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A common argument in favour of routine infant circumcision is that it eliminates the possibility a boy will have a foreskin pathology later in life requiring an adult circumcision. Unfortunately, there are no Australian studies examining how many therapeutic circumcisions are performed on adult men, so the debate is inevitably couched in terms of anecdote and hunches.
Using data extracted from the National Morbidity Database, the Australian Studies of Health and Relationships research database and the Australian Bureau of Statistics, I below analyse the rate of therapeutic circumcision among men aged 15-69 years for the sample financial year 2008* and among 20-year-olds for 1994 to 2010. I also analyse therapeutic circumcision in children (0-14 years), and attempt a cost-benefit analysis of the suggested strategy of Brian Morris's Circumcision Foundation of Australia to reintroduce universal infant circumcision.
Adult therapeutic circumcision
In 2008 there were 7,703,817 males aged 15-69 years of whom 3,529,059 were estimated to be intact. There were 2,316 therapeutic circumcisions in that group: for phimosis, paraphimosis, "redundant foreskin", and balanitis (including conditions such as BXO, Zoon's, etc). This is an annual rate of 66 per 100,000 intact men, and indicates a cumulative risk of therapeutic circumcision of 3.6% to age 70. In different age groups the annual rates were little different: 0.07% for 15-19, 20-29, and 50-69 years; 0.05% for 30-39 years; and 0.06% for 40-49 years.
In other words, 3.6 per cent of intact 15-year-olds today could expect to be circumcised for medical reasons by the time they turn 70, based on practices and patterns prevailing in 2008.
The barometer cohort: twentysomethings
Males aged 20-29 have seen large changes in circumcision status over the past couple of decades, from 539,085 intact (38%) in 1994 to 1,217,465 in 2010 (72%). All the required data exists to calculate the rate of therapeutic circumcison for each year from 1994 to 2010, allowing us to detect any trends. And indeed in 1994-1999 the mean rate was 83 per 100,000, while in 2000-10 it was 66 per 100,000, a statistically significant fall of more than three standard deviations (the SD for both means was 5 per 100,000) or 21 per cent.
The implication is that as the intact penis becomes the norm, both doctors and patients are less likely to opt for circumcision as a therapeutic choice.
Child therapeutic circumcision
The rate of therapeutic circumcision for children since the 1990s has fallen even more, in line with trends observed in England and Scotland. In 1994 the cumulative risk for boys aged 0-14 years was 5%, while in 2008 it was 3.2% (3,619 cases from 1,695,410 intact boys). In terms of age breakdown, 1-4 and 5-9 years each accounted for about 36% of procedures in 2008, with 10-14 years accounting for 20%, and 7% occuring in the first year of life.
The total picture
What this means is that in Australia today a newborn boy who is not routinely circumcised has at most a 6.8 per cent cumulative risk of developing a foreskin pathology that would require a circumcion sometime by the age of 70. (It should be noted that terms such as "foreskin pathology" and "require circumcision" are matters of clinical judgement and their meanings have changed as medical practice guidelines evolved, and continue to evolve, towards less invasive approaches.)
Put another way, at least 93 per cent of boys will never require a circumcision, so inflicting RIC on them to avoid such a possibility is at best pointless and at worst a criminal infringement of their human rights and bodily integrity.
Cost-Benefit of universal infant circumcision
The core argument of Morris and his collaborators is that prophylactic RIC, as a public health measure, is a cost-effective means of preventing illness, and the associated costs, later in life.
The immediate aim would presumably be to prevent the 2,316 adult therapeutic circumcisions identified in this study. Cost-mix data indicate that these circumcisions cost the health system about $3.4 million.
The alternative, says Morris, is (through increasing the Medicare rebate, reintroducing RIC in all public hospitals, and reversing the medical establishment's long-standing opposition to RIC) to circumcise the entire male birth cohort in the first year of life, every year. What would this cost? Well, using a very conservative average of $500 per procedure (bearing in mind there would be a mix of hospitals, day surgeries and doctors' rooms, as now), the cost of such a policy, even if it could be implemented, would be at least $75 million annually.
Now if we use the same metric to calculate the cost of child therapeutic circumcision in 2008, we get $1.8 million. So we have a total cost of $5.2 million for all current therapeutic circumcisions versus a proposed cost of more than $75 million for universal RIC.
And what about complications? Following the RACP and using the 2010 systematic review by pro-circ researchers (Weiss, Larke, Halperin, et al) to estimate an immediate complication rate in infants of 1.5%, there would be 2,265 complications annually, ie about the same number as the adult circumcisions one is trying to prevent in the first place.
'Health Benefits'
Of course proponents claim there are a range of other "health benefits" accruing from circumcision. But there is a fatal flaw in this argument. Even if circumcision did provide a measure of risk reduction for some conditions (a contention which is at the very least debatable), that is irrelevant. What needs to be shown for the public health argument to be valid is that, in Australia, circumcision provides differential outcomes at a population level.
But this is precisely what is missing. The biggest population study ever undertaken in a developed-world country to consider the effects of circumcision -- the Australian Studies of Health and Relationships -- shows precisely no significant health effect. And of course, non-circumcising countries in the developed world all show lower levels than the US of the very conditions for which circumcision is supposed to provide a risk reduction.
Conclusion
As at least 93 per cent of boys will never require a circumcision for medical reasons, it is neither rational nor ethical to impose prophylactic circumcision on them "just in case".
Universal infant circumcision as a public health strategy to deal with adult foreskin pathologies would be both immensely costly and ultimately counter-productive, even on conservative estimates of likely complications. The existence of other "health benefits" that might modify the equation has not been established in Australia or other non-circumcising developed-world populations, probably because such benefits do not exist in these societies.
* Method note: The years 2001, 2006 and 2010 were also fully sampled, and confirmed the stability of the adult therapeutic rate (65-71 per 100,000) over the decade. The year 2008 was chosen because it was the last year in a run of dozen where the cumulative circumcision rate for boys aged 0-14 years was essentially unchanged, which allowed the most reliable estimation of the number of intact boys.
Using data extracted from the National Morbidity Database, the Australian Studies of Health and Relationships research database and the Australian Bureau of Statistics, I below analyse the rate of therapeutic circumcision among men aged 15-69 years for the sample financial year 2008* and among 20-year-olds for 1994 to 2010. I also analyse therapeutic circumcision in children (0-14 years), and attempt a cost-benefit analysis of the suggested strategy of Brian Morris's Circumcision Foundation of Australia to reintroduce universal infant circumcision.
Adult therapeutic circumcision
In 2008 there were 7,703,817 males aged 15-69 years of whom 3,529,059 were estimated to be intact. There were 2,316 therapeutic circumcisions in that group: for phimosis, paraphimosis, "redundant foreskin", and balanitis (including conditions such as BXO, Zoon's, etc). This is an annual rate of 66 per 100,000 intact men, and indicates a cumulative risk of therapeutic circumcision of 3.6% to age 70. In different age groups the annual rates were little different: 0.07% for 15-19, 20-29, and 50-69 years; 0.05% for 30-39 years; and 0.06% for 40-49 years.
In other words, 3.6 per cent of intact 15-year-olds today could expect to be circumcised for medical reasons by the time they turn 70, based on practices and patterns prevailing in 2008.
The barometer cohort: twentysomethings
Males aged 20-29 have seen large changes in circumcision status over the past couple of decades, from 539,085 intact (38%) in 1994 to 1,217,465 in 2010 (72%). All the required data exists to calculate the rate of therapeutic circumcison for each year from 1994 to 2010, allowing us to detect any trends. And indeed in 1994-1999 the mean rate was 83 per 100,000, while in 2000-10 it was 66 per 100,000, a statistically significant fall of more than three standard deviations (the SD for both means was 5 per 100,000) or 21 per cent.
The implication is that as the intact penis becomes the norm, both doctors and patients are less likely to opt for circumcision as a therapeutic choice.
Child therapeutic circumcision
The rate of therapeutic circumcision for children since the 1990s has fallen even more, in line with trends observed in England and Scotland. In 1994 the cumulative risk for boys aged 0-14 years was 5%, while in 2008 it was 3.2% (3,619 cases from 1,695,410 intact boys). In terms of age breakdown, 1-4 and 5-9 years each accounted for about 36% of procedures in 2008, with 10-14 years accounting for 20%, and 7% occuring in the first year of life.
The total picture
What this means is that in Australia today a newborn boy who is not routinely circumcised has at most a 6.8 per cent cumulative risk of developing a foreskin pathology that would require a circumcion sometime by the age of 70. (It should be noted that terms such as "foreskin pathology" and "require circumcision" are matters of clinical judgement and their meanings have changed as medical practice guidelines evolved, and continue to evolve, towards less invasive approaches.)
Put another way, at least 93 per cent of boys will never require a circumcision, so inflicting RIC on them to avoid such a possibility is at best pointless and at worst a criminal infringement of their human rights and bodily integrity.
Cost-Benefit of universal infant circumcision
The core argument of Morris and his collaborators is that prophylactic RIC, as a public health measure, is a cost-effective means of preventing illness, and the associated costs, later in life.
The immediate aim would presumably be to prevent the 2,316 adult therapeutic circumcisions identified in this study. Cost-mix data indicate that these circumcisions cost the health system about $3.4 million.
The alternative, says Morris, is (through increasing the Medicare rebate, reintroducing RIC in all public hospitals, and reversing the medical establishment's long-standing opposition to RIC) to circumcise the entire male birth cohort in the first year of life, every year. What would this cost? Well, using a very conservative average of $500 per procedure (bearing in mind there would be a mix of hospitals, day surgeries and doctors' rooms, as now), the cost of such a policy, even if it could be implemented, would be at least $75 million annually.
Now if we use the same metric to calculate the cost of child therapeutic circumcision in 2008, we get $1.8 million. So we have a total cost of $5.2 million for all current therapeutic circumcisions versus a proposed cost of more than $75 million for universal RIC.
And what about complications? Following the RACP and using the 2010 systematic review by pro-circ researchers (Weiss, Larke, Halperin, et al) to estimate an immediate complication rate in infants of 1.5%, there would be 2,265 complications annually, ie about the same number as the adult circumcisions one is trying to prevent in the first place.
'Health Benefits'
Of course proponents claim there are a range of other "health benefits" accruing from circumcision. But there is a fatal flaw in this argument. Even if circumcision did provide a measure of risk reduction for some conditions (a contention which is at the very least debatable), that is irrelevant. What needs to be shown for the public health argument to be valid is that, in Australia, circumcision provides differential outcomes at a population level.
But this is precisely what is missing. The biggest population study ever undertaken in a developed-world country to consider the effects of circumcision -- the Australian Studies of Health and Relationships -- shows precisely no significant health effect. And of course, non-circumcising countries in the developed world all show lower levels than the US of the very conditions for which circumcision is supposed to provide a risk reduction.
Conclusion
As at least 93 per cent of boys will never require a circumcision for medical reasons, it is neither rational nor ethical to impose prophylactic circumcision on them "just in case".
Universal infant circumcision as a public health strategy to deal with adult foreskin pathologies would be both immensely costly and ultimately counter-productive, even on conservative estimates of likely complications. The existence of other "health benefits" that might modify the equation has not been established in Australia or other non-circumcising developed-world populations, probably because such benefits do not exist in these societies.
* Method note: The years 2001, 2006 and 2010 were also fully sampled, and confirmed the stability of the adult therapeutic rate (65-71 per 100,000) over the decade. The year 2008 was chosen because it was the last year in a run of dozen where the cumulative circumcision rate for boys aged 0-14 years was essentially unchanged, which allowed the most reliable estimation of the number of intact boys.
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