CIRCUMCISION OF MALE INFANTS RESEARCH PAPER,
Queensland Law Reform Commission, Brisbane.
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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-
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
(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
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
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
It has been suggested that complications will arise in
approximately 15 per cent of cases.113
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
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
* 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
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
* Urethral fistulas
Bleeding may require a suture. If the suture is
misplaced, it may result in a urethral fistula at the
Haemorrhage, which may go undetected when nappies are
used, has been the cause of death.123
* Incision line
May become infected.
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
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
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
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)
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
(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
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.
120 Oral report from a Paediatric Surgeon who treated the sick
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
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.
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
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
[Back to Contents]
- Circumcision of Male Infants Research Paper. Queensland Law
Reform Commission. Brisbane 1993.
(File prepared 8 June 1998, Revised 15 January 1999)