In reply: We support Hill in his call for improving the dissemination of information and data about foreskin development and management. Circumcision is a highly emotive issue.

Our study on phimosis1 was carried out under the Western Australian Safety and Quality of Surgical Care Project, established in 1996, to assess the safety, quality, appropriateness and outcomes of surgical care in the state. The purpose of our study was to provide data on the trends of medically indicated circumcision in Western Australia. The unusually high rates of circumcision for phimosis in children reported in our study support the findings of a study reported by Rickwood et al in 2000.2

Bailis and Cox raise concerns about the definition of phimosis we used in our study. We believe that phimosis requiring treatment by circumcision is a different entity to a non-retractile foreskin resulting from incomplete separation of the prepuce and glans. It is this latter condition that was reported in 20% of boys aged 5–13 years by Gairdner,3 and not phimosis as suggested by Cox. We used a more conservative definition of phimosis, as the current (2002) guidelines established by The Royal Australasian College of Physicians (RACP) do not recommend circumcision unless medically indicated, particularly in young children.4 In this context, we used the rate reported by Shankar and Rickwood5 as the denominator. Most boys circumcised to treat phimosis in our study were aged under 5 years, and were therefore unlikely to have had "pathological" phimosis. Instead, these boys were circumcised for a condition that they might have outgrown, or for which they might have had alternative treatment. Our concern is that parents and clinicians may be opting for circumcision without being fully aware of these possibilities.

However, given the confusion over the issue, as indicated in the editorial by Dewan,6 there is a clear need for medical texts and education curricula to clarify the definition and interpretation of phimosis as either pathological or physiological. This situation again would lend support for the call by Hill for a more standard definition to be devised that would be acceptable to the medical community.

There is also a clear international move towards reducing the practice of unnecessary or incidental removal of tissue or organs unless medically indicated. Not only has this rationale contributed to a dramatic decline in the incidental removal of the appendix over the last decade, it has also seen a reduction in the use of routine circumcision in Western countries.7,8 As Dewan explains, even most cases of pathological phimosis can be successfully treated with steroid cream without the need for circumcision.6 There are no historical data that show that removal of the foreskin has long-term public health benefits to the individual. In fact, just as saphenous veins are used for coronary artery bypass surgery, so can the foreskin be used for penile and urethral reconstructions and is a valuable adjunct as a non-hair-bearing area for such treatments. Health education today on appropriate foreskin management in the infant should be aimed at health practitioners and parents.

The letter by Morris is more difficult to discuss as it relates, on the whole, to the use of routine circumcision, which was not the focus of our article. The issues raised by Morris seem to be at complete odds with the 2002 Policy Statement on Circumcision by the RACP — which is also consistent with the recommendations of the Canadian Paediatric Society and the American Academy of Paediatrics.4 The RACP Policy Statement reviewed most of the points raised by Morris, including urinary tract infections, STDs, human papillomavirus and carcinomas of the cervix and penis. In each case, after an extensive review of the literature, the RACP reaffirmed that there is no medical indication for routine circumcision. Morris's view on the reduction of risk of sexual problems is at odds with the article by Darby,9 published in the same issue of the Journal as our article, and is beyond the scope of our study. His claim that circumcision improves appearance is highly subjective and unsubstantiated, and should not be used to justify the surgical removal of tissue that may have a benefit to the individual later in life.