Circumcision in Australia: neither needed nor ethical

Although Australian medical authorities have given a firm thumbs down to routine (prophylactic) circumcision of male infants and boys, the practice persists among a shrinking minority of parents. They are urged on by a small but vocal coterie of circumcision advocates, who blur the issues by referring to "male circumcision" as though the operation is the same in all contexts. Here I argue that circumcision is like sexual intercourse: legitimate in some circumstances, illegitimate in others.

What is circumcision?

Circumcision refers to the surgical removal of part of the external genitalia; in males it means the excision of a component of the penis known as the foreskin; in females the term refers to a wide variety of surgical procedures, ranging from a slight scratch to the amputation of the clitoris. To talk about the acceptability of circumcision in general makes as much sense as to discuss the ethics and acceptability of sexual intercourse in general. Sexual intercourse with consent is fine; sexual intercourse without consent is rape.

To determine whether circumcision is a legitimate intervention, the context must be specified: surgery that may be permissible when performed on an adult who has given informed consent is not necessarily permissible when imposed on an infant or child who, by definition, cannot give consent.

Here I shall consider the most common form of circumcision practised in Australia today: medically unnecessary circumcision of normal male infants and boys, performed either in the belief that it will reduce their risk of contracting certain diseases to which they may be exposed at some future date; or because their parents, for various social reasons, prefer them to be circumcised.

No evidence that circumcision has improved child health

The principal argument for circumcision has always been the promise of better health. Since the 1850s a small stream of Anglo-American medical opinion has urged the necessity for early circumcision, in a campaign that I have characterised as the "demonization of the foreskin". In my book A Surgical Temptation, I argue that their efforts have failed – there is no proof that child health has been improved by the imposition of widespread circumcision.

In Australia, reports by the Australian Institute of Health and Welfare in 2004 and 2009 found substantial improvements in child health in the 20 years from 1983 to 2003. This was the very period during which circumcision all but disappeared, falling from around 40% of boys in the early 1980s to less than 10% in the mid-1990s. If circumcision was as essential to health as its promoters claim, you would expect to find evidence of worsening child health in these surveys. In fact, the opposite occurred: as circumcision declined, child health improved.

To take another example, a report by the Organisation for Economic Cooperation and Development in 2009 on child health outcomes found that on many measures the United States scored so badly that it was on a par with Turkey and Mexico. Since circumcision is almost universal in Turkey, rare in Mexico, and in the United States is still imposed on about 50% of boys, it is plainly irrelevant to child health outcomes. The countries that scored best were northern Europe and Japan, where circumcision is practically unknown.

If circumcision does not noticeably improve child health, it should not be recommended as a health precaution, should not be performed as a routine and should certainly not be funded through Medicare.

These studies did not specifically cover the particular diseases that circumcision is supposed to prevent. But a recent article in Annals of Family Medicine subjected the claims of the circumcision lobby to an exhaustive review, and concluded that its value for child health is 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 was African data suggesting that adult males who got circumcised had a slightly lower risk of contracting HIV through unprotected intercourse with an infected female partner. But as the authors of the paper comment, Africa has unique health problems. Since the circumcision trials were on adult men the results cannot be applied to children, nor can the World Health Organisation recommendations for the underdeveloped world be transposed to developed countries. In Australia, unlike Africa, AIDS is not a heterosexual epidemic, but a relatively rare disease confined to specific sub-cultures – homosexual men and injecting drug users. 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 with HIV or any other STIs – 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 Australia.

The consensus of medical authorities

Because it is a highly emotional subject, arousing deep passions on both sides, the literature on circumcision – both for and against – is vast. Like the Bible, you can find a statistic for any claim you care to make, and if you go back to the nineteenth century you can find medico-scientific evidence that the foreskin is complicit in, and circumcision can prevent, anything from epilepsy, tuberculosis and polio to bed-wetting, pimples and brass poisoning. There may be an avalanche of evidence in favour of its benefits for health, but on closer inspection much of it turns out to be dross.

Nonetheless, task forces set up by medical authorities in countries where routine circumcision became established (Britain, the USA, Australia and Canada) have attempted to sift through the piles of mullock and reach an overall conclusion as to whether it is good, bad or indifferent. They have all concluded that that circumcision as a precaution is ethically questionable and medically unnecessary, and that it should not be performed unless there is an injury, deformity or disease that cannot be treated in any other way.

The most recent statement from the British Medical Association comments:

"There is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research. …

"Doctors should ensure that any parents seeking circumcision for their son in the belief that it confers health benefits are fully informed of the lack of consensus amongst the profession over such benefits, and how great any potential benefits and harms are. The BMA considers that the evidence concerning health benefit from non-therapeutic circumcision is insufficient for this alone to be a justification for doing it."

The current policy (October 2010) of the Royal Australasian College of Physicians states:

"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."

Summing up the pros and cons of circumcision, the statement continues: "The decision to circumcise or not to circumcise involves weighing up potential harms and potential benefits. The potential benefits include connectedness for particular socio-cultural groups and decreased risk of some diseases. The potential harms include contravention of individual rights, loss of choice, loss of function, procedural and psychological complications."

Since the harms appear to outweigh the potential benefits, and many adult men resent having been circumcised, it follows that the only person entitled to make the decision is the one who must bear the lifelong consequences. The statement agrees with the Royal Dutch Medical Association that leaving the circumcision decision to be made by the boy when he is old enough to make an informed choice has the merit of respecting individual autonomy, preserving everybody's options and respecting the "open future" principle.

Their bottom line is that (routine) preventive circumcision of minors offers no significant health benefit, carries significant risks, has an adverse effect on sexual sensation, is an affront to personal autonomy, is a violation of the right to bodily integrity, and should not be performed.

6. Medical ethics and human rights

Circumcision advocates refer to the objections to circumcision on medical ethics and human rights grounds as "nebulous", but I suggest that these issues are central to the whole question. No matter how great the benefits of circumcision may be, the fact remains that the foreskin belongs to its owner as surely as his fingers, toes, ears, liver and any other organ. The only health-related situation where it can be ethically removed without consent is in a life-threatening emergency, or in order to address a deformity, injury or disease that has not responded to conservative treatments after reasonable efforts.

To be ethically acceptable a medical intervention must pass the five tests proposed by bioethicists Beauchamp and Childress:

1. Beneficence - Does the proposed procedure provide a net therapeutic benefit to the patient, considering the risk, pain, and loss of normal function?
2. Non-maleficence - Does the procedure avoid permanently diminishing the patient in any way that could be avoided?
3. Proportionality - Will the final result provide a significant net benefit to the patient in proportion to the risk undertaken and the losses sustained?
4. Justice - Will the patient be treated as fairly as we would all wish to be treated?
5. 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 provides no therapeutic benefit (nor even a relevant prophylactic benefit, since a child is at zero risk of STIs). 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. And it fails to respect the boy's autonomy and preserve his future options as an adult individual. It has been strongly argued that such unwarranted interventions are unethical, violate the individual's right to physical integrity, and are of borderline legality.

Conclusion

Even if all the benefits of circumcision claimed by its promoters were true, they would only amount to a case that might persuade a cautious adult to elect the procedure for himself. The case was never sufficient to justify doing it to children without consent. Individuals are entitled to make their own choices about how they manage their health, and should not be deprived of normal body parts merely because somebody else thinks they would be better off without them.

It may be justifiable to perform circumcision on adults who have given informed consent, and even on children who cannot give consent in situations of therapeutic necessity (i.e. to correct a pathology that has not responded to conservative treatment); and it is arguable that it is justified if the parents are devout, conscientious, practising adherents of a religion which holds that children must be circumcised. Like sexual intercourse, it depends on the circumstances: with the consent of a person above the legal age of consent, sexual intercourse is justifiable; without consent, or if the person is below the statutory age, it is sexual assault or rape. There is no reason why the rules for permanent bodily alterations, particularly in such a physically and psychologically sensitive area as the penis, should be less strict than the rules for sexual activity.