Introduction

The Australasian Institute for Genital Autonomy (“AIGA”) is pleased to be given the opportunity to provide feedback on the recommendations in the report from the Urology Clinical Committee (“the Committee”) for consideration by the MBS Review Taskforce (“the Taskforce”).

Our feedback makes reference to the recommendation listed under the section “Rationale for Recommendation 14” (to mandate the use of analgesia for item 30654), in particular, the following:

“The Committee noted that item 30654 should continue to include circumcisions conducted for religious and cultural reasons, reflecting both current practice and the need to ensure safe circumcisions.”

We strongly urge the Taskforce to consider that the complete opposite position be adopted. That is, that circumcisions (both items 30654 and 30658) should not be covered by the MBS for religious and cultural reasons, and to that end, strict “demonstrated clinical need” requirements be enforced, similar to the requirements introduced in 2014 for item 35534 – vulvoplasty or labioplasty.

Eligibility for benefits

We note that the Australian Constitution and the Health Insurance Act 1973 (Cth) limits the payment of benefits to providers for “clinically relevant services”. A medical service is clinically relevant if it is generally accepted in the medical profession as necessary for the appropriate treatment of the patient. In addition, the General Explanatory Note 13.1 lists “(d) non-therapeutic cosmetic surgery” as a service not attracting benefits.

Services provided for “religious and cultural reasons” fail to qualify for the payment of benefits on all of the requirements outlined in the above.

On the “clinically relevant” requirement, services undertaken for “religious and cultural reasons” alone are contradictory to this requirement, and therefore do not qualify for payment of benefits.

We put it to the Taskforce that when a person presents with normal genitalia, with no disease and no indications, then the appropriate treatment of the patient accepted in the medical profession is no treatment at all.

Furthermore, a 2012 survey published by the Australian Doctor publication1 found that “half of the Australian Doctor community believe that the circumcision of newborns is tantamount to child abuse and should never be performed” and 74% said the service should not be routinely offered to parents for their newborns.

While these services fall outside of the clinically relevant requirement, services provided for “religious and cultural reasons” fits with the “non-therapeutic cosmetic surgery” category which is explicitly prohibited from attracting benefits.

Circumcisions for “religious and cultural reasons” are not clinically relevant, explicitly fall within a category that does not qualify for benefits, are not generally accepted as appropriate treatment and therefore the MBS would be beyond jurisdiction to continue to pay benefits for them.

Goals of the review

Providing circumcisions for “religious and cultural reasons” does not align with three of the key goals of the review, namely:

Best practice health services: It should be noted that not a single national medical or paediatric body anywhere in the world recommends routine circumcision, with most taking a firm position against the practice. Australian health authorities have firmly and consistently recommended against the practice since 1971. In September 2010 Royal Australasian College of Physicians who published:

“After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.”

Value for the individual patient: This goal relates to providing “real clinical value”, for which circumcisions for “religious and cultural reasons” clearly provide no clinical value at all. It also sets out to “not expose the patient to unnecessary risk or expense”. All surgery has an element of risk and with infant circumcision this ranges from localised infection through to the loss of the entire penis and even death. This is all unnecessary risk from an unnecessary procedure.

Value for the health system: We note that for FY2016/17 there were combined benefits paid of $1,223,804 for items 30654 and 30658. Estimates of “clinically relevant” circumcisions are hard to come by. One local study showed the rate to be about 2% excluding ICD Diagnosis Codes for “routine” or non-indicated circumcisions2. Our submission is that the MBS can redirect these funds to other needy clinical services by restricting benefits for male genital surgery to demonstrated clinical need for treatment of individual patient pathology rather than the religious or cultural preferences of the patient’s family.

International medical opinion

We highlight a 2013 article written by an international group of 38 eminent physicians from 16 European countries, published in the American Academy of Pediatrics publication Pediatrics3.  These physicians concluded:

“…physicians should discourage parents from circumcising their healthy infant boys because nontherapeutic circumcision of underage boys in Western societies has no compelling health benefits, causes postoperative pain, can have serious long-term consequences, constitutes a violation of the United Nations’ Declaration of the Rights of the Child, and conflicts with the Hippocratic oath: primum non nocere: First, do no harm.”

Precedents and hypotheticals

We ask the Taskforce to consider: What other procedures are funded through the MBS, or would be considered under the MBS where they involved removing healthy body parts for cultural and/or religious purposes only? What if these procedures were forced upon a person who cannot, and does not consent?  What if the procedure removed an important, deeply personal, sensitive and protective body part? We put it to the Taskforce that circumcision items are the only items where (with only the rarest of exceptions) there are no indications, there is no disease and, when performed on an infant, there is no consent. We propose that this anomaly should be urgently corrected and this review is the opportunity to do so.

Demonstrated clinical need requirements

We note and applaud the introduction in 2014 of the demonstrated clinical need requirement for item 35534 (vulvoplasty or labioplasty), which required that services can only be paid for health reasons, where “if it can be demonstrated that: (a) the structural abnormality is causing significant functional impairment; and (b) non-surgical treatments have failed”. Introducing similar requirements to items relating to circumcision (items 30654 and 30658) would not only resolve the issues we have raised above, but also result in consistency in relation to the payment of benefits for cosmetic genital surgery between genders.

Conclusion

This is an irresponsible, unethical and self-serving push from the Committee, which in making this recommendation has shown no regard for the rights and autonomy of the normal, healthy child, no consideration for the “clinically relevant” requirements under the Health Insurance Act 1973 or for the goals of the Review and no adherence to the Hippocratic oath.

Their recommendation is designed to lead to the continuation of funding for an outdated and damaging custom which is often forced on a perfectly healthy and non-consenting person.

We reiterate that genital cutting for religious and cultural reasons does not meet the MBS requirement for “clinically relevant services”, fails under the objectives of the Taskforce, creates gender inequality in relation to MBS items for cosmetic genital surgery and when performed on a non-consenting child has significant ethical problems and constitutes a violation of the United Nations’ Declaration of the Rights of the Child. We urge the Taskforce to remove this anomaly by introducing demonstrated clinical need requirements for items 30654 and 30658.

 

1 Strong opposition to newborn circumcision, Australian Doctor, 9 August 2012: https://www.australiandoctor.com.au/news/strong-opposition-newborn-circumcision

2 Routine Circumcision Practice on Western Australia 1981-1999, Spilsbury K., at al, ANZ J Surg., 2003; 73; 610-614

3 Cultural Bias in the AAPs 2012 Technical Report and Policy Statement on Male Circumcision, Frisch et al, Pediatrics, 2013:
http://m.pediatrics.aappublications.org/content/early/2013/03/12/peds.2012-2896.full.pdf

 

About AIGA

AIGA is an incorporated association formed under the Associations Incorporation Act 1981 (Queensland), founded on 7 May 2013. This date was significant as it was the first anniversary of a court decision in Cologne (Köln), Germany in the matter of “Re: Dr K”, where a District Court held that genital surgery on a child without any therapeutic need is a breach of the child’s human rights, and an assault at law. The primary objective of AIGA is to promote the human rights of children including their protection from medically unnecessary genital surgery and irreversible hormonal therapy – the Right of Genital Autonomy.

Contact

Email: info@aiga.org.au
Website:
www.aiga.org.au
Mobile:  0412 615 730

A PDF version of our response can be found here:
AIGA response – Urology Clinical Committee 2018