Queensland Law Reform Commission Research Paper (Queensland Law Reform Commission, Brisbane), December 1993.
There appear to be no universally accepted, unequivocal medical indications for neonatal circumcision.54
The Australian Medical Association does not encourage routine neonatal circumcision. The Association has written to the Commission stating:55
Circumcision of the newborn male is a practice which the Australian medical profession generally discourages, always recognising that there may be medical justification for it in conditions such as phimosis. While the AMA has no formal policy on this matter, it generally supports the relevant position adopted by the Australian College of Paediatrics.
The Australian College of Paediatrics policy statement reads:
The Royal Australian College of Obstetricians and Gyncaecologists also discourages routine male circumcision. The College states:56
The suggested benefit does not outweigh the financial cost of the procedure on a community basis and the real cost of the occasional fatality in male infants directly arising from circumcision.
The Queensland Nurses Union does not have a specific policy on routine circumcision but would support the refusal of any of its members to participate in the procedure.57
Neonatal circumcision should not be considered when the neonate is premature, has a neonatal illness, any congenital anomaly (most importantly hypospadious58) or has a bleeding disorder. The procedure should never be performed within the first 24 hours of life.59
Routine neonatal circumcision continues to be performed by a number of general medical practitioners and possibly specialists in Queensland.
There are a number of conditions which may indicate a need for circumcision in older children or men.
This is a medical condition in which the prepuce will not pull back over the glans of the penis because the `opening' is too tight. This is not a problem for young boys. When erections occur the preputial opening may split. Healing then causes linear contraction and further narrowing of the circular orifice. If very tight, it may restrict urine flow and cause ballooning of the preputial sac. It may also lead to infection or balanoposthitis.61 This would be an indication for circumcision.
This is an uncommon condition resulting in the inability of the phimosed prepuce to be pulled forward again. The prepuce tends to became oedematous63 and a tight constriction then develops at the coronal sulcus behind the glans, aggravating the condition. This is more common in older men and rare in children. Circumcision will be necessary in younger men but in the elderly a dorsal slit, under local aeaesthetic will suffice. In one study, paraphimosis in boys was found to be usually caused by an overzealous parent forcibly retracting, in the bath, a still congenitally adherent foreskin in a child less than three years of age, on the misguided advice of a doctor.64
Adhesions normally exist between the prepuce and the glans from birth are are progressively broken down as erections occur. By three or four years of age the prepuce is usually fully retractable. Plugs of smegma65 may be retained behind the prepuce and be mistaken for `pus' or may predispose to infection.
Dr E P Arnold has observed:66
Non-retractable prepuce is not usually an indication for circumcision and can be managed conservatively in the expectation that the adhesions will break down as the child grows. If infections become a problem, the adhesions can be separated an hour after applying a transcutaneous local anaesthetic cream (e.g. EMCA). [sic, should be EMLA] For two weeks after this, daily saline baths, gently withdrawing the prepuce for cleaning and then applying vaseline to the glans before pulling the prepuce forward again are useful manoeuvres to prevent re-formation of adhesions. Should they recur or infections remain a problem, circumcision should be advised.
Leitch observes:67
A prepuce made fully retractable after the age of 3 years by simple separation of adhesions with a blunt probe, not necessarily under anaesthesia, would assist hygiene, decrease balanitis and true phimosis, and prevent the accumulation of smegma, thus decreasing the risk of carcinoma of the penis, possibly to an almost negligible level.
By 16 years of age only about one per cent of boys still have a non-retractable prepuce.68
This is a condition of inflammation of the glans penis, usually where phimosis is present.
Conscientious Objection is a right to refuse to participate where the refusal is based on beliefs about that which is right or wrong to do, and where the belief of personal conscience is the dominant guide to the individual's decision. Fear, personal convenience or preference are not sufficient basis for conscientious objection.
Surely this shows the need for proper education of those members of the medical profession most closely associated with these problems.
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