Australian Circumcision - why 50 years of social change?
Discussion about circumcision often becomes emotionally charged and centred around the rights and wrongs of this procedure. The question of why and how Australian societal traditions moved from routinely circumcising baby boys is not often clearly discussed.
We've surveyed data with the circumcision status of 45,000 Aussie men born between 1936 and 2000. We've also reviewed Medicare data covering all subsequent births.
This piece has also reviewed medical papers from the early 1970s, 1980s and turn of the millennium; medical statistics from the 1960s and since turn of the millennium; plus research on immigration and the distribution of immigration within Australia's three largest cities by suburban region; alongside dating profile data analysed by ethnicity and suburban region.
We don't look at men who choose to be circumcised at a later age, or religious or medically necessary circumcision.
It finds that whilst further research is needed, a five point hypothesis as to why routine infant circumcision changed in Australia is credible:
Medical opinion and advice: 1. In the early 1970s Australian medical practitioners moved away from routine neonatal circumcision because they were concerned about the number of complications being experienced. 2. This evolved into an anti circumcision position in 1983 when the advise became to discourage circumcision, rather than simply not encourage it.
Impact of social class and migrant tradition: 3. At this point wealthier Anglo-Saxon Australian's began to drop the procedure and by the mid 1980s the lowest rates of circumcision were seen in relatively wealthy areas. 4. Prior to this 1983 change regions with a high proportion of first generation immigrants from Europe and the UK tended to have the lowest circumcision rates as their homeland cultures have little or no tradition of circumcising routinely. 5. Less wealthy Anglo-Saxon Australian families have been the least likely to change their family tradition of circumcision, choosing based upon social anecdotes and family experience rather than medical advice, although today the majority do not circumcise.
This review is broken down into 5 sections
1.0 Background 2.0 1936 Routine Infant Circumcision era to the millennium (split between states and capitals) 3.0 Year 2000 onwards (split between states) 4.0 Medical research into why parents choose to circumcise (Australian medical research) 5.0 Thoughts
By the early 1960s GP Surveys in Melbourne found that 70% of male babies were circumcised, which corresponds with the lower blue line below. Doctors from the period reported that social custom was the main reason for circumcising babies in Australia. Today 92% of Melbourne’s baby boys are not.
Circumcision became the social norm following the world wars, where anecdotally, circumcision was thought to improve hygiene by eliminating sand accumulation under the foreskin. Puritan values of prominent medical leaders taught that retracting a foreskin to clean would lead to, or was, an act of masturbation and that circumcision was therefore necessary. As returning soldiers became fathers, circumcised newborns became the norm, aiming to prevent balanitis and allow their boys to fit in with the norm.
Circumcision remained steady for around 30 years, but began to loose favour in the major east coast cities by the late 1960s (lower green line on the chart above). By the end of the last century, most parts of the country saw between 76-80% of births left intact (upper green line on the chart above). This trend is shown in the table above, which is based on a 45,000 man survey sample.
Since the millennium, circumcision has become even less popular, today all states (other than SA) see more than 90% of male births left intact. The table below is not a sample survey, it is data covering all births.
Social and medical trends were about to change as the 1960s ended which accompanied a move away from circumcising boys. So how did such an entrenched social norm change?
1.1 Changing medical opinion
Up until the early 1960s, Australian medical professionals were represented by the British Medical Association. The BMA's aims traditionally included promoting medicine as a science, which would help protect doctors interests against quackery and old anecdotes. Paediatric medicine was an area regarded by some as one ruled by hearsay and many suspected that this caused unnecessary suffering. Dr Douglas Gairdner was a practicing paediatrician, plus a research scientist and lecturer at the University of Cambridge. Gairdner strongly believed scientific research and rigour would reduce child suffering. In the BMA's December 1949 journal Gairdner published scientific research which concluded, "the many and varied reasons commonly advanced for circumcising infants are critically examined. None are convincing." This caused a u turn in the UK which abandoned circumcision, but was largely ignored in Australia by practicing doctors.
Young Australian paediatricians who received their training during the 1950s and 1960s were educated using books which reflected Gairdner's research, at odds with Australian practice. By 1970 the thought of medics in Australian was catching up with the UK, as younger professionals questioned the difference between their training and the daily reality.
This was demonstrated by three papers published in the June 1970 “Australian Paediatric Journal”. The first, “Circumcision - A continuing Enigma” by I.O.W. Leitch then a Junior Registrar at Adelaide Children’s Hospital, is a pros/cons analysis of the procedure. Leitch concluded the level of complications experienced outweighed the benefits and that "Hospital waiting lists [should] be unburdened of unnecessary routine circumcisions, and that if parents request the operation as a social ritual, it should be done in private, not public beds". The second paper, “Circumcision” by R.G. Birrell, recounted 9 cases the author had treated over a 6 year period where circumcision was either proven or suspected to be the cause of septicaemia, with intensive care treatment required to save the baby’s life. The final paper “Another View of Circumcision” by E. Durham Smith highlighted that the medical profession did not have a uniform view for graduates to offer parents as advise.
Shortly afterwards in September 1970, the Journal of the American Medical Association published “Whither the Foreskin?” which concluded, “there are no valid medical indications for circumcision in the neonatal period”. This became formal policy of the American Academy of Paediatrics in 1971.
Following on from Smith’s call for uniform guidance in Australia, concern about the level of post circumcision complications being experienced in Australia and US research concluding neonatal circumcision had no medical purpose, some members of the Australian Paediatric Association sought clarification.
The result was a unanimous resolution during April 1971 where the Australian Paediatric Association declared, “The Australian Pædiatric Association recommends that newborn male infants should not, as a routine, be circumcised.”
The message was revisited in 1983 when the Australian College of Paediatrics stated, “The ACP should continue to discourage the practice of circumcision in the newborn male infant”. Around this time the Medicare rebate for neonatal circumcision was withdrawn, although it was later reintroduced. This second statement was somewhat firmer than the first, moving from a passive position to one where circumcision should be discouraged.
1.2 A changing country
Throughout the 1960s Australian Government migration schemes were expanded from Commonwealth countries to include Greeks and Italians.
Greek and Italian immigration was largely clustered. Today half of Australian’s who are Greek born live in Victoria and a third in New South Wales. As a result Melbourne and Sydney have large Greek descent communities, Melbourne is the largest Greek City outside of Greece and the home of Greek Immigration to Australia.
A similar trend was experienced with Italian immigrants. The number of Italy-born Victorian’s peaked at 121,000 in 1971. Italian immigration then declined, but Italians are still the fifth-largest immigrant community in Victoria after the English community, with 76,906 Italy-born people recorded in the 2011 census.
1969 was the peak year for the Commonwealth scheme, with more than 80,000 people coming to Australia mainly from the UK, although around a quarter from the commonwealth left within a few years.
Although circumcision had some decades earlier become established in wealthier British groups, during the post war period rates dropped dramatically and the practice never became established in the working classes, from whom the “£10 Poms” were largely drawn. Circumcision in Italy and Greece is unheard of.
Referring back to the first line chart, you can see that in the late 1960s (lower green line) the shift away from circumcision started in Melbourne and Sydney, but not elsewhere. This coincides with the immigration described above, which was centred on those cities.
So as Australia entered the 1970s it had a medical establishment turning against circumcision, plus many children being born to young immigrants with no family tradition of circumcision.
2.0 1936 Routine Infant Circumcision era to the Millennium
2.1 Melbourne Overall the majority of Melbournian’s born over the last 40 years are intact, but there are differences between suburbs.
For the city as a whole around 82% of those born 1996-2000 are intact, reducing to 77% for those born in the early 1990s, approximately 73% for those born in the late 1980s and 64% for the early 1980s.
Melbourne is unusual in that it has areas where the majority of men in their 40s are intact, with those from the North and East 53% intact. However for the city overall 55% in this age group are circumcised.
The map below illustrates there are significant differences between suburbs, discussed below. The charts start on the left with 1966 and end in 1999. Dark purple is intact men, the light circumcised men.
Broadly speaking there are more older intact males in the west and north, popular immigrant areas for Greeks and Italians. The wealthier mainly Anglo East and South continued to circumcise more more often or not until the 1980s. This is when the medical standpoint moved to the stronger discourage policy position.
2.1.1 Route Infant Circumcision era Throughout the RIC era around 75% of males were circumcised, using data from 1936 to the mid 1960s.
2.1.2 Births 1968-1972
The Peninsular saw 80% of births circumcised, with the South not far behind at 67%. Conversely 49% of those born in the West and 40% in the north were left intact.
This may reflect the higher proportion of first generation European immigrants who moved to the Western and Northern suburbs during the 1960s and early 1970s who started families upon settling.
2.1.3 Births 1973-1977
Circumcision rates in the South and Peninsular remained fairly stable. However in the North almost 2/3rd were left intact. At this point the divide between immigrant and Anglo-Saxon areas was quite stark.
2.1.4 Births 1978-1982
The Western and Northern Suburbs see 65% of resident men in their late thirties intact, compared to a minority of 45% in the East, 38% along the Peninsular. This trend had remained fairly stable for much of the 1970s.
2.1.5 Births 1983-1987
However for births between 1983 and 1987 the differences begin to narrow. Intact rates in the northern suburbs remained fairly steady at about 65%, but the more working class Western Suburbs and wealthier East saw around 80% of males born during the period left intact. By 1986-1987 the Peninsular saw 83% of births left intact too, but the trend was slower to change with 73% of those born in the whole period intact. The trend observed on the Peninsular was repeated in the South suburbs with around 70% of those born between 1982-87 left intact, but with a spiked increase towards the end of the period.
The 1983 statement appears to have influenced a significant change in the behaviour of parents from wealthier areas. Up until roughly 1986 children born to parents in predominantly working class areas were more likely to be left intact. However about this time that changed, with parents from wealthier backgrounds becoming more likely to leave their child intact than those from less affluent areas. This change appears to have started around 1983 and reached a tipping point by 1986.
2.1.6 Births 1988-1992
Births between 1988 and 1992 on the Peninsular demonstrate this, with 88% left intact. The South and Eastern suburbs both saw over 80% of births left intact during the same period. By comparison the more working class northern suburbs left 71% intact, some 9-17% behind the wealthier areas.
2.1.7 Births 1993-1999
By the mid 1990s (between 1993 and 1997) circumcision rates on the Peninsular appear to mirror Europe. This is broadly true of the Southern suburbs with 85% of births during the period left intact. The Northern and Western suburbs saw about 80% of children left intact
2.1.8 Births 2000 onwards
Due to the age of this group only medical statistics are available, which don’t split the population by area.
Statewide around 93% of births were left intact fairly evenly across the period, although this excludes males who would be circumcised after the first six months of life for medical or religious reasons.
2.1.9 Melbourne observations
A relatively large proportion of the populous suburbs with a high proportion of European immigrants saw much lower rates of circumcision compared to other areas until the mid 1980s. As medical advice changed wealthy areas saw a short and sharp drop in circumcision rates to European levels, where they remain until this day.
Overall the majority of Sydneysiders born over the last 40 years are intact, but the rate lags behind Melbourne and varies between suburbs.
For the city as a whole, 73% of those born in the late 1990s are intact, 70% of those born in the early 1990s, 67% of those born in the late 1980s and 57% of those born in the early 1980s.
As with Melbourne, there are significant differences between areas which are discussed below. Again the dark purple is intact men and light purple circumcised. The outer Western suburbs and Eastern suburbs moved away from routine circumcision earlier than elsewhere in the city. During the 1980s and 1990s wealthier Eastern, inner West and North Shore had lower circumcision rates than outer suburbs.
2.2.1 Routine Infant Circumcision era
Sydney had one of the highest rates of RIC, at over 75% from at least the mid 1930s to mid 1960s.
2.2.3 Births 1968-1972
The majority of births across all areas of Sydney were circumcised, 66% across the city as a whole. The Upper North Shore, Sutherland and Inner West were all within a couple of percentage points of this average. The outliers were the Western and Eastern Suburbs with a slightly lower 56-59% and the South West at 82%.
As with Melbourne, areas with higher rates of first generation immigrants are associated with lower circumcision rates than more established Anglo-Saxon areas. Western Sydney saw a significant influx of Italian and Greek settlers, whilst between 5-10% of those in the Eastern Suburbs were born in the UK.
2.2.4 Births 1973-1977
During this period a notable reduction in the circumcision rate occurred, with 58% overall circumcised.
The South West and Inner West saw rates drop significantly, catching up with the Eastern Suburbs, Western Sydney, all ranged between 54-56% circumcised. The Upper North Shore and Sutherland remained steady with more births circumcised than other areas.
2.2.5 Births 1978-1982
Only men in the western suburbs are more likely to be intact, with rates of ranging from 53 to 57%. As with Melbourne, this would be consistent with first generation immigrants from the 1960s and 1970s settling and starting a family. Elsewhere circumcision was still the norm, with 35% in Sutherland, 40% on the Upper North Shore, 43% in the South West and 50/50 in the Eastern Suburbs left intact.
2.2.6 Births 1983-1987
During this period a sharp change in the trends is noted. The Outer Western Suburbs where leaving a child intact was already the norm remained fairly stable at about 56%, but elsewhere trends changed and it became the norm to leave children intact. The Inner West, Eastern Suburbs and Upper North Shore led the way with 64-67% left intact. Somewhat lower figures were found in the Southwest and much lower in Sutherland at 53%.
This change is similar to that seen in Melbourne but less pronounced.
2.2.7 Births 1988-1999
On average this period saw 72% of children left intact and the rate remained fairly stable, but with a wide variation of almost 20 points depending upon area.
On one hand the Southwest and Sutherland continued to lag other areas, with around about 55% intact, although the rate in Sydney’s Southwest eventually reached 75% by the late 1990s.
On the other hand Sydney’s Inner West, Eastern Suburbs and Upper North Shore saw between 70-75% of children left intact throughout, with rates in the Eastern suburbs reaching 80% by the mid 1990s. 2.3 Brisbane
Rates in Brisbane are similar to Melbourne, with the majority of males born in the last 40 years left intact.
For Brisbane as a whole around 77% of men born in the late 1990s are intact, slightly above the 73% for early 1990s. That reduces to 68% for those from the late 1980s and 62% for those born in the early 1980s.
2.3.1 Routine Infant Circumcision era
From the mid 1930s to 1970 around 75% of infant males were circumcised. The 1970/71 policy change saw a sharp drop (yellow bar above).
2.3.2 Births 1978-1982
The wealthier riverside suburbs such as Hawthorne saw 62% intact, with the northside and Caboolture at 71% intact which is a very high level for the time. However in the South and West circumcision was still the norm with 44% left intact, similar to the Sunshine Coast.
Brisbane did not see the same level of European immigration during the 1960s and 70s as Sydney or Melbourne. However the number of commonwealth immigrants from the UK is fairly high (between 5-10%) on the northside and which is roughly double that found southside, suggesting young British immigrants did not circumcise their sons.
2.3.3 Births 1983-1987
The trends during this period show quite a number of regional differences. Firstly the northside and riverside suburb rates continued as per the previous five years. However the Sunshine Coast saw a dramatic change, with 77% left intact, a trend that has remained fairly stable ever since. This is one of the most dramatic change in rates found nationwide. The south and west saw a slower change, with 50/50 rates seen.
Again the most dramatic change coincides with the 1983 statement.
2.3.4 Births 1988-1992
During this period rates remained fairly stable on the northside and Sunshine Coast. However the riverside suburbs, west and southside saw a leap to 76% left intact.
2.3.5 Births 1993-1999
Once again the northside which had always seen a high rate of births left intact remained fairly stable, alongside the south and west. However the Sunshine Coast and riverside suburbs both saw the number of births left intact grow to around 80%. 2.4 Other parts of Australia
2.4.1 Rural Queensland Rural Queensland was fairly slow to move away from Route Infant Circumcision, with rates remaining fairly steady from 1936 until the mid 1970s. The late 1970s saw a significant shift, but the largest change occurred in the early 1980s, again coinciding with the 'discourage' medical policy. Around 70% of births from 1986-1995 were left intact, with a further significant shift to 80% left intact during the late 1990s.
2.4.2 Rural NSW Rural NSW has always had a higher circumcision rate than elsewhere. The initial policy statement in 1971 appears to have coincided with a 5-10% increase in the number of boys left intact, which remained steady throughout the 1970s. The 1980s saw a significant shift, again coinciding with the 'discourage' policy commencing. The number of boys left intact was steady in the mid 60s from the mid 1980s to change of the millennium.
2.4.3 Rural Vic Rural Victoria has traditionally seen lower circumcision rates when compared to neighbouring states. Rates were steady at around 75% for 30 years, although by the late 1960s the rate has reduced slightly to 70%. The 1970/71 debate coincides with a major change in popularity (yellow bar), with a reduction of just under 20%. The tougher 1983 stance coincides with a shift during the 1980s (red bar) when rates dropped by just under 20% again. During the 1990s around 4/5th of births were left intact, a greater percentage than had been circumcised during the 1930s-1960s routine circumcision era.
2.4.4 South Australia Relatively low sample sizes makes it harder to understand SA's trends. The 1966 and 1971 samples are odd, with one likely being a statistical blip. However it is not possible to know which (or if either) it is. As with other states the early 1980s are when trends flipped, with the majority being left intact. This trend continued to 1990 and has remained fairly stable since. SA had a comparitively high circumcision rate during the 1990s
2.4.5 West Australia WA has historically had lower rates of circumcision than elsewhere in Australia. Trends changed slightly in the mid 1960s, but the markedly in the mid 1970s. In the 15 years from 1976 to 1990 the number of children left intact roughly doubled, shifting at a fairly steady rate. As the circumcision rate had always been slightly lower than elsewhere, the majority of births from the mid 1970s onwards were left intact. By the late 1990s just under 80% of births were left intact.
3.0 Year 2000 onwards
For Gen Z, a greater proportion of males are left intact than were circumcised during the routine era, but differences remain across Australia. Unlike for earlier periods, this data is not a survey sample, it covers all births. However, it will exclude those circumcised at an older age (e.g. Muslim or Islander traditional circumcision).
Tasmania and NT reported European rates with 98% left intact throughout the period from 2004 until today, with 2004 seeing a step change from 91%.
The ACT, Victoria and WA also saw very low levels of circumcision, with around 93% left intact. Rates further dropped in the ACT from 2014.
South Australia saw 86% left intact in 2004 and the trend remained fairly flat through to 2015. NSW started at a slightly lower level, but from 2012 levels equalled SA. Queensland has seen the greatest change, starting with the lowest level of births left intact (but still over 80%), which changed to 90% by 2015, with a major shift in 2010.
This data does not divide between location within each state. If the historic trend of circumcision being more popular in the country remains, then probably a higher rate of males are left intact in the capital cities than these rates suggest, but fewer in rural areas.
4.0 Medical research into why parents choose to circumcise
There were two medical studies around the millennium which sought to understand the reasons behind parents decision to circumcise or not.
4.1 West Australia Study
For those born in the 1990s the "more disadvantaged" parents circumcised their kids twice as often as the wealthy "least disadvantaged”. Some of the data discussed above is consistent with this finding, for example during the early 1990s those from wealthier areas (e.g. Melbourne’s Peninsular) were about 12% likely to circumcise, against 27% for those from Sunshine, a more working class area.
During that period there was a similar trend in Sydney but less pronounced, with lower circumcision rates in wealthier areas such as the Eastern Suburbs when compared to Parramatta or Campbelltown.
Data from Brisbane does not seem to provide much evidence to support the research. It is true that the wealthy riverside suburbs usually shows some of highest rates of intact births nationwide, which is consistent. However the divide in Brisbane seems more north/south of the river. Generally the northside would not be regarded as wealthier than the south, but there is a higher proportion of British immigrants in the north which may explain the difference.
The WA study concluded births in the country were much more likely to be circumcised than those in urban or outback areas. Because of the amount of data available, this piece has not tried to evaluate differences between city, country and outback areas. However, there is a higher rate of circumcision shown in rural NSW and Vic when compared to Sydney and Melbourne.
4.2 Port Macquarie Study
The second research was carried out at Port Macquarie looking at births 1999-2002.
That research found higher circumcision rates in children of less well educated parents. This would be broadly consistent with the above research, as there are well accepted links between educational attainment and wealth.
This research found mothers who chose circumcision were younger, more likely to have circumcised partners and fathers plus be less well educated. They were influenced by old societal perceived advantages of circumcision including pseudo-medical reasons (prevention of HIV, infections and cancers) and social reasons ("to look like dad", be cleaner, prevent masturbation etc). Mothers who chose circumcision claimed not to understand the risks of carrying out an operation on a baby. Parents who circumcised were more likely to profess a religious faith.
Parents who did not circumcise were better educated and more likely to understand the risks of carrying out an operation on a baby and formed their judgement using current medical evidence.
These observations mainly cover men born over the period between 1936 and 2000.
The rate of circumcision was extremely consistant from 1936 for 30 years, at around 75%, varying from 80% in rural NSW to 70% in WA.
A combination of changing demographics and medical opinion saw the rate of circumcision shift from around 70% at the beginning of the 1970s to around half and half by decade’s end.
In 1983 the ACP's position became stronger against circumcision, changing from simply not routinely circumcising, to discouraging it. Anglo-Saxon parents in wealthier areas seem to be more strongly swayed by current medical opinion. Since ACP's stronger stance in medical opinion this group of people moved away from circumcision. Wealthier areas have seen the lowest circumcision rates since the mid 1980s which is a reverse to earlier times.
Non Anglo-Saxon parents and British immigrants seem almost entirely swayed by their family cultural tradition, evidenced by historically higher rates of children left intact in areas where immigrants from Europe make a higher proportion of the population. Coming from cultures where circumcision has never been the norm, coupled with Australian medical opinion turning away from circumcision, these groups appear unlikely to have circumcised throughout the last 40 years.
Anglo-Saxon parents from less wealthy backgrounds have been slower to move away from circumcision as a social tradition which became embedded during the routine infant circumcision era. The result is a significant minority of parents who continue to circumcise, against the trend of other societal groups. However despite this, it was still the norm for parents from this background to leave their child intact for most of the period.
It is unclear if these trends remain today or have applied since the millennium, because the available medical data cannot be analysed by background.