CIRCUMCISION OF MALE INFANTS RESEARCH PAPER,
Queensland Law Reform Commission, Brisbane.
December 1993.


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8. REASONS AGAINST ROUTINE REMOVAL OF PREPUCE Apart from the controversy concerning the possible health reasons for removal of the prepuce and the prophylactic advantages of routine removal, a number of fundamental arguments have been promoted against routine circumcision of male infants. Dr R G Birrell, a paediatrician, writing to the Australian Paediatric Journal notes that:106 The neonatal period provides the time for maximal risk of complication for this procedure. He suggests that, if the procedure is to be done, delay until 12-15 months of age seems the only reasonable approach. Although infection is then less of a hazard, the risks of complications still remain very significant.107 Another paediatrician, Dr E Durham-Smith, suggests elective circumcision in the second or third year of life.108 Anaesthesia is required at this time, and the risks of this must be weighed against the advantages of circum- cision. He goes on to state that:109 Under the conditions pertaining in most neonatal nurseries, and especially the serious, albeit rare, complication of septicemia, routine circumcision in the neonatal period should not be performed; and in fact is undesirable at any time during the first year of life. (a) The prepuce has a function In babies, the prepuce protects the glans from urine and faeces and thus reduces the likelihood of infection.110 (b) Pain Neonatal circumcision is the only surgical operation routinely conducted without anaesthesia. Even local anaesthesia may lead to complications - mainly haematomas and local skin necrosis and occasionally death.111 The United States Task Force on Circumcision notes:112 Even a small dose of lidocaine can result in blood levels high enough to produce measurable systemic responses in neonates. Local anesthesia adds an element of risk ... Circumferential anesthesia may be hazardous. (c) Complications It has been suggested that complications will arise in approximately 15 per cent of cases.113 * Death The most serious complication is death. Although it is rare for babies to die as a result of circumcision, there are a number of reports of death. The Commission has been advised of a recent case in Queensland where an infant was being circumcised in a general practitioner's surgery. Because the child was exhibiting signs of discomfort, more than the recommended dose of local anaesthetic was applied. As a result of the overdoes of anaesthetic, the baby suffered a seizure and a cardiac arrest. The doctor did not have appropriate resuscitation equipment in his surgery. The baby was rushed to hospital but died shortly after.114 Gairdner referred to a United Kingdom mortality rate of 1.8 per 10,000 circumcisions.115 In a recent New York study, 500,000 circumcisions were completed without a death.116 A Western Australian study of four desperately ill newborns in Australia with bacterial meningitis from infected circumcision sites reported that two of the babies recovered, one survived with cerebral palsy and one died.117 * Damage to shaft Excessive skin of the penile shaft may be removed, resulting in concealed penis or a denuded shaft.118 * Damage to urethra The urethra may be caught in a circumcision clamp. This usually results in a fistula at the corona. It may be difficult to close the fistula. This may involve two separate procedures.119 The Commission has been advised of a recent case in Queensland where a child haemorrhaged after a circumcision operation performed in a general practitioner's surgery. The doctor stitched the wound and mistakenly stitched the urethra at the same time. The child was admitted to hospital a few days later, not having urinated during that time, gravely ill with septicaemia.120 * Amputation The glans or even the penis may be amputated. There are reports of gangrene of the penis, avulsion of the scrotum and removal of needed skin for hypospadias repair.121 * Unsightly appearance Asymmetrical or inadequate removal of the prepuce may result in an unsightly appearance - "the frilly lizard look". This is frequently the basis for a request for recircumcision.122 * Urethral fistulas Bleeding may require a suture. If the suture is misplaced, it may result in a urethral fistula at the corona. * Haemorrhage Haemorrhage, which may go undetected when nappies are used, has been the cause of death.123 * Incision line May become infected. Hirst reports:124 This is usually responsive to local treatment, but there are reports of progression on to the staphylococcal scalded syndrome, and in some cases, septicaemia occasionally leading to death of the infant. * Phimosis Phimosis can occur as a direct result of inadequate circumcision rather than as a primary indication for the procedure. Hirst explains:125 The re-approximated line between the skin and the deep preputial layer heals by scarring and where an inadequate removal/ of the prepuce has been performed, contracture of the scar prevents retraction of the residual prepuce and hence a phimosis. Recircumcision is then required. * Infection of meatus Hirst explains:126 Meatus and meatal stenosis may occur ... the intact foreskin protects the glans and meatus from the noxious effects of ammoniacal dermatitis [nappy rash]. In the absence of the prepuce, `nappy rash' may affect the glans and particularly the meatus, causing meatitis. Healing produces narrowing of the orifice and resultant meatal stenosis. Meatal stenosis may cause a diminished or angulated stream, but rarely results in a bladder outlet obstruction. Meatal stenosis may require a definitive meatomy. One Australian paediatrician describes a personal series of 5 proven cases of septicaemia in a 6 year period - 3 other cases of septicaemia in which the circumcision site was probably the portal entry of the bacterium, were also treated:127 In the 5 proven cases the organism cultured in the blood and on the infected site matched perfectly as to anabiotic sensitivities. Two of these proven cases were gravely ill, and one child survived peripheral circulatory failure, pneumonia, pyonephrosis and 2 sites of osteomyelitis. From another babe 5 pathogens - proteus, strep. facealis, staph. aureus and 2 types of E. Coli were cultured from his circumcision site. The proteus caused the septicaemia in this later case. No deaths occurred in this series of cases, but required intensive care. (d) The cost Newborn circumcision is not paid by the National Health Service in Britain. In 1948 it was classified as cosmetic surgery and the rate of circumcision dropped to .5%. In 1985 the Australian Federal Health Minister removed the rebate for circumcision from the Medical Benefits Schedule.129 The Minister suggested that circumcision rates should be reduced by education and community discussion. He expressed a fear of `back-yard' circumcisions with a greater risk of fatality, trauma and infection.130 The financial cost of circumcision is difficult to calculate. In 1992/93 Medicare reimbursed patients $98,781 for circumcisions performed on infants less than 6 months of age. If the procedure is performed on a newborn prior to leaving the hospital after birth, there is unlikely to be a hospital bed charge. Medicare will pay 85% of the scheduled fee and here is no gap paid. Private health funds are prohibited from paying the gap in these cases because newborns are not considered patients under the Health Insurance Act 1973 (Cmth) unless in a neonatal intensive care unit. If the child is returned to hospital after birth for circumcision, there will be a bed charge. Medicare will pay 75% of the scheduled fee and private funds may pick up the remaining 25%. For an infant under 6 months of age, the doctor's scheduled fee is $33.10 [significantly more for older children]. The Australian Medical Association recommends that doctors charge $57 for performing a circumcision on an infant under 6 months of age. If the procedure is performed on a public patient in a public hospital there will be no additional hospital fee. If the procedure is performed as a private patient in a public hospital or on a private patient in a private hospital there will be additional charges which will vary from hospital to hospital. Queensland private hospitals charge up to $173 for bed fees or theatre fees MBF will pay up to $115 of hospital fees for members with top hospital cover. The real cost to the community per infant (under 6 months of age will be in the vicinity of $175 (hospital) + $57 (doctor's fee) per procedure. Notes: 106 Birrel RG. Circumcision Australian Paediatric Journal, Vol 6 (1970): 66-67. 107 The US Task Force on Circumcision [Paediatrics, Vol 84(4) Aug 1989: 388 at 389] noted a number of techniques that may reduce postoperative complications. (1) Using a surgical marking pen to mark the location of the coronal sulcus on the shaft skin preoperatively; (2) identifying the urethral meatus; (3) Bluntly freeing the foreskin from the glans with a flexible probe. (4) Completely retracting the foreskin; and (5) identifying the coronal sulcus. all before applying the clamp or Plastibell and before excising any foreskin. Electrocautery should not be used in conjection with metal clamps. 108 Durham-Smith E. Another View of Circumcision. Australian Paediatric Journal, Vol 6 (1970: 66, at 68. 109 Id at 69. 110 This function has been recognised for many years. See Gairdner D. The Fate of the Foreskin. British Medical Journal, Vol 2 (1949): 1433, at 1434. See also information distributed by health authorities such as the Child Adolescent and Family Health Service (SA) Heath Thoughts: Uncircumcised Baby Boys: The foreskin protects the `glans' on top of the penis from the irritation of wet nappies and reduces the likelihood of infection. A circumcised baby is more likely to develop problems because he lacks this protection. 111 See case referred to below. 112 Report of the Task Force on Circumcision. Paediatrics, Vol 84(4) (1989): 388, at 390. 113 Leitch IOW. Circumcision - A Continuing Enigma. Australian Paediatric Journal, Vol 6 (1970): 59, at 61. In a study of 200 cases at Adelaide Children's Hospital, complications arose in 31 cases or 15.5% Complications included haemorrhaging (from mild to moderate), meatal ulcers, recircumcision - after being circumcised in the neonatal period for social reasons. Of 19 recircum- cisions, 18 were simple circumcisions and in one a dorsal slit was followed by circumcision. Complications in the recircumcisions involved infection, meatal stenosis and mild haemorrhaging. Note, however, the mean age of patients in the survey was 2 years 4 months. Russell T in The Case for Circumcision, Medical Observer, 1 October 1993 at 60 observes that a child is exposed to less risk of complications if circumcised earlier. 114 Oral report from a Consultant Paediatrician who was involved in the treatment of the dying baby. 115 Gairdner D. The Fate of the Foreskin. British Medical Journal Vol 2 (1949):1433-1437. 116 King LR. Neonatal Circumcision in the United States in 1982. Journal of Urology Vol 128 (1982): 117 Scurlock JM. Neonatal Meningitis and Circumcision Medical Journal of Australia (1977):323-333. 118 Hirst G. Controversies Surrounding Circumcision. Patient Management. September 1984: 12, at 16. 119 Ibid. 120 Oral report from a Paediatric Surgeon who treated the sick infant. 121 See St Margaret's Hospital for Women (Sydney) v McKibbin (1987) Aust Torts Rep 59009 (NSW C of A) where 19 year old plaintiff sued for damages resulting from loss of glans of penis as result of negligent neonatal circumcision (at 6 days old). Number of social, psychiatric and psychological problems resulted Jury at trial awarded $500,000. Award reduced to $275,000 on appeal. In a number of reported US cases male infants were circumcised by electrosurgical knife. The device was designed to cut and cauterize but was not meant to be used on tiny penises. In four cases in Georgia surgeons destroyed the penises. In one case, it was decided to do a transexual procedure - turning the boy into a girl. [Refer Patients set on fire as Surgeons get Careless. The Age 15 October 1993, p.9]. Williams G. Newborn Circumcision - An Enigma of Health, delivered to the Second International Homebirth Conference, 4-7 October 1992, Sydney, describes a case reported by Money J and Tucker P [Sexual Signatures. Little Brown and Company Boston Toronto 1975 pp. 91-98]: A young couple took their normal, identical twin boys to a physician to be circumcised when the boys were seven months old. The physician in the operating theatre used an electric cauterizing needle to remove the foreskin of one twin. When the baby's foreskin didn't give on the first try or on the second, the doctor increased the current. On the third attempt the surge of heat from the electricity literally cooked the baby's penis. Unable to heal, the penis dried up and in a few days sloughed off completely, like the stub of an umbilical cord. At the age of twenty-one months the `little girl' was brought back to the John Hopkins Hospital for surgical feminization and removal of testes. Her mother has reported that dolls and a doll carriage headed her Christmas list when she was five and that, quite unlike her brother, the girl was neat and dainty, experimented happily with styles of her long hair, and often tried to help in the kitchen. Finger pressure applied above the urethral opening ensured a downward urine stream. Vaginoplasty and hormone replacement were planned at puberty but the girl was not ready to accept hospitalization. King LR. Neonatal Circumcision in the United States in 1982. Journal of Urology, Vol 128 (1982) at 1135 notes that: The glans or even the penis itself may be amputated. Reanastomosis should be attempted using microsurgical techniques which have been successful. ... Cautery also has burned the penis completely when applied to circumcision clamps. These complications can be terrible and usually are the result of use of a circumcision clamp by inexperienced operators. Freehand techniques are much preferred by the occasional operator ... Fortunately new microsurgical techniques allow construction of a missing penis from revascularized and reinnervated grafts. These patients eventually can be outfitted with a penile prosthesis for erection, permitting intercourse. However, the nerve endings of the glans cannot be replaced. Obviously boys who lose the penis in infancy should continue to be reared and reconstructed as girls. 122 Hirst G. Controversies Surrounding Circumcision. Patient Management, September 1984:12, at 14. 123 Ibid. 124 Ibid. 125 Ibid. 126 Ibid. Also, Birrel RG. Circumcision Australian Paediatric Journal, Vol 6 (1970): 66-67 notes: The bared glans often bleeds where adhesions have been broken down, and is commonly left to rub against a urine-sodden `nappie'. This predisposes to meatal ulceration, and often significant stenosis when the healing is complete. 127 Ibid at 66. 128 Williams G. Newborn Circumcision - An Enigma of Health, Paper delivered to The Second International Homebirth Conference, 4-7 Oct 1992, Sydney. 129 This action had been advised by the National Health and Medical Research Council at its 95th Session in Adelaide, June 1983 (see Report of Session at p.130): The Council recommended that the Director-General of Health draw the attention of the Medical Benefits Schedule Revision Committee to the Council's statement on the subject of neonatal circumcision made at its Ninety-fourth Session which states: The Council having considered the opinion of the Australian College of Paediatrics and the Health Commission of N.S.W., was of the opinion that there is no medical indication for undertaking routine circumcision on newborn male infants, and that hazards of the operation at this age outweigh any possible advantages. In this context the Council requested that the Medical Benefits Schedule Revision Committee be asked to consider whether routine neonatal circumcision should be removed from the Medical Benefits Schedule. 130 Ibid. Perth Sunday Times, July 14, 1985. 131 1992/93 in Queensland 3,780 private patients under 6 months X $232 = $876,960. In 1991 77 public patients under 6 months of age were circumcised. 304 public patients between 6 months and 10 years of age were circumcised in that year. 150 patients over 10 years were circumcised (information provided by Health Information Services Unit, Queensland Health, 26 Nov 1993.

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Cite as:
(File prepared 8 June 1998, Revised 15 January 1999)