Circumcision has historically been a topic of emotive and often irrational debate. At
least part of the reason is that a sex organ is involved. (Compare, for example, ear
piercing.) During the past two decades the medical profession have tended to advise
parents not to circumcise their baby boys. In fact there have even been reports of
harrassment by medical professionals of new mothers, especially those belonging to
religious groups that practice circumcision, in an attempt to stop them having this
procedure carried out. Such attitudes are a far cry from the situation years ago when baby
boys were circumcised routinely in Australia. But over the past 20 years the rate has
declined to as low as 10%.
However, a reversal of this trend is starting to occur. In the light of an increasing volume of medical scientific evidence (many
publications cited below) pointing to the benefits of neonatal circumcision a new
policy statement was formulated by a working party of the Australian College of
Paediatrics in August 1995 and adopted by the College in May 1996 [2] . In this document medical practitioners are now
urged to fully inform parents of the benefits of having their male children circumcised.
Similar recommendations were made recently by the Canadian Paediatric Society who also
conducted an evaluation of the literature, although concluded that the benefits and harms
were very evenly balanced. As discussed below the American College of Pediatrics has moved
far closer to an advocacy position.
In the present article I would like to focus principally on the protection afforded by
circumcision against infections, including sexually transmitted diseases (STDs). I might
add that I am a university academic who teaches medical and science students and who does
medical research, including that involving genital cancer virology. I am not Jewish, nor a
medical practitioner or lawyer, so have no religious bias or medico-legal concerns that
might get in the way of a rational discussion of this issue.
The increased risk of infection may be a consequence of the fact that the foreskin
presents the penis with a larger surface area, the moist skin under it represents a
thinner epidermal barrier than the drier, more cornified skin of the circumcised penis,
the presence of a prepuce is likely to result in greater microtrauma during sexual
intercourse and, as one might expect, the warm, moist mucosal environment under the
foreskin favours growth of micro-organisms.
In the 1950s and 60s 90% of boys in the USA and Australia were circumcised soon after
birth. The major benefits at that time were seen as improved lifetime genital hygiene,
elimination of phimosis (inability to retract the foreskin) and prevention of penile
cancer. The trend not to circumcise started about 20 years ago, after the American Academy
of Paediatrics Committee for the Newborn stated, in 1971, that there are ?no valid medical
indications for circumcision?. In 1975 this was modified to ?no absolute valid ... ?,
which remained in the 1983 statement, but in 1989 it changed significantly to ?New
evidence has suggested possible medical benefits ...? [49] .
Dr Edgar Schoen, Chairman of the Task Force on Circumcision of the American Academy of
Pediatrics, has stated that the benefits of routine circumcision of newborns as a
preventative health measure far exceed the risks of the procedure [48] . During the period 1985-92 there was an
increase in the frequency of postnewborn circumcision and during that time Schoen points
out that the association of lack of circumcision and urinary tract infection has moved
from ?suggestive? to ?conclusive? [48]
. At the same time associations with other infectious agents, including HIV, have been
demonstrated. In fact he goes on to say that ?Current newborn circumcision may be
considered a preventative health measure analogous to immunization in that side
effects and complications are immediate and usually minor, but benefits accrue for a
lifetime? [48] .
Benefits included: a decrease in physical problems such as phimosis [36] , reduction in balanitis (inflammation of the
glans, the head of the penis) [17]
, reduced urinary tract infections, fewer problems with erections at puberty, decreased
sexually transmitted diseases (STDs), elimination of penile cancer in middle-aged men and,
in addition, in older men, a decrease in urological problems and infections [reviewed in: 2, 18, 30,
44, 47, 49].
Therefore the benefits are different at different ages.
Neonatologists only see the problems of the operation itself. However, urologists who deal
with the problems of uncircumcised men cannot understand why all newborns are not
circumcised [47, 48] . The demand for circumcision
later in childhood has increased, but, with age, problems, such as anaesthetic risk, are
higher. Thus Schoen states ?Current evidence concerning the life-time medical benefit of
newborn circumcision favours an affirmative choice? [48] .
In a letter written by Dr Schoen to Dr Terry Russell in Brisbane in 1994 Schoen derides an
organization known as ?NOCIRC? for their use of ?distortions, anecdotes and testimonials
to try to influence professional and legislative bodies and the public, stating that in
the past few years they have become increasingly desperate and outrageous as the medical
literature has documented the benefits. For example they have compared circumcision with
female genital mutilation, which is equivalent to cutting off the penis. In 1993 the rate
of circumcision had risen to 80% in the USA and Schoen suggests that ?Perhaps NOCIRC has
decided to export their ?message? to Australia since their efforts are proving
increasingly futile in the US?. He also noted that when Chairman of the Task Force his
committee was bombarded with inaccurate and misleading communications from this group.
Another of these groups is ?UNCIRC?, which promotes procedures to reverse circumcision,
by, for example, stretching the loose skin on the shaft of the retracted penis. Claimed
benefits of ?increased sensitivity? in reality appear to be a result of the friction of
the foreskin, whether intact or newly created, on the moist or sweaty glans and
undersurface of the prepuce in the unaroused state and would obviously in the
?re-uncircumcised? penis have nothing to do with an increase in touch receptors. The
sensitivity during sexual intercourse is in fact identical, according to men circumcised
as adults.
Another respected authority is Dr Tom Wiswell, who states ?As a pediatrician and
neonatologist, I am a child advocate and try to do what is best for children. For many
years I was an outspoken opponent of circumcision ... I have gradually changed my opinion?
[56, 57] . This ability to keep an open mind on the
issue and to make a sound judgement on the balance of all available information is to his
credit ? he did change his mind!
The complication rates of having or not having the procedure have been examined. Amongst
136,000 boys born in US army hospitals between 1980 and 1985, 100,000 were circumcised and
193 (0.19%) had complications, with no deaths [58] . Of the 36,000 who were not circumcised the
complication rate was 0.24% and there were 2 deaths [58] . In 1989 of the 11,000 circumcisions
performed at New York?s Sloane Hospital, only 6 led to complications, none of which were
fatal [44] . Also no
adverse psychological aftermath has been demonstrated [46] . Cortisol levels have registered an increase
during and shortly after the procedure, indicating that the baby is not unaware of the
procedure in its unanaesthetized state and one has to weigh up the need to inflict this
short term pain in the context of a lifetime of gain from prevention or reduction of
subsequent problems. Anaesthetic creams and other means appear to be at least partially
effective in reducing trauma and some babies show no signs of distress at all when the
procedure is performed without anaesthetic.
The proponents of not circumcising nevertheless stress that lifelong penile hygiene is
required. This acknowledges that something harmful or unpleasant is happening under the
prepuce. Moreover, a study of British schoolboys found that penile hygiene does not exist [44] . Furthermore, Dr Terry Russell,
writing in the Medical Observer states ?What man after a night of passion is going
to perform penile hygiene before rolling over and snoring the night away (with pathogenic
organisms multiplying in the warm moist environment under the prepuce)? [44] .
The reasons for circumcision, at least in a survey carried out as part of a study at
Sydney Hospital, were: 3% for religious reasons, 1-2% for medical, with the remainder
presumably being ?to be like dad? or a preference of one or both parents for whatever
reason [16] . The actual
proportion of men who were circumcised when examined at this clinic was 62%. Of those
studied, 95% were Caucasian, with younger men just as likely to be circumcised as older
men. In Adelaide a similar proportion has been noted, with 55% of younger men being
circumcised. In Britain, however, the rate is only 7-10%, much like Europe, and in the
USA, as indicated above, the rate of circumcision has always been high [16] .
Neonatal urinary tract infections
A study by Wiswell of 400,000 newborns over the period 1975-84 found that the
uncircumcised had an 11-fold higher incidence of urinary tract infections (UTIs) [58] . During this decade the
frequency of circumcision in the USA decreased from 84% to 74% and this decrease was
associated with an increase in rate of UTI [61]
. UTI was lower in circumcised, but higher in uncircumcised. In a 1982 series 95% of UTI
cases were in uncircumcised [60]
. A study by Roberts in 1986 found that 4% of uncircumcised boys got UTI, compared with
0.4% of girls and 0.2% of circumcised boys [42]
. This indicated a 20-fold higher risk for uncircumcised boys. In a 1993 study by Wiswell
of 200,000 infants born between 1985 and 1990, 1000 got UTI in their first year of life [59] . The number was equal for boys
and girls, but was 10-times higher for uncircumcised boys. Of these 23% had bacteraemia.
The infection can travel up the urinary tract to affect the kidney and higher rate of
problems such as pyelonephritis is seen in uncircumcised children [43, 52]
. These and other reports [e.g., 21, 43,
52] all point to the benefits of circumcision in reducing
UTI.
Indeed, Wiswell performed a meta-analysis of all 9 previous studies and found that every
one indicated an increase in UTI in the uncircumcised [59] . The average was 12-fold higher and the range
was 5 to 89-fold, with 95% confidence intervals of 11-14 [59] . Meta-analyses by others have reached similar
conclusions. Other studies, including one of men with an average age of 30 years, have
indicated that circumcision also reduces UTI in adulthood [51] . The fact that the bacterium E. coli ,
which is pathogenic to the urinary tract, has been shown to be capable of adhering to the
foreskin, satisfies one of the criteria for causality [52, 62, and refs in 18]. Since the
absolute risk of UTI in uncircumcised boys is approx. 1 in 25 (0.05) and in circumcised
boys is 1 in 500 (0.002), the absolute risk reduction is 0.048. Thus 20 baby boys need to
be circumcised to prevent one UTI. However, the potential seriousness and pain of UTI,
which can in rare cases even lead to death, should weigh heavily on the minds of parents.
The complications of UTI that can lead to death are: kidney failure, meningitis and
infection of bone marrow. The data thus show that much suffering has resulted from leaving
the foreskin intact. Lifelong genital hygiene in an attempt to reduce such infections is
also part of the price that would have to be paid if the foreskin were to be retained.
However, given the difficulty in keeping bacteria at bay in this part of the body [38, 48] , not performing circumcision would appear to
be far less effective than having it done in the first instance [48] .
Sexually-transmitted diseases
Early studies showed higher rates of gonococcal and nonspecific urethritis in
uncircumcised men [39, 48] . Recent studies have yielded
similar findings. In addition, the earlier work showed higher chancroid, syphilis,
papillomavirus and herpes [53]
. However, there were methodological problems with the design of these studies, leading to
criticisms. As a result there is still no overwhelming agreement. In 1947 a study of 1300
consecutive patients in a Canadian Army unit showed that being uncircumcised was
associated with a 9-fold higher risk of syphilis and 3-times more gonorrhea [55] . At the University of Western
Australia a 1983 study showed twice as much herpes and gonorrhea, 5-times more candidiasis
and 5-fold greater incidence of syphilis [39]
. In South Australia a study in 1992 showed that uncircumcised men had more chlamidia
(odds ratio 1.3) and gonoccocal infections (odds ratio 2.1). Similarly in 1988 a study in
Seattle of 2,800 heterosexual men reported higher syphilis and gonnorrhea in uncircumcised
men, but no difference in herpes, chlamidia and non-specific urethritis (NSU). Like this
report, a study in 1994 in the USA, found higher gonnorhea and syphilis, but no difference
in other common STDs [12] .
In the same year Dr Basil Donovan and associates reported the results of a study of 300
consecutive heterosexual male patients attending Sydney STD Centre at Sydney Hospital [16] . They found no difference in
genital herpes, seropositivity for HSV-2, genital warts and NSU. As mentioned above, 62%
were circumcised and the two groups had a similar age, number of partners and education.
Gonorrhea, syphilis and hepatitis B were too uncommon in this Sydney study for them to
conclude anything about these. Thus on the bulk of evidence it would seem that at least
some STDs may be more common in the uncircumcised, but this conclusion is by no means
absolute and the incidence may be influenced by factors such as the degree of genital
hygiene, availability of running water and socioeconomic group being studied.
Cancer of the penis
The incidence of penile cancer in the USA is 1 per 100,000 men per year (i.e., 750-1000
cases annually) and mortality rate is 25-33% [27,
31] . It represents
approximately 1% of all malignancies in men in the USA. This data has to be viewed,
moreover, in the context of the high proportion of circumcised men in the USA, especially
in older age groups, and the age group affected, where older men represent only a portion
of the total male population. In a study in Melbourne published in Australasian
Radiology in 1990, although 60% of affected men were over 60 years of age, 40% were
under 60 [45] . In 5 major
series in the USA since 1932, not one man with penile cancer had been circumcised
neonatally [31] , i.e.,
this disease only occurs in uncircumcised men and, less commonly, in those circumcised
after the newborn period. The proportion of penile malignancies as a fraction of total
cancers in uncircumcised men would thus be considerable. The predicted life-time risk has
been estimated as 1 in 600 in the USA and 1 in 900 in Denmark [27] . In under-developed countries the incidence
is higher: approx. 3-6 cases per 100,000 per year [27] .
The so-called ?high-risk? papillomavirus types 16 and 18 (HPV 16/18) are found in a large
proportion of cases and there is good reason to suspect that they are involved in the
causation of this cancer, as is true for most cases of cervical cancer (see below). HPV 16
and 18 are, moreover, more common in uncircumcised males [35] . These types of HPV produce flat warts that
are normally only visible by application of dilute acetic acid (vinegar) to the penis and
the data on high-risk HPVs should not be confused with the incidence figures for genital
warts, which although large and readily visible, are caused by the relatively benign HPV
types 6 and 11. Other factors, such as poor hygiene and other STDs have been suspected as
contributing to penile cancer as well [8,
31] .
In Australia between 1960 and 1966 there were 78 deaths from cancer of the penis and 2
from circumcision. (Circumcision fatalities these days are virtually unknown.) At the
Peter McCallum Cancer Institute 102 cases of penile cancer were seen between 1954 and
1984, with twice as many in the latter decade compared with the first. Moreover, several
authors have linked the rising incidence of penile cancer to a decrease in the number of
neonatal circumcisions [13,
45] . It would thus seem
that ?prevention by circumcision in infancy is the best policy?.
Cervical cancer in female partners of uncircumcised men
A number of studies have documented higher rates of cervical cancer in women who have had
one or more male sexual partners who were uncircumcised. These studies have to be looked
at critically, however, to see to what extent cultural and other influences might be
contributing in groups with different circumcision practices. In a study of 5000 cervical
and 300 penile cancer cases in Madras between 1982 and 1990 the incidence was low amongst
Muslim women, when compared with Hindu and Christian, and was not seen at all in Muslim
men [22] . In a
case-control study of 1107 Indian women with cervical cancer, sex with uncircumcised men
or those circumcised after the age of 1 year was reported in 1993 to be associated with a
4-fold higher risk of cervical cancer, after controlling for factors such as age, age of
first intercourse and education [1]
. Another study published in 1993 concerning various types of cancer in the Valley of
Kashmir concluded that universal male circumcision in the majority community was
responsible for the low rate of cervical cancer compared with the rest of India [14] . In Israel, a 1994 report of 4
groups of women aged 17-60 found that gynaecologically healthy Moshav residents had no HPV
16/18, whereas healthy Kibbutz residents had a 1.8% incidence [24] . Amongst those with gynaecological complaints
HPV 16/18 was found in 9% of Jewish and 12% of non-Jewish women. HPV types 16 and 18 cause
penile intraepithelial neoplasia (PIN) and a study published in the New England Journal
of Medicine in 1987 found that women with cervical cancer were more likely to have
partners with PIN, the male equivalent of cervical intraepithelial neoplasia (CIN) [6] . Thus the epidemic of cervical
cancer in Australia, and indeed most countries in the world, would appear to be due at
least in part to the uncircumcised male and would therefore be expected to get even worse
as the large proportion that were born in the past 10-20 years and not circumcised reach
sexual maturity.
AIDS virus
In the USA the estimated risk of HIV per heterosexual exposure is 1 in 10,000 to 1 in
100,000. If one partner is HIV positive and otherwise healthy then a single act of
unprotected vaginal sex carries a 1 in 300 risk for a woman and as low as a 1 in 1000 risk
for a man [9] . (The rates
are very much higher for unprotected anal sex and intravenous injection). In Africa,
however, the rate of HIV infection is up to 10% in some cities. (A possible reason for
this big difference will be discussed later.) In Nairobi it was first noticed that among
340 men being treated for STDs they were 3-times as likely to be HIV positive if they had
genital ulcers or were uncircumcised (11% of these men had HIV) [50] . Subsequently another report showed that
amongst 409 African ethnic groups spread over 37 countries the geographical distribution
of circumcision practices indicated a correlation of lack of circumcision and high
incidence of AIDS [7] . In
1990 Moses in International Journal of Epidemiology reported that amongst 700
African societies involving 140 locations and 41 countries there was a considerably lower
incidence of HIV in those localities where circumcision was practiced [33, 34]
. Truck drivers, who generally exhibit more frequent prostitute contact, have shown a
higher rate of HIV if uncircumcised. Interestingly, in a West African setting, men who
were circumcised but had residual foreskin were more likely to be HIV-2 positive than
those in whom circumcision was complete [40]
.
Of 26 cross-sectional studies, 18 have reported statistically significant association
[e.g., 15, 23, 25, 54], by univariate and
multivariate analysis, between the presence of the foreskin and HIV infection, and 4
reported a trend. The findings have, moreover, led various workers such as Moses and
Caldwell to propose that circumcision be used as an important intervention strategy in
order to reduce AIDS [9, 19, 23, 26, 32-34].
Perhaps the most interesting study of the risk of HIV infection imposed by having a
foreskin is that by Cameron, Plummer and associates published as a large article in Lancet
in 1989 [10] . This had the
advantage of being prospective. It was conducted in Nairobi. These workers followed HIV
negative men until they became infected. The men were visiting prostitutes, numbering
approx. 1000, amongst whom there had been an explosive increase in the incidence of HIV
from 4% in 1981 to 85% in 1986. These men were thus at high risk of exposure to HIV, as
well as other STDs. From March to December 1987, 422 men were enrolled into the study. Of
these, 51% had presented with genital ulcer disease (89% chancroid, 4% syphilis, 5%
herpes) and the other 49% with urethritis (68% being gonorrhea). 12% were initially
positive for HIV-1. Amongst the whole group, 27% were not circumcised. They were followed
up each 2 weeks for 3 months and then monthly until March 1988. During this time 8% of 293
men seroconverted (i.e., 24 men), the mean time being 8 weeks. These displayed greater
prostitute contact per month (risk ratio = 3), more presented with genital ulcers (risk
ratio = 8; P <0.001) and more were uncircumcised (risk ratio = 10; P
<0.001). Logistic regression analysis indicated that the risk of seroconversion was
independently associated with being uncircumcised (risk ratio = 8.2; P <0.0001),
genital ulcers (risk ratio = 4.7; P = 0.02) and regular prostitute contact (risk
ratio = 3.2; P = 0.02). The cumulative frequency of seroconversion was 18% and was
only 2% for men with no risk factors, compared to 53% for men with both risk factors. Only
one circumcised man with no ulcer seroconverted. Thus 98% of seroconversion was associated
with either or both cofactors. In 65% there appeared to be additive synergy, the reason
being that ulcers increase infectivity for HIV. This involves increased viral shedding in
the female genital tract of women with ulcers, where HIV-1 has been isolated from surface
ulcers in the genital tract of HIV-1 infected women.
It has been suggested that the foreskin could physically trap HIV-infected vaginal
secretions and provide a more hospitable environment for the infectious innoculum. Also,
the increased surface area, traumatic physical disruption during intercourse and
inflammation of the glans penis (balanitis) could aid in recruitment of target cells for
HIV-1. The port of entry could potentially be the glans, subprepuce and/or urethra. In a
circumcised penis the dry, cornified skin may prevent entry and account for the findings.
In this African study the rate of transmission of HIV following a single exposure was 13%
(i.e., very much higher than in the USA). It was suggested that concomitant STDs,
particularly chancroid [9] ,
may be a big risk factor, but there could be other explanations as well. Studies in the
USA have not been as conclusive. Some studies have shown a higher incidence in
uncircumcised men. Others do not. In New York City, for example, no correlation was found,
but the patients were mainly intravenous drug users and homosexuals, so that any existing
effect may have been obscured. A study in Miami, however, of heterosexual couples did find
a higher incidence in men who were uncircumcised, and, in Seattle homosexual men were
twice as likely to be HIV positive if they were uncircumcised [28] .
The reason for the big difference in apparent rate of transmission of HIV in Africa and
Asia, where heterosexual exposure has led to a rapid spread through these populations and
is the main method of transmission, compared with the very slow rate of penetration into
the heterosexual community in the USA and Australia, now appears to be related at least in
part to a difference in the type of HIV-1 itself [29] . In 1995 an article in Nature Medicine
discussed findings concerning marked differences in the properties of different HIV-1
subtypes in different geographical locations [37]
. A class of HIV-1 termed ?clade E? is prevalent in Asia and differs from the ?clade B?
found in developed countries in being highly capable of infecting Langerhans cells found
in the foreskin, so accounting for its ready transmission across mucosal membranes. The
Langerhans cells are part of the immune system and in turn carry the HIV to the T-cells,
whose numbers are severely depleted as a key feature of AIDS. The arrival of the Asian
strain in Australia was reported in Nov 1995 and has the potential to utilise the
uncircumcised male as a vehicle for rapid spread through the heterosexual community of
this country in a similar manner as it has done in Asia. It could thus be a time-bomb
about to go off and should be a major concern for health officials.
To summarize:
Lack of circumcision:
There is no evidence of any long-term psychological harm arising from circumcision. The risk of damage to the penis is extremely rare and avoidable by using a competent, experienced doctor. Surgical methods use a procedure that protects the penis during excision of the foreskin. As an alternative, for those who might prefer it, a device (PlastiBell) is in use that clamps the foreskin, which then falls off after a few days, and so eliminates the need to actually cut the foreskin off [20] . For some, cultural or religious beliefs dictate the method.
Sociological aspects
Finally, a brief mention of other findings relating to circumcision in the setting of
Australia.
In a survey of circumcised vs uncircumcised men and their partners that was conducted by
Sydney scientist James Badger [4,
5] (who regards himself as
neutral on the issue of circumcision) it was found that:
Why are human males born with a foreskin?
The foreskin probably protected the head of the penis from long grass, shrubbery, etc when
humans wore no clothes, where evolutionarily our basic physiology and psychology are
little different than our cave-dwelling ancestors. However, Dr Guy Cox from The University
of Sydney has recently supplemented this suggestion with a novel idea, namely that the
foreskin could be the male equivalent of the hymen, and served as an impediment to sexual
intercourse during adolescence [11]
. The ritual removal of the foreskin in diverse human traditional cultures, ranging from
Muslims to Aboriginal Australians, is a sign of civilization in that human society
acquired the ability to control through education and religion the age at which sexual
intercourse could begin. Food for thought and discussion!
Conclusion
The information available today will assist medical practitioners, health workers and
parents by making advice and choices concerning circumcision much more informed. Although
there are benefits to be had at any age, they are greater the younger the child. Issues of
?informed consent? may be analogous to those parents have to consider for other medical
procedures, such as whether or not to immunize their child. The question to be answered is
?do the benefits outweigh the risks?. When considering each factor in isolation there
could be some difficulty in choosing. However, when viewed as a whole, in my opinion the
answer to whether to circumcise a male baby is ?yes?. Nevertheless, everybody needs to
weigh up all of the pros and cons for themselves and make their own best decision. I trust
that the information I have provided in this article will help in the decision-making
process.
| Brian J. Morris, PhD DSc | Fax: +61 2 9351 2058 |
| University Academic (in medical sciences) | Email: brianm@physiol.usyd.edu.au |
Source:University of Northumbria at Newcastle. Islamic Society. |