Australian Circumcision - why 50 years of social change?
Discussion about circumcision becomes emotionally charged. The rights and wrongs are controversial. In 2017/18 6% of baby boys were circumcised. But why and how did society stop from routinely circumcising baby boys?
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.
Our research included: - medical papers from the early 1970s, 1980s and turn of the millennium - medical statistics from the 1960s and since turn of the millennium - research on immigration within Australia's three largest cities by suburban region - dating profile data analysed by ethnicity and suburban region.
We don't look at men who choose to be circumcised at a later age. We also don't review religious or medically necessary circumcision.
We found that further research is needed. However, there seem five key reasons for this change:
Medical opinion and advice: 1. In the early 1970s Australian doctors stopped routine neonatal circumcision. They were concerned about the number of complications being experienced. 2. In 1983 the advise became to discourage circumcision. Until then they'd simply not encouraged it.
Impact of social class and migrant tradition: 3. From the 1983 change of message, wealthier Anglo-Saxon Australian's began to drop the procedure. By the mid 1980s, wealthy areas has the lowest rates of circumcision. 4. Before 1983, suburbs with many first generation European immigrants had the lowest circumcision rates. Their homeland cultures have little or no tradition of circumcision and this continued in Australia. 5. Today less wealthy Anglo-Saxon Australian families are the most likely to circumcise. This is based upon social anecdotes and family experience rather than medical advice. 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. This corresponds with the lower blue line below. Doctors reported that social custom was the main reason. Today more than 95% of Melbourne’s baby boys are not.
In the early 20th century, prominent Australian medical leaders were puritans. They taught that retracting a foreskin to clean was masturbation. Therefore, as the ANZACs headed off to the old continent, Puritan medics told the soldiers they would need to be circumcised for cleanliness. Following the world wars, returning soldiers became fathers. Based on those teachings and wanting what they had been told was best for their children, circumcised newborns became the norm.
That remained the case for decades. But by the late 1960s the trend begun to change. By the year 2000, most parts of Australia saw between 76-80% of births left intact.
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 covers 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?
a 1.1 Changing medical opinion
Changing medical opinion was the first cause of change.
The British Medical Association represented Australian doctors until the early 196os. The BMA promoted medicine as a science. They wanted to protect doctors and patients against quackery and old anecdotes. Many suspected that these old approaches caused needless child suffering.
Dr Douglas Gairdner was a practicing paediatrician. He was also a research scientist and lecturer at the University of Cambridge in England. Gairdner believed science would reduce child suffering. In the BMA's December 1949 journal, Gairdner published landmark scientific research. It concluded, "the many and varied reasons commonly advanced for circumcising infants are critically examined. None are convincing." Following this, in the UK circumcision was abandoned. Australian doctors ignored Gairdner, as they weren't going to be lectured by a pommie whizz kid.
In the 1950s and 60s, study books used to educate young medics taught Gairdner's findings. This was at odds with Australian practice. By 1970, younger Australian medics questioned why their training and the daily reality they discovered in the field were different.
It came to a head with three papers published in the June 1970 “Australian Paediatric Journal”. The first, “Circumcision - A continuing Enigma” by I.O.W. Leitch, is a pros/cons analysis of circumcision. Leitch found the number of complications outweighed the benefits. He concluded 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 was “Circumcision” by R.G. Birrell. Bircell wrote about 9 cases he had treated over 6 years. In each, circumcision was either proven or suspected to have caused septicaemia. Only intensive care saved the babies lives. The final paper was “Another View of Circumcision”. This paper was worried that doctors didn't have official advise for parents.
In September 1970, the Journal of the American Medical Association published “Whither the Foreskin?”. It concluded, “there are no valid medical indications for circumcision in the neonatal period”. That became American Academy of Paediatrics policy in 1971, fueling calls for Australian guidance.
So, during April 1971 the Australian Paediatric Association released a policy. They said, “The Australian Pædiatric Association recommends that newborn male infants should not, as a routine, be circumcised.”
This message was a response to the rate of complications being experienced by circumcision procedures.
In 1983 the ACP updated their policy. It became firmer than before. They changed from a passive policy, to one where circumcision would be discouraged. They said, “The ACP should continue to discourage the practice of circumcision in the newborn male infant”.
Medicare also withdrew the rebate for neonatal circumcision. It was later reintroduced.
1.2 A changing country
In the 1960s, to address a shortage of labor, Australian migration schemes begun 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 NSW. As a result, Melbourne and Sydney have large Greek descent communities.
Italian immigration was similar. The number of Italy-born Victorian’s peaked at 121,000 in 1971. Today Italians are still the fifth-largest immigrant community in Victoria. There were 76,906 Italy-born people recorded in the 2011 census.
1969 was the peak year for Commonwealth immigration. It saw more than 80,000 people coming to Australia, mainly from the UK. Around a quarter of those from the commonwealth left within a few years.
In the early 20th century, circumcision had become popular in wealthier British groups. From 1950 it was abandoned. Circumcision was never established in the working classes. The “£10 Poms” were largely working class. Circumcision in Italy and Greece is unheard of.
In the late 1960s circumcision became less popular in Melbourne and Sydney. This was not seen elsewhere. That change 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 - many children being born to young immigrants who continued their tradition of not even considering circumcision.
2.0 1936 Routine Infant Circumcision era to the Millennium
The move away from circumcision varied between different parts of Australia. City hospitals were more likely to adopt recent medical advances, due to their closer links with research universities. Also, immigrants from overseas were clustered around the three major cities. 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 - 77% of those born in the early 1990s are intact - 73% of those born in the late 1980s are intact - 64% of those born in the early 1980s are intact.
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 shows there are significant differences between suburbs. 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 demographic East and South continued to routinely circumcise until the early 1980s. This is when medical advice moved to the stronger discourage policy.
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. The South was 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 big.
2.1.4 Births 1978-1982
The Western and Northern Suburbs see 65% of resident men in their late thirties intact. That compares to a minority of 45% in the East and 38% along the Peninsular. This trend had been fairly stable for much of the 1970s.
2.1.5 Births 1983-1987
For births between 1983 and 1987 the differences begin to narrow. Intact rates in the northern suburbs remained fairly steady at about 65%. The more working class Western Suburbs and wealthier East had similar rates for the first time. They both saw around 80% of males born during the period left intact. By 1986-1987 the Peninsular saw 83% of births left intact. Here 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 Southern suburbs. Here around 70% of those born between 1982-87 were left intact, with a spiked increase towards the end of the period.
The new 1983 policy statement appears to have changed 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 trends swapped.
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.
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 are intact - 67% of those born in the late 1980s are intact - 57% of those born in the early 1980s are intact.
As with Melbourne, there are big differences between areas. The dark purple is intact men and light purple circumcised. The outer Western and Eastern suburbs stopped routine circumcision earlier than elsewhere. Later, the lowest circumcision rates were in wealthier areas. Specifically, the Eastern Suburbs, inner West and North Shore.
2.2.1 Routine Infant Circumcision era
Sydney had one of the highest rates of RIC in Australia. Over 75% of baby boys from at least the mid 1930s to mid 1960s were circumcised.
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%. Elsewhere 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. However there were wide variations of almost 20 points depending upon area.
On one hand the Southwest and Sutherland continued to lag other areas. Here about 55% were left intact. 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. Rates in the Eastern suburbs reaching 80% intact by the mid 1990s. 2.3 Brisbane
Brisbane is similar to Melbourne, with the majority of males born in the last 40 years left intact.
For Brisbane as a whole: - 77% of men born in the late 1990s are intact - 73% for early 1990s - 68% for those from the late 1980s - 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 change, perhaps more so than other places (yellow bar above).
2.3.2 Births 1978-1982
Brisbane was a city of two halves. Wealthier riverside suburbs such as Hawthorne saw 62% intact. The northside and Caboolture had 71% left intact, which is very high for the time.
However in the South and West circumcision was the norm, with only 44% left intact. That is similar to the Sunshine Coast.
Brisbane did not see the same level of European immigration as Sydney or Melbourne. However, the number of UK immigrants was fairly high. About 10% on the northside were born in Britain, roughly double that found on the southside. This suggests young British immigrants did not circumcise their sons.
2.3.3 Births 1983-1987
Brisbane remained split. Firstly the northside and riverside saw rates continue as before. However the Sunshine Coast saw a dramatic change, with 77% left intact. This has remained fairly stable ever since. That sharp change is one of the most dramatic 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 west and southside saw a dramatic leap to 76% left intact.
2.3.5 Births 1993-1999
Once again the northside which had long 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. Rates remained 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 this coincided with the 'discourage' medical policy. Around 70% of births from 1986-1995 were left intact. There was a further big 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. This remained steady throughout the 1970s. The early 1980s saw a significant shift, again coinciding with the 'discourage' policy commencing. The number of boys left intact jumped again in the mid 1980s. Rates then remained stabled to 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. However by the late 1960s they had dropped 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. Differences remain across Australia. Unlike earlier periods, this data is not a survey sample, it covers all births. However, it excludes 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.
In 2017/18 the circumcision rate was 6% nationwide. State-by-state: NSW: 7% Vic: 4% Qld: 8% SA: 11% WA: 6% Tas: 2% NT: 2% ACT: 1%
4.0 Medical research into why parents choose to circumcise
Two medical studies around the millennium investigated why parents decide to circumcise or not.
4.1 West Australia Study
For births in the 1990s, the poorer "more disadvantaged" parents circumcised their kids twice as often as the wealthy "least disadvantaged”. Some of the data reviewed 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, but less pronounced, in Sydney. Wealthier areas such as the Eastern Suburbs had lower circumcision rates when compared to Parramatta or Campbelltown.
Data from Brisbane does not seem to provide much evidence to support the WA 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, we have not tried to evaluate this. 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 study was carried out at Port Macquarie. It looked at births between 1999-2002.
That research found higher circumcision rates in children of less well educated parents. This would be broadly consistent with the above research. 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 - be less well educated.
They were influenced by old societal perceived advantages. These included 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. They were 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%. There was small variation, from 80% in rural NSW to 70% in WA.
A combination of changing demographics and medical opinion saw the rate of circumcision reduce. At the beginning of the 1970s around 70% were circumcised. This became around 50% by decade’s end.
In 1983 the ACP's position became stronger against circumcision. It changed 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. That is the opposite of earlier times.
Non Anglo-Saxon parents and British immigrants seem almost entirely swayed by their family cultural tradition. This is evidenced by historically higher rates of children left intact in areas where immigrants from Europe settled. 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. They maintained the social tradition which became embedded during the routine infant circumcision era. The result has been 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 social trends remain today, because the available medical data cannot be analysed in that way.