A new Britannia in another world

When Australia was first settled by the British the only form of circumcision on the continent was practised as a male initiation ritual by a limited number of Aboriginal nations in Arnhem Land and the desert areas of what is now the Northern Territory and parts of Western and South Australia. The first reports of such customs were greeted with horrified incredulity; in his study Prehistoric Times (1865), Sir John Lubbock listed the operation among a number of "horrible rites" practised by these peoples, and cited it as evidence of their remoteness from civilization. The additional exercise known as subincision found in some tribes - slitting the underside of the penis - he found so shocking and incredible that he reported the gory details in Latin. These rites had no influence on white practice, and little was known about them until the investigations of Baldwin Spencer and other anthropologists around the turn of the century.

Attitudes to circumcision changed sharply at the same time. However deeply British doctors might despise the backwardness of these savages, they found themselves in agreement with them on one sensitive point: that boys should indeed have their foreskins removed, but preferably in infancy or boyhood rather than at puberty, and for moral and health rather than social and customary reasons.

In Australia the rise of circumcision followed the British example, but the practice endured longer and affected a greater proportion of boys. Since most doctors were British, were educated in Britain or received their medical training in Australia from British teachers, it is not surprising that they reproduced the orthodoxies of their colleagues and mentors. In the late nineteenth century circumcision was recommended principally as a cure for spermatorrhoea in men and as a preventive of masturbation and nervous complaints in the young, but around 1900 the need to treat "congenital phimosis" in infants and boys and provide protection against the later possibility of venereal disease became paramount. The incidence of circumcision rose sharply between 1910 and 1920 as the First World War intensified fears of syphilis, and by the 1920s most doctors and child care manuals urged early circumcision as the act of a responsible parent. It was at this time that the practice of routinely circumcising normal baby boys before they left the hospital became common. Greater social equality, a less rigid status system and higher living standards are the social factors which probably explain why this advice was followed by parents across the social spectrum, not principally among the upper classes as in Britain.

Although Britain itself dropped routine circumcision in the late 1940s (and New Zealand in the 1950s), Australia followed United States practice, and the figure rose steadily to a peak of about 85 per cent in the mid-1950s, before falling back again: down to 50 per cent by 1975, and only 10 per cent by 1995.

NOTE: Figures before Medicare data became available in the 1970s are speculative and impressionistic. They should not be regarded as hard data.

For further statistical information about the incidence of circumcision in Australia today, see:

http://www.circumstitions.com/Australia.html
http://www.cirp.org/library/statistics/Australia/

It can be seen from the table that the biggest jump in the rate of routine neonatal circumcision (RNC) occurred in the decade 1910-1920, giving Australia the distinction of being the first modern nation to circumcise half its male babies. This was a period of acute fear of venereal disease, particularly syphilis; the erroneous belief that circumcision would provide protection against syphilis was probably an important reason why more parents were having their boys cut at this time. The year 2000 was a landmark as the first time since 1945 when the total number of uncut males in Australia outnumbered the circumcised. Interestingly, though, despite the hight rate of RNC, the total number of cut males has never exceeded 61 per cent - less than two thirds.

Medicalisation of childbirth

Another significant factor in both the rise and decline of circumcision was the medicalisation of childbirth. In the late nineteenth century the practitioners of the new "scientific" medicine consolidated their position as the only legitimate source of medical advice and treatment, and by the 1920s "the Australian medical profession had achieved a nearly unchallenged dominance over the supply of personal health services" [1]. In the process, and with a little help from state legislation, they drove out alternative practitioners, and the rising specialism of obstetrics gradually displaced the midwives who had traditionally looked after women giving birth. In this context the decision of the Commonwealth Government, in 1912, to pay a maternity allowance (a generous 5 pounds) was also important. Expectant mothers tended to use the money to buy medical attendance at their confinement, thus bringing more doctors onto the childbirth scene and ensuring that more women gave birth in a hospital rather than at home. The proportion of births supervised by a doctor, at 63 per cent, was already quite high by 1913, but by 1935 it had increased to 83 per cent. [2] These developments have often been seen as vital factors in the decline of childbirth mortality, but in 1929 a study by Janet Campbell found that midwives actually lost fewer babies than doctors. [3]

Doctors were thus in a highly strategic position: being on the spot, if they thought that the baby ought to be circumcised, there was a very good chance that he would be, and for fifty years or so he usually was. But if this medical dominance [4] can help to explain the rapid rise of neonatal circumcision between the First and Second World Wars, it also helps to explain the rapid decline of the practice in the 1970s and 80s. Once doctors had decided that circumcision was a bad idea, they were in an equally strong position to ensure that the operation was not performed. This point is also relevant to the slowing (and in some states, the slight reversal) of the decline in circumcision incidence in the late 1990s. By this time the medical profession had lost its monopoly position, and parents were increasingly exposed to an often bewildering array of alternative sources of advice on health and child care issues - women's and parenting magazines, informal mothers' groups, websites, bulletin boards and endless reports and commentary in the media etc. Among this flood of information, both old and new circumcision enthusiasts have been able to spread their alarmist message.

Circumcision and infant health

Over the past thirty years there has been considerable research into maternal and child health during the first half of twentieth century Australia, including major studies by Diana Wyndham, Phillipa Mein Smith, Milton Lewis [5] and Janet McCalman. [6] Although these scholars have scoured the records and covered the relevant issues in great detail, there is one word which makes not a single appearance in their pages: circumcision. Although its incidence was steadily increasing over this period, the authors apparently found no evidence that it made the slightest contribution to the improvements in infant survival rates and general child health observed at the same time. Examining the remarkable fall in infant and maternal mortality that occurred roughly between 1905 and the 1930s, they note that it was a phenomenon observed throughout the developed world, in Europe as much as in Britain or Australia, and they conclude that it is largely attributable to improved nutrition (including more breast feeding), cleaner environments and the provision of sewerage systems and clean domestic water supplies. The last of these is particularly important in explaining the fall in deaths from one of the major nineteenth century killers, diarrhoea. This was usually the result of gastro-intestinal infections caught from contaminated food or water, but the final cause of death was often dehydration - a problem which many Victorian doctors completely misinterpreted. Noticing that the boy was not urinating they concluded, not that he was dying of thirst and needed water, but that "congenital phimosis" - his appropriately tight foreskin - was preventing him from urinating, and thus that the solution to the problem was surgical.

The reasonable conclusion, that the rising incidence of circumcision over the first half of the twentieth century made no contribution to improved child health outcomes, is confirmed by a recent report from the Australian Institute of Health and Welfare covering the period 1983 to 2003. The report, A picture of Australia's children, shows major improvements in child health over the 20 years from 1983 to 2003, and a halving of infant mortality. These are very significant dates, since 1983 was the beginning of the dramatic slide in Australian circumcision incidence, from about 40 per cent of boys in the early 1980s to less than 12 per cent in 2003. It is thus good empirical proof that "lack of circumcision" does not increase child health problems. Even more significantly, it is a decisive refutation of "scientific" predictions by various antiquated circumcision enthusiasts that the fall in the circumcision rate would lead to an explosion of genito-urinary problems in boys. No such problems are identified in this report, which does not even mention any health problems affecting the genito-urinary area.

If one were to be as unscrupulous in mixing up correlation with causation as many pro-circumcision zealots tend to be, one could reasonably conclude that Australian children have become healthier because the incidence of circumcision has fallen, not merely at the same time. But there is no need to go that far. At the very least A picture of Australia's children is definitive proof that there is zero connection between circumcision and improved health outcomes.

The report can be downloaded from the AIHW website in several pdfs here.

Current situation

The popularity of routine circumcision declined steadily in the 1980s and 90s and looked set to fall below 5 per cent nationally, but there has been a slight rise in the frequency of the procedure since 1999, probably as a response to recent scares, heavily beaten up by the popular media, over STDs (especially HIV-AIDS), urinary tract infections (UTIs) and most recently human papillomavirus (HPV) - the wart virus implicated in cancer of the penis and cervix. Long-time advocates of RNC have been doing their best to exploit popular fears of these diseases (rare in developed countries) in order to put pressure on the medical profession to revive the procedure as a public health measure. This is despite powerful criticism of their claims in the medical literature and increasing warnings that the procedure is unethical and potentially illegal (as the Queensland Law Reform Commission warned in 1993).

Where the Australian experience differs most markedly from the British is in the long survival of routine circumcision - which reached its peak incidence at over 80 per cent per cent of boys in the 1950s - after Gairdner's debunking of "congenital phimosis". The reasons for this have not been studied, but it may be related to the increased influence of US medical advice (particularly Benjamin Spock's Baby and child care) as a result of the Second World War, and the substantially greater incidence of the procedure at that point, meaning that there was a higher peak from which to descend, more mothers not knowing how to look after a foreskinned penis, and more circumcised fathers not wanting their sons to look different. Although Gairdner's paper was approvingly discussed as early as 1953, it was not until the late 1960s that it really made an impact, and not until 1971 that the Australian Paediatric Association decided to recommend that "male infants should not, as a routine, be circumcised". This policy was cautiously endorsed by the Medical Journal of Australia, and the incidence of circumcision then fell steadily to its current low of about 12 per cent. The trend was accelerated by a stronger statement issued by the Australian College of Paediatrics in 1983 and slowed down by a weaker and rather equivocal one which mysteriously appeared in 1996. It is likely that the detailed policy issued by the Royal Australasian College of Physicians in 2002, confirming the original stance that there is no medical justification for routine circumcision, will lead to the resumption of the declining trend.

The sequence observed, therefore, is that routine circumcision began slowly as a doctor-driven innovation; became established in the medical repertoire and spread rapidly; and then declined slowly as doctors ceased to recommend it, but parents, having absorbed the advice of the generation before, and many fathers themselves being circumcised, continued to ask for it. Even today surveys find that a high proportion of young mothers of British origin, especially those living in country areas, continue to expect their sons to be circumcised and are resentful when doctors refuse to do it. A significant factor in the decline of circumcision in the 1960s - before the paediatricians took a stand - was the arrival of large numbers of immigrants from non-circumcising European countries, most of whom settled in the cities; a recent study in Western Australia found a higher incidence of circumcision in country areas, with their greater proportion of older Anglo-Celtic stock, than in major urban centres, with their more multicultural and better educated populations.

Wide variation among the states

There is also an enormous difference in circumcision incidence between the states, with the ACT, the Northern Territory, Tasmania, Victoria and Western Australia at around 5 per cent or less, South Australia at about 14 per cent, and New South Wales and Queensland at nearly 20 per cent. Such differences have nothing to do with health needs but reflect differences of policy and attitude among doctors and health officials at the state level.

A further factor in the survival of routine circumcision is the continuing subsidy of the operation through the Medicare rebate. Although the Medicare guidelines state that the rebate is not available for cosmetic procedures or for medical treatment that is not clinically necessary, there has been no attempt (since an ill-fated decision in 1985) to drop circumcision from the Medical Benefits Schedule. The subsidy not only makes the operation more affordable, but sends a signal that it is socially acceptable and perhaps medically desirable. As with the 1912 baby bonus, the rise and survival of circumcision has as more to do with social expectation and economics than with health.

References

1. James Gillespie, The price of health: Australian governments and medical politics, 1910-1960 (Cambridge University Press, 1991), p. 3

2. Philippa Mein Smith, Mothers and King baby: Infant survival and welfare in an imperial world - Australia 1880-1950 (London: Macmillan, 1997), p. 200

3. Diana Wyndham, Striving for national fitness: Eugenics in Australia, 1910s to 1930s (PhD thesis, University of Sydney, 1996), p. 198

4. Tony Pensabene, The rise of the medical practitioner in Victoria (Canberra: Australian National University Health Research Project, Research Monograph, No. 2, 1980); Evan Willis, Medical dominance: The division of labour in Australian health care (Sydney: Allen and Unwin, 1983)

5. Milton Lewis, Populate or perish: Aspects of infant and maternal health in Sydney, 1870-1939 (PhD thesis, Australian National University, 1976)

6. Janet McCalman, Sex and suffering: Women's health and a women's hospital - The Royal Women's Hospital, Melbourne, 1856-1996 (Melbourne University Press, 1998)