THE PROFESSOR BRIAN MORRIS
THERE is an overwhelming body of high quality scientific evidence that male circumcision is akin to immunisation. It provides strong protection against urinary tract infections and infant kidney damage; phimosis; paraphimosis; balanoposthitis; foreskin tearing; HIV; common heterosexually transmitted infections such as cancer-causing HPV, genital herpes, trichomonas and genital ulcer disease; thrush; inferior hygiene; penile cancer and prostate cancer.
Together these affect half of uncircumcised males over their lifetime. Benefits exceed risks by more than 100 to 1.
There are no adverse effects on penile sensitivity or function. If anything sex is better. Male circumcision can also help protect women against HPV, herpes, cervical cancer, bacterial vaginosis and infertility.
Adverse effects are uncommon, virtually all being minor and easily treated. For maximum benefits, safety, convenience and cost savings, circumcision should be performed in infancy with local anaesthesia. Twelve clinical and academic experts, including five Fellows of the Royal Australasian College of Physicians, recently published on behalf of the Circumcision Foundation of Australia the first evidence-based policy statement on infant male circumcision.
They then wrote to the federal Health Minister requesting that infant circumcision be placed in the same category as childhood vaccination. In recognition of the government's policy supporting preventive health they asked that the Medicare rebate be increased substantially and that it cover elective circumcisions.
Parental education and steps to facilitate access and affordability were called for in the interests of public health and individual wellbeing.
Arguments that circumcision be delayed until the boy can make up his own mind are specious. Infancy is the best time based on safety, cost, convenience, cosmetic outcome and childhood disease prevention. If delayed, barriers are considerable, so circumcision will probably not happen even if the boy or man wants it.
Advocating this simple, inexpensive procedure for baby boys is about as effective and safe as childhood vaccination. But just as for vaccination there is a vocal minority of opponents who promulgate dangerous misinformation.
The federal government should support this "surgical vaccine" by increasing the Medicare rebate and reducing barriers to uptake. State governments should also restore elective circumcision to public hospitals.
Brian Morris is the scientific spokesman for the Circumcision Foundation of Australia.
THE CRITIC 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.
THE DOCTOR ALEX WODAK
INCREASING the Medicare rebate for infant male circumcision would prevent disease, protect public health and reduce the growing pressure on the healthcare system.
The evidence for the benefits of infant male circumcision is impressive and growing. Benefits outweigh negatives by a large margin. These benefits, identified from rigorous studies, include a reduction in urinary tract infections, kidney disease, complications from infection and scarring of the foreskin, some sexually transmitted infections (including a 60 per cent reduction in female-to-male HIV) and cancer of the penis.
Circumcision of their male partner also benefits women by reducing cancer of the cervix and various common genital infections.
HIV is increasingly attributed to heterosexual contact in Europe and North America. The same trend is apparent in Australia but is not as strong. Higher rates of infant male circumcision now may help prevent a heterosexual HIV epidemic in Australia in decades to come. Given overseas examples, surely it is better to err on the side of protecting Australians from a possible hard-to-control future HIV epidemic.
The Medicare benefit for elective male circumcision has gradually been eroded and may soon be terminated. Middle and upper-income families can easily afford infant male circumcision but low-income families cannot. The cost can be $800.
Complications are uncommon, minor and easily treated. There is no sound evidence that male circumcision affects the pleasure of intercourse for the male or his partner. Infancy is the best time for the procedure as this maximises the benefits, safety, convenience and cost savings.
The most common reason for infant male circumcision in Australia today is the desire by young parents to protect the health of their newborn son. The benefit/risk and ethics of infant male circumcision and childhood vaccination are very similar.
A recent rapid increase in circumcision in Africa led to a considerable growth in good research. Consequently there have been many major improvements in technical aspects. Infant male circumcision with local anaesthesia is now virtually pain free.
In Australia, only 2 per cent of the health budget is spent on prevention. Yet prevention provided more than 80 per cent of the 30-year increase in life expectancy in the 20th century United States.
Health ministers often say they want more emphasis on prevention. Here's a good opportunity to show they mean it. Particularly curious is that elective male circumcision is banned in public hospitals, except in Queensland.
Dr Alex Wodak is the director of the Alcohol and Drug Service at St Vincents Hospital.
THE HISTORIAN ROBERT DARBY
THE federal government is under pressure to balance budgets, give more recognition to individual human rights, promote gender equity and protect children from harm. One way to make progress on all these fronts is to drop non-therapeutic circumcision from the Medical Benefits Schedule.
Medicare provides a no-questions-asked rebate for circumcision, despite the fact most of these operations have no medical indication, and so are in defiance of Medicare's 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.
The Royal Australasian College of Surgeons states "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 is no health case for routine circumcision. All the medical authorities that have policies on routine circumcision have rejected the operation as unwarranted and potentially harmful, most recently the Royal Australasian College of Physicians in a statement of October 2010.
Australia is the only country in the world that provides an automatic rebate for medically unnecessary circumcision. Even in the US, 18 states have dropped circumcision from the list of benefits, and more are considering the question.
Most 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 bio-ethical and human rights perspective, and may even be unlawful.
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.
Government welfare programs should be targeted at genuine need and be administered with prudence. 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 bio-ethics and gender equity, the rebate for circumcision should be abolished except for cases of medical need.
Dr Robert Darby is an independent scholar who has written extensively on the history and ethics of circumcision.