Deaths and complications from circumcision in Australia
as reported in selected Australian sources, 1919-2006

Adverse circumcision outcomes under-reported

Unlike in underdeveloped countries, such as Turkey, Iran or Nigeria, where the incidence of serious adverse outcomes from circumcision runs as high as 20 per cent, [1] it is clear that deaths or serious complications from circumcision are not common in developed countries. Australia has an enviable record with respect to deaths from circumcision, none having been reported since 1993. There is, however, no room for complacency. As well as good medical practice, the absence of such reports is as much a consequence of the declining and now low incidence of infant circumcision and the difficulty of attributing deaths to circumcision when they are the result of later complications, such as infection, or of long term sequelae, such as depression and suicide. As shown on the above table, several authorities agree that there is no reliable record of mortality, and the Australian Institute of Health and Welfare has admitted that their statistics cannot identify deaths due indirectly to circumcision:

“We have information on circumcision and there are external cause codes for complications of medical and surgical care. However, it is not possible to tell if the complication was a result of the circumcision. For example, the circumcision may have been undertaken in a previous admission, and the patient readmitted with a complication. If this was the case, we couldn’t tell that it was the same patient and we wouldn’t know for sure that the complication was due to the circumcision.” [2]

It is a similar picture with respect to complications, the incidence of which is the subject of wide disagreement. In 1970 Leitch suggested a rate of 15.5 per cent, [3] while more recently the Royal Australasian College of Physicians cites estimates ranging from an implausible 0.06 per cent to an equally unlikely 55 per cent, depending on definition. It seems to regard a likely incidence as falling within the range of 2 to 10 per cent, and it warns that “serious complications, such as bleeding, septicaemia and meningitis may occasionally cause death”. [4] If the rate of complications is 15, 10 or even only 2 per cent, it is apparent that the small number of cases that get publicly reported represent only the tip of the iceberg; this under-reporting contributes to the illusion that circumcision is a safe and “harmless” operation. [5]

Whatever the figure – and it seems unlikely that definitive statistics will ever emerge – it will readily be agreed that there must be a lower threshold of tolerance for adverse outcomes from unnecessary or cosmetic surgical procedures than from those which are genuinely required for a person’s health. This principle is all the more important when the person does not choose the surgery for himself.

References:

1. Ozdemir E. Significantly increased complications risk with mass circumcision. British Journal of Urology 1997; 80: 136-139; Yegane RA, Kheirollahi AR, Salehi NA, et al. Late complications of circumcision in Iran. Padiatr Surg Int, 2006; 22: 442-445. A study of neonatal circumcision in Nigeria found a complication rate of 20.2 percent, with 3.1 per cent of the operations resulting in amputation of part of the glans – Okeke LI, Asinobi AA, Ikuerowo OS. Epidemiology of complications of circumcision in Ibadan, Nigeria. BMC Urology, 2006; 6: 21
2. Narelle Grayson, Hospitals and Mental Health Services Unit, AIHW, email message to Shane Peterson, 14 January 2004
3. I.O.W. Leitch, Circumcision: A continuing enigma, Australian Paediatric Journal, Vol. 6, 1970, 60
4. RACP Policy statement on circumcision, 2009
5. Circumcision practitioners in Australia boast that the method they usually employ, the plastibell device, is painless, non-surgical and completely safe. All these claims are false and misleading. Because the foreskin is densely networked with nerves, cutting (or any rough handling) there is extremely painful; EMLA cream commonly used to dull the pain is not fully effective and is not recommended for use on the very young. Because the removal of the foreskin involves the amputation of tissue, it is certainly surgery. And there are over a dozen references in the medical literature to complications arising from use of the plastibell device. As recently as 2007 a baby boy in Canada died as a direct consequence of a plastibell circumcision.
   Details of the dangers of EMLA cream
   Further information about deaths
   Further information about complications
6. The victim sued the hospital and in 1987 was awarded $275,000 damages. Case reported in Australian Torts Reports 1987, Case 80-130, St Margaret’s Hospital for Women, Sydney, v. McKibbin; case discussed in Gregory J Boyle, J Steven Svoboda, Christopher P Price, J Neville Turner. Circumcision of Healthy Boys: Criminal Assault? 7 J Law Med 301, 2000; and Frank Bates. Males, medical mutilation and the law: Some recent developments. 9 J Law Med 68, 2001
7. Shane Peterson, “Assaulted and mutilated: A personal account of circumcision trauma”, in George Denniston, Frederick Hodges and Marilyn Milos (eds), Understanding Circumcision: A Multi-disciplinary Approach to a Multi-dimensional Problem (London and New York: Kluwer Academic and Plenum Press, 2000).

 

Death of Ryleigh McWillis after Plastibell circumcision

The following letter was sent by Circumcision Information Australia to the medical board in each state and territory in Australia, and to state health departments in South Australia, New South Wales and Queensland in March 2004.

Risks associated with circumcision of male infants and children

A recent Coroner's report from the province of British Columbia in Canada indicates that the risks inherent in the circumcision of male infants are greater than commonly appreciated. We enclose a copy of the Coroner's report for your information.

The report shows that the baby, Ryleigh Roman Bryan McWillis, aged one month, was circumcised in the Penticton Regional Hospital on 20 August 2002. He was released from the hospital into the care of his parents; suffered extensive bleeding from the wound; was returned to Penticton Hospital; and was subsequently transferred to the B.C. Children's Hospital, where he died less than 48 hours after the operation. The Coroner concluded that the death was due to "multiorgan hypoxic/ischemic injury due to hypovolemic shock as a result of massive hemorrhage from a circumcision site." Tragic though it is, there is nothing extraordinary in this outcome: bleeding and death are well-known complications of circumcision. [1-3] A similar case was reported by the Miami Herald in 1993, [4] a case occurred in Ireland in 2003, [5] and cases have also been recorded in Australia. (See below and Attachment 1.)

Since the prepuce is highly vascularized, it is likely to haemorrhage when cut, and severing of the frenular artery is also possible during circumcision procedures. [6] Infants have a very small volume of blood in their bodies, and they can tolerate only about a 20 per cent blood loss before hypovolemia and hypovolemic shock set in, followed quickly by death. A 4000 gram male newborn has only 11.5 oz (340 ml) of total blood volume at birth, 85 ml per kilogram of weight. [7] Blood loss of only 2.3 oz (68 ml) - about a quarter of a cup - represents 20 per cent of total blood volume at birth, and is sufficient to cause hypovolemia. [8] The quantity of blood loss that might kill an infant - 85 ml - is easily concealed in today's highly absorbent diapers: Ryleigh's parents were quoted by the Canadian Broadcasting Corporation as stating that they had no way to know that their baby boy was bleeding to death. [9] Circumcision of infants, even in optimum conditions, thus carries an inherent danger of hypovolemic shock and death.

The Coroner further shows that the doctor at Penticton Hospital performed the circumcision in the absence of any medical indication or need, but at the request of his parents. This practice - needless circumcision at parental request - is thus shown to be hazardous to children's lives. As Watters and Carroll have shown in their study of parental attitudes in rural New South Wales, parents rarely appreciate the risks associated with the excision of an infant's prepuce, and are ill-equipped to make decisions that should properly be made after expert paediatric advice or left to the boy himself. [10]

It is a widely accepted principle that the primary duty of doctors is to consider the well-being of their patient above all else. [11] Medically unnecessary circumcisions at parental request are inconsistent with that paramount duty. Doctors must comply with ethical guidelines issued by the Australian Medical Association to "practise the science and art of medicine to the best of your ability." [12] Circumcision of male infants in the absence of any medical indication or need carries serious risks, offers no significant therapeutic benefit, and is inconsistent with those duties.

Parents have a duty to protect their children and to act in their best interests. [13] Non-therapeutic circumcision of children infringes children's legal right to bodily integrity and their rights as human beings to life and security of person. [14] Election of medically unnecessary circumcision is inconsistent with parents' responsibilities to the child; indeed, it is debatable whether it is legally possible for them to give valid consent to the non-therapeutic circumcision of an incompetent minor. [15]

We do not suggest that deaths or serious complications from circumcision are common in developed countries: Australia has an enviable record with respect to deaths from circumcision, none having been reported since 1993. There is, however, no room for complacency. As well as good medical practice, the absence of such reports is as much a consequence of the declining and now low incidence of infant circumcision (see Attachment 2) and the difficulty of attributing deaths to circumcision when they are the result of later complications, such as infection, or of long term sequelae, such as suicide. Several authorities agree that there is no reliable record of mortality (see Attachment 1), and the Australian Institute of Health and Welfare has admitted that their statistics cannot identify deaths due indirectly to circumcision:

"We have information on circumcision and there are external cause codes for complications of medical and surgical care. However, it is not possible to tell if the complication was a result of the circumcision. For example, the circumcision may have been undertaken in a previous admission, and the patient readmitted with a complication. If this was the case, we couldn't tell that it was the same patient and we wouldn't know for sure that the complication was due to the circumcision." [16]

It is a similar picture with respect to complications, the incidence of which is the subject of wide disagreement. In 1970 Leitch suggested a rate of 15.5 per cent, [17] while more recently the Royal Australasian College of Physicians cites estimates ranging from an implausible 0.06 per cent to an equally unlikely 55 per cent, depending on definition. It seems to regard a likely incidence as falling within the range of 2 to 10 per cent, and it warns that "serious complications, such as bleeding, septicaemia and meningitis may occasionally cause death". [18] If the rate of complications is 15, 10 or even only 2 per cent, it is apparent that the small number of cases that get publicly reported represent only the tip of the iceberg; this understatement contributes to the impression that circumcision is a safe operation.

Whatever the figure - and it seems unlikely that definitive statistics will ever emerge - it will readily be agreed that there must be a lower threshold of tolerance for adverse outcomes from unnecessary or cosmetic surgical procedures than from those which are required for a person's health. This principle is all the more important when the person does not choose the surgery for himself. Although the incidence of circumcision in Australia is low by historic standards (around 12 per cent, compared with about 50 per cent in the early 1970s), there has been a gradual increase since 1993, and it is still disturbingly prevalent in New South Wales, South Australia and Queensland. If the frequency of the operation continues to increase, complications and adverse outcomes will become more common. It is clear that the surest way to avoid both complications and death from circumcision is by not performing the operation in the first place.

Your attention is particularly drawn to the disturbingly high and increasing incidence of circumcision in New South Wales. Its frequency has risen by about 30 per cent over the past ten years and is now double that found in Victoria, the ACT, Tasmania, Western Australia and the Northern Territory.

We suggest that the Canadian tragedy makes it timely to remind medical practitioners of the unavoidable risks of surgery and of their duty to protect infants and children from procedures that are not needed for, and which may well harm, their health and happiness. By ratifying the United Nations Convention on the Rights of the Child, Australia has pledged itself to protect children from "traditional procedures prejudicial to the health of children", [19] and it is hard to see how non-therapeutic male circumcision would not fall into that category.

We seek your advice on how you propose to ensure that tragedies like the McWillis case do not occur in your state. We also ask you to advise us on whether you would be willing to adopt measures in order to:

• alert health care providers to this incident;
• ensure that they follow the recommendations of the RACP's Policy statement on circumcision (2002) in warning parents who seek the operation of the real risks of the procedure;
• remind them that is their duty to act in the best interests of the child;
• point out that circumcision should be performed only when there is a compelling and immediate medical indication, and only after conservative treatments of foreskin problems have failed. (Medical ethics dictate conservative treatment prior to radical surgery involving amputation of tissue. [20])

We believe that such reminders would go far towards minimising the danger of exsanguination, hypovolemic shock and death as a consequence of non- therapeutic circumcision and greatly reduce the risk of adverse outcomes from therapeutically or otherwise justified circumcision. We urge that you take appropriate action and thereby continue to fulfil your board's obligation to protect the public, [21] especially its smallest and weakest members.

Yours sincerely

Shane Peterson

Circumcision Information Australia
22 March 2004

References

A pdf copy of the Coroner's report is available here. http://www.cirp.org/library/death/

1.  Williams N, Kapila L. Complications of circumcision. Brit J Surg 1993; 80: 1231-6

2. Fetus and Newborn Committee, Canadian Paediatric Society (CPS). Neonatal circumcision revisited. Can Med Assoc J 1996; 154(6):769-80.
http://www.cps.ca/english/statements/FN/fn96-01.htm

3. Beasley S, Darlow B, Craig J, et al. Position statement on circumcision. Sydney: Royal Australasian College of Physicians, 2002

4. Baby bleeds to death after circumcision. Miami Herald, June 26, 1993. http://www.cirp.org/news/1993.06.21_death/

5. Neans McSweeney. Baby dies after botched circumcision. Irish Examiner, Cork, Thursday, 21 August 2003
http://www.cirporg/news/irishexaminer08-21-03b/

6. Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 Suppl. 1:34-44. http://www.cirporg/library/anatomy/cold-taylor/

7. Paediatric Handbook, editors J Smart, T Nolan, Sixth Edition, Blackwell Science Asia, Carlton South, Victoria, Australia, 2000, page 82.

8. Glancy GL. Shock in children warrants special considerations. Ski Patrol Magazine 1997, Summer

9. Canadian Broadcasting Corporation, Wednesday, 11 February 2004. Circumcision under attack.

http://www.cirp.org/news/cbc02-11-04a/

10. Greg Watters and John Carroll, Just like dad: Maternal attitudes to neonatal circumcision in an Anglo-Celtic society, paper given to Urological Society of Australasia, Scientific Meeting, Queenstown, NZ, 6 March 2003

11. Australian Medical Association. Code of Ethics (1996).

12. Ibid.

13. Beasley S, Darlow B, Craig J, et al. Position statement on circumcision. Sydney: Royal Australasian College of Physicians, 2002.

14. Articles 3 and 5. Universal Declaration of Human Rights, G.A. res. 217A (III), U.N. Doc A/810 at 71 (1948).
http://www1.umn.edu/humanrts/instree/b1udhr.htm

15. Gregory J Boyle, J Steven Svoboda, Christopher P Price, J Neville Turner. Circumcision of Healthy Boys: Criminal Assault? 7 J Law Med 301 (2000). http://www.cirp.org/library/legal/boyle1/

16. Narelle Grayson, Hospitals and Mental Health Services Unit, AIHW, email message to Shane Peterson, 14 January 2004

17. I.O.W. Leitch, "Circumcision: A continuing enigma", Australian Paediatric Journal, Vol. 6,1970, 60 http://www.cirp.org/library/general/leitch1/

18. RACP Policy statement on circumcision, 2002

19. Article 24.3, U.N. Convention on the Rights of the Child (1989). UN General Assembly Document A/RES/44/25.
http://www1.umn.edu/humanrts/instree/k2crc.htm

20. Committee on Medical Ethics. The law & ethics of male circumcision - guidance for doctors. London: British Medical Association, 2003.

21. New South Wales, Medical Practice Act 1992. Section 2A (1)

 

Melbourne doctor suspended after plastibell circumcision goes wrong

Melbourne, 12 November 2010: A Melbourne doctor has been suspended for inflicting severe injuries on a 2-year old boy during a “routine” circumcision operation. The boy was circumcised by Dr Mohammed Mateen Ui Jabbar, using the plastibell device on 29 January 2008, as a result of which he suffered gross swelling and severe scarring of his penis. The boy was unable to urinate after the operation and was taken to the Royal Children’s Hospital, where he required surgery to remove the plastibell device and six further operations on his penis, including plastic surgery.

Dr Jabbar's disciplinary hearing at the Victorian Civil and Administrative Tribunal was held on 11-12 October, and the determination issued on 5 November. The case was reported in the Melbourne Herald-Sun on 11 November; the full determination can be read at the Australasian Legal Information Institute (Austlii).

This was the fourth time that Dr Jabbar had been reprimanded by the Victorian Medical Board, despite which he has been permitted to continue practising until his 3-month suspension takes effect on 22 November 2010. On previous occasions the doctor had been reprimanded for improperly touching a woman’s breasts and for prescribing testosterone for a male client without medical need. During an examination in 2006, the woman had asked for a routine skin inspection, but instead Dr Jabbar had squeezed her breasts and told her she needed cosmetic surgery because they were sagging but could be corrected with a breast lift or implants. On this occasion Dr Jabbar was reprimanded by the Medical Board and ordered to undergo counselling sessions.

The fate of the boy is similar to a case in Canada, where a baby boy died after circumcision with the plastibell device, which strangled his penis and blocked the urine passage.

The plastibell device is the most common method of circumcision used in Australia today. It consists of a kind of tourniquet that is tightened around the penis, thus strangling the foreskin, cutting of the blood supply and causing the tissue to die and fall off. It is similar to the rubber ring devices commonly used on farms to castrate calves and lambs. Some circumcision providers call this a bloodless or non-surgical method, but the truth is that any removal of tissue is surgery and will involve blood if the foreskin needs to be cut in order to apply the device. In another Canadian case a baby bled to death after a routine circumcision using the plastibell.

Complications from plastibell circumcision operations are quite common.

Sex discrimination – against boys

It is instructive to compare the mild censure given to Dr Jabbar with the criminal charges brought against Dr Graham Reeves, the “butcher of Bega”, for mutilating operations on women. At his trial in Sydney Dr Reeves attempted to defend his actions – involving the surgical removal of all or part of the external genitals of his female patients – by claiming that he was only doing it to save their lives. We might call this the circumcisers’ defence, since advocates of male circumcision likewise claim that they only circumcise boys in order to save them from future health problems or death from the terrible diseases they are sure to pick up if their foreskin is allowed to survive. It would appear that while doctors who harm women can end up on criminal charges, the most a doctor who harms boys can fear is a gentle slap on the wrist. One wonders how many other boys have suffered disfiguring injuries at the hands of Dr Jabbar.

Disciplinary action against medical practitioners

In 2010 State medical boards were replaced by a Commonwealth body, the Australian Health Practitioner Regulation Agency. Details of charges of misconduct brought against medical practitioners can be searched on its website.

 

Another reason not to circumcise: Australia faces big MRSA problem

THE growing incidence of methicillin-resistant Staphylococcus aureus (MRSA) in the community has highlighted the need for Australian clinical practice guidelines to be developed for its treatment, experts say. Associate Professor Graeme Nimmo, State Director of Microbiology for Pathology Queensland and president of the Australian Society for Antimicrobials (ASA), said the steady increase in the prevalence of community MRSA was of national concern and all doctors and members of the community needed to be aware of it. He said it now accounted for 15-20% of all S. aureus infections in Australia and that rate was increasing. “The prevalence has been increasing steadily in the past decade,” he said.

Professor Nimmo, who is also chair of the Australian Group for Antimicrobial Resistance, said MRSA appeared to be under control in hospitals, thanks to infection control initiatives. “Hospital strains [of MRSA] are not on the increase; in fact, they seem to be decreasing, but they are being replaced by the community ones,” he said.

Professor Keryn Christiansen, a past president of both the ASA and the International Society for Infectious Diseases (ASID), said community MRSA was a major problem, particularly as it was infecting young, healthy people. It was extremely important for GPs to be aware of the big problem of community-acquired MRSA and to be able to recognise these infections, which were characterised by “a lot of pus”, she said. “I see people who come into hospital who require drainage and they have gone to their GP who has just put them on standard anti-Staph therapy that has no effect on MRSA,” Professor Christiansen, clinical microbiologist at PathWest Laboratory Medicine, Royal Perth Hospital, WA, said.

The number one treatment was drainage of boils and abscesses, followed by broad-spectrum antibiotic therapy, culture and testing, and a change of antibiotics if MRSA was found on culture and sensitivity testing. Strains of particular concern that were becoming more common in Australia produced a toxin called Panton‒Valentine leukocidin (PVL), which caused more severe disease with a lot of pus formation and abscesses and required drainage and a longer hospital stay, Professor Christiansen said. “[PVL-positive MRSA] is sweeping across Australia and now accounts for around 20% of our community MRSA in WA and the vast majority of community MRSA on the east coast,” she said. “The other major worrying side of this is that the PVL-positive clones are infecting young, healthy people … in their teens, 20s and 30s.”

Comment by A/Prof Michael Guinness

Our experience exactly. I work in country NSW, where CA-MRSA has gone from nil in 2000 to 27% of all S.aureus isolated in 2009. Of shared concern is the greatly increased number of otherwise healthy young patients who are now being hospitalised for surgical management. … We have had four deaths so far ... how many more do they need before becoming proactive?

Source: MJA Insight, Monday 17 January 2011

Comment: Doctors’ surgeries or specialist clinics where minor procedures such as circumcisions are performed are prime sites for the presence of MRSA, and pose a real risk of infection any time the skin is cut or punctures. This is yet another reason why unnecessary surgeries such as non-therapeutic circumcision should be avoided.

 

Warning on risks of Plastibell circumcision device

The authors of a study circumcision complications issue a particular warning against the Plastibell circumcision device, used on nearly 60% of the boys in their survey who required emergency treatment, pointing out that is not as safe as claimed by the circumcision providers and “specialist circumcision clinics” that commonly use it. They identify 4 recent studies detailing complications arising from the device and comment: “While it is reported to be a quick and simple method preferred by many providers, these studies have revealed method-dependent concerns. This includes concern about what is the appropriate length of time for the device to be retained, an increase in infection and increase in analgesia requirement post-operatively. We identified that 54 boys (58.7%) were circumcised by this method in the community. There was particular concern and poor understanding about the appropriate length of time the Plastibell ring should remain in situ, which could be addressed in improved information for parents.”

Source: Grace Gold, Simon Young, Mike O’Brien, Franz E Babl. Complications following circumcision: Presentations to the emergency department. Journal of Paediatrics and Child Health 51 (December 2015): 1158–1163.

 

Melbourne 2015: High incidence of circumcision complications

A study in Melbourne has found a disturbingly high incidence of circumcision complications requiring emergency treatment. Over a period of 29 months 167 boys were brought to the Royal Children’s Hospital casualty department suffering from circumcision-related injuries. The principal problems were: bleeding (53.9%), pain (38.3%), swelling (37.1%), redness (25.7%), decreased urine output (13.8%), fever (7.2%) and infection (6%). In addition, 29.9% were brought in because parents were shocked at the ugly post-circumcision appearance of the boy’s penis. About half the circumcisions (54%) had been performed for religious/cultural reasons, 30% for so-called medical reasons, and the remainder for reasons unknown. There was some difference in the incidence of complications between hospital-performed operations (40%) and those performed in the community, presumably by GPs and “specialist” clinic (60%), but not enough to justify the common assumption that hospital-performed operations are completely safe. The mean age of the boys was 3 years, but the boys circumcised by so-called community operators were much younger and had the highest incidence of complications.

Since the total number of circumcision operations performed is unknown, it is impossible to work out the rate of complications, but 167 emergency presentations in a 2-year period seems disturbingly high, especially as Victoria’s overall incidence of circumcision is about half that of Australia as a whole (12% nationally). Such injuries represent a cruel burden of pain, suffering and disfigurement on baby boys, and absorb significant public health resources – a situation that is doubly unfortunate as the original surgery was completely unnecessary. While over half (54%) of the circumcisions were performed for cultural/religious reasons (mainly the preference of Muslim parents), 30% of the procedures were for “medical reasons”. Given the age of the boys this figure seems highly dubious and probably reflects mistaken diagnoses of phimosis (usually curable with medications if genuine) or even fraudulent attempts to ensure the Medicare rebate or free hospital treatment.

Several other features of the study deserve comment.

The age of the boys undergoing hospital circumcision (median age 4.23 years, mean 5.6 years) is markedly higher than those circumcised in the community (median age 3.9 MONTHS, mean 1.4 YEAR). The authors do not adequately discuss this when comparing their associated complication frequencies. While some people will misinterpret this study to claim that hospital doctors are better at circumcision operations than GPs and other community operators, you could just as well argue that infant circumcisions are more often associated with complications than circumcision at older ages. However, both claims may be true or false, and this study does not settle the matter.

The study does not demonstrate markedly higher rates of complications following community-based compared hospital-based circumcisions. Since the study base is unknown, we cannot tell what proportions of all performed circumcisions (whether in hospitals or in the community) these 167 cases actually represent. Complications following hospital-based circumcisions are plausibly more likely to result in contacts to the hospital, because parents are routinely instructed by the operator/nurse to contact the emergency department in case of complications. On the other hand, we can only speculate as to what selected part of the total of community-based circumcisions will end up in the emergency department. Self-selection by parents and religious circumcisers of which boys with complications after community-based circumcisions should be referred to the emergency department may result in a skewed group of patients with relatively serious complications. This might partly explain the markedly higher hospital admission rate and greater proportion needing reoperation among community compared with hospital circumcisions.

A puzzling feature of Table 1 is that 18 (30%) of the hospital-based circumcisions were of boys from Muslim families, but only 6 (10%) were circumcised for cultural/religious reasons. This means that 12 boys from Muslim families who ended up in the emergency department had been circumcised in the hospital for “medical reasons”. While some such boys may plausibly be referred for the same (often ill-advised or mistaken) “medical reasons” as boys from non-Muslim families, it seems odd that twice the number of hospital-circumcised Muslim boys end up in the ED when the circumcision was performed for medical reasons as compared with cultural/religious reasons (12 vs 6).

Plastibell circumcision device criticized

The authors of the study also warn that the Plastibell circumcision device, used on nearly 60% of the boys who required emergency treatment, is not as safe as claimed by the circumcision providers and clinics that commonly use it. They identify 4 studies detailing complications arising from the device and comment: “While it is reported to be a quick and simple method preferred by many providers, these studies have revealed method-dependent concerns. This includes concern about what is the appropriate length of time for the device to be retained, an increase in infection and increase in analgesia requirement post-operatively. We identified that 54 boys (58.7%) were circumcised by this method in the community. There was particular concern and poor understanding about the appropriate length of time the Plastibell ring should remain in situ, which could be addressed in improved information for parents.”

Comment

The whole situation described in this report is very sad. Despite the claim of “medical reason”, very few (if any) of the original circumcision procedures were medically necessary (and thus in the best interests of he child), and the result has been a cruel burden of suffering borne by innocent children and, on top of that, avoidable demands on the public health system. Circumcision advocates are keen to prove that the earlier circumcision is done the safer, but this study suggests the opposite: that it was the youngest boys who suffered the greatest number of complications. From an ethical point of view it hardly matters, as any non-therapeutic circumcision of a minor is in violation of basic bioethical and human rights principles. A more relevant comparison would be between child and adult circumcision, as adults can make their own choices and give informed consent. It is sometimes claimed that “better training” of operators would lead to a lower incidence of complications, but the real problem is the complexity, variability and tiny size of the juvenile penis: there can be little doubt that the only truly effective way to avoid complications not to circumcise in the first place.

The authors of the study could have made more effort in their conclusions: it is hard to see that counseling parents as to the appearance of the penis following circumcision does the boys any good. They would have benefited from not being circumcised in the first place. What is needed is regulation of the circumcision industry, as recommended by the Tasmania Law Reform Institute report, and counseling of parents that circumcision is not necessary and not recommended.

Source: Grace Gold, Simon Young, Mike O’Brien, Franz E Babl. Complications following circumcision: Presentations to the emergency department. Journal of Paediatrics and Child Health 51 (December 2015): 1158–1163.