Circumcision
@Book 2,
Number 0495:
Abu
Huraira reported: Five are the acts quite akin to the Fitra, or five are the
acts of Fitra: circumcision, shaving the pubes, cutting the nails, plucking the
hair under the armpits and clipping the moustache.
MEDICAL
BENEFITS FROM CIRCUMCISION
Circumcision is
the removal of a fold of loose skin (the foreskin) that covers the head (glens)
of the unerect penis. The amount of this skin varies from virtually none, to a
considerable amount that droops down from the end of the flaccid penis. The
practice is common amongst many divergent human cultures. A variety of methods
are, moreover, used and the amount of foreskin removed also varies.
Historically
circumcision has 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 in Australia have
tended to advise parents not to circumcise their baby boys. In fact there have
even been reports of harassment 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 16-19%.
However, a
reversal of this trend is starting to occur. In the light of an increasing
volume of medical scientific evidence pointing to the benefits of neonatal
circumcision a new policy statement was formulated by a working party of the
Australian College of Pediatrics in August 1995 and adopted by the College in
May 1996 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 Pediatric Society who also
conducted an evaluation of the literature, although concluded that the benefits
and harms were very evenly balanced. The American Academy of Pediatrics has
moved far closer to an advocacy position and many recognized authorities in the
USA strongly advocate circumcision of all newborn boys. More details of their
statements appear later.
In the present
literature review I would like to focus principally on the protection afforded
by circumcision against infection by micro-organisms, some of which can cause
disease and even death, but will also touch on other aspects, including sexual
benefits. 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, as well as molecular biology and genetics of cardiovascular
disease. 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
presentation of the information that has been published in reputable journals.
Why the foreskin
increases infection risk
It has been
suggested that the increased risk of infection in the uncircumcised 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 cornfield skin of the circumcised penis (the glens of which
develops a thick stratum corneum layer), and the presence of a prepuce is likely
to result in greater micro trauma during sexual intercourse, thereby permitting
an entry point into the bloodstream for infectious agents. Also, as one might
expect and as has been observed, the warm, moist mucosal environment under the
foreskin favors growth of micro-organisms (discussed later). The perpetual sac
has even been referred to by Dr Gerald Weiss, an American surgeon, as a
‘cesspool for infection’, as its unfortunate anatomy wrapped around the end of
the penis results in accumulation of secretions, excretions (urine), dead cells
and growths of bacteria. Parents are told not to retract the foreskin of male
infants which makes cleaning difficult. Even if optimal cleansing is performed
there is no evidence that it confers protection.
History
Circumcision
has been practiced widely in Western countries this century. In the USA it
increased from 8% in 1870 to 56% in 1910. In Britain it rose from 19% for those
born in 1914 to 22% for 1924 and 30% for 1930. From at least the mid-1940s to
mid-1970s over 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.
A trend not to
circumcise started in the mid to late 1970s, after the American Academy of
Pediatrics Committee for the Newborn stated, in 1971, that there are ‘no valid
medical indications for circumcision’. However, 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
...’. A new statement is to appear in 1998.
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. During the
period 1985-92 there was an increase in the frequency of post newborn
circumcision and during that same time Schoen points out that the association of
lack of circumcision and urinary tract infection (UTI) has moved from
‘suggestive’ to ‘conclusive’. Moreover, it heralded the finding of associations
with other infectious agents, including HIV. 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’.
Benefits
included: a decrease in physical problems involving a tight foreskin lower
incidence of inflammation of the head of the penis reduced urinary tract
infections, problems with erections, especially at puberty, decrease in certain
sexually transmitted diseases (STDs) such as HIV, and, in older men, elimination
of penile cancer and a decrease in urological problems and infections [reviewed
in]. Therefore the benefits are different at different ages.
Different
specialists see different things
Neonatologists
only see the problems of the operation itself. Moreover such problems occur in
only a minor proportion of boys, and generally because of poor technique by an
inexperienced operator. However, urologists who see and have to treat the
problems of uncircumcised men cannot understand why all newborns are not
circumcised Other health care workers in hospitals and aged care homes also have
adverse comments about the uncircumcised penises they see. The demand for
circumcision later in childhood has increased, but, with age, there is an
inevitable increase in worry to the boy or man in the lead up to having this
done, and there may be a more visible scar left. This, coupled with the
advantages of early circumcision, led Schoen to state ‘Current evidence
concerning the life-time medical benefit of newborn circumcision favors an
affirmative choice’
Anti-circumcision lobby groups
There are
several of these. One of the largest is ‘NOCIRC’. In a letter written by Dr
Schoen to Dr Terry Russell in Brisbane in 1994 Schoen derides ‘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 USA’. One only has to do a search
on the World Wide Web to read the statements from this group and others like it
and any intelligent person can quickly make up their own mind about the quality
of their material and the message they are trying to promulgate. Some of these
people mean well and some are intelligent, but lack a broad perspective. Dr
Schoen also noted that when Chairman of the Task Force his committee was
bombarded with inaccurate and misleading communications from this group. A
member of NOCIRC emailed me from the USA to say: "I've come to learn I can't
trust [NOCIRC] when it comes to this subject. I think they are causing a
tremendous degree of pyschological harm with their campaign and I've suffered a
lot from their nonsense."
The anti-circ.
groups have an array of literature and even publish their own ‘journal’, ‘Circumcision’,
which appears only on the world-wide web, and includes articles that are not
subjected to unbiased peer review. This propaganda vehicle should really be
titled ‘Anti-circumcision’. The Editor of this ‘journal’ is an outspoken
critic of circumcision. His writings appear superficially convincing to the
naive. However, various authorities have shown how he distorts, misquotes, and
misrepresents the bulk of the literature he claims support his opinions and even
misconstrues his own published findings (on banalities) .The anti-circ.
documents quote a Dr Paul Fleiss extensively. Fleiss was given a suspended
sentence for laundering the business proceeds of his infamous daughter, Heidi
Fleiss, the Hollywood madam who provided prostitutes to celebrities. This raises
the question of credibility.
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 or
the use of surgery. This has led to genital mutilation 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 glens 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.
Indeed, nerves do not regenerate. Moreover, the sensitivity during sexual
intercourse is in fact identical, according to men circumcised as adults. In the
first detailed professional analysis of psychiatric aspects eight patients
seeking prepuce restoration were studied and several psychological disorders
were noted These included narcissistic and exhibitionistic body image,
depressions, major defects in early mothering, and ego pathology. These men had
a preoccupation with their absent foreskins and represented a subgroup within
the homosexual community Subsequently some skin-stretchers can now be found
amongst heterosexuals, representing 10% of the 1,200 members of one ‘uncirc’
organization (cf. 80% homosexual and 10% bisexual), with 65% uncircumcised, 30%
circumcised, and 5% partially circumcised. Although many were happy with the
result (thus justifying to themselves the decision to undertake this ordeal),
others disliked their new genital status, even choosing to undergo
recircumcision
Benefits
outweigh the risks
Dr Tom Wiswell,
a respected authority in the USA was a strong opponent, but then switched camps
as a result of his own research findings and the findings of others. This is
what he has to say: "As a pediatrician and Neonatologists, 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" This ability
to keep an open mind on the issue and to make a sound judgment on the balance of
all available information is to his credit — he did change his mind!
Wiswell looked
at the complication rates of having or not having it performed in a study of
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, but of the 36,000
who were not circumcised the complication rate was 0.24% and there were 2 deaths
A study by others found that of the 11,000 circumcisions performed at New York’s
Sloane Hospital in 1989, only 6 led to complications, none of which were fatal
An early survey saw only one death amongst 566,483 baby boys circumcised in New
York between 1939 and 1951 (There are no deaths today.)
A retrospective
study of boys aged 4 months to 12 years found significantly greater frequency of
penile problems (14% vs 6%; P < 0.001) and medical visits for penile
problems (10% vs 5%; P < 0.05) among those who were uncircumcised,
compared with those who were circumcised
Pain and
memory
No adverse
psychological aftermath has been demonstrated It must be recognized that there
are many painful experiences encountered by the child before, during and after
birth Circumcision, if performed without anaesthetic is one of these. Cortisol
levels have registered an increase during and shortly after the procedure
indicating that the baby is not unaware of having had something painful done in
its unanaesthetized state. Nevertheless, some babies show no signs of distress
at all. Most do, however, and this may be contributed by the restraining
procedure, as well as the surgery itself. In the past doctors and parents had 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. However, today,
effective anaesthetic procedures are available that make circumcsion virtually
pain-free. These will be discussed later.
Penile
hygiene
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. Studies of middle class British and Scandanavian schoolboys
concluded that penile hygiene, as such, is at best poor and at worst
nonexistant. Furthermore, Dr Terry Russell, an Australian medical practitioner
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)’ The bacteria start
multiplying again immediately after washing and contribute, along with skin
secretions, to the whitish film, termed ‘smegma’, that is found under the
foreskin. Bacteria give off an offensive odor. Men differ in their sensitivity
to this smell and some shower several times a day as a result. Some
uncircumcised men, and/or their partners, find the stench so unpleasant that
this smell has caused these men to seek a circumcision on this basis alone. For
mothers and fathers, it is far easier to maintain cleanliness of their son’s
penis if it is circumcised. If their son isn’t the messages are confusing:
should they clean under the foreskin or leave it alone?
What
motivates parents to get their baby boy circumcised and the rates
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
suggested by the researchers as ‘to be like dad’ or a preference of one or both
parents for whatever reason The main reason may have more to do with hygiene and
appearance, as will be discussed later in the section on socio-sexual aspects.
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, South Australia, 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. Rates in Africa,
Asia and India vary according to religion and cuture, with higher rates amongst
Muslims and certain tribes and low rates amongst other groups and nations. In
the USA, as indicated above, the rate of circumcision has always been high,
although differs in different regions: the rates for 1991, 1992, 1993 and 1994
in the northeast region were 62%, 68%, 65% and 70%, in each respective year; for
the midwest they were 78%, 78%, 74% and 80%, respectively; for the southern
region: 64%, 63%, 61% and 65%; and for the western region: 41%, 38%, 36% and 34%
The actual rates are higher than indicated by this data, as they represent only
the numbers reported, whereas not all are Even when they are supposed to be,
they are often not listed on the medical record face sheet used in NCHS surveys,
so that when the oversights were corrected in one study, infant circumcision
rate increased from 75% to 89%
In Canada the
rate varies markedly between different regions. Even in the same province,
Ontario, for example, the rate between different districts ranges from 2% to
70%, with a mean of around 50%. (Data from Ontario Ministry of Health and
Statistics Canada, and Institute for Clinical Evaluative Sciences.)
Physical
problems
Phimosis(inability to retract the foreskin) is normal in very young boys, but is
gone by age 3 in 90%. If still present after age 6 it is regarded as a problem
and affects 2-10% of uncircumcised males. The narrow foreskin opening causes
urinary obstruction that can be partial or complete. Backward pressure to the
kidney may impede its function and lead to high blood pressure, which is
associated with increased risk of heart attack to stroke.
Paraphimosis (where the
retracted foreskin cannot be brought back again over the glens) is a very
painful problem, relieved by circumcision or slitting the dorsal surface of the
foreskin.
To pediatrics
surgeons, the most obvious medical reasons for circumcision are balanitis
(inflammation of the glens) and posthitis (inflammation of the foreskin), which
are very painful conditions virtually limited to uncircumcised males. In babies,
banalities is caused by soiled diapers, playing and sitting in dirty areas,
antibiotic therapy, as well as yeast and other micro-organisms. The incidence of
banalities is twice as high in uncircumcised boys and is greater than 5-fold
higher in uncircumcised adults Banalities caused by the group A
haemolytic variety of streptococcus is present exclusively in uncircumcised
Balanoposthitis (inflammation of the foreskin and glens) is common in
uncircumcised diabetic men owing to a weakened, shrunken penis and such men also
have more intercourse problems. Diabetes is common and inherited, so a family
history of this disease may add to considerations about whether to circumcise at
birth.
The foreskin of
uncircumcised boys can become accidentally entrapped in zippers, resulting in
pain, trauma, swelling and scarring of this appendage.
In elderly men,
infections and pain from balanoposthitis, phimosis and paraphimosis are seen and
carers report problems in achieving optimal hygiene in uncircumcised men. The
need for an appliance for urinary drainage in quadraplegics and in senile men is
facilitated if they are circumcised. Boys and men who are not circumcised can be
a source of irritation if they do not retract the foreskin when they urinate, as
‘splatter’ will occur. Although not a medical problem, it is a source of
annoyance for other people (such as a parent or partner) if it is they that have
the job of cleaning the bathroom. Foreskin problems also mean intercourse is
painful.
Another
condition, Frenular chordee, results from an unusually thick and often
tight frenulum and prevents the foreskin from fully retracting, being present in
a quarter of all uncircumcised males The frenulum then tears during intercourse
or masturbation. Since scar tissue is generally more fragile and less elastic
than normal tissue, the tear often reoccurs causing pain, bleeding and the
inability to have sexual relations. This problem can be solved by excising the
frenulum during a circumcision. Frenoplasty (removing just the tight frenulum)
is also possible.
Follow-up 5
years later of 117 boys circumcised for phimosis, balanitis scarring of the
prepuce, or ballooning when urinating found that 95% expressed complete
satisfaction and the only psychological effect was slight shyness in the school
change-room in 9% of boys in this Swedish study The study showed that parents
had nothing to fear for their son’s psychological well-being from circumcision.
Neonatal
urinary tract infections
In 1982 it was
reported that 95% of UTIs in boys aged 5 days to 8 months were in uncircumcised
infants This was confirmed by Wiswell and a few years later Wiswell and
colleagues found that in 5,261 infants born at one US Army hospital, 4% of UTI
cases were in uncircumcised males, but only 0.2% in those who were circumcised
Wiswell then went on to examine the records for 427,698 infants (219,755 boys)
born in US Armed Forces hospitals from 1975-79 and found that the uncircumcised
had an 11-fold higher incidence of UTIs 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 Reviews by others in the mid-80s
concluded there was a lower incidence in circumcised boys The rate in girls was
stable during the period it was increasing in boys, in whom circumcision was in
a decline. In a 1993 study by Wiswell of 209,399 infants born between 1985 and
1990 in US Army hospitals world-wide, 1046 (496 boys) got UTI in their first
year of life The number was equal for boys and girls, but was 10-times higher
for uncircumcised boys. Among the uncircumcised boys younger than 3 months, 23%
had bacteraemia, caused by the same organism responsible for the UTI. It should
be noted that these studies gave figures for infants admitted to hospital for
UTI, so that the actual rate would undoubtedly have been higher. The infection
can travel up the urinary tract to affect the kidney and a higher rate of
problems such as pyelonephritis and renal scarring (seen in 7.5% is reported in
uncircumcised children These and other reports [e.g., all point to the benefits
of circumcision in reducing UTI.
Indeed, Wiswell
performed a meta-analysis of all 9 studies that had been published up until 1992
and found that every one had found an increase in UTI in the uncircumcised The
average was 12-fold higher and the range was 5 to 89-fold, with 95% confidence
intervals of 11-14 Meta-analyses by others have reached similar conclusions.
In Australia, a
relatively small study in Sydney involving boys under 5 years of age (mean 6
months) found that 6% of uncircumcised boys got a UTI, but only 1% of
circumcised
The benefit
appears to extend beyond childhood and into adult life. In a study of men aged,
on average, 30 years, and matched for race, age and sexual activity, the
circumcised had a lower rate of UTI
The fact that
fimbriated strains of the bacterium Escherichia coli which are pathogenic
to the urinary tract and pyelonephritogenic, have been shown to be capable of
adhering to the foreskin, satisfies one of the criteria for causality Thus in
infancy and childhood the prepuce becomes colonized with bacteria. Fimbriated
strains of Proteus mirabilis, non-fimbriated Pseudomonas, as well
as species of Klebsiella and Serratia also bind closely to the
mucosal surface of the foreskin within the first few days of life Circumcision
prevents such colonization and subsequent ascending infection of the urinary
tract
A recent report
found that swabs were taken of the per urethral area (the region of the penis
where urine is discharged) in 46 circumcised and 125 uncircumcised healthy males
(mean age = 27; range = 2 to 54 years) showed a predominance of Gram positive
cocci in both groups, facultative Gram negative rods in 17% of uncircumcised
males, but in only 4% of circumcised (P = 0.01); streptococci, strict
anaerobes (bacteria that can grow without oxygen) and genital mycoplasms
(bacteria that lack a cell wall) were found almost exclusively in uncircumcised
males over the age of 15 years (82% of the study group) Since these organisms
are common inhabitants of the female genital tract, acquisition via sexual
transmission was suggested. These latter categories of bacteria, unlike the Gram
positive cocci, are potential pathogens capable of causing UTIs. It was
speculated that when Gram negative organisms are the only colonizers of the
preputial space they achieve higher concentrations and that the quantitative
difference may contribute to the development of UTI. The findings of this study
provide a microbiological basis for the observed higher risk of UTI in
uncircumcised adult men. The authors also concluded that their results pointed
to a role for the prepuce as a reservoir for sexually transmitted organisms
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 not performing circumcision would appear to be far less effective than
having it done in the first instance
Sexually-transmitted diseases
In 1947 a study
of 1,300 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 Work in the mid-70s showed higher chancroid, syphilis,
papillomavirus and herpes in uncircumcised men At the University of Western
Australia a 1983 study showed twice as much herpes and gonorrhea, 5-times more
candidacies and 5-fold greater incidence of syphilis Others have reported higher
rates of nongonococcal urethritis in uncircumcised men In South Australia a
study in 1992 showed that uncircumcised men had more Chlamydia (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 gonorrhea in
uncircumcised men, but no difference in herpes, Chlamydia and non-specific
urethritis (NSU). Like this report, a study in 1994 in the USA, found higher
gonorrhea and syphilis, but no difference in other common STDs 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 They found no difference in genital herpes, NSU, seropositivity for
HSV-2 and genital warts (i.e., the benign, so-called ‘low-risk’ human
papillomavirus types 6 and 11, which are visible on physical examination, unlike
the ‘high-risk’ types 16 and 18, which are not). 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 other STDs. Similar findings
were obtained in the National Health and Social Life Survey in the USA, which
asked about gonorrhea, syphilis, Chlamydia, nongonoccocal urethritis, herpes and
HIV (which is more often acquired intravenously) although some under-reporting
by uncircumcised men was likely as they tended to be less educated. Also,
circumcision at birth was assumed, so that the number who sought circumcision
later in life for problems, such as STDs and/or other infections, and therefore
had switched group, was not taken into account. Design aspects of a number of
the studies have in fact been criticised. As a result there is still no
overwhelming agreement. Nevertheless, on the bulk of evidence it would seem that
at least some STDs could be more common in the uncircumcised, but this
conclusion is by no means absolute in western settings, and the incidence may be
influenced by factors such as the degree of genital hygiene, availability of
running water and socioeconomic group being studied. In some more recent studies
in developed nations, in which hygiene is good, no difference was apparent.
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% 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. Thus 1 in 100,000 per year of life
translates to 75 in 100,000 during each man’s lifetime, but since it occurs
almost entirely in uncircumcised men, if we assume that these represent 30% of
males in the USA, the chance an uncircumcised man will get it would be 75 per
30,000 = 1 in 400. In a study in Melbourne in 1990, although 60% of affected men
were over 60 years of age, 40% were under 60 In 5 major series in the USA since
1932 not one man with penile cancer had been circumcised neon tally i.e., this
disease is almost completely confined to uncircumcised men and, less commonly,
in those circumcised after the newborn period. In fact penile cancer is so rare
in a circumcised man, that when it does occur it can be the subject of a
published case report [60]. The finite residual risk in those circumcised after
the newborn period is the major contributing factor to estimates of lifetime
risk in the total population of circumcised men of 1 in 50,000 to 1 in
12,000,000 Overall there have been 50,000 cases of penile cancer in the USA
since the early 1930s and these resulted in 10,000 deaths. Only 10 of these
cases were in circumcised men and, as indicated, these had been circumcised
later in life. The predicted life-time risk for an uncircumcised man has been
estimated as 1 in 600 in the USA and 1 in 900 in Denmark In Denmark
(circumcision rate = 2%), penile cancer has been decreasing steadily [39] in
parallel with an increase in indoor b bathrooms. Urban unmarried men were more
likely to get it. Since the rate of penile cancer in Denmark is lower than in
the USA other factors besides circumcision are also at work in these
climatically, genetically and culturally different countries. The statistics for
Denmark have been used by anti-circs to draw a sweeping and fallacious
conclusion about lack of circumcison per se in penile cancer. The Danish
themselves have concluded that although their uncircumcised men are at lower
risk, this is only 1 in 900 as opposed to 1 in 600 in the USA, as stated above
In
underdeveloped countries the incidence is higher: approx. 3-6 cases per 100,000
per year In those underdeveloped countries where circumcision is not routinely
practiced it can be ten times more common than in developed countries,
representing 11% to 12% of all male cancers In Uganda it is the most common
malignancy in males, leading to calls for greater circumcision in that country
In Australia,
figures from the New South Wales Cancer Council (for 1993) show 28 cases per
year (including one in a child), with 5 deaths, which is similar to the 1 in
100,000 figure above and applies to a population in which the majority of the
older men are circumcised. The rate could be set to escalate, however, as more
of the males who were not circumcised during the period after the mid 1970s
reach the ages when this cancer generally begins to appear.
The so-called
‘high-risk’ human 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 penile cancer as is true for most, if not all,
cases of cervical cancer (see below). HPV 16 and 18 are, moreover, more common
in uncircumcised males 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 93% of men whose female partner was
positive for early signs of cervical cancer (cervical intraepithelial neoplasia,
CIN) had the male equivalent, penile intraepithelial neoplasia (PIN) Oncogenic
HPV was present in 75% of patients with PIN grade I, 93% with PIN grade II and
100% of PIN grade III, which is one step before penile cancer itself Moreover,
the rate of PIN was 10% in uncircumcised men cf. only 6% in circumcised men
Other factors, such as smoking, poor hygiene and other STDs have been suspected
as contributing to penile cancer as well but it would seem that lack of
circumcision is the primary prerequisite, with such other factors adding to the
risk in the uncircumcised man. Financial considerations are, moreover, not
inconsiderable. In the USA it was estimated that the cost for treatment and lost
earnings in a man of 50 with cancer, even in 1980, was $103,000 The amount today
is very much higher.
In Australia
between 1960 and 1966 there were 78 deaths from cancer of the penis and 2 from
circumcision. (Circumcision fatalities today 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 It would thus seem that
"prevention by circumcision in infancy is the best policy". Indeed it would be
an unusual parent who did not want to ensure their child was completely
protected by this simple procedure.
Prostate
cancer
Prostate cancer
accounts for 27% of new cancers in males and 7% of deaths Uncircumcised men have
twice the incidence of prostate cancer compared with circumcised and this cancer
is rare amongst Jews No association has been seen between rate of prostate
cancer and rate of cervical cancer in different geographic localities However,
in a study of 20,243 men in Finland, infection with HPV18 was associated with a
2.6-fold increase in risk of prostate cancer (P < 0.005) For HPV16 the
increased risk was 2.4-fold.
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. Premarital sex is uncommon in the various religious groups in India
and surrounding countries. In a study of 5,000 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 In a case-control study of 1,107 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
Another study published in 1993 concerning various types of cancer in the Valley
of Kashmir concluded that universal male circumcsion in the majority community
was responsible for the low rate of cervical cancer compared with the rest of
India In Israel, a 1994 report of 4 groups of women aged 17-60 found that Moshav
residents with no gynaecological complaints had no HPV 16/18 and healthy Kibbutz
residents had a 1.8% incidence Amongst those who had a gynaecological complaint
HPV 16/18 was found in 9% of Jewish and 12% of non-Jewish women. Thus the
causative agent (high-risk HPV) can be found in Jewish women. The source of this
(circumcised vs. uncircumcised partners) was not explored.
So-called
‘high-risk’ HPV types 16, 18 and some rarer forms are responsible for virtually
every case cervical of cervical cancer These same high-risk HPVs also cause
penile intraepithelial neoplasia (PIN). In a study published in the New
England Journal of Medicine in 1987 it was found that women with cervical
cancer were more likely to have partners with PIN, the male equivalent of
cervical intraepithelial neoplasia (CIN) A study in 1994 found that in women
with CIN, PIN was present in the male partner in 93% of cases CIN may lead to
cancer or, more often, it goes away. Thus co-factors are suspected.
Interestingly, smegma (the film of bacteria, secretions and other material under
the foreskin), obtained from human and horse has been shown to be capable of
producing cervical cancer in mice in one study but not in another Thus the
epidemic of cervical cancer in Australia, and indeed most countries in the
world, would appear to be contributed, at least in part, by the uncircumcised
male and would therefore be expected to get even worse as the large proportion
of men 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 (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) 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 In 1990 Moses in the
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
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
Of 33
cross-sectional studies, 22 have reported statistically significant association
[e.g., by univariate and multivariate analysis, between the presence of the
foreskin and HIV infection (4 of these were from the USA). 5 reported a trend
(including 1 US study) The 6 that saw no difference were 4 from Rwanda and 2
from Tanzania. In addition there have been 5 prospective studies and 2 from
Kenya and 1 from Tanzania reported statistically significant association. The
increased risk in the significant studies ranged from 1.5 to 9.6. One study, in
1998 from Dar es Salaam, Tanzania, where most men are circumcised, noted that
married women, with one sex partner, had a 4-fold higher relative risk of HIV if
their husband was uncircumcised
The findings
have, moreover, led various workers, Moses and Caldwell included, to propose
that circumcision be used as an important intervention strategy in order to
reduce AIDS Such advice has been taken up, with newspaper advertisements from
clinics in Tanzania offering this service to protect against AIDS.
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 It was conducted in Nairobi. Rather than look at the existing
infection rate in each group, these workers followed HIV negative men until they
became infected. The men were visiting prostitutes, numbering approx. 1,000,
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 woo men with ulcers, where HIV-1 has been isolated
from surface ulcers in the genital tract of HIV-1 infected women. 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 may be a big risk factor, but there could be other
explanations as well.
It was
suggested that the foreskin could physically trap HIV-infected vaginal
secretions and provide a more hospitable environment for the infectious
inoculums. Also, the increased surface area, traumatic physical disruption
during intercourse and inflammation of the glens penis (balanitis) could aid in
recruitment of target cells for HIV-1. The port of entry could potentially be
the glens, sub prepuce and/or urethra. In a circumcised penis the drier,
cornified skin may prevent entry and account for the findings. The inner lining
of the foreskin is relatively ‘immune deficient’, with only 8 of the
immune-protective Langerhan’s cells per square millimetre in the uncircumcised
cf. 174 on the external surface of the foreskin, as for other exposed skin on
the penis and body in general
Studies in the
USA have not been as conclusive. Some studies have shown a higher incidence in
uncircumcised men But in one in New York City, for example, no significant
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
In an editorial
review in 1994 of 26 studies it was pointed out that more work was needed in
order to reduce potential biases in some of the previous data At least one study
since then has controlled for such potential confounding factors, confirming a
significantly lower HIV prevalence among circumcised men
The sorts of
health problems faced by the ‘third-world’, coupled with a lack of circumcision
may account for the rapid spread of HIV through Asia 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, could be related at
least in part to a difference in the type of HIV-1 itself In 1995 an article in
Nature Medicine discussed findings concerning marked differences in the
properties of different HIV-1 subtypes in different geographical locations 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 utilize 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 waiting to go off
and should be a major concern for health officials.
Sexual
transmission of HIV and other STDs would be reduced by use of barrier protection
such as condoms. Despite the campaigns, passion will over-ride compliance on
occasions in the most sexually promiscuous, at-risk group, who are at an age
when risk-taking behavior is prevalent (cf. smoking in young people vis-a-vis
the anti-smoking campaign), with tragic consequences. Many young people do not
use condoms and openly scoff at the idea, despite the health warnings. Indeed it
may be a sign of machismo to the young adult. Thus education is only part of the
answer and where an additional simple procedure is available to reduce the risk,
then logic dictates that it should be used. The result will be many lives saved.
Comment :
Islam mentions
nothing about circumcision girls . The circumcision only for boys