Excessive removal of skin and mucosa is one of the most common results of neonatal circumcision, yet the true frequency of this injury and its adverse effects on physical and psychological development have never been adequately documented. In this account, Shane Peterson tells his own story of the lifelong trauma he has suffered as a result of the "routine neonatal circumcision" to which he was subjected soon after birth – an operation in which nearly all the skin of the penis shaft was removed in addition to the skin and mucosa of the foreskin.

The horrific results and damaging long term sequelae of this iatrogenic injury distorted Shane's physical and psychological development, his sexuality, his perceived place in society, and his career. Doctors and psychiatrists were unsympathetic when he complained of pain and disfigurement. Reconstructive surgery to resolve the physical injury yielded such disappointing results that he attempted suicide. Eventually, Shane was able to achieve partial resolution of the psychological trauma through a combination of ongoing counselling, successful litigation against the operator, and an active commitment to public education about the detrimental effects of circumcision.

Shane Peterson's story

The following account was written in 2000, when the author was 27 years old and studying for a PhD at the Australian National University.

Introduction

I am a 27-year-old postgraduate student (doing PhD) who was badly injured by a routine neonatal circumcision performed within days of my birth. For the last nine years, I have struggled to cope with this injury and to seek legal redress for my suffering, while at the same time I have successfully pursued a career in medical science. I recently achieved a precedent-setting legal victory in Australia with an admission of liability and AU $360,000 in damages for my injury. I view routine circumcision as an act of assault and a breach of human rights, and I am dedicated to the eradication of this unnecessary and potentially disastrous procedure.

Overview

This article is an account of my experience of the possible, and largely unpublicized, complications that can arise from routine neonatal circumcision. Circumcision and other forms of male and female genital mutilation originated in primitive societies and have been practiced for several thousand years. Despite this long tradition of mutilation, the resulting complications, injuries and deaths have been consistently unreported.

Ironically, many contemporary advocates of male circumcision claim that the historic development of this practice in primitive societies is evidence that male circumcision is beneficial to health. For example, circumcision advocates Szabo and Short [1] claim that male circumcision is depicted in a controversial relief from the Old Kingdom tomb of Ankhmahor at Saqqara, Egypt. This relief may be one of the oldest records of male genital mutilation in the ancient world, and dates from around 2400 BC. [2-3] A number of trained Egyptologists, however, doubt this claim. A number of alternative interpretations have been offered by experts in the field. Some Egyptologists argue that this is a scene of a ritual shaving, [4]while others suggest that it might be a scene of emergency dorsal slit surgery to relieve a case of paraphimosis. [5] Even if genital mutilation is depicted in this relief, controversy exists over the similarity of this practice to circumcision, and its cultural significance to the Ancient Egyptians. [6]

Regardless of the type of genital mutilation depicted in the Ankhmahor tomb relief, it is apparent that one man has been forcibly restrained. This can be interpreted as involuntary genital mutilation. The relief provides evidence that, since ancient times, it has been normal for individuals to be very unhappy and distressed when forcibly subjected to an act of mutilation. All forms and degrees of genital alteration, including circumcision, have always been a phenomenon that should be a matter of personal choice.

Major life events

I was born and circumcised in Western Australia in 1973, but was unaware of any genital abnormality as a young child. Because I was circumcised as an infant and not informed of this fact, I was not aware that my body had undergone any surgery. I had no reason to suspect that I had a penile problem until puberty. At the age of 18, in 1992, I underwent reconstructive surgery. The outcome of this surgery was exceedingly disappointing, and I attempted suicide six months later. In 1993, six months after the suicide attempt, I underwent further surgery.

Between 1993 and 1997, I concentrated on pursuing my academic career and resolving the emotional and ethical issues associated with my injury. I first sought legal advice in 1994, then commenced a legal claim for medical negligence with a Writ of Summons issued in October of 1997. This claim was finalized in 1999 with an admission of liability and payment of damages. I have since had several interviews with the media and am now dedicated to promoting public awareness of the detrimental affects of routine circumcision.

Birth and circumcision

My early childhood was happy. I had many interests, most especially in science. I was unaware of any complications with my circumcision. The circumcision scar was at the extremity of the penis, just below the corona glandis. Having no conception of what my penis looked like prior to circumcision, I was completely unaware that the family doctor who circumcised me had removed not only the foreskin but also most of the penile shaft skin. He then pulled up the scrotal skin and stitched it just under the corona. As an infant and young child, the excessive removal of skin was less obvious because of the lack of pubic hair.

There were two reasons why my parents decided to have me circumcised. First, my father had been circumcised shortly after birth, and was unaware he had lost tissue of any value. Second, my father's younger brother was spared circumcised as an infant but was subsequently circumcised at the age of eight, allegedly due to painful adhesions, bleeding, and repeated infections. My father remembered how traumatic this experience was, and my parents wanted to spare me from suffering similar problems. From information provided later by my grandmother, it appears likely that my uncle's "problems" were actually the result of repeated, forcible premature retraction of the foreskin for cleaning during infancy.

My mother had concerns about circumcision. She was a young mother of 17 years and knew nothing about how circumcision was performed, what risks were involved, and what the expected result should be. When family members suggested that she should have her unborn child circumcised if it was a boy, she sought advice from her family doctor during a prenatal check up. She was advised not to worry: "Just one little snip and it would all be over." The doctor assured her there were no risks and that it was such a simple procedure that Jewish mohels, with no medical qualifications, could perform circumcisions. Consequently, I was circumcised by this family doctor. My parents did not notice that anything was amiss during my early childhood. My mother does recall the penile skin appearing very tight during erections when I was a baby. She thought little of this, as my father's penile skin was similar.

Adolescent years (1986-1990)

With the onset of puberty between the ages of 12 and 13, I became aware of pubic hair growth and penile erections. These erections were very tight and painful, with the hair-bearing scrotal skin pulled up onto the penile shaft. With the onset of this pain, I suspected that my penis might be abnormal. There was, and still is, however, a lack of available, accurate information about the normal anatomy and function of the penis. Instructors for the sex education classes at school advised that it was normal for adolescents to feel concerned that the changes taking place in their bodies during puberty might not be normal. We were taught that these doubts are a normal part of growing up and there was no need for concern.

Although I took this advice and tried not to worry, I still suspected that I had been born deformed. The severity of the problems increased as I progressed through my teenage years at high school. As the penis grew, the skin became tighter and more painful, and the bending of the penis to the left became more apparent. This physical deformity had a major impact on my confidence and self esteem. I was reluctant to use public change rooms after physical recreation classes and tried to avoid sporting activities. I became very shy, self-conscious, and found it difficult to interact spontaneously with other teenagers my age. Because of these difficulties, I withdrew socially and made less of an effort to make friends. Because I often appeared quiet and shy, I was susceptible to victimization. I was bullied and bashed on a regular basis. Because I did not make my interest in the opposite sex obvious in a chauvinist manner, I was, occasionally, labelled as 'gay.' This experience indicates to me that I live in a prudish society that is unable to deal competently with sexual issues.

Young adult years

In 1991, at the age of 17, I was relieved to escape the bullying environment of high school and commence university studies. At that time, I believed I could achieve my life ambitions by succeeding at university. Unfortunately, by this time, the severity of the erectile deformity, tightness, and pain had increased to the extent that I could no longer achieve a full erection. As a university student, I was exposed to relationship and sexual issues. Although I met people I felt attracted too, I was unable to deal with these issues because of my belief that I had been born deformed and would be rejected. At this time, I was still unaware that my deformity was due to a circumcision injury.

I felt very ashamed of my deformity and was unable to seek help. This situation led to anxiety and depression, and I failed courses at university. The depression and anxiety, combined with the lack of success at university, eventually overwhelmed me. I did not know what do and regularly contemplated suicide. Although I had previously been sexually attracted to the opposite sex, at this point in my life I began to consider alternative options. During my second year at university, in 1992, I reached a crisis point. I felt compelled to confide in someone, so I told my mother. My mother was shocked and immediately suspected the deformity could be related to my circumcision. This was the first occasion that either one of my parents had ever mentioned that I had been circumcised.

I made an appointment with my family doctor on 11 April 1992. This appointment was not with the doctor who had delivered and circumcised me. I had seen my family doctor regularly from the age of six months. During the examination, the physician took one look at my penis and said that whoever circumcised me had not known what he was doing. The doctor informed me that I had suffered an aggressive circumcision, and that far too much skin had been amputated. He then referred me to a urological surgeon, whom I saw on 23 April.

The urological surgeon examined me more closely, but appeared reluctant to admit that my penis had been damaged. He commented that if anything was wrong, it was not obvious. After I insisted that a problem definitely existed, the urologist conceded that any potential problems would be more apparent upon an artificial erection. When I asked if the problem could be repaired, the urologist informed me that the tissue removed by the circumcision could never be replaced. I was told that I might just have to put up with the situation. This scenario was intolerable to me, so the urologist referred me to a plastic and reconstructive surgeon. I was examined by the plastic surgeon on 7 May 1992. This surgeon specialized in the treatment of severe burn victims, especially small children. Upon examination, the plastic surgeon advised that my injury would be very difficult to treat, but she believed that she might be able to improve my situation.

My reaction

It was difficult for me to cope with the above events, all of which took place within the space of only one month during the first university semester of 1992. I was shocked and angered to learn that I had not been born deformed, but was injured because my body had been interfered with by another person. I hated the family doctor who circumcised me, and I hated my parents for allowing it to be done. I began to feel disgust towards Australian society, which has historically maintained that routine neonatal circumcision is a beneficial practice. I also resented members of my extended family who were reluctant to believe that I was seriously injured by a simple procedure that, in their minds, removed only "the useless piece of skin on the end of a man's dick."

Research findings

As a university student, I was trained in research skills and had access to medical libraries. I began to research the topic of circumcision intensively in order to explore possible treatment options. The results of my research were dismaying. I was angered to find that my circumcision had been completely unnecessary from a medical standpoint. [7] I was horrified to find that, in addition to excessive skin removal, circumcision results in a range of injuries referred to as "complications." [8-11] I suspect that this sort of ruse serves to dissociate the blame of the injuries from the surgery that caused them. Such injuries include:

1.   Haemorrhage [12]
2.   Urinary retention [13]
3.   Meatitis, meatal ulcer and meatal stenosis [14]
4.   Adhesions or skin bridges [15-16]
5.   Infection: including gangrene, [17] septicemia and meningitis [18]
6.   Chordee [19]
7.   Cysts [20]
8.   Urethral injury and fistula [21-23]
9.   Hypospadias and epispadias [24-25]
10. Impotence [26-27]
11.  Psycho-social issues, such as schizophrenia [28-29]
12. Amputation or necrosis of the glans [30-32]
13. Total necrosis, ablation or amputation of the penis [33-35]
14. Death [36-37]

I was stunned to learn that in cases of penile amputation during routine neonatal circumcision, infants have been surgically reassigned to the female gender. [38-40] There are many ways by which an unnecessary routine circumcision can destroy a man's life, and not all of them are listed as complications. Many of the most frequent complications, as in my case, are seldom listed as such. All complications, both major and minor, can exert a negative impact on the quality of a man's life. This is especially true when circumcision is imposed on an individual without his permission, as is always the case with routine neonatal circumcision.

I also learned from my research that the quantity of skin removed during neonatal circumcision is highly variable between patients. [41] It is evident that excessive skin removal is one of the most common injuries. [42] Indeed, one contemporary urological textbook includes a subheading under circumcision:

If a victim's skin is not picked up off the floor and reattached, a far less satisfactory option is reconstructive surgery involving skin grafts to the penis in an attempt to replace the excess removed during circumcision. I also learned that the penile skin, mucosa, and nerves that are removed by circumcision can never be replaced, [44] and skin-graft recipients can be very dissatisfied with the results of such surgery. Grafted skin is not a satisfactory surrogate for the penile skin and mucosa and lacks the necessary innervation, elasticity, and suppleness. It is interesting that the highly unique characteristics of preputial tissue make it an excellent candidate for grafting to repair dermal trauma of other areas of the body, such as severe lacerations or burn injuries. [45]

Life options

My options in early 1992 were to endure my circumcision injury for the rest of my life, commit suicide, or try surgery. By this time, I had seriously considered suicide for more than a year. Rather than enduring the circumcision injury for the rest of my life, suicide represented an attractive option, as it would free me from my physical pain and psychological trauma. First, however, I chose reconstructive surgery as the only available option before the final resort of suicide. While reviewing the medical literature, I was interested in function more than cosmetics, and took an evidence-based approach. If a sex-change operation would yield the most functional end result, I might even have pursued that option. After assessing the medical literature, however, I was satisfied that penile reconstruction with skin grafts was more likely to achieve a functional result than a gender reassignment.

The option of non-surgical skin stretching requires special consideration. Although it is likely that I lacked sufficient remaining skin to stretch, I am disappointed that I was not made aware of this alternative in 1992. Unfortunately, non-surgical options were not presented in the literature that I surveyed nor offered by my surgeons. I have observed that medical practitioners are generally immersed in a surgical paradigm and often fail to advise patients of less invasive alternatives to surgery. Surgery is one of the most invasive and high-risk forms of medical intervention. As such, surgery should always be the absolute last resort for the treatment of a condition, to be employed only after all other less invasive options have failed.

Reconstructive surgery

I underwent reconstructive surgery on 30 June 1992. A full-thickness skin autograft of 12 cm by 14 cm was harvested from my left thigh for grafting to the penis. The thigh was the only prospective donor site that was large enough to supply a graft of the appropriate dimensions. A split-thickness graft was then harvested from my right thigh and applied to cover the exposed subcutaneous tissue at the left thigh donor site. Overall, the reconstructive procedure resulted in two large wounds to my thighs.

A full-thickness skin graft is composed of the full thickness of skin (dermis and epidermis), with the dermal surface of the graft trimmed of the underlying fat or subcutaneous tissues. [46] A split-thickness graft contains only the epidermis and a portion of the dermis. Although a split-thickness skin graft involves less trauma to the donor site, these grafts tend to be brittle and often contract when placed on unsupported tissue. My surgeons grafted a full-thickness of skin to the penis out of concern that a split-thickness graft might contract and erectile function would again be restricted.

Description of penis before reconstruction

Prior to reconstruction, the circumcision scar was very prominent and had migrated towards the base of the penis, due to the tethering and tension. The remnant inner preputial mucosa was stretched and distorted, with pitting and scarring evident. The shape of the glans was also distorted by the tension. The circumcision scar was highly irregular, as excision of the preputial tissue was asymmetrical, with more skin removed from the left side of the penis, than the right side. This created tethering and deviation of the penis towards the left upon erection. During erection, due to the extreme skin deficit and tension, the scrotal skin migrated more than two thirds of the distance along the penile shaft towards the glans.

A damaged remnant of the frenulum remained, which was particularly sensitive. As occurs in all circumcisions, the normally moist glans mucosa underwent keratinization and has been covered by a dry layer of dead epithelium. This represents a further reduction in sexual sensitivity of the penis, in addition to that caused by excision of the preputial mucosa and erogenous nerve endings.

Operative procedure

An artificial erection was produced by placement of a tourniquet around the base of the penis and injection of normal saline solution into the left corpus cavernosum. The chordee (deviation) of the penis to the left was made quite evident through this procedure. Next, an incision was made along the circumcision scar. Upon release of the tension, the hair-bearing scrotal skin retreated to the base of the penis. The underlying connective tissue (Buck's fascia) was completely exposed, illustrating the severe skin deficit due to the removal of almost all the shaft skin by the neonatal circumcision.

Another critical observation made at this stage of the operation was the complete absence of the dartos fascia. This abnormal situation, caused by the original circumcision, was not detected until this stage of the surgery. The dartos fascia is a delicate layer of areolar tissue that assists with the mobility of preputial tissue over the penis. [47] It should not be completely removed during circumcision, and its removal in my case resulted in painful adhesions between the remnant preputial mucosa and underlying Buck's fascia. These adhesions caused further tethering of the penis. In conjunction with the excessive and asymmetrical excision of preputial tissue, the absence of the dartos fascia and resultant adhesions would have rendered non-surgical techniques of skin stretching ineffective.

The remnant preputial mucosa was subsequently excised due to adhesions to the Buck's fascia. With excision and the release of tension, the preputial mucosa contracted to one fifth of its pre-operative size. Post-operatively, I discovered that removal of this mucosa had resulted in a dramatic loss of sexual sensitivity. I could not have appreciated the significance of this loss had I not experienced it myself. This loss is made all the more significant when combined with the sensitivity lost as a result of the large amount of preputial tissue removed during the original circumcision. Therefore, having experienced a "second circumcision", I can attest from experience that circumcision dramatically reduces sexual sensation.

The full thickness skin graft from the left thigh was placed around the penis. The skin graft was attached to the penis with Histoacryl tissue adhesive (Braun) with the suture line along the underside of penis in the position of the raphe. Surgery concluded with the application of a compression bandage to secure the skin graft to the penis and facilitate the establishment of a blood supply. The thigh donor sites were also bandaged. Postoperative pain was acute, and pethidine injections were given at the base of the penis at two or three hourly intervals for one week. Similar pain was also experienced in the donor sites.

Short-term results

The end result of the surgery was more aesthetically pleasing than the appearance when the bandages were removed, one week post-operatively. A large amount of swelling was evident, and I was surprised that any part of my body could swell to such a large size. The skin graft had an unpleasant consistency of thick, dried leather. With the topical application of vitamin E oil twice daily, the graft gradually became more supple over a period of several weeks, and the swelling subsided. Unfortunately, as the suppleness and elasticity of the graft increased, the graft contracted as it does not express the genes and hormones that instruct natural penile skin to remain loose. A series of ridges formed, which later developed into red hypertrophic scarring. The graft also developed hair due to follicles inadvertently transplanted with the graft from the thigh.

The donor site wounds were very similar to burn injuries, and were treated as such. DuoDERM E, a semi-permeable polyurethane wound dressing, was worn for several weeks post-operatively to facilitate re-epithelialization and reduce pain. [48] After wound closure was complete, the thigh donor sites also developed prominent red hypertrophic scarring during the healing process over subsequent weeks.

To reduce the hypertrophic scarring of the penile graft and thigh donor sites, I was advised by the surgeon to massage twice daily with vitamin E oil, and wear compression bandages on the donor sites as much as possible. Although very inconvenient and uncomfortable, I disciplined myself to massage with vitamin E oil and wear the compression bandages as directed. Although not directed to do so, I also wore condoms to compress and assist in scar reduction of the penile skin graft. Compression bandages and condoms were worn for over two years postoperatively.

Electrolysis

In June 1993, electrolysis was performed to destroy the hair follicles transferred with the graft from the thigh to the penis. A steroid injection was also given to assist in scar reduction for the penile skin graft. Unfortunately, the outcome of electrolysis was horrific, with extreme swelling and pain. Due to the fragility of the penile skin graft, necrosis and atrophy of tissue occurred in a radius of several millimeters around each electrolyzed hair follicle. Although these wounds have healed, dark scars and pitting remain.

Long-term results

The penile skin graft reduced tethering and enabled fuller erections. Upon erection, the penis became longer and the deviation to the left less severe. The remaining deviation is due to the restricted growth of the left corpus cavernosum - a permanent result of the tethering during puberty. This deformity demonstrates that penile growth and development are severely restricted when the penis is denuded by circumcision. The prominent scarring of the thigh donor sites is an unpleasant outcome of the surgery, as the damage caused by the neonatal circumcision has disfigured other areas of my body. These bright red scars were prominent while I was naked in change rooms or wearing shorts in summer. The scars have attracted attention and caused embarrassment on a number of occasions, including in the workplace.

The prominent redness of the donor sites faded after approximately three years, and the raised edges of the scars were reduced by the bandages and vitamin E massage oil. The graft sites, however, are now conspicuously pale, with ridging of the skin and an absence of hair. They still attract unwelcome curiosity. Despite the application of vitamin E oil and compression with condoms, the reduction of the scarring on the penis has been much less successful than for the donor sites.

Pain persisted in the graft and donor sites for many years after the surgery, but the intensity and frequency subsided with time. I now experience aches and pains only occasionally. However, since the surgery I have also experienced unpleasant or altered sensations, such as itching or tingling, and numbness. These still persist. Apart from this sensory disturbance in the underlying tissue, I have no sensation in the penile skin graft and also large areas of the donor sites. Due to the absence of the dartos fascia, the graft has adhered to the underlying buck's fascia and is not mobile like natural penile skin. The graft has also contracted and is approximately six to eight times thicker than normal penile skin.

Suicide attempt

There was no way that I could have been psychologically prepared for the highly invasive and extreme nature of the reconstructive surgery, and the resulting pain, trauma, and embarrassment. Members of my extended family were still reluctant to believe that I had been injured, as were a number of psychiatrists whom I consulted. A number of these professionals appeared to be biased in favour of circumcision due to their medical training, and told me that my problems were "all in my head." They advised that I should "just get over" my perceived problems and get on with my life. I felt alone and isolated. I also began to view my injury as a result of assault, and I felt that I had been mutilated. These feelings first emerged before the reconstructive surgery, and increased in intensity with the trauma of surgery.

Six months after the surgery, I attempted suicide on 7 January 1993. I had concluded that the impact of the circumcision injury on my life was insoluble. With the exception of my parents and close friends, few people were willing to acknowledge the severity of my injury and trauma, and even fewer people wanted to help. I felt as though I was living in a society where circumcision was still beyond criticism and few people were willing to accept the reality that routine circumcision is a harmful and destructive practice. I could not allow myself to be a hypocrite and live silently in a society where unnecessary circumcision was still condoned and practiced.

Legal action

After surviving a suicide attempt, I experienced a fuller appreciation that the cause of my horrendous experiences is unethical and completely unacceptable. I realized that I could not live with myself if I did nothing to prevent the practice of unnecessary circumcision and spare others from enduring what I had suffered. I decided that I was unwilling to remain yet another victim whose silence was taken by society as an affirmation that circumcision is harmless.

For several subsequent years, I concentrated on my university studies and tried to resolve the psychological trauma. This was most difficult. Overall, my Bachelor degree was delayed by four years due to the reconstructive surgery and associated trauma. During this time, I also considered the possibility of taking legal action to gain recognition of my injury and provide proof to Australian society that male circumcision is a highly destructive practice. I first sought legal advice from Dwyer Durack in 1994, but felt overwhelmed by the potential emotional trauma and financial expense of my case. Consequently, I did not proceed with an action at that time.

In October of 1997, I was finally approaching the final examinations for my degree. Unfortunately, I was also approaching my 24th birthday. This birthday represented the expiry date for the Statute of Limitations for issue of a Writ of Summons against the doctor who circumcised me. I was not psychologically prepared to commence legal action in 1997, but I was determined not to miss any potential opportunity for justice with expiry of the Statute of Limitations. A writ was issued against Dr. Michael Morley in October 1997, based on the failure of Morley to fulfil his duty of care. The Statement of Claim included loss of quality of life, pain and suffering, and special damages that included a psychological component. My solicitor at Slater and Gordon estimated that I might receive between AU $50,000 to $100,000 in compensation. I replied that, after my horrendous experiences, I would accept no less than AU $500,000 and would prefer in excess of AU $1,000,000.

The legal action was difficult due to a lack of similar claims and precedents in Australia. An additional disadvantage was that civil cases in Western Australia are determined by a judge only, in contrast to a judge and jury in other Australian states. Western Australia is also the most conservative state with respect to the treatment of sexual issues by the judicial system. For these reasons, I tried to avoid proceeding to trial. My solicitors found my case difficult to research, prepare, and discuss. It was necessary for me to maintain constant communication and an assertive attitude to ensure the progress of my case. I also completed as much of the research and photocopying as possible to assist my solicitors and to minimize costs.

In August 1999, my claim proceeded to a pre-trial conference. I interrupted my doctoral studies at Australian National University and returned to Perth for the first conference on 30 August. As the solicitors for the Defendant requested further evidence, two more pre-trial conference sessions were held on 27 September and 2 November. My psychological health and studies suffered due to the time required for gathering additional evidence, the financial cost, emotional drain, and the associated stress and depression. I felt that I was in danger of losing my PhD candidature.

A settlement was still not reached at the final pre-trial conference. Not satisfied that the Defendant's solicitors gave my injury due recognition, I directed my solicitor to issue a 24A offer. This offer gave the Defendant one final opportunity to settle before the claim proceeded directly to trial. The terms of my offer were:

1. The Defendant pay the Plaintiff the sum of AU$360,000 plus repayment to the Health Insurance Commission of AU$5,070.40.

2. The Defendant pay the Plaintiff's costs and disbursements of the action up to and including the date of acceptance of this offer, to be taxed if not agreed.

3. The Defendant admit liability.

The Defendant accepted this offer in late November 1999. Although my private health insurance fund paid approximately AU$5,000 of my medical expenses, the Defendant refused to recognize or refund this money. Despite the Defendant's agreement to pay costs, I was required to pay approximately half of the legal costs involved.

The admission of liability was vital to my sense of victory and vindication. I wanted public acknowledgement that I had been injured by routine neonatal circumcision. This injury was inflicted on me and has deprived me of freedom, liberty, and a normal life. For this reason, I refused to forego my freedom of speech and would not agree to a settlement that included a confidentiality clause, or a clause denying the medical practitioner's responsibility for my injury.

Current status

I am still in a state of shock from my experiences. I am unhappy to have endured such severe injury and trauma due to a surgical procedure that was completely unnecessary. I would never have consented to circumcision if I had received an opportunity to make the choice that was rightfully mine. Since 1999, I have focused on public awareness to help prospective parents be aware that routine circumcision is completely unnecessary and very destructive. My parents would never have consented to my circumcision if this information had been made available to them. Public awareness was most successfully achieved by an article published in Woman's Day, which included an interview with Dr David Brand, the current head of the Australian Medical Association. Woman's Day obtained an unprecedented statement:

The Australian Medical Association had never previously acknowledged to the public that circumcision could lead to scarring and deformity.

What I would like to see happen in Australia

Routine circumcision is a controversial issue, with no easy solution. I believe that no person has the right to surgically inflict their religious, sexual, or cosmetic preferences on another person. I contend that no parent or adult has the right to inflict medically unnecessary and irreversible surgery on a child. The Australian legal system must address this issue, as it has done for the issue of sterilization of intellectually disabled females (Family Law Council, 1994), for which Court permission is now required by a new division in the Family Law Act. [50] Likewise, Court permission should be required to perform circumcision on a child under the age of 18, or an adult incapable of giving informed consent, unless there is documented proof of the absolute medical necessity for the health of the individual to support the decision to operate without consent.

Many people respect an individual's right to engage in unprotected sex with multiple sexual partners, yet maintain a mistaken belief that the risk of disease transmission may be reduced through the forcible removal of a normal and healthy body part from non-consenting babies. This view fails to recognize or acknowledge that it is solely my right to choose the sexual practices that I will engage in, and solely my right to choose which body parts I will retain or discard.

It is also solely my right to choose the religious beliefs and cultural traditions I will subscribe to, and again, solely my right to choose which body parts I will retain or discard. Members of some ethnic groups claim that they have a right to dictate the cultural and religious beliefs that their children will adopt. Such views fail to recognize that children are not the property or the chattel of their parents. I contend that children require an opportunity to learn about their cultural heritage and exercise freedom of choice over the beliefs and traditional practices they will adopt. Parents have a duty to protect their children from harmful practices, and no tradition should be enforced by the permanent alteration or disfigurement of the body of an individual who is legally incapable of providing informed consent.

As with many issues concerning human rights, it is difficult to convey these messages to society. The public needs to be accurately informed and educated about circumcision and its associated risks and disadvantages. My mother was shocked to learn that the "useless bit of skin" removed from me was actually rich in sensory nerve endings. [51] She now considers male circumcision the equivalent of female circumcision - a cultural practice that the majority of parents in western societies would never contemplate inflicting on their daughters. It would be beneficial to promote public awareness of the similarities in cultural origins and destructive consequences of male and female genital mutilation.

I would like also like to see it become unlawful for family doctors and other inadequately qualified individuals to perform circumcision. Only a pediatric surgeon has the necessary expertise and experience to perform surgery on small children and deal with the possible injuries and complications that circumcision can cause. A step in this direction was recently taken in Israel, following the heavily publicized case of glans amputation during a ritual circumcision. [52] The Israeli Health Ministry has agreed to issue a directive to Israeli hospitals, for the first time allowing them to certify doctors to perform circumcisions. [53]

It should also be unlawful for surgery of any kind to be practiced without adequate pain relief. Several ethnic groups and a number of medical practitioners have disseminated a primitive, self-serving belief that infants do not experience pain when subjected to circumcision. [54] The extreme pain and distress experienced by infants who undergo circumcision, however, is well documented. [55-56] For the less than 1% of the male population who may require circumcision for genuine medical reasons, [57] adequate pain relief should be provided, both during the procedure and postoperatively. As a means of discouraging the current widespread practice of circumcision without adequate pain relief, laws should be passed to imprison any individual who is guilty of such conduct for inflicting torture and grievous bodily harm.

Rebates for circumcision should be limited on the Medicare Benefits Schedule. Rebates should not be given for routine circumcision or any other unnecessary medical intervention. The Australian public health system is currently in financial crisis. Patients with life-threatening conditions are being denied prompt and essential treatment. Public awareness of the human and economic costs of medically unwarranted circumcision, and the resulting injuries and trauma, may assist in changing attitudes towards this unnecessary and harmful practice.

Acknowledgements

I thank Mrs. Kerry Peterson and Dr. George Williams for their assistance with the preparation of my symposium presentation and this manuscript. I also thank all those who were present at the Sixth International Symposium on Genital Integrity (Sydney 2000), where this paper was first given . Their encouragement and support helped me to deliver this most difficult account of my experiences.

References

1. Szabo R, Short RV. How does male circumcision protect against HIV infection? BMJ 2000;320(7249):1592-4.

2. Kanawati N, Hassan A. The Teti Cemetery at Saqqara. vol. II. The Tomb of Ankhmahor. The Australian Centre for Egyptology: Reports 9. Warminster: Aris & Phillips Ltd. 1997. pp. 49-50.

3. Bailey E. Circumcision in ancient Egypt. The Bulletin of the Australian Centre for Egyptology. 1996;7:15-28.

4. Roth AM. Egyptian Phyles in the Old Kingdom: The Evolution of a System of Social Organization. Chicago: Oriental Institute of the University of Chicago; 1991. pp. 62-75.

5. Spiegelman M. The circumcision scene in the tomb of Ankhmahor: the first record of emergency surgery. The Bulletin of the Australian Centre for Egyptology 1997;8:91-100.

6. See the discussion in: Hodges FM. The ideal prepuce in ancient Greece and Rome: male genital aesthetics and their relation to lipodermos, circumcision, foreskin restoration, and the kynodesme. Bulletin of the History of Medicine 2001;75:375-405.

7. Duckett JW. The neonatal circumcision debate. In: King LR, editor. Urologic Surgery in Neonates & Young Infants. Philadelphia: Saunders; 1988. pp. 291-9.

8. Broecker BH. Circumcision. In: Glen JE, Graham SD, Boyce WH, Turner-Warnick R, Brendler CB, et al., editors. Urologic Surgery. Philadelphia: Lippincott; 1991. pp. 841-4.

9. Clark P. On the penis. In: Operations in Urology. New York: Churchill Livingstone; 1985. pp. 107-112. [here, p. 111.]

10. Kaplan GW. Complications of circumcision. Urol Clin North Am 1983;10(3):543-9.

11. Redman JF. Rare penile anomalies presenting with complication of circumcision. Urology 1988;32(2):130-2.

12. Wiswell TE, Geschke DW. Risks from circumcision during the first month of life compared with those for uncircumcised boys. Pediatrics 1989;83(6):1011-5.

13. Berman W. Letter: Urinary retention due to ritual circumcision. Pediatrics 1975;56(4):621.

14. Bennett HJ, Weissman M. Circumcisions: knowledge isn't enough. Pediatrics 1981;68(5):750.

15. Ritchey ML, Bloom DA. Re: Skin bridge-a complication of paediatric circumcision. Br J Urol 1991;68(3):331.

16. Talarico RD, Jasaitis JE. Concealed penis: a complication of neonatal circumcision. J Urol 1973;110(6):732-3.

17. Sussman SJ, Schiller RP, Shashikumar VL. Fournier's syndrome. Report of three cases and review of the literature. Am J Dis Child 1978;132(12):1189-91.

18. Menahem S. Complications arising from ritual circumcision: pathogenesis and possible prevention. Isr J Med Sci 1981;17(1):45-8.

19. Kaplan GW. Circumcision - an overview. Curr Probl Pediatr 1977;7(5):1-33.

20. Kaplan GW. Circumcision - an overview. Curr Probl Pediatr 1977;7(5):1-33.

21. Lackey JT, Mannion RA, Kerr JE. Urethral fistula following circumcision. Jama 1968;206(10):2318.

22. Limaye RD, Hancock RA. Penile urethral fistula as a complication of circumcision. J Pediatr 1968;72(1):105-6.

23. Redman JF. Rare penile anomalies presenting with complication of circumcision. Urology 1988;32(2):130-2.

24. McGowan AJ. A complication of circumcision. JAMA 1969;207(11):2104-5.

25. Vyas PR, Roth DR, Perlmutter AD. Experience with free grafts in urethral reconstruction. J Urol 1987;137(3):471-4.

26. Hanash KA. Plastic reconstruction of partially amputated penis at circumcision. Urology 1981;18(3):291-3.

27. Palmer JM, Link D. Impotence following anesthesia for elective circumcision. JAMA 1979;241(24):2635-6.

28. Ball JR, Grounds AD. Head injury, hypopituitarism and paranoid psychosis: Circumcision for the "Singapore virus". Med J Aust 1974;2(11):403-5.

29. Flaherty JA. Circumcision and schizophrenia. J Clin Psychiatry 1980;41(3):96-8.

30. Rosefsky JB. Glans necrosis as a complication of circumcision. Pediatrics 1967;39(5):774-6.

31. Sterenberg N, Golan J, Ben-Hur N. Necrosis of the glans penis following neonatal circumcision. Plast Reconstr Surg 1981;68(2):237-9.

32. St Margaret's Hospital for Women (Sydney) vs McKibben. Hearing before the Supreme Court of New South Wales, Court of Appeal. BC8701368. 14 May 1987.

33. Gearhart JP, Rock JA. Total ablation of the penis after circumcision with electrocautery: a method of management and long-term followup. J Urol 1989;142(3):799-801.

34. Hanash KA. Plastic reconstruction of partially amputated penis at circumcision. Urology 1981;18(3):291-3.

35. Izzidien AY. Successful replantation of a traumatically amputated penis in a neonate. J Pediatr Surg 1981;16(2):202-3.

36. Gairdner DM. The fate of the foreskin: A study of circumcision. BMJ 1949;2:1433-7.

37. Gee WF, Ansell JS. Neonatal circumcision: a ten-year overview: with comparison of the Gomco clamp and the Plastibell device. Pediatrics 1976;58(6):824-7.

38. Gearhart JP, Rock JA. Total ablation of the penis after circumcision with electrocautery: a method of management and long-term followup. J Urol 1989;142(3):799-801.

39. Money J. Ablatio penis: normal male infant sex-reassigned as a girl. Arch Sex Behav 1975;4(1):65-71.

40. Diamond M, Sigmundson K. Sex Reassignment at Birth: Long-term Review and Clinical Implications. Arch Pediatr Adolesc Med 1997;151(3):298-304.

41. Patel H. The problem of routine circumcision. Can Med Assoc J 1966;95(11):576-81.

42. Gee WF, Ansell JS. Neonatal circumcision: a ten-year overview: with comparison of the Gomco clamp and the Plastibell device. Pediatrics 1976;58(6):824-7.

43. Clark P. On the penis. In: Operations in Urology. New York. Churchill Livingstone; 1985. pp. 107-112. [here, p. 111.]

44. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77(2):291-5.

45. Jordan GH. Grafts and flaps in urology. In: Glen JE, Graham SD, Boyce WH, Turner-Warnick R, Brendler CB, et al., editors. Urologic Surgery. Philadelphia. Lippincott; 1991. pp. 1085-97.

46. Jordan GH, Schlossberg SM, Devine CJ. Surgery of the penis and urethra. In: Walsh PC, Retick AB, Vaughan ED, Wein AJ. Campbell's Urology, 4 vols., 7th ed. Philadelphia: W.B. Saunders; 1998. vol. 2. pp. 3316-33.

47. Jordan GH, Schlossberg SM, Devine CJ. Surgery of the penis and urethra. In: Walsh PC, Retick AB, Vaughan ED, Wein AJ. Campbell's Urology, 4 vols., 7th ed. Philadelphia: W.B. Saunders; 1998. vol. 2. pp. 3316-33.

48. Hermans MH. Duoderm E in the treatment of donor sites: a report. Annals of the MBC 1990;3(3):166-9. [September 1990]

49. Stanley D. Shane's circumcision nightmare: I wish I'd never been born. Woman's Day (Sydney, Australia), (1 May 2000): pp. 24-5.

50. A report to the Attorney-General prepared by the Family Law Council. Sterilisation and Other Medical Procedures on Children. Commonwealth of Australia 1994.

51. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77(2):291-5.

52. Siegel-Itzkovich J. Baby's penis reattached after botched circumcision. BMJ 2000;321(7260):529. [2 September 2000]

53. Siegel-Itzkovich J. Israel's health ministry ends circumcisers' monopoly. BMJ 2001;322(7277):10. [6 January 2001]

54. Weiss GN, Weiss EB. A perspective on controversies over neonatal circumcision. Clin Pediatr (Phila) 1994;33(12):726-30.

55. Taddio A, Pollock N, Gilbert-MacLeond C, Ohlsson K, et al. Combined analgesia and local anesthesia to minimize pain during circumcision. Arch Pediatr Adolesc Med 2000;154(6):620-3.

56. Anand KJ, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med 1987;317(21):1321-9. [19 November 1987]

57. Rickwood AM, Kenny SE, Donnell SC. Towards evidence based circumcision of English boys: survey of trends in practice. BMJ 2000;321(7264):792-3. [30 September 2000]