The turning tide

Male circumcision rates may plummet as a result of evidence-based medicine and a fear of litigation, writes Bob Beale.

THE fad for body modification - everything from modest tattoos to studded tongues - reflects an age-old aesthetic dissatisfaction with the bare essentials of human anatomy.

For reasons that are both obvious and obscure, the penis has been singled out for particular attention.

Despite its vital role in reproduction and pleasure - or perhaps because of it - the penis has been subjected to a battery of adornments and alterations. At various times and places, it has been lengthened, scarred, tattooed, padded, pierced with bars and rings, and even had objects inserted beneath its skin to give a bizarre lumpy texture.

But the single most common and widespread penile modification has been circumcision, which goes back at least to ancient Egyptian times.

Today, an estimated 15% of males - about 450 million individuals - have been circumcised, largely as a result of the procedure being medicalised since the 19th century, according to the World Health Organization. And, as if to quote Macbeth - "If it were done when 'tis done, then 'twere well it were done quickly" - the period soon after birth has found most favour.

In Victorian times, circumcision was credited with all manner of medical and moral benefits, notably as a deterrent to masturbation and sexual pleasure seeking.

Circumcision reached its pinnacle in the US in the early 1970s, when the rate rose to almost 80%, but it has since declined a little.

In Australia and New Zealand, by contrast, only an estimated 10-15% of male infants are now routinely circumcised, according to the Royal Australasian College of Physicians (RACP). And the growing influence of evidence-based medicine seems set to send that rate lower still.

A number of professional associations around the world have reviewed the risks and benefits of routine circumcision, concluding that it simply cannot be justified on scientific, ethical or socio-legal grounds.

These bodies variously assert that circumcision constitutes unwarranted invasive surgery, or that no medical indications exist for its routine application.

The RACP policy issued last September is representative. The college position was endorsed by the Australasian Association of Paediatric Surgeons, the New Zealand Society of Paediatric Surgeons, the Urological Society of Australasia, the Royal Australasian College of Surgeons and the Paediatric Society of New Zealand.

Briefly, the policy notes increasing claims of health benefits from routine male circumcision, especially with regard to urinary tract infections, HIV and later cancer of the penis.

The policy says that urinary tract infections in boys are uncommon - affecting at most 1-2% - and may be about five times less frequent in circumcised boys.

But it says the evidence for a lower risk of acquisition of HIV "is conflicting, and can not be seen as an argument in favour of universal neonatal circumcision in countries with a low prevalence of HIV".

It also notes that penile cancer has an incidence of around one per 100,000 in developed countries, and says "the rarity of the condition is such that universal circumcision is clearly not justified on these grounds", even though evidence suggests neonatal circumcision may reduce the risk 10-fold.

And circumcision itself has a complication rate of 1-5%, the RACP says. Complications include local infection, bleeding and damage to the penis, the college says. And, although rare, some complications can be severe indeed: bleeding, septicaemia and meningitis may occasionally cause death.

The RACP policy concludes that "review of the literature in relation to risks and benefits shows … no evidence of benefit outweighing harm for circumcision as a routine procedure".

However, the head of the anti-circumcision advocacy group No Circ Australia, Dr George Williams, while endorsing the opposition to routine circumcision, has criticised the policy for what it fails to include.

Dr Williams says the RACP policy has not warned doctors of a real and increasing danger of litigation on the part of individuals who, without necessarily suffering complications, grow up and wish that they had not been circumcised.

This point is already being considered in Canada.

The College of Physicians and Surgeons of Saskatchewan, for example, recently warned doctors to consider not only the physical risk to the patient but the legal risk to the physician before becoming involved in the routine circumcision of infants.

The college said circumcisions should be performed only when medically indicated or, if sought for religious and cultural reasons, only after thorough discussion with parents to ensure that a legally defensible informed consent process had been followed.

In the wake of such overwhelming opposition to routine circumcision, how is it then that 10-15% of Australian boys are still having the procedure done?

Religious beliefs will account for a small proportion of these, with Jewish and Muslim people advocating circumcision.

There are also medical indications. A recent WA study in the MJA predicts that as many as 4% of all boys will be circumcised before the age of 15 for intractable phimosis. However, the researchers have called for a review of this indication as their study also found that half of these boys would have the operation before the age of five, despite severe phimosis being very rare in this age group.

Then there are those doctors who remain staunch advocates of the procedure.

Brisbane GP Terry Russell specialises in circumcision, performing about 2000 a year. He claims the procedure when done using the Plastibell and EMLA cream is safe and painless in infant boys and promotes health and hygiene.

He claims the foreskin is redundant. It did perform a protective function when we were running around the jungle naked but these days it is no longer necessary, he says. "Males are better off without it."

Dr Russell disputes much of the evidence for long-term detrimental effects of circumcision.

"No-one's ever shown [circumcision] reduces sensitivity," he says. He cites a large US study in the late 90s which found a higher proportion of sexual dysfunction in uncircumcised males. He also dismisses the legal ramifications as ludicrous and suggests it might be the uncircumcised population that might be taking legal action.

"Any patient who was advised against or denied circumcision on spurious grounds who then goes on to suffer one of the conditions that might reasonably have been prevented or minimised by circumcision has a right to damages from the person who advised against or denied the procedure," he suggests.

Dr Russell has also criticised the RACP policy, saying it misrepresents the demographics of the procedure in Australia.

He notes the policy incorrectly states that most circumcisions "are now performed under a general anaesthetic on boys older than six months", claiming Health Insurance Commission statistics over the past three years show that about 75% are performed under the age of six months.

"The statement concerning demographics is so diametrically opposed to the truth and so demonstrably wrong that it must cast grave doubts on the whole policy statement, which is clouded in tones of grey," Dr Russell told Medical Observer.

So while the RACP's recent statement attempts to resolve the issue of circumcision, it would seem the debate looks set to continue for some time yet. MO