The Australasian Association of Paediatric Surgeons

          Assoc. Prof. J. Fred Leditschke

          Department of Child Health
          Royal Children's Hospital
          Hersion, Queensland 4029

          Tel: (07) 3363 3163
          Fax: (07) 3363 3455

          Division of Paediatric Surgery, R.A.C.S.

Guidelines for Circumcision

Preamble: The Australasian Association of Paediatric Surgeons does not support the routine circumcision of male neonates, infants or children in Australia. It is considered to be inappropriate and unnecessary as a routine to remove the prepuce, based on the current evidence available.

Due to religious beliefs, Jewish children are circumcised by the seventh day of life, as a mark of dedication to God. [sic] Children born into the Muslim faith will likewise be circumcised for religious reasons, although the timing for the procedure is less clearly defined. There are Christian groups in other parts of the world, who insist on ritual religious circumcision, as well as tribal or cultural customs promoting male circumcision.

We do not support the removal of a normal part of the body, unless there are definite indications to justify the complications and risks which may arise. In particular, we are opposed to male children being subjected to a procedure, which had they been old enough to consider the advantages and disadvantages, may well have opted to reject the operation and retain their prepuce.

Indications for male circumcision:

    Balanitis Xerotica Obliterans
    Recurrent Balanoposthitis
    Phimosis resistant to steroid cream
Contraindications to male circumcision:

    Hypospadias and other congenital anomalies of the penis, e.g. epispadias, chordee.
    Sick and unstable infants
    Family history of a bleeding disorder or an actual bleeding disorder.
Timing of surgery:

Neonatal male circumcision has no medical indication. It is a traumatic procedure performed without anaesthesia to remove a normal functional and protective prepuce. At birth, the prepuce has not separated from the underlying glans and must be forcibly torn apart to deliver the glans, prior to removal of the prepuce distal to the coronal groove.

Balantitis Xerotica Obliterans, when diagnosed, should be treated by circumcision.

Timing of circumcision for recurrent balanoposthitis is difficult to define. Many infants and children will have an episode of preputial inflammation. If successive occurrences of dysuria with associated redness and purulent discharge from beneath the prepuce have been treated and the previously fully or partially retractable prepuce is less readily retractable after the subsidence of the inflammation, circumcision should be considered.

The physiological phimosis will normally resolve by the age of 3­4 years. If it fails to respond to steroid cream/ointment applied several times daily for 4­6 weeks, there is a reasonable probability that these boys will have problems in the future.

Infants and children who have a proven urinary tract infection and, on investigation, are found to have a significant urinary tract anomaly, e.g. posterior urethral valves or significant vesico­ureteric reflux, may benefit from circumcision. This will reduce the normal bacterial flora resident under the prepuce, which in the presence of a urinary tract anomaly may be associated with an increased risk of further upper tract infections with possible local and systemic damage.

The risk of carcinoma of the penis developing in the uncircumcised is very low. Lifetime penile hygiene is the key to penile health and a reduction in the incidence of carcinoma of the penis.

Personal sexual behavior patterns will determine whether sexually transmitted infections with human papilloma virus, herpes simplex virus and the human immune deficiency virus are contracted. Routine or infant male circumcision is not justified in Australia to protect males from contracting diseases that some may acquire through their ignoring the recognized precautions to be taken during their sexually active life.

Consent for surgery:

Parents requesting circumcision of their male children should have the complications both general and local, explained to them. These complications are usually minor but can be severe and may result in the death of the child. Time should also be spent discussing the advantages and disadvantages of the operation, both in the short and long term, as is currently applicable in Australia. There are many adults in the community who hold a very strong opinion as to the place of circumcision. This may be for religious reasons or for family "custom" or a claim of "cleanliness" or other reasons. In this event the procedure should be performed electively after six months of age. When performed, it should be carried out by a surgeon performing circumcisions on children on a regular basis with an anaesthetist using appropriate techniques. This would imply that the anaesthetist is fully trained in the art of paediatric anaesthesia, including the ability to perform caudal and penile regional or local anaesthesia. The operation should be carried out in a paediatrically orientated environment, designed to reduce the risk to the child and providing support to the parents or caregivers.

Points of Interest:

Marshall in 1960, reporting to the Society of Pediatric Urologists in Philadelphia and quoted by John Duckett, a distinguished pediatric urologist in Philadelphia, calculated that 140 boys a week for 24 weeks would need to be circumcised to prevent one case of carcinoma of the penis.

The Jewish Talmud stated that "the third child was excused from circumcision if the first two had died as a result of the circumcision".

Dr. Derek Llewellyn in his book "Everywoman" published by Faber and Faber Limited in 1971, stated that "Mothers demand it, doctors profit by it and babies cannot complain about it".

The 1989 United Nations Convention on the Rights of the Child states that "State parties should take all effective and appropriate measures with a view to abolishing traditional practices prejudical to the health of children."

"Circumcision of male infants" was addressed in a research paper published by the Queensland Law Reform Commission in December 1993. The preface addresses the problem when it states "From the Commission's research to date, it is apparent that there are two quite vocal sides of the debate on routine male circumcision. One side advocates the practice, primarily on a preventative health basis or on religious grounds. The other side opposes the practice, primarily on human rights and preservation of bodily integrity grounds. Both sides rely on medical evidence and opinion to support their respective views". Having considered all the information the paper concludes with "The Commission has yet to decide what, if any reform of the law should be recommended in relation to infant male circumcision."

J. Fred Leditschke,
President, A.A.P.S.,
April, 1996

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