Cutting both ways

Making the cut - The circumcision debate sharpens up
Making the cut - The circumcision debate sharpens up 

The thought of circumcising their baby appals many parents today. But what if it could potentially save their life? Sarina Lewis investigates.

There was no debate about the issue of infant male circumcision for Jacinda Fraser. "I always knew I wanted to have my son - or sons - circumcised," says the 24-year-old mother of one. It was a decision made long before she met husband Shane and long before she gave birth to baby Byron, now five months old. It was a stance taken as far back as the mid-'90s, when 11-year-old Jacinda watched her eight-year-old brother go through the procedure.

"I remember how traumatic it was for him having it done at that age," Jacinda recounts of the circumcision, instigated by recurrent infections due to phimosis. (Occurring in about 1 per cent of uncircumcised boys, phimosis sees the foreskin tighten around the head of the penis, making good hygiene difficult and infections common.) "He went through pain and had a week off school. It wasn't fun."

Fast-forward 13 years to the birth of the couple's baby boy, and the Frasers were surprised at the difficulty encountered in executing their joint parental decision to circumcise their son. The staff of their regional Victorian hospital were reluctant to discuss it: "No one supplied us with information to explain the risks and the benefits of having it done," Jacinda recalls. "It was mainly just judgement by them as to why we would want to get it done when it's not a necessary thing."

The couple turned to the internet seeking personal stories and opinion, and attempted to decipher the medical research. Eventually it led them to the website of Melbourne's Dr Hershel Goldman and - four months after the birth of baby Byron - their son's circumcision. "It's strange," reflects Shane, 27. "It's like they're not putting the information out there just to steer people away from doing it."

You don't take a baby's tonsils out in case they become infected and need to be taken out later in life.

But the Frasers seem to be in a minority, according to the statistics. Data from the Royal Australasian College of Physicians (RACP) indicates that while up to 60 per cent of the male population underwent neonatal circumcision in the 1950s and 1960s, as little as 10 to 20 per cent of the male population is circumcised in Australia today: infant male circumcision rates sit at around 5 per cent in Victoria and South Australia, 7 per cent in Western Australia, 25 per cent in NSW and about 35 per cent in Queensland.

But recent research into the link between circumcision and reduction in the transmission of sexually transmitted disease has once again blown open the debate. Large-scale trials of circumcision in African countries have shown circumcised, heterosexual men are 60 per cent less likely to become infected with HIV than their uncircumcised counterparts. Current international studies also suggest circumcision of male partners can provide women with substantial protection from cervical cancer and chlamydia, a known cause of infertility in adult women if left untreated.

It is a great deal of benefit to attribute to the removal of a tiny piece of skin, smaller on a newborn baby boy than the nail on an adult's little toe. But what the neonatal foreskin lacks in size it clearly makes up for in emotive pulling power.

"It just generates such passion and anger," says Professor David Forbes, chair of the paediatrics and child health policy and advocacy committee of the RACP. "It's the interface for many people of politics of self and religion - and, I think for some people, sexuality." While RACP policy has never advocated routine circumcision of infant males, the degree of opposition has in the past been much less vehement. It wasn't until a 2004 review that the RACP stated "there is no medical indication for routine newborn male circumcision".

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Today that statement is again under review and Forbes is the man in charge.

"I thought because of what was happening internationally that the policy would probably need to change to a stronger endorsement of circumcision." However, he says the focus is more on HIV and AIDS, sexually transmitted diseases and the circumcision of adults, rather than infants. The professor insists that the RACP would need to be convinced of circumcision's long-term health benefits as relating to infants before considering a shift in policy: "Benefits [relating to spread of sexual disease] accrue after the age of puberty." At that time, Forbes adds, an adolescent male can make an informed decision on his own behalf.

"You can decrease the risk of urinary tract infections in boys by circumcising them, but boys have a much lower rate than girls anyway," says Forbes. "But if you say we want to have it done because it looks nicer or we want [our son] to be the same as his father, that's cosmetic surgery on an infant who doesn't have a choice. I don't think that's logical, and I don't think it's ethical."

Certainly, Amity Dry, mother and author of the Essential Baby Blog, sees it this way. Although Dry faced a battle in bringing her husband Phil Rankine, 40, around to her way of thinking, the Adelaide-based couple ultimately chose not to circumcise Jamison, now three. "I see it the same way as the tonsils," says Dry, whose circumcised husband had presumed his son would follow in his footsteps. "You don't take a baby's tonsils out in case they become infected and need to be taken out later in life, so the idea of doing it as prevention just didn't really make sense to me."

As for the evidence showing reduced rates of sexually transmitted diseases, the 31-year-old says she plans to teach her son to practise safe sex. Better that, believes Dry, than removal of the foreskin. "If they're not supposed to have that piece of skin, why were they born with it?" she questions.

It's the type of response pro-circumcision advocate and molecular biologist Dr Brian Morris finds infuriating. A passionate supporter of the procedure (for days following our conversation, Morris sent email after email, each containing studies reporting the purported health benefits of circumcision), the professor of molecular medical science at the University of Sydney believes there is overwhelming evidence pointing to neonatal male circumcision as a medical necessity.

During development of a procedure which can test for the virus that causes cervical cancer, Morris discovered women with circumcised partners were at much lower risk of the disease. "It's the perfect environment for an infection," Morris says of the uncircumcised penis. "It's yucky, gunky and I could add smelly, too." Morris, founder of circinfo.net, a pro-circumcision site, bats away arguments citing pain and reduced sensitivity as "gobbledygook".

"If there's any issue around at the moment where science needs to be listened to, it's circumcision," he says. "And the baby need feel absolutely no pain using the Russell technique."

Developed by Brisbane's Dr Terry Russell, the technique uses a device called the Plastibell combined with the application of anaesthetic cream. "The risks of conventional circumcision were bleeding, infection and the risk it would be botched up surgically," says Russell, who claims his procedure is "totally painless".

This played a large part in the decision of Brisbane couple Andre and Craig Allan in having their baby boy, Cooper, circumcised. The procedure was performed when he was eight weeks old and Andre, 37, says while she suffered some anxiety, Cooper showed no reaction. The Allans say their friends have offered little in the way of response either for or against the procedure.

For their part, the Allans could see no difference between the decision to circumcise and the decision to immunise. Craig, 40, explains: "Like you may choose to immunise or not to immunise your children, we found that it would be in his best interests for his health and well-being if we did go through with the circumcision."

But for newborn specialist, paediatrician and anti-circumcision activist Dr George Williams, these arguments aren't convincing. "I know children who have died from circumcision or who have either lost their whole penis or lost part of their penis. I've witnessed many circumcisions and I actively counsel parents against it." Williams, the medical advisor and founder of circinfo.org, an anti-circumcision website, believes it's a question of human rights.

"We have laws against female circumcision but we don't seem to want to protect male children, and the outcomes are the same," says Williams. "If you look at the 1800s and 1900s, circumcision was done to protect against masturbation, mental illness - every 20 or 30 years there's a new excuse. In the '70s it was urinary tract infections, and now it's HIV/AIDS.

"When you're imposing unnecessary surgery on children without any medical benefit, you're violating the rights of that child for self-determination," says Williams. "But if an adult decides to get circumcised that's his choice and I've got no issue with that."


 

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