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.
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