For some time now, all the departments of health in Australia have based their policy on male circumcision on reviews of the scientific literature carried out periodically by the Royal Australasian College of Physicians (RACP). But the lack of a strong basis on evidence means the government should reconsider this reliance.
An RACP policy statement in 2004 argued that the available evidence didn’t justify infant male circumcision being carried out to prevent illness. But when a withering critique of that 2004 policy was published in the Australia and New Zealand Journal of Public Health in 2006, the authors of the 2004 report didn’t even attempt to defend their work. This is generally considered an ominous sign in science.
In 2010, the RACP published its most recent policy Circumcision of infant males. Again, the policy argued that the evidence didn’t justify infant male circumcision being carried out to prevent illness. But the 2010 policy statement was not quite as strongly opposed to infant circumcision as the 2004 policy had been.
We have just published a comprehensive evaluation of the 2010 RACP policy in the College’s Internal Medicine Journal. All nine co-authors of the paper, including ourselves, are public health and public policy experts.
Our critique concludes that the RACP policy is not a fair and balanced representation of the literature on male circumcision because it is not based on research evidence. Instead, the RACP policy ignores, downplays, obfuscates or misrepresents the considerable body of research that shows circumcising males offers strong protection against a number of diseases.
Benefits include reduced childhood urinary tract infections, which are common, painful and often cause permanent kidney damage. Male circumcision also provides some protection against many common, as well as not so common, sexually transmitted infections, including the epidemic of cancer-causing types of human papillomavirus and genital herpes, genital ulcer disease and HIV, among others.
Circumcision also helps protect against penile candidiasis (thrush), inflammatory skin conditions and inferior penile hygiene. It can help those with physical problems, such as a tight foreskin that interferes with passing urine, and an inability to return the foreskin after it is retracted. It virtually eliminates the risk of penile cancer that occurs in one in 1,000 uncircumcised males over their lifetime. And there may also be some reduction in the risk of prostate cancer.
Women with circumcised male partners are protected to varying degrees against cancer-causing human papillomavirus infection, genital herpes, bacterial vaginosis (Gardneralla), and cervical cancer. Although the RACP’s policy statement claims otherwise, complications of infant male circumcision are uncommon and virtually all minor and easily treated.
The RACP policy statement claims that “the foreskin has a functional role” and “is a primary sensory part of the penis”. However, extensive high quality research, including randomised controlled trials, show no adverse effect on sexual function, sensitivity, sensation or satisfaction.
Instead of citing good research, such as large meta-analyses and randomised trials, the RACP policy selectively cites a poor quality study that has been criticised. The RACP’s claim – without support from a literature-based risk-benefit analysis – that the currently available evidence does “not warrant routine infant circumcision in Australia and New Zealand” is misleading.
A risk-benefit analysis by a number of us who also wrote the Internal Medicine Journal article was published recently in the Open Journal of Preventive Medicine. We found that the benefits of male circumcision were considerable and exceeded risks by a large margin; the risks are virtually all minor, while conditions prevented are often serious.
Our Internal Medicine Journal article concludes that because the RACP’s policy “is not a fair and balanced representation of the current literature it should not be used to guide policy.” We recommend that an extensive, comprehensive, balanced review of the scientific literature and a risk-benefit analysis should be conducted to formulate policy, in the interests of public health and individual well-being.
Such a review was recently undertaken by the Circumcision Foundation of Australia. Health bodies, governments, doctors and the general public should use this evidence-based policy statement as a reliable guide to decision-making and health policy development.
Facing rising health costs, the federal government has recently increased its emphasis on prevention. Infant male circumcision is a good example of how difficult it can be to implement preventative measures. The process starts with basing policy fairly and squarely on evidence and continues with overcoming obstruction from groups opposed to policy based on evidence. Watch this space.