 10 years. From 1 July 2013 to 30 June 2017, Medicare paid General Practitioners for the circumcision of 26 women and girls. 9 of these were girls from 5 to 14 years of age and a further 7 were between the ages of 15 and 24. (The rest were older.) From 1 July 2013 to 30 June 2017, Medicare paid specialists for the circumcision of 38 women and girls. 9 of these were girls from 5 to 14 years of age and a further 5 were between the ages of 15 and 24. (The rest were older.) Female circumcision under the new item numbers From 1 November 2016, the Medicare announced the removal of item numbers 30653, 30656, 30659 and 30660 and their replacement by two new item numbers, 30654 (all other circumcision procedures) and 30658 (circumcision with anaesthesia). In 8 months, Medicare Item number 30654 subsidised the circumcision of 158 women and girls, 44 of whom were under the age of 5 and 5 of whom were between the ages of 5 and 14. In 8 months, Medicare item number 30658, subsidised the circumcision of 53 women and girls, 18 of whom were below the age of 5 and 5 of whom were between the ages of 5 and 14. Altogether, in the 4 years since 1 July 2013, Medicare subsidised the circumcision of 603 women and girls, 272 of them (just over 45%) in the most recent financial year. Cost of the Medicare payments for circumcising females The total cost of the Medicare payments for circumcising females in the 4 years from 1 July 2013 to 30 June 2017 is $59,424. The total cost for circumcising females in the most recent financial year (2016/2017) is $29,347. It cost more than 49% of the total cost for the four years to circumcise just over 45% of the total number of females, so the cost to Medicare had risen even faster than the number of females who were circumcised. <h3>Comment</h3> For the last four years, Medicare appears to have been subsidising the circumcision of hundreds of women, girls and baby girls. Whether this is lawful or criminal depends on whether the operations can validly be judged to be medically necessary for the health of the patient. (This was <a href="https://www.circinfo.org/Genital_mutilation_doctor_guilty.html" rel="noopener" target="_blank">Dr Graeme Reeves' defence</a> and the reason the jury at his first trial was unable to reach a verdict.) While it is plausible that operations on adult women who have given informed consent is lawful, a big question mark hangs over the operations of female minors: is it really likely that hundreds of baby girls suffer from such severe genital pathologies that something called circumcision is required? It seems especially unlikely that the 256 girls below the age of 6 months circumcised between July 2013 and June 2017 really needed the operation for medical reasons. At a time when the government is desperate to save money, the cost of these procedures is also a matter for concern. The Medicare subsidy for this has cost the taxpayer $60,000. The Government and the taxpayer appears to have been defrauded this amount because the item numbers were supposed to be for the circumcision of males. The latest figures show that under the new Medicare numbers, the number of females circumcised has risen dramatically, but the cost to Medicare has risen even faster. <h2>Some parts of puzzle answered, but questions about FGM remain</h2> In response to inquiries from Mr Michael Glass, a Sydney human rights advocate, the Medicare statistics section has explained that the changes to the schedule were made in response to a directive from the Attorney General’s Department following amendments to the Sex Discrimination Act in 2013: According to Carla Cook, “The Department of Human Services complies with the 2013 direction of the Attorney-General’s department that introduced new protections from discrimination** on the grounds of sexual orientation, gender identity and intersex status in many areas of public life. As such, there are no gender based restrictions on accessing Medicare items.” In other words, the 1995 restriction on Medicare providing a rebate for female genital cutting has been removed in the name of non-discrimination. In response to questions about the legality of genital cutting procedures on women and girls Ms Cook further explained that all procedures under Medicare had to be clinically relevant in order to qualify for a rebate: “Medicare benefits are claimable only for ‘clinically relevant’ services rendered by an appropriate health practitioner. A ‘clinically relevant’ service is one which is generally accepted by the relevant profession as necessary for the appropriate treatment of the patient.” She added that “Services listed in the MBS must be rendered according to the provisions of the relevant Commonwealth, State and Territory laws.” ** This refers to a document called <a href="https://www.ag.gov.au/Publications/Pages/AustralianGovernmentGuidelinesontheRecognitionofSexandGender.aspx" rel="noopener" target="_blank">Australian Government Guidelines on the Recognition of Sex and Gender</a> (July 2013), published by Attorney General’s Department Mr Glass’s email and reply from Medicare statistics are below. <h2>Comment: A strange situation</h2> It does seem extraordinary that such startling changes to Medicare procedures should have occurred so quietly, without any comment in the media (so far as we are aware) and no alarm from women’s and human rights groups that it now covers circumcision of girls and women as well as boys and men. The rules state that all benefits (for males as much as females) are payable only for services that are clinically necessary for the person’s health; but the question is whether these rules are being observed and what safeguards are in place to ensure that they are observed and to prevent unscrupulous practitioners from rorting the system, defrauding the government and taxpayer, and (in the case of FGM) performing an illegal operation. We have always argued that the principles of gender equity and non-discrimination require that boys and girls enjoy equal protection under the law; but our position is that this should be achieved by raising the level of protection available to boys, not by reducing the level of protection for girls. If it is a crime to cut a female’s genitals without her informed consent, it should be a crime to cut a male’s genitals without his informed consent – allowing for genuine medical necessity in both cases. It is reasonable that women and girls should be able to receive a rebate for genital cutting operations that are genuinely medically necessary for their health, along with boys and men; it is unreasonable and unacceptable that any person, male or female, should receive a rebate in cases where the cutting is performed for cultural, religious, cosmetic, social or other non-medical reasons. <h3>Vital questions that must be answered</h3> We address the following questions to the Minister for Health: 1. Under the new Medicare codes, circumcision is classified as a therapeutic procedure, i.e. necessary to address a pathological problem that is not susceptible to conservative treatment. Furthermore, the rules state that a Medicare benefit is payable “only for ‘clinically relevant’ services rendered by an appropriate health practitioner”, i.e. a service “generally accepted by the relevant profession as necessary for the appropriate treatment of the patient.” What safeguards are in place to ensure that rebates provided under the new codes are in fact confined to therapeutic procedures, i.e. procedures that are clinically necessary to address a pathological condition? 2. Is the Minister confident that these codes are not being used to provide a rebate for circumcision performed for cultural, religious, social, cosmetic or other non-therapeutic reasons? 3. What safeguards are in place to ensure that the above rules are complied with and that the codes are not misapplied? 4. Information from a report to the Minister on the Department of Health website states that item 30658 is for circumcision performed under anaesthesia, and that item 30654 is for all other circumcision procedures. Does this mean that circumcision under item 30654 is performed without anaesthesia? 5. Is the Minister aware that the current policy of the Royal Australasian College of Physicians is that routine (non-therapeutic) circumcision of male minors is not warranted in Australia or New Zealand? Is she also aware that in 2012 the Tasmania Law Reform Institute, in an exhaustive analysis of the medical, legal and ethical status of non-therapeutic circumcision, concluded that it was medically unnecessary and ethically objectionable, and that it ought to be legally regulated and restricted to certain specified situations? <h2>Accessing Medicare Circumcision statistics</h2> If you look at Medicare statistics, here: http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp A wealth of information can open up. You can find the number of services and the Medicare contribution to the benefit. <ul> <li>This can be expressed as a count or on a per capita basis</li> <li>It can be broken down into states or into both states and over time. The time period can be expressed in months, quarters, calendar years or financial years.</li> <li>The start date of the statistics can be as far back as July 1993 and the end date can be as recent as the previous month or two.</li> <li>You can get age and gender details by clicking on the hyperlinked item number.</li> </ul> <h2>Michael Glass’s questions for the Medicare statistics unit and reply</h2> The following questions were sent by Michael Glass to the Medicare statistics inquiry address. They are reproduced below, with the replies from Carla Cook, Information Strategy, Governance and Release Section, Information Services Branch, Department of Human Services. (Links to web pages have been deleted.) Thank you for your patience with this one, we have now received a response from the business area with relevant advice (please see below) relating to your queries. Please note that the questions highlighted in yellow have been directed to the Department of Health as it best sits with them for response. I hope the information provided is of assistance to you. I will be in contact with you shortly once a response is received from Health. I have some questions about the recent changes in the item numbers regarding circumcision. According to this document some circumcision item numbers have been abolished and replaced with other item numbers. 1. Why were changes made to some of the circumcision-related item numbers? 2 The four circumcision items (30653, 30656, 30659 and 30660) have been removed and replaced with two new items (30654 and 30658). However, as late as July 2017 the older items were still in the Medicare statistical reports. Why is this so? “Medicare statistical reporting captures all claims processed by the Department of Human Services within the specified period. This is not the same as the date the service was originally provided. For example, an item 30653 may have been performed on 15 October 2016 but the claim was not submitted to Medicare until July 2017. In this instance the item 30653 would appear in a statistical report of claims processed in July 2017.” 3. Item numbers 30654 and 30658 include “circumcision procedures” on females. 62 of these were under the age of 5, A further 10 of them were between 5 and 14. However, the descriptions of the item number state that they both were about the circumcision of the penis. What is going on? “The Department of Human Services complies with the 2013 direction of the Attorney-General’s department** that introduced new protections from discrimination on the grounds of sexual orientation, gender identity and intersex status in many areas of public life. As such, there are no gender based restrictions on accessing Medicare items. The Department of Human Services does note that it is the responsibility of the servicing practitioner to ensure that the services are billed against the correct patient on the Medicare card.” ** https://www.ag.gov.au/Publications/Pages/AustralianGovernmentGuidelinesontheRecognitionofSexandGender.aspx Under item 30654, 158 women and girls underwent a “circumcision procedure” up until the end of June, 2017. 44 of these females were aged from 0 to 4 and 5 were aged 5 to 14. Under item number 30658, 53 females underwent a “circumcision procedure up until the end of 2017.18 of these females were aged from 0 to 4 and 5 were aged 5 to 14. (a) How can funding for the circumcision of boys be used to fund “circumcision procedures” on women and girls? “As outlined above, the Department of Human Services complies with the 2013 direction of the Attorney-General’s department that introduced new protection from discrimination on the grounds of sexual orientation, gender identity and intersex status.” (b) Was it the intent of Medicare to also fund the sexual cutting of girls? If so, why? “Health will be able to provide a details answer to this question. However, Medicare benefits are claimable only for ‘clinically relevant’ services rendered by an appropriate health practitioner. A ‘clinically relevant’ service is one which is generally accepted by the relevant profession as necessary for the appropriate treatment of the patient. Services listed in the MBS must be rendered according to the provisions of the relevant Commonwealth, State and Territory laws.” 4. Isn’t the genital cutting of underage girls against the law? If so, why is Medicare funding it? “As outlined above.” 5. According to this web page: https://www.researchgate.net/figure/278675359_tbl2_Table-6-MBS-item-numbers-and-descriptors-for-male-circumcision [See note below] the fee for item number 30653 (circumcision of a child under 6 months) was $46.50; the fee for item number 30656 (circumcision of a child from 6 months but under 10 years) the fee was $108.15; for item number 30659 (circumcision of a male 10 years of age or over by a GP) the fee was $127.30; for item number 30660 (circumcision of a male 10 years of age or over by a specialist) the fee was $139.20 Were these fees still current in October 2016? “The table provided in your email outlines the Fee, in-hospital benefit payable (75%) and out of hospital benefit amount payable (85%) for the item. The fees for these items in October 2016 were as follows: 30653 $46.50 30656 $108.15 30659 $149.75 30660 $185.60 As indicated above, the benefit payable for the service is determined by the hospital status of the patient. Services provided to an admitted patient receive benefits at 75% of the fee for the item. Non-admitted patients receive benefits at 85% of the fee for the item.” 6. According to the latest schedule of fees, there are now only two items for circumcision (a) for item number 30654 (circumcision of the penis) when a nerve block or anaesthetic is NOT being used) the fee is $46.50; (b) for item number 30658 (circumcision of the penis, when performed in conjunction with a regional or field nerve block or anaesthetics) the fee is $142. Does this mean that males can be circumcised without any form of pain relief? Does this mean that general practitioners are now being paid a lot more for circumcisions when pain relief is used? 7. Does this web page mean that item 30654 cost the taxpayer over half a million dollars in 2016-17? “Correct, this report does indicate that the total amount of benefits assigned for item 30654 in the 2016-17 financial year was $525,877.” 8. Does this web page mean that item 30658 cost the taxpayer almost $700,000 in 2016-17? “Correct, this report does indicate that the total amount of benefits assigned for item 30658 in the 2016-17 financial year was $697,927.” <h3>NOTE by Circumcision information Australia</h3> The page referred to is a table from a longer document, MBS Reviews Paediatric Services Male Circumcision Services: Review Report, by Robyn Lambert, Yasoba Atukorale, Alun Cameron, David Tivey, published by the Department of Health in July 2014. This appears to be a review of circumcision practices in Australia, with particular reference to the rebates available from Medicare; but it confesses that it was not able to find much information about Australian circumcision practices, and it has a very limited bibliography that contains nothing on the bioethical, human rights and legal aspects of the question. The paper makes no recommendations, except that “further study needed”. The paper does, however, contain much useful factual information on the number of boys being circumcised up until 2012, the identity of the operators (GPs, ObGyns, surgeons etc) and the associated costs to the public. <a href="https://www.researchgate.net/publication/278675359_MBS_Reviews_Paediatric_Services_Male_Circumcision_Services" rel="noopener" target="_blank">Full text available here.</a> <h2>Further information on this site</h2> <a href="https://www.circinfo.org/Medicare_circumcision_review.html" rel="noopener" target="_blank">Medicare must not pay for medically unnecessary circumcision</a> <a href="https://www.circinfo.org/Medicare_coverage_for_circumcision.html" rel="noopener" target="_blank">Medicare should not cover non-therapeutic circumcision: Submission to Medical Services Review, 2015</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Changes to Medicare coverage, female circumcision now covered darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Royal Australasian College of Physicians disowns Brian Morris</h2> The following letter was sent to the Sydney Morning Herald by Professor David Forbes, Chair of the Paediatrics & Child Health Policy & Advocacy Committee, Royal Australasian College of Physicians. He is commenting on a disgraceful article about the RACP's recently released circumcision policy - an article that is not really a news item at all, but an editorial defending routine circumcision of innocent babies, criticising the RACP for rejecting the practice, and giving sympathetic coverage to the maverick views of the notorious circumcision fanatic, Professor Brian Morris. The article is quite in keeping with the SMH's decrepit pro-circumcision policy and expresses its complete failure to keep up with developments in science, medicine, medical ethics, human rights and law. Wake up, granny! The letter was posted at <a href="http://www.6minutes.com.au/articles/z1/view.asp?id=498029">6minutes - Interesting stuff for doctors today</a>. Please find copied below a letter sent to the SMH today in response to this article from the RACP. Dear Editor, Your Friday 11 article "Doctors circumspect on circumcision" warrants clarification on a number of issues. The key point of the recently released RACP statement on circumcision is that the RACP believes that at the present time there is not evidence to support routine circumcision of newborn and infant males. Your article sends a dangerous public health message that circumcision prevents HIV transmission. It is vital that everyone engage in safe sexual practices such as condom use, whether circumcised or not. Recent reports of circumcision offering some protection against HIV infection in Africa relate to circumcision of adult males, not of infants. Further the stated benefits of protection against urinary tract infection are marginal, and do not justify mass circumcision. Our changing understanding of the relationship between urinary tract infection and chronic renal disease further weakens the case for routine circumcision. There is evidence that circumcision does result in memory of painful experiences, and is not quite as simple and low risk as your report states. The Colleges' recent statement is not anti-circumcision, but clearly states that parents should be informed of risks and benefits, and then supported in their decision. When circumcision is undertaken it should be with appropriate anaesthesia, and by a skilled operator who can minimise the risks of side effects. The option of delaying the decision to circumcise is one way of dealing with the ethical and potential legal issues of undertaking an elective procedure on a minor. The procedure is not to be equated with vaccination, either in its delivery or in its effectiveness. It should be noted that Professor Morris, quoted in your report, is not a member of the RACP and is not and has not been engaged as a reviewer for the College. Yours faithfully, David Forbes, Chair, Paediatrics & Child Health Policy & Advocacy Committee Royal Australasian College of Physicians. 11 September 2009 <a href="http://www.6minutes.com.au/articles/z1/view.asp?id=498029">6minutes - Interesting stuff for doctors today</a> <a href="https://www.historyofcircumcision.com/templates/pages/medical_authorities_maintain_opposition_to_circumcision.html">RACP's new circumcision policy available here</a> <h3>The wit and wisdom of Brian Morris</h3> Professor Morris has been waging a one-man war against the foreskin since the mid-1990s, using his professorial position at Sydney University to give the impression that he speaks with the voice of medical authority. ("As a full professor at Australia's largest medical school I must insist ... etc etc etc".) On at least one earlier occasion in the past the university has felt obliged to caution Professor Morris for claiming to speak on behalf of the university, when he was only uttering his personal opinion. (Though the university has not gone so far as to require Morris to move his eccentric website from the Physiology Department's server.) Among Morris's charming eccentricities are the following gems: <ul style="font-weight: 400;"> <li>Louis XVI of France was forced to get circumcised in order to become capable of having sex with his wife.</li> <li>The former Pope died of a urinary tract infection caused by his foreskin.</li> <li>Boys should be circumcised to prevent their foreskins getting caught in the zipper of their jeans.</li> <li>Uncircumcised men need three showers a day to keep the stench of their foreskin down.</li> <li>Uncircumcised men always make a mess on the bathroom floor when taking a leak.</li> <li>Circumcision must be performed in infancy because if the choice was left up to the individual to make when he grew up he would make the wrong decision.</li> </ul> It is quite disgraceful that the SMH fawns on this maverick and cites his minority opinions against the considered judgement of Australian medical authorities. <h2>Sydney Morning Herald's twisted logic in attacking/defending circumcision</h2> Editorial: Arguments as old as the practice MORE than a billion men are circumcised and billions more have undergone the ritual over the centuries. The practice is both ancient and commonplace. Yet now we are supposed to accept the argument, promoted in some ethical circles, that circumcision is both dangerous and an infringement on the rights of the child. Any surgical procedure, however minor, is dangerous if performed crudely. The world is full of risks, with children the most vulnerable. What matters is proportionality. A report from the Tasmanian Law Reform Institute, released this week, suggests that, in the absence of specific laws relating to the practice of circumcision, it may be an abuse of the rights of the child. The report goes so far as to countenance that circumcision itself may, by its very nature, be an act of cruelty, law or no law. The matter has been given an airing after the Tasmanian Children's Commissioner, Paul Mason, sought guidance from the institute for the handling of cases where, for example, a dispute arises over whether a child should be circumcised. This is a nettlesome legal issue because cultural practice is divided and the law is largely silent. The cultural direction in Australia is moving away from circumcision. Western medical organisations no longer recommend routine neonatal circumcision. What used to be commonplace, involving more than 90 per cent of male infants born in Australia in the 1950s, has become a minority position. Only about one in seven newborn boys are circumcised. The majority of circumcisions involve religious customs, largely the rites of Muslims and Jews. The arguments for and against male circumcision are as old as the practice itself. In Australia, the procedure has a negligible rate of serious physical injury. Proponents argue the practice leads to lower rates of infection from sexually transmitted diseases, and has no adverse impact on sexual function. Opposition has largely come in the form of ethical arguments over the rights of the child being compromised by a procedure performed for no reason other than cultural practice, with the possibility of later psychological injury. The argument that circumcision involves psychological risks is finding growing support in medical studies. Common sense suggests that in a dispute between or within families over whether to circumcise, prudence favours leaving the child untouched. Common sense also suggests that where both parents want their child circumcised there are no compelling medical, legal or ethical grounds for not doing so. <a href="http://www.smh.com.au/news/opinion/editorial/tough-cop-on-site/2009/06/03/1243708503896.html?page=2" style="font-weight: 400;">Sydney Morning Herald, 4 June 2009</a> <h3>Comment</h3> The Sydney Morning Herald's editorial is quite in accord with its longstanding practice of giving prominent publicity to every half-baked slander against the foreskin that posthephobic toilers in America's bloated medical research industry cook up, and ignoring the vast body evidence to the effect that circumcision of minors is a harmful, cruel and unnecessary procedure that violates the rights of the child and is already technically illegal under existing laws of assault, mayhem and molestation - as the <a href="http://www.cirp.org/library/legal/QLRC/">Queensland Law Reform Commission found in 1993</a>. So long as ignorant editorial writers use their unaccountable power to champion bad habits it is unlikely that there will be any laws to restrict the practice of male genital mutilation, let alone the degree of protection from female genital mutilation afforded to women. The key facts that refute the editorial's concluding pontification are its earlier admissions that circumcision has always been a controversial and contested operation, and on a world scale a minority practice. These facts alone dictate that the only person entitled to make an irreversible decision about the shape of his penis is its owner. At least the SMH had the decency to publish Paul Mason's letter, pointing out the crazed illogic in the editorial's position. The way some circumcision promoters attempt to argue, you would think it was a large chunk of their brain that had been surgically removed in infancy. <a href="http://www.law.utas.edu.au/reform/">The paper by Tasmanian Law Reform Institute is here</a>. <h2>Stopping circumcision a matter of human rights</h2> Your editorial ("Arguments as old as the practice", June 4) misrepresents my input into the Tasmanian Law Reform Institute's issues paper on the validity of parental consent to unnecessary circumcision, and reveals a glaring non sequitur. You conclude that "there are no compelling medical, legal or ethical reasons for not" operating on a boy without his informed consent -- but only after observing that "the law is silent"; that circumcision "may be an act of cruelty"; that medical organisations no longer recommend routine circumcision; that "the possibility of ... psychological risks is finding growing support in medical studies"; and that "prudence favours leaving the child untouched". I did not refer the issue to the institute in connection with cases where a dispute arises whether to circumcise: the law is pretty clear that it will not proceed in those cases. I referred it in the context that babies are human beings and all human beings have the right to bodily integrity assured by the Universal Declaration of Human Rights (1948). I referred it in the context that the first principle of the Hippocratic Oath is "Do no harm" and that the irreversible, invasive and painful removal of any neurologically complex external organ of a powerless patient at the request of a third party is an ethical travesty. Your editorial seeks to seduce readers into denying babies and children their legal and human rights, while taxpayers are footing the bill through Medicare - circumcision is the only item that requires no medical indication for payment. One reason for its declining popularity in the West since the 1970s may be the influence of women, who see their babies as perfect and not for cutting: from this perspective unnecessary circumcision is a feminist issue. Paul Mason Commissioner for Children, Hobart <a href="http://www.smh.com.au/news/opinion/letters/stopping-circumcision-a-matter-of-human-rights/2009/06/05/1243708622222.html" style="font-weight: 400;">Letter: Sydney Morning Herald, 6 June 2009</a> <h2>Australian children healthier than ever: Boys with foreskins are happier</h2> The health of Australia's children continues to improve, according to the latest report on child health from the Australian Institute of Health and Welfare. During the period 1986-2006 there was a dramatic decline in infant and child deaths (which fell by half), improved survival in cases of cancer, and a reduction in the incidence of asthma. These are significant findings, given that the period 1986 to 2006 witnessed a huge decline in the incidence of circumcision, from about 40 per cent of boys in the early 1980s to about 10 per cent in 2006. It is thus good empirical proof that "lack of circumcision" does not increase child health problems. Even more significantly, it is a decisive refutation of "scientific" predictions by Terry Russell, Brian Morris and other diehard promoters of routine circumcision that the fall in the circumcision rate would lead to an explosion of genito-urinary problems in boys and an ever-increasing death toll from urinary tract and bladder infections. No such problems are identified in this report, which does not even mention any health problems affecting the genito-urinary area. On the contrary, the halving of the death rate among infants and children suggests that leaving the foreskin in place has significantly improved child health outcomes and contributed to the decline in infant and child mortality. It is, after all, quite illogical to claim that a boy with great wound in his penis is somehow healthier than a boy who has not been injured there. As the British child health expert N.R.C. Roberton points out, "it is fundamentally illogical that mutilating someone might be beneficial." * Problems identified by the AIHW report include an increasing incidence or diabetes and obesity, more, tooth decay, too much television, not enough vegetables, and persistent poor health among indigenous Australians. It is hard to see how even a fanatic like Brian Morris could blame "lack of circumcision" for children not eating their vegetables. The Australian Institute of Health and Welfare is the Australian Government's premier health research foundation. <a href="http://www.aihw.gov.au/publications/index.cfm/title/10704">The full report and press release can be downloaded from the AIHW website. </a> Reference N.R.C. Roberton, "Care of the Normal Term Newborn Baby," in Textbook of Neonatology, eds. Janet M. Rennie, N.R.C. Roberton, 3rd edn. (Edinburgh: Churchill Livingston, 1999), 378-379. <h2>Circumcision criticised in Human Rights Consultation: Submission argues that boys need protection even more than girls</h2> The Commonwealth Government is holding a <a href="http://www.humanrightsconsultation.gov.au/">National Human Rights Consultation</a>, providing the individuals with an opportunity for you to express their views on human rights. The Consultation is run by an independent Committee, supported by a Secretariat within the Attorney-General's Department. The Consultation is a chance to hear people's ideas about human rights and talk about ways to protect and promote human rights in the future. The questions in which it is most interested are <ul> <li>Which human rights and responsibilities should be protected and promoted?</li> <li>Are human rights sufficiently protected and promoted?</li> <li>How could Australia better protect and promote human rights?</li> </ul> The Committee has called for public submissions that address these questions and any other human rights about which people are concerned. <a href="http://www.humanrightsconsultation.gov.au/">For further details see the website.</a> A substantial submission from Dr Robert Darby has raised the question of circumcision and asked why boys are given no protection from unwanted alterations to their genitals when similar operations on girls or women are a serious criminal offence in most states. The submission argues that human rights include the right to bodily integrity and to protection from unwanted surgical interventions: In this submission it is argued that there is a glaring gap in the Australian human rights framework, namely, that boys are not given any protection against unwanted and unnecessary surgical interventions such as circumcision. It is suggested that boys are entitled to as much protection from circumcision (male genital mutilation) as girls from female genital mutilation (female circumcision). Since it is unlikely that any such protection will be provided by legislative measures, alternative means such as public education and the removal of financial incentives are proposed. <a href="http://www.humanrightsconsultation.gov.au/www/nhrcc/nhrcc.nsf/Page/Publicsubmissions_Submissions-Childrenandyoungpeoplesrights">Read the full submission here.</a> <a href="https://www.historyofcircumcision.com/templates/pages/human_rights_and_bodily_integrity.html">Submission text also available on this site.</a> <h2>Circumcision of male children "a hidden human rights violation"</h2> In the April 2007 issue of the Australian Journal of Human Rights, Ranipal Narulla argues that circumcision of male minors should be recognised as a violation of human rights. Synopsis Male circumcision is an accepted practice within Australian society, despite the fact that female circumcision is widely reviled in the Western developed world. This article will consider why society and the law treat circumcision of males and female differently. Analysis will focus upon the circumcision of male children in Australia, with reference to the United Kingdom and the United States of America. The similar social history of the practice within these jurisdictions is instructive when critically analysing the Australian context. The discussion will encompass the circumcision of all male children, as the issues of lack of consent and the imposition of a parent's religious and cultural norms upon the child are consistent for all minors, with specific focus on neonatal children where such extreme youth creates additional vulnerability. The absence of domestic law in Australia dealing with the circumcision of male children invites analysis of the protection afforded under international human rights instruments to which Australia is legally bound. This article deconstructs the medical myths that surround the circumcision of male children, and in so doing makes a strong argument for the need to recognise circumcision of male minors as a human rights violation. Ranipal Narulla, "Circumscribing circumcision: Traversing the moral and legal ground around a hidden human rights violation", Australian Journal of Human Rights, Vol. 12, April 2007, pp. 89-118 The Australian Journal of Human Rights is published by the <a href="http://www.ahrcentre.org/content/research_ajhr.htm" style="font-weight: 400;">Australian Human Rights Centre </a>at the University of New South Wales <a href="http://www.austlii.edu.au/au/journals/AJHR/" style="font-weight: 400;">On-line issues available from AustLii</a> <h4>Tasmanian Children's Commissioner wants circumcision banned</h4> <a href="http://www.childcomm.tas.gov.au/" style="font-weight: 400;">Tasmania's Children's Commissioner</a>, Paul Mason, wants the State Government to ban the non-medical circumcision of young boys. Female genital mutilation is illegal in Tasmania. Mr Mason said it's unfair that boys aren't given the same protection. "We're discriminating against the little baby boys themselves, because they're not safe whereas the little girls are," he said. He said circumcision is an abuse of human rights and should be outlawed until the person is old enough to decide for themselves. "It's a permanent procedure. They get no choice. It's painful -- even under anaesthetic." Mr Mason has prepared a report on the issue for the Council of Obstetric and Paediatric Mortality and Morbidity. The Council will forward a recommendation to the State Government. <a href="http://www.abc.net.au/news/stories/2007/08/13/2002944.htm?site=hobart" style="font-weight: 400;">ABC News, 13 August, 2007</a> <h4>Circumcision specialist censured and fined for improper conduct</h4> Dr Terry Russell, the ageing Queensland GP who has made a career and a fortune out of amputating the foreskins from baby boys, also seems keen to cut boys' tongues. In 2004 he was fined and censured by the Commonwealth Professional Services Review of Medicare services for falsely diagnosing "tongue tie" when the boys were brought to be circumcised, and cutting their tongue as well as their penis. The frenulum that tethers the tongue to the floor of the mouth is very similar to the frenulum that tethers the foreskin to the rest of the penis. Perhaps Dr Russell feels that any body part resembling the foreskin should be removed "just to be on the safe side". There was a time, back in the nineteenth century, when many doctors believed that surgery to correct so called "tongue tie" should be as routine as cutting off the foreskin. The Review reported that Dr Russell had been reprimanded, counselled and ordered to repay the $4,488.88 he had claimed from Medicare. The Committee noted that there was no clinical indication for cutting the tongue and thus that there was no basis for performing the procedure, nor for claiming the cost of the service under Medicare. Had the Committee looked into the cases of the boys brought in to be circumcised, it would have found that there was no clinical indication for circumcision either, and thus that there was no basis for that procedure to be charged to Medicare. Apparently, the government believes that it is OK to alter the appearance and function of the (highly visible) penis without the consent of the owner, but not to interfere with anybody's (usually concealed) tongue. The Medicare guidelines state clearly that Medicare does not cover "medical services which are not clinically necessary" or "surgery solely for cosmetic reasons". Why, then, does it continue to waste taxpayers' money on clinically unnecessary circumcision procedures? The full text of the report on Dr Russell follows. Director Dr John Holmes The Hon. Tony Abbott MHR Minister for Health and Ageing Parliament House Canberra ACT 2600 Dear Minister In accordance with subsection 63(1) of the Public Service Act 1999 and section 106ZQ of the Health Insurance Act 1973, I provide you with the 2003-2004 Annual Report of Professional Services Review for your presentation to Parliament. This report has been prepared in accordance with the Requirements for Annual Reports approved on behalf of the parliament by the joint Committee of Public Accounts and Audit under section 63 of the Public Service Act 1999. Yours sincerely John Holmes 5 October 2004 Dr Charles Terence Russell, General Practitioner, Qld Dr Russell practiced at Macgregor and Browns Plains in Queensland during the referral period of 1 January 1999 to 31 December 1999 inclusive. In relation to the rendering of MBS item 30278 (repair of tongue-tie) Dr Russell's conduct was found by the committee to be unacceptable to the general body of general practitioners. In the majority of services examined, the patients had seen Dr Russell for circumcision procedures. He subsequently performed repairs to tongue-ties. Given this pattern, the committee was concerned that while parents consulted with Dr Russell for circumcisions, he opportunistically diagnosed tongue-tie. The committee found there were no clinical indications for the services. The services were examined in accordance with an approved sampling methodology which resulted in a finding that 90 per cent of MBS item 30278 services rendered by Dr Russell during the referral period were inappropriate. The committee detailed its reasons in a final report to the Determining Authority. Dr Russell did not make a submission on the draft determination. The Authority issued a final determination directing that Dr Russell be reprimanded, counselled and repay $4 488.88. The determination came into effect on 13 February 2004. <a href="http://72.14.253.104/search?q=cache:qEsyOtL7VSwJ:www.psr.gov.au/docs/publications/PSRAR04.rtf+Russell+%2B+tongue-tie+%2B+Medicare&hl=en&ct=clnk&cd=3&gl=au" style="font-weight: 400;">Text available on-line here.</a> If the link does not work, <a href="https://www.google.com.au/search?source=ig&hl=en&rlz=&q=Russell+%2B+tongue-tie+%2B+Medicare&btnG=Google+Search&meta=cr%3DcountryAU%3E" style="font-weight: 400;">search for Russell +tongue tie +Medicare on Google</a>. <h4>Age op-ed writer calls circumcision male genital mutilation</h4> It's child abuse and it's time it was cut out Catherine Deveny <a href="http://www.theage.com.au/news/opinion/its-child-abuse-and-its-time-it-was-cut-out/2007/10/23/1192941062383.html" style="font-weight: 400;">The Age (Melbourne), October 24, 2007</a> People give plenty of reasons for circumcising their male children, writes Catherine Deveny. But most of them don't amount to anything. NO ONE seems to be able to explain to me why the circumcision of baby boys is not considered child abuse. Why in 2007 is it still acceptable for parents to have their babies' foreskins ripped off? How can it be legal, let alone ethical, for any human being to choose for another human being's body to be irreversibly mutilated? No medical reason, no rational thought and in many cases no aesthetic. Just because. I suggest that we should ban the use of the term "circumcision" and force people to use the term "genital mutilation". Because that's what it is. It's not "a personal choice", because that person is not making a choice. It's human rights abuse. The We Circumcised For Religious Reasons camp justify genital mutilation citing religion. They embrace the parts of religious texts that suit them and dismiss the ones that don't. And when I say "they", not all of them do. Many believers I know have all applied a little rational thought to the equation and just decided not to inflict unnecessary pain on their child or expose them to avoidable risk. They've decided to file that bit of the Holy Book under the other things that just don't fit; like selling your daughter into slavery or killing your neighbour if they work on the Sabbath. What kind of God would disapprove of you, stop loving you, or not give you eternal life if you don't mutilate your child's genitals? That doesn't sound like a nice kind of God. And what caring community would shun you, judge you or ostracise you for not inflicting genital mutilation on your child? Then we have the We Circumcised Our Boys So They Look The Same As Their Father camp. Sure, it's not fair for me to pick on people less fortunate in the brains department than the rest of us, but when they are subjecting innocent children to genital mutilation I'm going in swinging. I'm not going to bother asking the hard question "why do you need them to look like their father?", because you cannot reason with something that has not come from reason but from mindlessness. I ask the So They Look The Same As Their Father camp, why stop there? If you want them to look the same as their father, dye their hair, have them undergo cosmetic surgery and if the father has any tattoos or facial hair, sort that out too. Related to this camp is the We Circumcised Our Boys Because A Circumcised Penis Looks Nicer camp. We are talking the shallow end of the intelligence pool here. How would they feel if they had had their nipples, nose or ears cut off by their parents when they were a child because their parents thought "it looked nicer"? I must say that I do applaud these two camps on their frankness and honesty despite it revealing their stunning stupidity. After all, they could do what others do and make the decision for no rational reason and then rationalise it by joining the We Circumcised Our Boys For Health And Hygiene Despite Looking Closely At The Research camp. I have read the various studies suggesting that circumcision may reduce the spread of HIV and cervical cancer. I have also read the studies disproving the circumcision-reduces-infection myth. Here in Australia, all of these risks can be effectively and safely managed with condoms and cleanliness. That's right, a bit of frangers and face washers, rubbers and rubbing. Why would you expose a child to an unnecessary medical procedure and all the risks that come with it when you could teach them how to clean themselves and use a condom? Because you can, I suppose. By the same logic, removing all your children's teeth would prevent them getting fillings. Unless, of course, there is a sound medical reason to circumcise. And when I say sound, I mean sound as in last resort. I don't mean that you walk into a GP with a seven-year-old with a constricted foreskin that is not retracting and walk out with a referral to a surgeon to have your child's genitals mutilated, as a family I know could have. One of their sons had that very problem. They were offered a referral to a surgeon to have him circumcised. They didn't like the sound of that. Luckily they didn't have private health insurance, because that meant that they were given a referral to the Royal Children's Hospital, where they saw a general pediatric surgeon, or as their son referred to her, a Dick Doctor. Yes, she said, he could be circumcised, but she was having great success using an ointment available over the counter from the chemist. Three days later, the boy had a retracting foreskin. And two years later, he still does. The wonders of a health service on a budget as opposed to a private business. So if he wants to get himself circumcised as an adult, that's his choice. And he'll have that choice. Because when you circumcise someone, you can't uncircumcise them. <h4>Professor fails history:</h4> <h4>No evidence that Louis XVI was circumcised</h4> In the latest rewrite of his familiar list of "compelling" reasons as to why boys must not be allowed to keep their foreskins [1], Professor Brian Morris makes the extraordinary claim that Louis XVI, King of France 1754-93, was prevented from consummating his marriage to Marie Antoinette by his "tight foreskin", and was obliged to submit to circumcision so that he could perform his marital duties. This assertion is presented as one of the numerous reasons why circumcision is "a biomedical imperative" for the 21st century. The first point to make is that there is no evidence at all that Louis XVI was circumcised. Professor Morris seems to be awkwardly aware of the absence of evidence, for the only citation he provides for his claim is a reference to his own website. The story is one of the many anecdotes recorded as "compelling reasons" for circumcision by the notoriously unreliable circumcision evangelist <a href="https://www.historyofcircumcision.com/templates/pages/1902_dr_remondino_blasts_anti_circumcision_activists.html">Peter Charles Remondino</a>, who wrote in the 1890s that the King "was afflicted by a congenital phimosis which prevented the flow of semen from properly discharging itself". But even a fanatic such as Remondino was forced to concede that that there was no truth in the circumcision rumours, for even if it had been suggested, Louis refused to submit to the operation. Instead, according to Dr Remondino, he worked on dilating his foreskin manually, with such success that he soon fathered three children. [2] There has been much speculation as to why Louis and Marie took eight years to produce an heir. Explanations offered have included their strict religious educations, their traumatic childhoods, the extreme youth of the two spouses, and the condition of the King's foreskin. A reliable review of the case is provided by the Greek urologist G. Androutsos, who concludes that there is no evidence that Louis was circumcised, but suggests that he was probably late in reaching puberty and also that he might have had an associated persistent <a href="http://www.cirp.org/library/treatment/phimosis/">phimosis</a> or a short frenulum <a href="http://www.circumstitions.com/Frenbrev.html">(frenulum breve)</a> that made intercourse difficult. If so, it is possible that the problem was corrected by a very mild surgical intervention, involving no more than nicking the strands of tissue that tethered the foreskin, and not by amputating anything from the royal person. [3] This would have been similar to the operation for phimosis later recommended by the French sexual health authority Philippe Ricord, and practised in England by William Acton. [4] There is no firm evidence that Louis ever had any kind of surgery on his penis, but if he did have an operation, this is the most likely contender. Professor Morris's airy assertion that Louis was circumcised at the insistence of Marie-Antoinette's brother, Joseph II of Austria, is plainly false. References 1. Brian Morris, "Why circumcision is a biomedical imperative for the 21st century", BioEssays, November 2007 2. Peter Charles Remondino, History of Circumcision from the Earliest Times to the Present: Moral and Physical Reasons for its Performance, Philadelphia and London, F.A. Davis, 1891, pp. 201-2 3. Androutsos G., Le phimosis de Louis XVI (1754-1793) aurait-il ete a l'origine de ses difficultes sexuelles et de sa fecundite retardee?. Prog Urol. 2002; 12(1):132-7. <a href="https://www.historyofcircumcision.com/templates/pages/the_truth_about_louis_xvis_marital_difficulties.html">An English translation of this article is available on this site.</a> <ol> <li style="font-weight: 400;">William Acton,A Practical Treatise on the Diseases of the Urinary and Generative Organs (in Both Sexes), 2nd edition, London, Churchill, 1851, pp. 77-78</li> </ol> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Circumcision in the news in Australia darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> Confirming previous studies <a href="https://www.circinfo.org/news_upto2010.html#News5">summarised on this site</a>, reports issued this year by the Australian Institute of Health and Welfare show that the health of Australian children continues to improve, and that while males generally are less healthy than women, their problems have nothing to do with lack of circumcision. Most strikingly, the infant mortality rate has more than halved since 1986, the very period during which the incidence of routine circumcision fell from around 40 per cent of boys under 6 months to around 12 per cent today. The most serious child health problems identified by the report are asthma, lack of breast feeding, and arising from social factors such as poverty and Aboriginality. These reports offer good empirical proof that “lack of circumcision” does not increase child health problems. Even more significantly, it is a decisive refutation of “scientific” predictions by various antiquated circumcision enthusiasts that the fall in the circumcision rate would lead to an explosion of genito-urinary problems in boys. No such problems are identified in these reports, which do not even mention any health problems affecting the genito-urinary area. If we were to be as unscrupulous in mixing up correlation with causation as many pro-circumcision zealots tend to be, we could reasonably conclude that Australian children have become healthier because the incidence of circumcision has fallen, not merely at the same time. But there is no need to go that far. At the very least, A Picture of Australia’s children is definitive proof that there is zero connection between circumcision and improved child health outcomes. The reporst tells a similar story with male health, finding that the main risk factors for poor health problems to be living in remote or country areas; being poor; getting old; and being of Aboriginal or Torres Strait Islander descent. None of these social factors has anything to do with circumcision. Further information on this site <a href="https://www.circinfo.org/health.html#child" rel="noopener" target="_blank">Health and disease</a> <a href="https://www.circinfo.org/Circumcision_and_public_health.html" rel="noopener" target="_blank">Circumcision and public health</a> <h3>Health of Australia’s males: Summary</h3> This report is the second in a series on the health of Australia’s males. It examines the distinct health profiles of five population groups, characterised by Aboriginal and Torres Strait Islander status, remoteness, socioeconomic disadvantage, region of birth, and age. Key findings Aboriginal and Torres Strait Islander males generally experience poorer health than the overall population, highlighted by a life expectancy of 67 years (11.5 years less than that for non-Indigenous males). Factors that contribute to this poorer health status include: <ul> <li>high rates of tobacco smoking, risky alcohol consumption and illicit substance usage;</li> <li>higher rates of chronic diseases (such as lung cancer, diabetes and kidney disease) and health conditions (such as scabies, trachoma and acute rheumatic fever) that are uncommon in the general population;</li> <li>higher rates of hospitalisation, with 45% of these for dialysis.</li> </ul> Remoteness is associated with poorer health. Males living in remote areas generally have a shorter life expectancy and poorer self-assessed health status. As remoteness increases, the following health-related factors also increase: <ul> <li>rates of obesity, tobacco smoking and risky alcohol consumption;</li> <li>new cases of lung cancer, and deaths from chronic obstructive pulmonary disease, diabetes and suicide;</li> <li>hospitalisations for Type 2 diabetes mellitus.</li> </ul> Socioeconomic disadvantage is also associated with poorer health. Males living in more socially disadvantaged areas generally have a shorter life expectancy. As socioeconomic disadvantage increases, the following health-related factors also increase: <ul> <li>rates of obesity and tobacco smoking;</li> <li>new cases of lung cancer, and deaths from coronary heart disease, lung cancer, chronic obstructive;</li> <li>pulmonary disease, diabetes and suicide;</li> <li>hospitalisations for Type 2 diabetes mellitus.</li> </ul> Males born overseas generally enjoy better health than other males, with fewer risk factors and lower overall mortality and hospitalisations. There are areas where males born overseas experience poorer health, compared with males born in Australia, with: <ul> <li>lower rates of physical activity and bowel cancer screening;</li> <li>higher rates of lung cancer, and more deaths from diabetes and lung cancer;</li> <li>higher rates of hospitalisations for Type 2 diabetes mellitus and heart attack.</li> </ul> Older males (aged 65 and over) are living longer than ever before, and generally have fewer risk factors such as overweight/obesity and tobacco smoking than younger males. As age increases, the following health-related factors also increase: <ul> <li>inadequate vegetable intakes and inadequate physical activity;</li> <li>new cases of bowel cancer and melanoma, and rates of dementia and of injury from falls;</li> <li>all hospitalisations, including cardiac rehabilitation, cataract and melanoma of the skin.</li> </ul> The AIHW is a major national agency set up by the Australian Government to provide reliable, regular and relevant information and statistics on Australia's health and welfare. <a href="http://aihw.gov.au/publication-detail/?id=10737421980" rel="noopener" target="_blank">The full report can be downloaded from the AIHW website</a> <h2>Health of Aussie kids continues to improve as incidence of circumcision declines</h2> <h3>Infant deaths halved since 1986</h3> A picture of Australia's children 2012 provides the latest information on the health and wellbeing of Australia's children aged 0-14. Many are faring well, but there is scope for further gains, particularly among Aboriginal and Torres Strait Islander children and those living in areas with the lowest socioeconomic status. The good news Death rates for infants (aged under 1) and children (aged 1-14) more than halved between 1986 and 2010, with rates slightly ahead of the Organisation for Economic Co-operation and Development (OECD) average for infants, and equal to the average for children under 5. Notably, child deaths from injuries halved between 1997 and 2010. The prevalence of asthma has decreased, while the incidences of diabetes and cancer have remained stable. Almost three-quarters of children aged 0-2 have stories read or told to them regularly, and most children achieve above the national minimum standard for reading and numeracy. Australia's average score for mathematics was in the top half of OECD countries. Smoking in households with children has decreased, while rates of risky drinking and smoking among children have declined. Most parents rate their health as excellent, or (very) good, and the majority of households with children perceive their neighbourhood as safe. Most households with children, including Indigenous, reported that they could get assistance from outside the household in times of crisis. Areas where improvement needed Around 1 in 7 women smoked during pregnancy, and about half of pregnant women drank alcohol. Exclusive breastfeeding was initiated for 90% of infants at birth; however only 2 in 5 infants were exclusively breastfed to around 4 months. An estimated 45% of children aged 6 and 39% of children aged 12 experienced dental decay. Almost a quarter of children were developmentally vulnerable on one or more domains of the Australian Early Development Index at school entry. About 15% of parents were affected by mental health problems. Aboriginal and Torres Strait Islander children experience higher death rates, including from injuries, than the national average. They were less likely to have achieved the reading and numeracy minimum standards, and had higher smoking rates than the general child population. Children living in the lowest socioeconomic status (SES) areas were less likely to have stories read or told to them regularly, more likely to be exposed to tobacco smoke in the home, and more likely to smoke themselves than children living in the highest SES areas. Teenage birth rates were higher in the lowest SES areas than in the highest SES areas, and parents living in the lowest SES areas were more likely to report fair/poor health and poorer mental health compared with those in the highest SES areas. AIHW media release <h3>Most Aussie kids doing well, room for further gains</h3> Most Australian children are doing well in terms of their health and wellbeing, but there is room for improvement for some, according to a report released by the Australian Institute of Health and Welfare (AIHW). The report, A picture of Australia's children 2012, shows that death rates for infants and children halved since 1986, the prevalence of asthma among children has dropped, and rates of risky drinking and smoking among children aged 12-14 are down. Smoking in households with children has also dropped. Almost three-quarters of children aged 0-2 have stories read or told to them regularly and most children achieve above the national minimum standard for reading and numeracy. The majority of households with children in Australia perceive their neighbourhood as safe. Most households also reported that they could get assistance from outside the household in times of crisis. “The report indeed shows that most Australian children are faring well, but despite this good news, there are several areas where improvements could be made,” said AIHW spokesperson Dr Fadwa Al-Yaman. For example, while exclusive breastfeeding was initiated for 90% of infants at birth, only 40% of infants were exclusively breastfed to around 4 months (exclusive breastfeeding is recommended to 6 months). Around 45% of children aged 6 have dental decay, as do 39% of children aged 12. The report also shows that almost one-quarter of children are developmentally vulnerable at school entry. About 7% of Australian children had a disability in 2009 and, of these, over half had profound or severe core activity limitations. The most common disability types among children were intellectual, affecting 161,600 children (3.9%), and sensory/speech (119,100 children or 2.9%). Injury and cancer are the two leading causes of death in children. In 2008-2010, injuries contributed to 662 deaths of children-a rate of 5 per 100,000 children. Infants (aged less than one year) had the highest rate of injury death (11 per 100,000 infants). Over the period 2004-2008, an average of 583 new cases of cancer were diagnosed annually among children, and in 2008-2010, there were 274 cancer deaths among children-a rate of 2.2 per 100,000 children. This accounted for around 5% of all child deaths. Additional challenges exist among Aboriginal and Torres Strait Islander children and children living in areas of low socioeconomic status. Aboriginal and Torres Strait Islander children experience higher death rates than the national average. They also had higher smoking rates than the general child population and were less likely to have achieved reading and numeracy minimum standards. Children in the lowest socioeconomic status (SES) areas were less likely to be read to on a regular basis than children living in the highest SES areas, and their parents were more likely to report poorer physical and mental health. <a href="http://aihw.gov.au/publication-detail/?id=10737423343" rel="noopener" target="_blank">The full report can be downloaded from the AIHW website</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Health of Aussie boys and men improves as incidence of circumcision declines darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> Despite a series of reviews over the past few years aimed at containing costs and simplifying the system, there have been no significant changes to Medicare coverage of circumcision. The only changes have been to reduce the number codes (from four to two) and to make them unisex. This had had the unfortunate effect of making it impossible to calculate the number of circumcision procedures by age (thus obscuring the fact that the vast majority are of infants and young boys) and allowing circumcision of girls, as <a href="https://www.circinfo.org/Medicare_Coverage_Female_Circumcision.html" rel="noopener" target="_blank">previously documented on this site</a>. The latest report from one of the working groups, the Urology Clinical Committee, has proposed no changes to the circumcision codes at all, except for the requirement for analgesia (pain control). This is a desirable reform, but a less important issue than the fact that Medicare will continue to fund non-therapeutic (medically unnecessary) circumcision, including circumcision desired for religious, cultural and other social/cosmetic reasons. This is contrary to the provisions of the Health Insurance Act and the Medicare guidelines, which state clearly that benefits are payable only for “clinically relevant” services – i.e. procedures for which there is a demonstrated medical need. <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mbs-review-2018-taskforce-reports-cp/%24File/v2%20-%20Urology%20Clinical%20Committee%20-%20Report.pdf" rel="noopener" target="_blank">The Committee report is available here</a>; the section relating to circumcision are on pages 68-70. <h2>Medicare should not pay for non-therapeutic circumcision</h2> For some years the Commonwealth Government has been concerned at the ever-rising costs of the ever-expanding health budget, particularly the cost of Medicare. In 2015 it resolved to establish a reform process, the aim of which was to simplify the system and reduce costs by eliminating services of low medical value. Non-therapeutic circumcision was identified as an example of such a low-value service, giving rise to the expectation that it would be dropped from the Medicare Benefits Schedule. This has not happened. In the first round of reforms all that happened is that the codes for circumcision were reduce from four (distinguished by age) to two (distinguished by type of anaesthesia) – thus making it impossible to determine how many infants and boys were being circumcised. In addition, the codes were made gender-neutral, allowing them to be used for circumcision of females – as is apparently happening. In a further round of reforms the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/MBSR-consult-2018-taskforce-reports" rel="noopener" target="_blank">Urology Clinical Committee</a> tackled the circumcision codes and managed to produce a very small mouse. Of nearly 6000 items on the MBS, it managed to eliminate 18, of which circumcision was not one. The Committee’s sole recommendation was to require analgesia (pain control) for circumcision procedures, “thus ensuring patient wellbeing.” This is certainly a welcome move in the right direction, but it is not the main issue. More significantly, the Committee made no attempt to limit the availability of the circumcision rebate; on the contrary, it accepted the prevailing situation in which it is readily available for procedures carried out for religious or cultural reasons: The Committee noted that item 30654 should continue to include circumcisions conducted for religious and cultural reasons, reflecting both current practice and the need to ensure safe circumcisions. While this does not appear to be a formal recommendation, it presumably has the force of one. It is difficult to see how subsidising religious or cultural practices could be a legitimate use of the health budget, particularly as the Health Insurance Act and the Medicare guidelines state clearly that the rebate is available only for “clinically relevant” services – i.e. medical treatment that is actually needed for medical reasons. The policy is certainly in contradiction to the fundamental objective of the reform process: to rein in and control costs. The stated objectives of the reviews were to achieve: <ul> <li>Affordable and universal access</li> <li>Best-practice health service</li> <li>Value for the individual patient</li> <li>Value for the health system</li> </ul> An open-ended subsidy (essentially a blank cheque) for procedures of zero clinical relevance makes no contribution to achieving these objectives, and is in fact in complete contradiction to them, especially the last. Examining the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mbs-review-2018-taskforce-reports-cp/%24File/v2%20-%20Urology%20Clinical%20Committee%20-%20Report.pdf" rel="noopener" target="_blank">Urology Clinical Committee’s recommendations and observations on circumcision</a> in more detail, it is possible to raise six major objections to them, as set out below. Further information on this site <a href="https://www.circinfo.org/Medicare_circumcision_review.html" rel="noopener" target="_blank">Medicare Circumcision Review details</a> <a href="https://www.circinfo.org/Medicare_coverage_for_circumcision.html" rel="noopener" target="_blank">Medicare coverage of non-therapeutic circumcision criticised in submission</a> <a href="https://www.circinfo.org/Medicare_Coverage_Female_Circumcision.html" rel="noopener" target="_blank">Medicare coverage of female circumcision?</a> <h2>Medicare Benefits Schedule Review: Report of the Urology Clinical Committee</h2> <h3>A rational critique</h3> This response is directed at the recommendations relating to circumcision, at pages 68-70. 5.5.1 Recommendation 14 Amend the item descriptor to mandate the use of analgesia for this procedure. 5.5.2. Rationale for Recommendation 14 The item descriptor has been amended to mandate the use of analgesia, which ensures patient wellbeing. Comment While this is a progressive and desirable reform, it should be noted that analgesia does not necessarily “ensure patient wellbeing”, only that he is given a painless operation. The Committee noted that item 30654 should continue to include circumcisions conducted for religious and cultural reasons, reflecting both current practice and the need to ensure safe circumcisions. Comments 1. This proposal is regressive and inappropriate in that it is essentially offering a blank cheque to all parents who desire to have their boys circumcised, whatever their reason, as well as to those rare individuals who desire circumcision for themselves. The specification “religious and cultural” is meaningless and ineffective in the absence of a verification mechanism by which the religious/cultural credentials of the parents can be checked. Such a system is not proposed, and it would be complex to administer, and expensive even if the obvious difficulties could be overcome. In effect, the Committee has legitimised the existing open slather by which any individual who desires circumcision for himself or any parent who wishes to get a boy circumcised for any reason can require the public purse to meet part of the cost. Considering that the original objective of the various Medicare reviews was to rein in costs by eliminating procedures of low medical value, this seems highly counter-productive. 2. The argument about past practice is feeble and unacceptable. Merely because a certain policy has been followed in the past does not mean that it is desirable in or appropriate to current conditions; past practice is not best practice. The objective of reform exercises is to eliminate bad policies and replace them with good policies. Historical longevity is no basis for approving any practice in the contemporary world. As a matter of historical record, the government attempted to remove circumcision from the MBS in 1985, suggesting that in its original conception, Medicare was not intended to cover non-therapeutic circumcision at all. [1] 3. Related to (2), it is likely that payments for religious/cultural circumcision under Medicare are unlawful because the relevant act and associated guidelines provide that benefits are payable only for clinically needed procedures. As Michael Ryan, Assistant Secretary, MBS Policy and Specialist Services Branch, Department of Health, explains to Mr Peter Khalil MP (letter dated 6 November 2017, copy held by author): “The Medicare Benefits Schedule (MBS) provides benefits (or rebates) for a range of professional medical services, including circumcision. The Health Insurance Act 1973 stipulates that Medicare benefits are only payable for clinically relevant services provided by health practitioners. A clinically relevant service is one that is generally accepted by the relevant profession as necessary for the appropriate treatment of the patient. “On 1 November 2016 the MBS items for circumcision were restructured from four items to two items to separate them by the type of anaesthesia used, rather than by patient age. However, there have been no changes to the legal requirement that services must be clinically relevant, and there are no benefits available for non-therapeutic procedures.” In its current policy statement on circumcision the Royal Australasian College of Physicians concluded: “After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.” That being the case, non-therapeutic circumcision (including circumcision procedures desired for religious/cultural reasons), must be regarded as clinically not-relevant, and hence ineligible for a Medicare rebate. 4. The argument about the need to avoid the risk of additional harms or complications that might arise if needy parents (those who claim to be unable to meet the full cost) would resort to less expensive unqualified operators (as in the backyard abortions and kitchen-table surgery of infamous memory) fails for 2 reasons. First, the argument about avoiding the risk of additional harm is not a reply to the proposal that parents etc should meet the full costs of medically unnecessary procedures, but to the proposition that such procedures should be legally prohibited. The Royal Dutch Medical Association, which would like to see non-therapeutic circumcision of minors banned, raised this point as the only consideration which deterred the from making such a recommendation in their 2010 circumcision policy statement. [2] But the current proposal is not that circumcision should be prohibited or restricted in any way at all, merely that individuals or parents who desire a medically unnecessary circumcision should meet the full costs. The mere fact that the procedure is covered by Medicare does not guarantee “safe circumcisions”. Complications and “botches” are still common in clinical settings, and at the hands of fully credentialed operators, often requiring expensive surgical repairs and sudden appearances in hospital emergency departments. [3] Ensuring patient safety is not the task of the MBS, but of the medical regulatory authorities. Further evidence for this point is provided by the two Medicare items for “arrest of haemorrhage following circumcision”, items 30649 and 30663; from a policy perspective the risks and complications of circumcision are real enough and recognised. There is thus a question as to whether these circumcision-related MBS benefits encourage unnecessary risk-taking behaviour on the part of parents and compliant practitioners. But what level of complications is acceptable in a clinically-unnecessary procedure? Second, the test of whether a person really values a good or service is how much he is willing to pay for it. Members of the religious/cultural groups that traditionally practise circumcision may be insistent that it is vitally necessary, but if they are not willing to put a price on it – if they do not wish to meet the actual costs involved – it suggests that they do not really regard it as necessary at all. To allow the rebate in this situation would be like allowing low-income families to drive a car without paying the full costs of vehicle registration because the expense is a strain on their resources. And here the full cost includes the insurance component, to cover the cost of accidents etc; the parallel with surgical complications of circumcision and the cost of repairing “botches” is quite exact. Most people regard the ability to drive as so vital that they are willing to meet whatever costs are involved. Moreover, some religious groups celebrate the circumcision with a lavish family party. If they are willing to pay for that, they should also be willing to meet the full costs of the surgery that is the occasion for the event. One assumes that they do not expect the taxpayer to subsidise the party. 5. Now that the Medicare circumcision codes have been made unisex or gender neutral, there is the danger that retaining coverage of religious/cultural circumcision will lead to Medicare providing a rebate for circumcision or other forms of genital cutting on girls. There is in fact evidence that this is already happening. [4] The religious/cultural groups that practise circumcision or other forms of genital cutting on girls regard the procedures as just as important and meaningful as circumcision of boys; if they see the rebate available for circumcision of the latter, they are likely to expect or even demand it for the former as well. And if cultural/religious affiliation is to be the deciding factor, how can their request be denied? [5] 6. While some defenders of circumcision have begun to advocate toleration of “mild” forms of female genital cutting, partly as a way of reducing the blatancy of the double standard (FGM legally prohibited, with heavy criminal penalties, circumcision of boys legal and generally unregulated), a stronger current of opinion stresses the importance of “genital autonomy” and the need to protect all children – male, female, intersex – from any form of non-therapeutic genital cutting. [6-10] It is puzzling and disappointing that the Committee displayed no awareness of these developments. References 1. Robert Darby. Scientific advice, traditional practices and the politics of health-care: The Australian debate over public funding of non-therapeutic circumcision, 1985. Hygiea Internationalis: An Interdisciplinary Journal for the History of Public Health, Vol. 10, December 2011. Available at https://www.academia.edu/7028494/Scientific_advice_traditional_practices_and_the_politics_of_health-care_The_Australian_debate_over_public_funding_of_non-therapeutic_circumcision_1985 2. Details at http://www.circinfo.org/Dutch_circumcision_policy.html 3. Gold, G. et al. Complications following circumcision: Presentations to the emergency department. Journal of Paediatrics and Child Health 51 (12) 2015: 1158-63; Jacques Gallant. Secrecy questioned about baby’s death after circumcision. The Star (Toronto), 26 October 2015. https://www.thestar.com/news/gta/2015/10/26/secrecy-questioned-about-babys-death-after-circumcision.html 4. See for example http://www.circinfo.org/Medicare_Coverage_Female_Circumcision.html 5. Brian Earp. Between moral relativism and moral hypocrisy: Reframing the debate on FGM. Kennedy Institute of Ethics Journal 26 (2) 2016: 105-144. Available at: https://www.academia.edu/10197867/Between_moral_relativism_and_moral_hypocrisy_reframing_the_debate_on_FGM_ 6. Brian Earp and Rebecca Steinfeld. Gender and genital cutting: A new paradigm. Euromind Global, 6 April 2017. Available at: http://euromind.global/en/brian-d-earp-and-rebecca-steinfeld/?lang=en 7. Robert Darby. The child’s right to an open future: Is the principle applicable to non-therapeutic circumcision?” Journal of Medical Ethics 39 (2013): 463-468. Available at: https://www.academia.edu/17264543/The_childs_right_to_an_open_future_Is_the_principle_applicable_to_non-therapeutic_circumcision 8. Eldar Sarajlic. Can Culture Justify Infant Circumcision? Res Publica 20 (4) 2014: 327-343. 9. Steven Munzer. Examining non-therapeutic circumcision. Health-Matrix: The Journal of Law Medicine 28 (2018). Available at: https://scholarlycommons.law.case.edu/healthmatrix/vol28/iss1/5/ 10. Kai Möller. Ritual male circumcision and parental authority. Jurisprudence 8 (3) 2017: 461–79. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Lack of progress on Medicare reform criticised darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h1>Medicare should not pay for medically unnecessary circumcision</h1> A recent review of Medicare found evidence that between 2 and 3 billion dollars are spent inappropriately each year. The review, by Dr Tony Webber as Director of the Professional Services Review, noted that Medicare’s no-questions-asked policy led to serious financial abuses and failed to take account of the medical business environment. “The MBS [Medical Benefits Schedule] is riddled with misdirected incentives for practitioners … and has many examples of good public policy being thwarted by the MBS rules”, Webber writes. Among the scandals, he mentions cases where “the Safety Net was used in effect to subsidise cosmetic procedures such as surgery for designer vaginas at $5000-$6000 each” (Tony Webber, “What is wrong with Medicare?”, Medical Journal of Australia, 16 January 2012.) What is equally scandalous about Medicare is that it continues to subsidise cosmetic procedures such as surgery for “designer penises” – namely, non-therapeutic (medically unnecessary) circumcision of male infants and boys. There is no reason at all why the over-stretched health budget should continue to waste taxpayers’ money by paying for an operation, usually on non-consenting children, that medical authorities judge to be medically unnecessary, risky, potentially harmful, and contrary to accepted principles of medical ethics and human rights, including the principle of gender equity. The Commonwealth Sex Discrimination Act, Section 3 (b), states that the Act applies to the administration of Commonwealth laws and programs, while Section 22 (b) makes it illegal to discriminate on the basis of sex in the provision of goods, services and facilities. It could be argued that the exclusion of female circumcision from the MBS is a breach of this provision, since it denies to women a benefit given to men; whether or not circumcision is regarded as a benefit or a deprivation, it is certainly anomalous that the MBS specifically denies coverage for cutting procedures on the female genitals while providing no-questions-asked coverage for comparable procedures on the genitals of boys. Medicare should never have covered a non-therapeutic procedure such as circumcision. When Medibank was first introduced in 1975, Australian medical authorities <a href="https://www.circinfo.org/doctors.html">had already determined</a> that boys should not be circumcised; and when it was re-established as Medicare by the Hawke government in 1984-85 they had reaffirmed and strengthened their policy. Unfortunately, the politicians and health bureaucrats seem to have been behind the times. It is high time that medically unnecessary (non-therapeutic) circumcision was dropped from the Medical Benefits Schedule, and Medicare confined to its stated requirement to cover only “procedures that are clinically necessary”. UPDATE 2015 In response to calls for public comment on various reviews of the Medical Benefits Schedule, aimed at eliminating outdated or inappropriate services, <a href="https://www.darboninstitute.org/medicare_should_not_cover_non_therapeutic_circumcision" rel="noopener" target="_blank">a detailed submission on why Medicare should not cover non-therapeutic circumcision was prepared and submitted</a>. <h2> <a id="medi1" name="medi1"></a>1. Medicare should not cover non-therapeutic circumcision</h2> Dr Robert Darby’s letter to Medical Journal of Australia in response to Tony Webber’s article Any review of Medicare arising from Tony Webber’s critique [1] must reconsider its coverage of non-therapeutic circumcision. Australia is the only country in the world to provide a no-questions-asked rebate for such procedures, despite the fact that most have no medical indication and in defiance of Medicare’s own guidelines. These state that benefits are not payable for “medical services that are not clinically necessary”, nor “surgery for cosmetic reasons”. [2] A medical procedure is clinically necessary only if required to correct a diagnosed disease, injury or other pathological condition that cannot be treated conservatively. Surgery for any other reason, particularly cultural or social reasons, is cosmetic surgery, intended merely to alter the appearance of the body part in question. As the Royal Australasian College of Surgeons points out, “male non-therapeutic circumcision is not clinically necessary as it does not treat an underlying pathological process.” [3] The issue is doubly serious in that most circumcision procedures are on infants and other minors, few of whom present any pathology requiring surgery, thus contradicting the policy of the Royal Australasian College of Physicians that routine circumcision is not warranted. Since minors cannot give consent, payments for such operations are questionable from a bioethical and human rights perspective, and may even be unlawful. [4] There have been several calls to delete non-therapeutic circumcision from the Medical Benefits Schedule, including Spilsbury et al, who point out that “the potential savings to the public purse would be considerable if elective and discretionary circumcision was removed from the Medicare schedule in line with other cosmetic surgeries, leaving rebates for the genuine medically indicated circumcision.” [5] In 1985 the government did drop circumcision from the MBS, only to reinstate it after objections from Jewish community leaders, leading to the myth that the original decision aroused a community backlash. Recent research has established that the decision represented sound public policy, was widely supported, and that the objections were based on a sense of discrimination: their real concern was that the rebate was deleted only for boys younger than six months. [6] It is not clear why the government, rather than restoring the rebate, did not resolve the problem by requiring a medical indication at all ages, as would have been the simplest and most equitable course of action. It now has the opportunity to rectify this mistake. Medicare should no more fund the designer penises created by circumcision than the designer vaginas created by other cosmetic procedures. References 1. Webber, TD. What is wrong with Medicare? Med J Aust 2012; 196 (1): 18-19. 2. “What does Medicare cover?”, at http://www.medicareaustralia.gov.au/public/claims/what-cover.jsp. Accessed 21 January 2012. 3. Australian Safety and Efficacy Registry of New Interventional Procedures – Surgical. Report No. 65: Male non-therapeutic circumcision. Adelaide: Royal Australasian College of Surgeons, 2008. 4. Adler, P. Is it lawful to use Medicaid to pay for circumcision? J Law Med 2011; 19: 335-353. 5. Spilsbury K, Semmons JB, Wisniewski ZS, Holman CD. Routine circumcision practice in Western Australia 1981–1999. ANZ J Surgery 2003; 73(8): 610-614. 6. Darby, R. Scientific advice, traditional practices and the politics of health-care: The Australian debate over public funding of non-therapeutic circumcision, 1985. Hygiea Internationalis: An Interdisciplinary Journal for the History of Public Health 2011; 10: 53-73. Available at http://www.ep.liu.se/ej/hygiea/. Accessed 21 January 2012. (This letter was sent to the Medical Journal of Australia in response to Tony Webber’s article, but was not published.) <h2> <a id="medi2" name="medi2"></a>2. Medicare should not pay for medically unnecessary circumcision: Our viewpoint</h2> Although Australian medical authorities do not recommend circumcision as a routine or prophylactic procedure, Medicare continues to provide an automatic rebate for such operations, whether medically required or not. The propriety, ethics and even the lawfulness of this policy have been questioned in two recent studies, one by an American legal expert who argues that payments for non-therapeutic circumcision by the United States health insurance program Medicaid are unlawful; and the other by Australian medical historian Dr Robert Darby, who has examined the attempt by the Hawke government to drop circumcision from the Medical Benefits Schedule in 1985. He dispels the myth that the decision aroused widespread protest and shows, on the contrary, that it represented sound public policy and was widely supported. Taken together, these analyses raise serious questions about current Medicare policy on the circumcision rebate; here Robert Darby argues that, for reasons of consistent public policy, financial prudence and respect for established principles of human rights and gender equity, the rebate should be abolished except for cases of proven medical need. <h3>Introduction</h3> The Australian government is under pressure to balance budgets, give more recognition to individual human rights, promote gender equity and protect children from harm. One simple way to make progress on all these fronts is to drop non-therapeutic circumcision from the Medical Benefits Schedule. Medicare currently provides an automatic, no-questions-asked rebate for circumcision, despite the fact that the vast majority of these operations have no medical indication, and in defiance of Medicare’s own guidelines. These state that benefits are not payable for “medical services which are not clinically necessary”, nor “surgery for cosmetic reasons”. A medical procedure is clinically necessary only if it is essential to correct a diagnosed disease, injury, deformity or other pathological condition that has not responded to conservative (non-surgical) treatment. As the Royal Australasian College of Surgeons points out, “male non-therapeutic circumcision is not clinically necessary as it does not treat an underlying pathological process.” Surgery for any other reason, particularly cultural or social reasons, is essentially cosmetic surgery, intended to alter the appearance of the body part in question. According to its own published guidelines, Medicare should not cover such procedures. <h3>Opinions of medical authorities</h3> It is strange that it still does so, considering that Australian medical authorities have sought to discourage routine (medically unnecessary) circumcision since the early 1970s. In fact, the government did drop circumcision from the MBS in 1985, only to restore it a few weeks later, for obscure reasons, explained below. Nonetheless, Australian medical authorities have maintained their opposition to the practice, with the result that the incidence of circumcision in Australia continues to decline. The most recent statement (October 2010) by the Royal Australasian College of Physicians states clearly: “After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.” Stronger statements have been issued by the British Medical Association, the Canadian Pediatric Society, the Royal Dutch Medical Association, the South African Medical Association, and medical authorities in Denmark, Finland, Norway and Sweden. Even in the United States, where circumcision is deeply entrenched as a medicalised cultural ritual, the American Academy of Pediatrics does not recommend the operation or regard it as medically desirable, much less as necessary. This being the case, a study by a US legal expert argues that payments for non-therapeutic (medically unnecessary) circumcision by the United States health insurance scheme Medicaid violate the protocols for benefits under this program and are thus unlawful. The article, in the December 2011 issue of the Journal of Law and Medicine, shows that the federal and state Medicaid acts stipulate that physicians and patients can use Medicaid to pay for medical services only when they are clinically necessary. This provision clearly excludes non-essential medical services, and some states expressly exclude cosmetic surgery from the list of covered treatments. In addition, federal and state Medicaid law require diagnosis of a medical condition and recommendation of an effective treatment before any benefit is payable. Medicare has not been the subject of such a study, but it is quite possible (given the guidelines) that its own payments for non-therapeutic circumcision are not authorised by Parliament and are thus unlawful. <h3>Why Medicare should not pay for circumcision</h3> There are at least five other main reasons why non-therapeutic circumcision should be dropped from the MBS. These relate to the absence of a convincing health case; conformity with international practice; principles of ethics and human rights; gender equity; and financial prudence. 1. No health case for routine circumcision It is not only the authorities mentioned above that have examined the medical literature and concluded that there is no health case for routine circumcision of infants or boys. A survey by British experts Malone and Steinbrecher acknowledged the medical claims for routine circumcision, but concluded that the only definite indications in childhood were phimosis caused by balanitis xerotica obliterans and recurrent balanoposthitis. Preputial adhesions, ballooning on urination, and a non-retractile foreskin do not require treatment. Relative indications (meaning that therapeutic circumcision could be warranted in individual cases) were recurrent urinary tract infections plus an abnormal tract. They point out that most circumcisions are done for religious cultural reasons, and that complications “are well documented and can be drastic”. A study by researchers in Adelaide, published in Annals of Family Medicine, subjected the claims of the circumcision lobby to an exhaustive review, and concludes that its value for child health was close to zero. When the literature is considered as a whole (rather than cherry picked for papers supporting a particular thesis) there is no proof that circumcision provides any significant protection against urinary tract infections, sexually transmitted infections or cancer of the penis The only evidence for prophylactic efficacy came from Africa, where there was evidence that adult males who got themselves circumcised had a slightly lower risk of contracting HIV through unprotected intercourse with an infected female partner. And I say “slightly lower risk” because I do not consider a risk reduction of between 40 and 60 per cent to be impressive, particularly when compared with the 90 to 95 per cent protection offered by a condom. As the authors of the paper comment, Africa has unique health problems. The circumcision trials were on adult men and can no more be applied to children than the World Health Organisation recommendations for the underdeveloped world can be transferred to a developed country like Australia. In Australia, unlike Africa, HIV-AIDS is not a heterosexual epidemic, but a relatively rare disease confined to specific sub-cultures – homosexual men and injecting drug users. It is well established that these groups can derive no protection from circumcision at all. In any case, because it is a disease of promiscuous adults, children are not at any risk of infection – unless, of course, by surgery. When they become sexually active boys are old enough to understand the issues and make their own decisions about how to manage the risks of sexual activity with others. The Australian Federation of AIDS Organisations has stated that circumcision has no relevance to Australia’s HIV problem, and their conclusion has been endorsed by a paper in the Australian and New Zealand Journal of Public Health, which argues that circumcision is not a surgical vaccine and is not appropriate as an HIV control tactic in developed countries such as Australia. 2. International practice Australia is the only country in the world that provides automatic coverage of circumcision through the health budget. This policy is despite the fact that most State governments (Victoria, Western Australia, Tasmania, New South Wales and South Australia) do not provide free coverage of circumcision in public hospitals, and it is in sharp contrast with the practice of comparable developed nations. <ul> <li>In Britain the National Health Service has never included routine circumcision among its free procedures, and covers it only as a therapeutic procedure in cases of medical necessity. The same is true of New Zealand.</li> </ul> <ul> <li>In Canada, where medical insurance is the responsibility of the provinces, the only province to include circumcision in its cover is Manitoba; and even there doctors refuse to charge the state but bill the parents.</li> </ul> <ul> <li>In the United States, the federal government provides the funds for public health insurance to the states, which make their own decisions as to which services they cover. When the program was introduced in 1965 all states covered circumcision, but since then 18 of the 50 states have ceased to fund it, and more are likely to do so as budgetary constraints intensify.</li> </ul> Circumcision is not funded by the governments of Israel, Turkey, Indonesia, Iran or any other predominantly Islamic country where the procedure is widely practised as a cultural/religious ritual, not even when the operation is performed in hospitals rather than (as is traditional) in the boy’s home. The Dutch national health insurance service withdrew coverage of non-therapeutic circumcision in 2004 when it was realised that 90 per cent of the procedures were done for religious/cultural rather than for health-related reasons. 3. Ethics and human rights For a surgical intervention to be ethically acceptable (and indeed legal) the fundamental requirement is that the person must give informed consent. An adult male can consent to having himself circumcised (it’s his choice), but the question becomes difficult when parents wish to circumcise their children because minors can no more consent to surgery than to sexual relations with adults. Circumcision of children thus deprives them of choice and amounts to coercion. The problem is especially relevant to Medicare, since the vast majority of the circumcision procedures that it covers involve children. In FY 2010-11, of 25,842 circumcision procedures funded by Medicare, 22,491 (88%) were on boys aged under 10 years, and of these 18,503 (71% of the total) were aged less than 6 months. Very few of these operations could be regarded as therapeutic or clinically necessary. An additional 2641 procedures were on males aged 10 years or more, but Medicare provides no breakdown as to how many of these are adults and how many are still minors, though it is clear enough that very few adult males elect to have themselves circumcised. Surrogate consent for surgery on minors is valid only for life-saving medical treatment, or where the procedure is manifestly in the best interests of the child and passes the imputed judgement test – that is, it is an operation the child would choose for himself if he were a competent adult. It has been strongly argued that, in the absence of a life-threatening disorder, surrogate consent for non-therapeutic surgery such as circumcision is ethically problematic and may not be legally valid. When there is no urgency to intervene, it is best to wait until the child can make his own choice. In addition to informed consent, leading bioethicists propose five conditions that must be met in order for a medical procedure to be ethically permissible. Beneficence — Does the proposed procedure provide a net therapeutic benefit to the patient, considering the risk, pain, and loss of normal function? Non-maleficence — Does the procedure avoid permanently diminishing the patient in any way that could be avoided? Proportionality — Will the final result provide a significant net benefit to the patient in proportion to the risk undertaken and the losses sustained? Justice — Will the patient be treated as fairly as we would all wish to be treated? Autonomy — Lacking life-threatening urgency, will the procedure honour the patient’s right to his or her own likely choice? Could it wait for the patient’s assent? Non-therapeutic circumcision of minors fails all these tests. It is not beneficent because it does not provide a therapeutic benefit (nor even a relevant prophylactic benefit, since a child is at zero risk of sexually transmitted infections ). It is malefic because it diminishes the genitals. It is disproportional because the net gain (if any) is out of proportion to the loss, harm and risk of complications. It is unjust because adult preferences show clearly that if he had a choice in the matter the boy would refuse the operation. Finally, circumcision fails to respect the boy’s autonomy and preserve his future options as an adult individual. The British Medical Association and the Royal Dutch Medical Association have issued particularly strong warnings that non-therapeutic circumcision of minors is likely to breach accepted principles of bioethics and potentially of the law. In its policy statement (May 2010) the latter states: “Non-therapeutic circumcision of male minors is contrary to the rule that minors may only be exposed to medical treatments if illness or abnormalities are present, or if it can be convincingly demonstrated that the medical intervention is in the interest of the child, as in the case of vaccinations”; and further that such interventions violate “the child’s right to autonomy and physical integrity.” The RACP agrees: “The option of leaving circumcision until later, when the boy is old enough to make a decision for himself does need to be raised with parents and considered. … The ethical merit of this option is that it seeks to respect the child’s physical integrity, and capacity for autonomy by leaving the options open for him to make his own autonomous choice in the future.” International instruments are also relevant. Article 8 of the UNESCO Declaration on Human Rights and Bioethics (2005) states that “In applying and advancing scientific knowledge, medical practice and associated technologies, human vulnerability should be taken into account. Individuals and groups of special vulnerability should be protected and the personal integrity of such individuals respected.” Children certainly fall into this category. Given the government’s commitment to enhancing Australia’s commitment to individual human rights, it is highly anomalous that it allows Medicare to subsidise and thus encourage a disfiguring operation that denies them to so many children. 4. Gender equity Australia’s obligations under the Sex Discrimination Act 1984 and as a signatory to the United Nations Convention on the Rights of the Child require the national and State governments to treat males and females equally and without discrimination on the basis of sex, and to take action to eradicate traditional practices harmful to children. Article 24 (3) of the Convention requires parties to take “all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children.” In pursuance of this development several States passed laws to prohibit any form of female circumcision, and in 1995 the Commonwealth specifically excluded such procedures from the Medical Benefits Schedule. Although there was nothing in the wording of the Convention to suggest that it did not include male children, no action has yet been taken to protect boys. This failure is increasingly recognized, in Ranipal Narulla’s words, as “a hidden human rights violation”. The Commonwealth Sex Discrimination Act, Section 3 (b), states that the Act applies to the administration of Commonwealth laws and programs, while Section 22 (b) makes it illegal to discriminate on the basis of sex in the provision of goods, services and facilities. It could be argued that the exclusion of female circumcision from the MBS is a breach of this provision, since it denies to women a benefit given to men; whether or not circumcision is regarded as a benefit or a deprivation, it is certainly anomalous and inconsistent that the MBS specifically denies coverage for cutting procedures on the female genitals while providing a no-questions-asked rebate for comparable procedures on the genitals of boys. The situation is doubly discriminatory in that girls are denied a "benefit" that is given to boys, while boys are denied a protection from harm that is enjoyed by girls. The simplest way to remove such discrimination and restore the principle of equal treatment is to limit coverage of male circumcision to cases of proven medical necessity. 5. Economy and financial prudence All government welfare programs should be targeted at genuine need and be administered with prudence and economy. An open-slather approach to funding a medically unnecessary procedure is wasteful and invites over-servicing. It also acts as a signal that circumcision is a socially acceptable and even medically recommended operation, thus encouraging more parents to seek to have it done. Assuming 15,000 unnecessary circumcision procedures per year at a cost of between $100 and $1600 each, Katrina Spilsbury and colleagues have estimated that the removal of medically unnecessary circumcision from the MBS would save between $1.5 million and $24 million per year. They state that “the potential savings to the public purse would be considerable if elective and discretionary circumcision was removed from the Medicare schedule in line with other cosmetic surgeries, leaving rebates for the genuine medically indicated circumcision.” According to figures available on the Medicare website, the total cost of the rebate for all circumcision procedures in FY 2010-11 was $1,577,754, nearly half of which went to subsidise operations on infants less than 6 months old, almost none of whom could have had a genuine medical indication. This is not a large sum in the overall budget context, but the real cost to the government will be considerably higher, given that this figure does not include the cost of treating complications and long-term adverse effects, which may not become apparent until adolescence. A cost-utility analysis of neonatal circumcision by American researcher Robert Van Howe found that even if the extreme claims of circumcision advocates were true, the associated complications and adverse outcomes would cancel out and exceed the benefit to health by a considerable margin. On top of this there may be losses to revenue arising from tax rebates that parents are able to claim under the Medicare safety net for expenses related to child-bearing. These are not substantial sums in the context of today’s billion-dollar budgets, but when every effort is being made to rein in public expenditure, especially the ever-expanding health budget, every million saved can help to make a difference. Not only this: given the irresponsible media commentary on the role of circumcision in HIV control and the efforts of scaremongering evangelists and entrepreneurial circumcision practitioners to generate a mood of panic, the demand for circumcision could increase if parents are misled by their propaganda and become fearful of the alleged risks of not getting it done. It is thus possible that the cost of the circumcision subsidy will increase unless entitlement is restricted. Removal of non-therapeutic circumcision from the MBS will send a clear signal to Australian parents that routine circumcision is not a medically recommended procedure and is not necessary for the health and well-being of their child. Parental right to circumcise for religious reasons not affected The main argument for dropping non-therapeutic circumcision from the MBS is not the cost-saving, but the principles of prudent and targeted assistance to those in need; of adherence to stated entitlement guidelines and lawful program administration; of respecting current expert medical advice; of observing accepted principles of ethics and human rights; and of avoiding discrimination on the basis of sex. Allowing Medicare to provide a rebate for non-therapeutic circumcision sends the wrong signals to parents, suggesting that it is a socially and medically approved procedure, and thereby encouraging the practice. There is nothing in this proposal that will limit the right of parents to circumcise their children if they feel they have a compelling cultural or religious reason, merely that they will not receive a public subsidy for doing so. There is no intent to restrict the right of Jewish, Aboriginal or Muslim parents to circumcise their children in accordance with their respective traditions; but equally there is no reason why such rites and practices should be funded by the Australian taxpayer through the health budget. <h3>The Hawke government’s thwarted attempt to drop circumcision from the MBS in 1985</h3> It is true that when the Hawke government dropped circumcision from the MBS in 1985 it faced protests from Jewish community leaders and soon backed down, leading to the development of the myth that there was a “community backlash” and discouraging further attempts. This myth has been disproved in a detailed study of the incident by Dr Robert Darby, published in Hygiea, an international journal for the history of public health. His conclusions are that the decision was justified on medical and public policy grounds; that there was no wide public outcry and, indeed, that the decision was widely approved; and that the rapid reversal of the decision was the result of inept implementation, failure to consult, and a fortuitous combination of subsequent factors, including, vigorous lobbying by the groups who felt most deeply affected. The main objection of Jewish community leaders was not to the dropping of the rebate in itself, but the fact that it was dropped only from the code for circumcision of boys under 6 months, leaving the rebate in place for operations at later ages. Since Jewish people traditionally circumcise at 8 days, they justifiably felt that this was unreasonable discrimination. It is not clear why the government, rather than abjectly restoring the rebate, did not resolve the problem by requiring a medical indication at all ages, as would have been the simplest, most economical and most equitable course of action. The government now has the opportunity to rectify this mistake. If a proven medical requirement is attached to each of the codes for circumcision, there is no reason why the sensibilities of the Moslem and Jewish communities should be affronted, since the new rules would apply to everybody in the community, without discrimination. <h3>Conclusion</h3> There is no reason why Medicare, and thus the Australian taxpayer, should continue to fund operations that medical authorities have defined as unnecessary and potentially harmful, and which many people regard as an violation of the rights of the child, or even genital mutilation. The government must face up to its responsibilities, bite the bullet, rectify the mistakes it made in 1985, and delete non-therapeutic circumcision from the Medical Benefits Schedule. <h3>Appendix: Relevant MBS codes and payments (as at 1 January 2012)</h3> 30653: Circumcision of a male under 6 months of age Scheduled fee: $45.65; Benefit: $34.25 (75%); $38.85 (85%) 30656: Circumcision of a male under 10 years of age but not less than 6 months of age Scheduled fee: $106.15; Benefit: $79.65 (75%); $90.25 (85%) 30659: Circumcision of a male 10 years of age or over by a GP Scheduled fee: $146.95; Benefit $110.25 (75%); $124.95 (85%) 30660: Circumcision of a male 10 years of age or over by a specialist Scheduled fee: $182.15; Benefit $136.65 (75%); $154.85 (85%) 30663: Haemorrhage, arrest of, following circumcision requiring general anaesthesia Scheduled fee: $141.65; Benefit $106.25 (75%); $120.45 (85%) Until 1995 these codes were unisex and read “circumcision of a person”, thus authorising a benefit for circumcision of females as well as of males. In order to protect girls from genital mutilation as part of the general development of laws and policies against FGM that followed the passage of the UN Convention on the Rights of the Child, “person” was changed to “male”, thus introducing two elements of discrimination: females were denied a service that remained available to males; but males were denied the protection that was accorded to females. The deletion of non-therapeutic circumcision from the schedule can be effected by simply by adding the phrase “where medically indicated” to each of the codes above. “Medically indicated” means a case where (1) there is a medical problem that has not responded to conservative (non-surgical) treatment after reasonable efforts; and (2) this is certified by two qualified medical practitioners, one of whom must be an appropriate specialist, and neither of whom may be the surgeon or other operator who is to perform the surgery. <h3>Selected references</h3> Adler, Peter. “Is it lawful to use Medicaid to pay for circumcision?” Journal of Law and Medicine, Vol. 19, December 2011: 335-353. Australian Safety and Efficacy Registry of New Interventional Procedures – Surgical. Report No. 65: Male non-therapeutic circumcision. Adelaide: Royal Australasian College of Surgeons, 2008. Australian Federation of AIDS Organisations. Male circumcision has no role in the Australian HIV epidemic. Briefing paper, 23 July 2007. Beauchamp TL, Childress JF. Principles of Biomedical Ethics (6th edn). Oxford University Press: 2009. British Medical Association, The Law and Ethics of Male Circumcision: Guidance for Doctors (November 2007). Available at http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp Darby, Robert. “Infant circumcision in Australia: A preliminary estimate, 2000-2010”. Australian and New Zealand Journal of Public Health, Vol. 35, August 2011 Darby, Robert and Robert Van Howe. “Not a surgical vaccine: There is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia.” Australian And New Zealand Journal of Public Health, Vol. 35, October 2011: 459-465. Available at http://onlinelibrary.wiley.com/doi/10.1111/j.1753-6405.2011.00761.x/full Darby, Robert. “Scientific advice, traditional practices and the politics of health-care: The Australian debate over public funding of non-therapeutic circumcision, 1985.” Hygiea Internationalis: An Interdisciplinary Journal for the History of Public Health, Vol. 10, December 2011. Available at http://www.ep.liu.se/ej/hygiea/ Forbes, David. “No evidence to support routine circumcision.” Sydney Morning Herald, 12 September 2009. On-line at: http://www.smh.com.au/national/letters/no-evidence-to-support-routine-circumcision-20090911-fkna.html Malone, Padraig and Henrik Steinbrecher. “Medical aspects of male circumcision.” British Medical Journal 335 (8 December 2007): 1206-1209. Narulla, Ranipal. “Circumscribing circumcision: Traversing the moral and legal ground around a hidden human rights violation”. Australian Journal of Human Rights, Vol. 12, 2007, 89-118 Royal Australasian College of Physicians. Circumcision of Infant Males [Policy statement]. Sydney: October 2010. Available at http://www.racp.edu.au/page/policy-and-advocacy/paediatrics-and-child-health Royal Dutch Medical Association. Non-therapeutic Circumcision of Male Minors (May 2010). Available at http://knmg.artsennet.nl/Diensten/knmgpublicaties/KNMGpublicatie/Nontherapeutic-circumcision-of-male-minors-2010.htm Spilsbury K, Semmons JB, Wisniewski ZS, Holman CD. “Routine circumcision practice in Western Australia 1981–1999”. ANZ Journal of Surgery 2003;73(8):610-4. Available at http://www.cirp.org/library/procedure/spilsbury1/ Svoboda JS, Van Howe RS, Dwyer JG. “Informed consent for neonatal circumcision: An ethical and legal conundrum.” Journal of Contemporary Health Law and Policy 2000;17:61-133. Available at http://www.cirp.org/library/legal/conundrum/ Van Howe RS. “A cost-utility analysis of neonatal circumcision.” Medical Decision Making 2004;24:584-601. Available at http://www.cirp.org/library/procedure/vanhowe2004/ <h2> <a id="colorado" name="colorado"></a>A comparable case in Colorado</h2> In the United States of America, where even the most minor local issues tends to be politicised, insurance coverage of non-therapeutic circumcision tends to become a political football. Last year Colorado dropped payments for circumcision from Medicaid (the USA equivalent of Medicare), but this year politicians in the state legislature who had been misled by the usual scaremongering propaganda put out by the usual suspects tried to restore it. Their arguments - for example, that the foreskin caused spina bifida, or that circumcision was good because it deadened the penis and discouraged teenage sexual activity - demonstrate why politicians should not get involved in these questions unless they have done some research.** Colorado drops circumcision from Medicaid A bill that would have restored Medicaid funding for circumcisions in Colorado died Friday. The measure squeaked through a hearing in the House Health and Environment Committee on Thursday, then died in Appropriations Friday morning. Opponents, who included health professionals, budget hawks and anti-circumcision activists told health committee members on Thursday that circumcision is cosmetic and potentially harmful, and taxpayers should not fund it. Proponents for the bill argued that funding for circumcision for babies on Medicaid is a social justice issue. In general, insurance companies pay for the procedure for insured Colorado babies even though the American Academy of Pediatrics does not deem circumcisions to be “medically necessary.” Meanwhile, low-income parents who want their babies circumcised are being put on waiting lists for the procedure until parents can prove they’ve paid in advance. Sen. Irene Aguilar, D-Denver, an internal medicine doctor for Denver Health, testified on behalf of restoring public funding for circumcision. Last year, Colorado lawmakers decided to save money and cut funding for Medicaid circumcisions. They were following the lead of 17 other states. Proponents wanted taxpayers to once again pay for the procedures for parents who choose to have their infants circumcised. Fiscal analysts estimated that covering the procedures again would cost the state about $195,000 next year and $230,000 the year after that. “As a physician, I don’t try to influence parents one way or the other,” Aguilar said. “People make this decision based on religious and cultural reasons.” She said that there is some evidence that infant boys who don’t get circumcised have higher rates of urinary tract infections and that adult men who are uncircumcised and live in poverty tend to have increased rates of HPV, which can lead to higher rates of cervical cancer in female partners. [What business does a medical doctor have performing unnecessary surgery based on religious or cultural reasons?] Only one other doctor testified on behalf of circumcision. The rest of the witnesses opposed public funding for the procedure for a variety of reasons. They included Dr. Jennifer Johnson, a family physician who works with Medicaid and uninsured patients at Clinica Family Health Services. “I’ve done at least 100 circumcisions and just recently decided to stop,” Johnson testified. She said she and her husband, who is Jewish, decided not to circumcise their own son, who is now 4. She said she was concerned when she researched the issue and found that removing the foreskin from a boy’s penis damages numerous nerve endings. While circumcision is traditional in the Jewish community, Johnson said her husband was open to new research about the potential harms from circumcision. If boys or men decide to remove the foreskin as adults, then they can make that decision, Johnson said. But she decided that as a physician, she should no longer do a procedure that is potentially harmful. “This is not a necessary procedure,” Johnson said. “It’s a healthy, normal body part. There are a lot of medical needs in our population. We have no business using limited health care dollars on a medically unnecessary cosmetic procedure.” One lawmaker, Rep. Sue Schafer, D-Wheat Ridge, elicited laughter in the hearing room when she asked Dr. Johnson if circumcision might help reduce teen pregnancy rates and teen sexual activity by reducing nerve sensation in boys’ penises. “I’m wondering if there’s a risk of more sexual activity, more male irresponsibility” for uncircumcised boys, Schafer asked. Johnson answered that teen pregnancy is certainly a problem, but said circumcision won’t halt teen sexual activity. “Circumcision is not a cure for behavior. That’s about education,” she said. While circumcision is an ancient tradition in some religions, circumcision opponents said it became popular in the U.S. as a method to prevent masturbation among boys. Later, fathers wanted their sons to look like them. “Frankly that’s cosmetic surgery…and I strongly urge you to vote against it,” said Dr. Matt Mason, a physician from Telluride. He was skeptical about cost estimates and said circumcision is now rare in Western Europe, Canada and New Zealand. [He might have added Australia; circumcision has always been rare to vanishing point in all Europe, not just the west.] Source: Katie Kerwin McCrimmon, <a href="http://www.healthpolicysolutions.org/?s=circumcision+colorado&x=0&y=0">Circumcision bill dies in Colorado House, Health Policy Solutions</a>, 5 May 2012 ** Take the example of a local senator, who claimed in an email to constituents that “Reliable studies prove that male circumcision reduces instances of infectious disease, some congenital obstructive urinary tract anomalies, neurogenic bladder, spina bifida and urinary tract infections.” He continued to dispense this fiction despite having been challenged previously by a competent physician, Dr. Mat Masem, who stated, “There are rare therapeutic indications for male circumcision, which generally relate to pathologic conditions of the foreskin. However, a number of the conditions you mentioned as being positively affected by circumcision have absolutely nothing to do with the foreskin. Spina bifida is an anomaly of the spine; congenital obstructive urinary tract anomalies are related to urethral strictures or other abnormalities of the urinary tract; and neurogenic bladder is a neurological condition. ” Source: Jere DeBacker, <a href="http://www.healthpolicysolutions.org/2012/05/01/opinion-lawmakers-clueless-about-circumcision-research">Opinion: Lawmakers clueless about circumcision research</a>, Health Policy Solutions, 1 May 2012. Social disadvantage vs anatomical/physiological disadvantage As for the argument that Medicaid/Medicare should cover circumcision because otherwise poor people cannot afford it (“Circumcision a health right of the poor”, as Brian Morris and Jake Waskett have claimed) - surely it’s bad enough to be poor. Why should poor people be deprived of their foreskins as well? That is merely adding injury to insult. <h2> <a id="hawke" name="hawke"></a>4. The Hawke government's unsuccessful attempt to drop circumcision from the MBS</h2> Robert Darby, Scientific Advice, Traditional Practices and the Politics of Health-Care: The Australian Debate over Public Funding of Non-Therapeutic Circumcision, 1985. <a href="http://www.ep.liu.se/ej/hygiea/" rel="noopener" target="_blank">Hygiea Internationalis: An Interdisciplinary Journal for the History of Public Health</a>, Vol. 10, December 2011. ABSTRACT In 1985 the Australian Government sought to delete circumcision of infants from the benefits payable under its newly established universal health scheme, Medicare. Although the decision had been recommended by the government’s health advisers and was welcomed by medical authorities, it was soon reversed after protests from Jewish community leaders. I present a detailed narrative of this affair and explain why a decision based on sound medical knowledge advice was rescinded after quite mild objections. The answer is found to lie partly in contingent factors, such as the details of the policy change, the personalities of the government figures involved, and problems with implementation and communication; and partly in the sensibilities of the ethnic/religious communities most directly affected. I dispel the misconception that the original decision aroused widespread opposition and show, on the contrary, that it was based on good advice, represented sound public policy, and was widely supported. I conclude that the episode may have useful lessons for other governments seeking to implement or resist policy changes that affect the sensitivities of cultural minorities. <a href="https://independent.academia.edu/RobertDarby" rel="noopener" target="_blank">Available at Robert Darby's Academia.edu page</a> <h2> <a id="smh" name="smh"></a>5. Sydney Morning Herald, The Question - Should elective circumcision continue to be covered by Medicare?</h2> <h3>Medicare should not cover non-therapeutic circumcision</h3> (a) Medical historian, Dr Robert Darby The Australian government is under pressure to balance budgets, give more recognition to individual human rights, promote gender equity and protect children from harm. One simple way to make progress on all these fronts is to drop non-therapeutic circumcision from the Medical Benefits Schedule. Medicare currently provides a no-questions-asked rebate for circumcision, despite the fact that most of these operations have no medical indication, and in defiance of Medicare’s own guidelines. These state that benefits are not payable for “medical services which are not clinically necessary”, nor “surgery for cosmetic reasons”. A medical procedure is clinically necessary only if it is essential to correct a diagnosed disease, injury, deformity or other pathological condition. Surgery for cultural or social reasons is essentially cosmetic surgery, intended to alter the appearance of the body. According to the Royal Australasian College of Surgeons, “male non-therapeutic circumcision is not clinically necessary as it does not treat an underlying pathological process.” Medicare should not, therefore, cover such procedures. There are five further reasons. 1. No health case for routine circumcision. All the medical authorities that have issued policies on routine circumcision have rejected the operation as unwarranted and potentially harmful, most recently the Royal Australasian College of Physicians in a lengthy statement of October 2010. 2. Consistency with international practice. Australia is the only country in the world that provides an automatic rebate for medically unnecessary circumcision. Even in the United States, 18 states have dropped circumcision from the list of benefits, and more are considering the question. 3. Ethics and human rights. The vast majority of circumcision procedures funded by Medicare are on infants and other minors, few of whom present any pathology requiring surgery. Since minors cannot give consent and may prefer to keep their foreskins, payments for such operations are questionable from a bioethical and human rights perspective, and may even be unlawful. 4. Avoiding sex discrimination. Girls are legally protected from any mutilation of their genitals; the least we can do for boys is not provide a public subsidy for needlessly modifying theirs. 5. Economy and financial prudence. Government welfare programs should be targeted at genuine need and be administered with prudence and economy. An open-slather approach to funding a medically unnecessary procedure is wasteful and invites over-servicing. For reasons of consistent public policy, financial prudence and respect for established principles of bioethics and gender equity, the rebate for circumcision should be abolished except for cases of proven medical need. NOTE: This is the original text of Robert Darby’s contribution to the <a href="http://www.smh.com.au/opinion/the-question/should-elective-circumcision-continue-to-be-covered-by-medicare-20120511-1yhqb.html">Question of the Week, Sydney Morning Herald, Saturday 12 May 2012</a>. The text as published was slightly edited. Dr Darby is an independent scholar who has written extensively on the history and ethics of male and female circumcision. His publications include A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain (University of Chicago Press, 2005) and, most recently, “Scientific advice, traditional practices and the politics of health-care: The Australian debate over public funding of non-therapeutic circumcision, 1985.” Hygiea Internationalis: An Interdisciplinary Journal for the History of Public Health, Vol. 10, December 2011. Available at http://www.ep.liu.se/ej/hygiea/ (b) Urologist Dr Stan Wisniewski Male circumcision is performed for religious, medical and social reasons. Religious circumcision is performed outside the ambit of the public health purse and is cost neutral, as long as no complications occur. Advocates of universal circumcision in newborn infants believe the procedure is a prophylaxis against future disease and that the phallus looks better and somehow functions better. Circumcision for infection, poor skin retraction or neoplastic changes is required in 5 to 10 per cent of males in the West. This means more than 90 per cent would not need the procedure in their lifetime. Infections in the foreskin or urinary tract are rare in infancy. The foreskin becomes retractile between 5-10 years of age and teaching hygiene should be intrinsic to healthcare. Contraction and transmission of sexually contracted diseases cannot be prevented by circumcision. The argument that AIDS is not transmitted by circumcised males is not factual. Penile skin cancer is rare and seen in situations of neglect and poor hygiene. One would need to perform 100,000 circumcisions to prevent one case of penile cancer. The idea that circumcision improves virility or sexual prowess is not scientifically validated. The foreskin has many sensory receptors important for sensual pleasure, and the mechanics of intercourse change when foreskin mobility is removed. The reason for performing surgery on neonates is a matter of expediency rather than scientific dictum. The operation is often performed without appropriate analgesia and screams and wriggling are ignored. Studies show many boys carry psychological scars afterwards, leaving them agitated and irritable for long periods, sometimes into adulthood. Physical consequences such as excessive skin removal, penile shortening, disfigurement and complications with bleeding and death are all reported. Many circumcised men express anger at parents for their decisions which they now regret, to the point of parents being sued. This is not a benign procedure free of problems. Rates of neonatal circumcision in educated, sophisticated societies continue to fall. A Medicare rebate for prophylactic neonatal circumcision would allow crusaders to continue to perpetuate a practice that is not substantiated. Nature, honed by millennia of evolution, decrees the foreskin is part of the perfection of humans. Until the time that other changes transmute, why do we think we can do better? Dr Stan Wisniewski is past president of the Urological Society of Australia & New Zealand. Source: <a href="http://www.smh.com.au/opinion/the-question/should-elective-circumcision-continue-to-be-covered-by-medicare-20120511-1yhqb.html">Should elective circumcision continue to be covered by Medicare</a>, Sydney Morning Herald, 12 May 2012 <h2> <a id="anu" name="anu"></a>6. ANU law student writes on why Medicare should not continue to pay for non-therapeutic circumcision</h2> The following paper was written in 2009 by a third year Law student at the Australian National University, as an assignment for a medical law and ethics unit. The author wishes to remain anonymous. It’s time for Medicare Australia to stop providing rebates for infant male circumcision ABSTRACT Infant male circumcision is a controversial procedure that has been debated for years. The overwhelming body of Australian medical opinion is firmly against the procedure and clearly classes it as non-therapeutic, yet the procedure is still covered by Medicare, despite their own guidelines stating they do not cover non-therapeutic procedures. This means the Australian government is indirectly authorising a non-recommended procedure. With the medical opinion firm, and in light of recent debates about the ethics and legality of male circumcision, now is the time for Medicare to stop covering this procedure. * * * * * * For years the potential benefits, disadvantages and ethical issues surrounding male infant circumcision have been debated in Australia and overseas. While male infant circumcision used to be common, even routine, in Western nations including Australia, it has dropped significantly in popularity as doctors and parents have become aware that it is not medically necessary or even recommended. Currently, it is estimated that around 10% of newborn baby boys are circumcised in Australia each year, at parental choice. As Medicare provides a rebate for circumcision of a boy under 6 months old, this unnecessary procedure costs Medicare, and therefore the Australian taxpayers, roughly $2 million each year. This is despite Medicare’s own statements that they do not provide rebates for clinically unnecessary procedures. Recent policies, reviews and cases relating to the medical, ethical and legal aspects of infant circumcision – such as the Tasmanian Law Reform Institute review, the Royal Australian College of Physicians new policy statement, and a case from the Oregon Supreme Court – highlight the importance of there being a swift policy change in Australia so that Medicare and the Australian Government come in line with current medical opinion and no longer indirectly endorse a non-therapeutic, non-recommended procedure fraught with legal and ethical uncertainties. <a href="https://www.circinfo.org/documents/Natasha-Medicare.pdf">To read full text, download document as PDF here</a> <h1>Lack of progress on Medicare reform attracts criticism</h1> Despite a series of reviews over the past few years aimed at containing costs and simplifying the system, there have been no significant changes to Medicare coverage of circumcision. The only changes have been to reduce the number codes (from four to two) and to make them unisex. This had had the unfortunate effect of making it impossible to calculate the number of circumcision procedures by age (thus obscuring the fact that the vast majority are of infants and young boys) and allowing circumcision of girls, as <a href="https://www.circinfo.org/Medicare_Coverage_Female_Circumcision.html" rel="noopener" target="_blank">previously documented on this site</a>. The latest report from one of the working groups, the Urology Clinical Committee, has proposed no changes to the circumcision codes at all, except for the requirement for analgesia (pain control). This is a desirable reform, but a less important issue than the fact that Medicare will continue to fund non-therapeutic (medically unnecessary) circumcision, including circumcision desired for religious, cultural and other social/cosmetic reasons. This is contrary to the provisions of the Health Insurance Act and the Medicare guidelines, which state clearly that benefits are payable only for “clinically relevant” services – i.e. procedures for which there is a demonstrated medical need. <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mbs-review-2018-taskforce-reports-cp/%24File/v2%20-%20Urology%20Clinical%20Committee%20-%20Report.pdf" rel="noopener" target="_blank">The Committee report is available here</a>; the section relating to circumcision are on pages 68-70. <h2>Medicare should not pay for non-therapeutic circumcision</h2> For some years the Commonwealth Government has been concerned at the ever-rising costs of the ever-expanding health budget, particularly the cost of Medicare. In 2015 it resolved to establish a reform process, the aim of which was to simplify the system and reduce costs by eliminating services of low medical value. Non-therapeutic circumcision was identified as an example of such a low-value service, giving rise to the expectation that it would be dropped from the Medicare Benefits Schedule. This has not happened. In the first round of reforms all that happened is that the codes for circumcision were reduce from four (distinguished by age) to two (distinguished by type of anaesthesia) – thus making it impossible to determine how many infants and boys were being circumcised. In addition, the codes were made gender-neutral, allowing them to be used for circumcision of females – as is apparently happening. In a further round of reforms the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/MBSR-consult-2018-taskforce-reports" rel="noopener" target="_blank">Urology Clinical Committee</a> tackled the circumcision codes and managed to produce a very small mouse. Of nearly 6000 items on the MBS, it managed to eliminate 18, of which circumcision was not one. The Committee’s sole recommendation was to require analgesia (pain control) for circumcision procedures, “thus ensuring patient wellbeing.” This is certainly a welcome move in the right direction, but it is not the main issue. More significantly, the Committee made no attempt to limit the availability of the circumcision rebate; on the contrary, it accepted the prevailing situation in which it is readily available for procedures carried out for religious or cultural reasons: The Committee noted that item 30654 should continue to include circumcisions conducted for religious and cultural reasons, reflecting both current practice and the need to ensure safe circumcisions. While this does not appear to be a formal recommendation, it presumably has the force of one. It is difficult to see how subsidising religious or cultural practices could be a legitimate use of the health budget, particularly as the Health Insurance Act and the Medicare guidelines state clearly that the rebate is available only for “clinically relevant” services – i.e. medical treatment that is actually needed for medical reasons. The policy is certainly in contradiction to the fundamental objective of the reform process: to rein in and control costs. The stated objectives of the reviews were to achieve: <ul> <li>Affordable and universal access</li> <li>Best-practice health service</li> <li>Value for the individual patient</li> <li>Value for the health system</li> </ul> An open-ended subsidy (essentially a blank cheque) for procedures of zero clinical relevance makes no contribution to achieving these objectives, and is in fact in complete contradiction to them, especially the last. Examining the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mbs-review-2018-taskforce-reports-cp/%24File/v2%20-%20Urology%20Clinical%20Committee%20-%20Report.pdf" rel="noopener" target="_blank">Urology Clinical Committee’s recommendations and observations on circumcision</a> in more detail, it is possible to raise six major objections to them, as set out below. Further information on this site <a href="https://www.circinfo.org/Medicare_circumcision_review.html" rel="noopener" target="_blank">Medicare Circumcision Review details</a> <a href="https://www.circinfo.org/Medicare_coverage_for_circumcision.html" rel="noopener" target="_blank">Medicare coverage of non-therapeutic circumcision criticised in submission</a> <a href="https://www.circinfo.org/Medicare_Coverage_Female_Circumcision.html" rel="noopener" target="_blank">Medicare coverage of female circumcision?</a> <h2>Medicare Benefits Schedule Review: Report of the Urology Clinical Committee</h2> <h3>A rational critique</h3> This response is directed at the recommendations relating to circumcision, at pages 68-70. 5.5.1 Recommendation 14 Amend the item descriptor to mandate the use of analgesia for this procedure. 5.5.2. Rationale for Recommendation 14 The item descriptor has been amended to mandate the use of analgesia, which ensures patient wellbeing. Comment While this is a progressive and desirable reform, it should be noted that analgesia does not necessarily “ensure patient wellbeing”, only that he is given a painless operation. The Committee noted that item 30654 should continue to include circumcisions conducted for religious and cultural reasons, reflecting both current practice and the need to ensure safe circumcisions. Comments 1. This proposal is regressive and inappropriate in that it is essentially offering a blank cheque to all parents who desire to have their boys circumcised, whatever their reason, as well as to those rare individuals who desire circumcision for themselves. The specification “religious and cultural” is meaningless and ineffective in the absence of a verification mechanism by which the religious/cultural credentials of the parents can be checked. Such a system is not proposed, and it would be complex to administer, and expensive even if the obvious difficulties could be overcome. In effect, the Committee has legitimised the existing open slather by which any individual who desires circumcision for himself or any parent who wishes to get a boy circumcised for any reason can require the public purse to meet part of the cost. Considering that the original objective of the various Medicare reviews was to rein in costs by eliminating procedures of low medical value, this seems highly counter-productive. 2. The argument about past practice is feeble and unacceptable. Merely because a certain policy has been followed in the past does not mean that it is desirable in or appropriate to current conditions; past practice is not best practice. The objective of reform exercises is to eliminate bad policies and replace them with good policies. Historical longevity is no basis for approving any practice in the contemporary world. As a matter of historical record, the government attempted to remove circumcision from the MBS in 1985, suggesting that in its original conception, Medicare was not intended to cover non-therapeutic circumcision at all. [1] 3. Related to (2), it is likely that payments for religious/cultural circumcision under Medicare are unlawful because the relevant act and associated guidelines provide that benefits are payable only for clinically needed procedures. As Michael Ryan, Assistant Secretary, MBS Policy and Specialist Services Branch, Department of Health, explains to Mr Peter Khalil MP (letter dated 6 November 2017, copy held by author): “The Medicare Benefits Schedule (MBS) provides benefits (or rebates) for a range of professional medical services, including circumcision. The Health Insurance Act 1973 stipulates that Medicare benefits are only payable for clinically relevant services provided by health practitioners. A clinically relevant service is one that is generally accepted by the relevant profession as necessary for the appropriate treatment of the patient. “On 1 November 2016 the MBS items for circumcision were restructured from four items to two items to separate them by the type of anaesthesia used, rather than by patient age. However, there have been no changes to the legal requirement that services must be clinically relevant, and there are no benefits available for non-therapeutic procedures.” In its current policy statement on circumcision the Royal Australasian College of Physicians concluded: “After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.” That being the case, non-therapeutic circumcision (including circumcision procedures desired for religious/cultural reasons), must be regarded as clinically not-relevant, and hence ineligible for a Medicare rebate. 4. The argument about the need to avoid the risk of additional harms or complications that might arise if needy parents (those who claim to be unable to meet the full cost) would resort to less expensive unqualified operators (as in the backyard abortions and kitchen-table surgery of infamous memory) fails for 2 reasons. First, the argument about avoiding the risk of additional harm is not a reply to the proposal that parents etc should meet the full costs of medically unnecessary procedures, but to the proposition that such procedures should be legally prohibited. The Royal Dutch Medical Association, which would like to see non-therapeutic circumcision of minors banned, raised this point as the only consideration which deterred the from making such a recommendation in their 2010 circumcision policy statement. [2] But the current proposal is not that circumcision should be prohibited or restricted in any way at all, merely that individuals or parents who desire a medically unnecessary circumcision should meet the full costs. The mere fact that the procedure is covered by Medicare does not guarantee “safe circumcisions”. Complications and “botches” are still common in clinical settings, and at the hands of fully credentialed operators, often requiring expensive surgical repairs and sudden appearances in hospital emergency departments. [3] Ensuring patient safety is not the task of the MBS, but of the medical regulatory authorities. Further evidence for this point is provided by the two Medicare items for “arrest of haemorrhage following circumcision”, items 30649 and 30663; from a policy perspective the risks and complications of circumcision are real enough and recognised. There is thus a question as to whether these circumcision-related MBS benefits encourage unnecessary risk-taking behaviour on the part of parents and compliant practitioners. But what level of complications is acceptable in a clinically-unnecessary procedure? Second, the test of whether a person really values a good or service is how much he is willing to pay for it. Members of the religious/cultural groups that traditionally practise circumcision may be insistent that it is vitally necessary, but if they are not willing to put a price on it – if they do not wish to meet the actual costs involved – it suggests that they do not really regard it as necessary at all. To allow the rebate in this situation would be like allowing low-income families to drive a car without paying the full costs of vehicle registration because the expense is a strain on their resources. And here the full cost includes the insurance component, to cover the cost of accidents etc; the parallel with surgical complications of circumcision and the cost of repairing “botches” is quite exact. Most people regard the ability to drive as so vital that they are willing to meet whatever costs are involved. Moreover, some religious groups celebrate the circumcision with a lavish family party. If they are willing to pay for that, they should also be willing to meet the full costs of the surgery that is the occasion for the event. One assumes that they do not expect the taxpayer to subsidise the party. 5. Now that the Medicare circumcision codes have been made unisex or gender neutral, there is the danger that retaining coverage of religious/cultural circumcision will lead to Medicare providing a rebate for circumcision or other forms of genital cutting on girls. There is in fact evidence that this is already happening. [4] The religious/cultural groups that practise circumcision or other forms of genital cutting on girls regard the procedures as just as important and meaningful as circumcision of boys; if they see the rebate available for circumcision of the latter, they are likely to expect or even demand it for the former as well. And if cultural/religious affiliation is to be the deciding factor, how can their request be denied? [5] 6. While some defenders of circumcision have begun to advocate toleration of “mild” forms of female genital cutting, partly as a way of reducing the blatancy of the double standard (FGM legally prohibited, with heavy criminal penalties, circumcision of boys legal and generally unregulated), a stronger current of opinion stresses the importance of “genital autonomy” and the need to protect all children – male, female, intersex – from any form of non-therapeutic genital cutting. [6-10] It is puzzling and disappointing that the Committee displayed no awareness of these developments. References 1. Robert Darby. Scientific advice, traditional practices and the politics of health-care: The Australian debate over public funding of non-therapeutic circumcision, 1985. Hygiea Internationalis: An Interdisciplinary Journal for the History of Public Health, Vol. 10, December 2011. Available at https://www.academia.edu/7028494/Scientific_advice_traditional_practices_and_the_politics_of_health-care_The_Australian_debate_over_public_funding_of_non-therapeutic_circumcision_1985 2. Details at http://www.circinfo.org/Dutch_circumcision_policy.html 3. Gold, G. et al. Complications following circumcision: Presentations to the emergency department. Journal of Paediatrics and Child Health 51 (12) 2015: 1158-63; Jacques Gallant. Secrecy questioned about baby’s death after circumcision. The Star (Toronto), 26 October 2015. https://www.thestar.com/news/gta/2015/10/26/secrecy-questioned-about-babys-death-after-circumcision.html 4. See for example http://www.circinfo.org/Medicare_Coverage_Female_Circumcision.html 5. Brian Earp. Between moral relativism and moral hypocrisy: Reframing the debate on FGM. Kennedy Institute of Ethics Journal 26 (2) 2016: 105-144. Available at: https://www.academia.edu/10197867/Between_moral_relativism_and_moral_hypocrisy_reframing_the_debate_on_FGM_ 6. Brian Earp and Rebecca Steinfeld. Gender and genital cutting: A new paradigm. Euromind Global, 6 April 2017. Available at: http://euromind.global/en/brian-d-earp-and-rebecca-steinfeld/?lang=en 7. Robert Darby. The child’s right to an open future: Is the principle applicable to non-therapeutic circumcision?” Journal of Medical Ethics 39 (2013): 463-468. Available at: https://www.academia.edu/17264543/The_childs_right_to_an_open_future_Is_the_principle_applicable_to_non-therapeutic_circumcision 8. Eldar Sarajlic. Can Culture Justify Infant Circumcision? Res Publica 20 (4) 2014: 327-343. 9. Steven Munzer. Examining non-therapeutic circumcision. Health-Matrix: The Journal of Law Medicine 28 (2018). Available at: https://scholarlycommons.law.case.edu/healthmatrix/vol28/iss1/5/ 10. Kai Möller. Ritual male circumcision and parental authority. Jurisprudence 8 (3) 2017: 461–79. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Medicare should not pay for medically unnecessary circumcision darby