Guidelines on how to Perform Circumcision on Infant Males

USANZ issued guidelines on performing circumcision on infant males. The guidelines were approved by the Board of Directors on 18 August 2018 and reviewed in August 2022.

Download the guidelines.

Purpose and Scope

This statement provides guidance on how circumcisions should be performed, once that decision has been made.

This statement was developed in response to complaints to the Medical Council of NSW regarding adverse events as a result of request circumcisions. From these complaints, it was evident that some practitioners are performing circumcisions in their rooms, without adequate analgesia. The Medical Council of NSW has received an increasing number of complaints regarding adverse events after circumcision.

USANZ contributed to the development of the Royal Australasian College of Physicians (RACP) Statement on Circumcision of Infant Males and supports that statement. In summary the RACP Statement says that the risks of request circumcision outweigh the benefits. In other words, performing circumcisions in well patients may cause more problems than the procedure prevents.

Definitions

  1. a medical circumcision is a circumcision performed to treat a disease, such as pathological phimosis (lichen sclerosis), recurrent balanitis or recurrent urinary tract infections.
  2. a request circumcision is a circumcision performed for non-medical reasons, such as parental preference, religious reasons or to potentially prevent disease at some future time.
  3. a hospital is defined as an accredited institution under The National Safety and Quality Health Service (NSQHS) Standard.
     

Policy Background

Following the publication of the RACP Statement on Circumcision of Infant Males, the Children’s Hospital at Westmead implemented policy to no longer perform request circumcisions in view of the evidence of risk outweighing benefit. Allocation of scarce health resources to procedures without established health benefits was no longer supported.

Subsequently, NSW Ministry of Health adopted the same policy and applied it to all public hospitals within New South Wales. The Health Department in Victoria soon followed.

The remaining options for families seeking request circumcision were: having it performed in a private hospital; having it performed in a doctor’s rooms or clinic; or having the procedure performed by a non-medical practitioner.

Quality and Safety Considerations

There are three important aspects to quality surgical care. The first is that the procedure needs to have evidence to support its effectiveness. The second is that it needs to be safe. Lastly the procedure needs to be undertaken with minimal discomfort. With these aspects in mind, USANZ recommends that following criteria be considered minimum standard of practice for request circumcision. These represent consensus of expert opinion level of evidence 4.

  1. The consent process must include information to parents/guardians that the risks of request circumcision exceed the benefits and thus it is not recommended and not performed in public hospitals. In addition, parents/guardians must be informed that legally, they may only consent to medical procedures on their child that have a proven medical benefit. Since the medical benefit for request circumcision is disputed, this is currently a grey area in law.
  2. Adequate analgesia should be provided during circumcision. Under six months of age, local anaesthetic may be appropriate. Over six months of age, either general anaesthetic or spinal anaesthetic is recommended.
  3. Over six months of age, circumcision should be undertaken in a hospital setting to allow the safe administration of general or spinal anaesthetic.
  4. The practitioner undertaking the circumcision must have adequate training in performing circumcision and be able to produce documentation to that effect.
  5. The practitioner undertaking the circumcision must be available to evaluate and manage the acute complications of the procedure, such as pain and bleeding. Alternatively, they must have formally organised for another practitioner or health service to cover this role.
  6. The practitioner undertaking the circumcision must see their patients post operatively and document the outcome of the procedure. They must audit the results of the circumcisions they have undertaken from time to time.
  7. USANZ strongly recommends against circumcision being undertaken by non-medical practitioners

Roles and Responsibilities

The USANZ Board of Directors is the approval authority for Position Statements and other Policies that relate to patient care.

The Paediatric/Reconstructive Speciality Advisory Group (SAG) is responsible for the development and review of position statements and policies that relate to paediatric and/or reconstructive medical matters, and for making recommendations to the Board of Directors. The SAG may initiative the development of a position statement or policy where they identify a need.

Contact

For more information, email the USANZ President.


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