Medical Benefits from Circumcision
by Dr. Brian J. Morris
from Circ-Online
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:
- Is the biggest risk factor for heterosexually-acquired AIDS
virus infection in men (8-times higher risk by itself, and even
higher when lesions from STDs are added in). - Is responsible for a 12-fold higher risk of urinary tract infections.
- Carries a higher risk of death in the first year of life (from
complications of urinary tract infections: kidney failure, meningitis
and infection of bone marrow). - One in ~600-900 uncircumcised men will die from cancer of the
penis or require at least partial penile amputation as a result.
(In contrast, penile cancer never occurs in men circumcised
at birth). (Data from studies in the USA, Denmark and Australia,
which are not to be confused with the often quoted, but misleading,
annual incidence figures of 1 in 100,000). - Often leads to balanitis (inflammation of the glans), phimosis
(inability to retract the foreskin) and paraphimosis (constriction
of the penis by a tight foreskin). Up to 18% of uncircumcised
boys will develop one of these by 8 years of age, whereas all
are unknown in the circumcised. - Means problems that may result in a need for circumcision late
in life: complication risk = 1 in 100 (compared with 1 in
1000 in the newborn). - Is associated with higher incidence of cervical cancer in the
female partners of uncircumcised men.
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:
- 18% of uncircumcised males underwent circumcision later in life
anyway. - 21% of uncircumcised men who didn't, nevertheless wished they
were circumcised. (There were also almost as many men who wished
they hadn?t been circumcised and it could be that at least some
men of either category may have been seeking a scapegoat for their
sexual or other problems. In addition, this would no doubt be
yet another thing parents could be blamed for by their children,
whatever their decision was when the child was born.) - No difference in sexual performance (consistent with Masters
& Johnson). - Slightly higher sexual activity in circumcised men.
- No difference in frequency of sexual intercourse for older uncircumcised
vs. circumcised men. - Men circumcised as adults were very pleased with the result.
The local pain when they awoke from the anaesthetic was quickly
relieved by pain killers (needed only for one day), and all had
returned to normal sexual relations within 2 weeks, with no
decrease in sensitivity of the penis and claims of 'better
sex'. (Badger?s findings are, moreover, consistent with every
discussion I have ever had with men circumcised as adults. The
only case to the contrary was a testimonial in a letter I received
in the mail from a member of UNCIRC.) - Women with circumcised lovers were more likely to reach a simultaneous
climax. - Women with uncircumcised lovers were 3 times as likely to fail
to reach orgasm. (These data could, however, possibly reflect
behaviours of uncircumcised males that might belong to lower socio-economic
classes and/or ethnic groups whose attitudes may differ from groups
in which circumcision is more common.) - Circumcision was favoured by women for appearance and hygiene.
(Furthermore, some women were nauseated by the smell of the uncircumcised
penis, where, as mentioned above bacteria and other micro-organisms
proliferate under the foreskin.) - The uncircumcised penis was found by women to be easier to elicit
orgasm by hand. - The circumcised penis was favoured by women for oral sex.
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 |
- Agarwal SS, et al. Role of male behaviour
in cervical carcinogenesis among women with one lifetime sexual
partner. Cancer 1993; 72: 1666-9 - Australian College of Paediatrics. Policy statement
on neonatal male circumcision. 1995 - Aynaud O, et al. Penile intraepithelial
neoplasia - specific clinical features correlate with histologic
and virologic findings. Cancer 1994; 74: 1762-7 - Badger J. Circumcision. What you think.
Australian Forum 1989; 2 (11): 10-29 - Badger J. The great circumcision report part
2. Australian Forum 1989; 2 (12): 4-13 - Barrasso R, et al. High prevalence of
papillomavirus associated penile intraepithelial neoplasia in
sexual partners of women with cervical intraepithelial neoplasia.
N Engl J Med 1987; 317: 916-23 - Bongaarts J, et al. The relationship
between male circumcision and HIV infection in African populations.
AIDS 1989; 3: 373-7 - Brinton LA, et al. Risk factors for
penile cancer: results from a case-control study in China.
Int J Cancer 1991; 47: 504-9 - Caldwell JC, Caldwell P. The African AIDS epidemic.
Sci Am 1996; 274: 40-46 - Cameron BE, et al. Female to male transmission
of human immunodeficiency virus type 1: risk factors for seroconversion
in men. Lancet 1989; ii: 403-7 - Cook LS, et al. Circumcision and sexually
transmitted diseases. Am J Publ Health 1994; 84: 197-201 - Cox G. De virginibus Puerisque: The
function of the human foreskin considered from an evolutionary
perspective. Med Hypoth 1995; 45: 617-621 - Dagher R, et al. Carcinoma of the penis
and the anti-circumcision crusade. J Urol 1973; 110:
79-80 - Dahr GM, et al. Epidemiological trend
in the distribution of cancer in Kashmir Valley. J Epidemiol
Comm Hlth 1993; 47: 290-2 - Diallo MO, et al. HIV-1 and HIV-2 infections
in men attending sexually transmitted disease clinics in Abidjan,
Cote d?Ivoire. AIDS 1992; 6: 581-5 - Donovan B, et al. Male circumcision
and common sexually transmissible diseases in a developed nation
setting. Genitourin Med 1994; 70: - Fakjian N, et al. An argument for circumcision.
Prevention of balanitis in the adult. Arch Dermatol
1990; 126: 1046-7 - Fetus and Newborn Committee. Canadian Paediatric
Society. Neonatal circumcision revisited. Can Med Ass
J 1996; 154: 769-780 - Fink AJ. Newborn circumcision: a long-term
strategy for AIDS prevention. J Roy Soc Med
1990; 83: 673 - Gee WF, Ansell JS. Neonatal circumcision:
A ten-year overview, with comparison of the Gomco clamp and the
Plastibell device. Pediatrics 1976; 58: 824-7 - Ginsburg CM, McCracken GH. Urinary tract infections
in young children. Pediatrics 1982; 69: 409-12 - Galalakshmi CK, Shanta V. Association between
cervical and penile cancers in Madras, India. Acta Oncol
1993; 32: 617-20 - Hunter DJ. AIDS in sub-Saharan Africa: the
epidemiology of heterosexual transmission and the prospects of
prevention (Review). Epidemiology 1993; 4: 63-72 - Isacsohn M, et al. The inter-relationship
of herpes virus, papilloma 16/18 virus infection and Pap smear
pathology in Israeli women. Israel J Med Sci 1994;
30: 383-7 - Jessamine PG, et al. Human immunodeficiency
virus, genital ulcers and the male forskin: synergism in HIV-1
transmission. Scand J Infect Dis 1990 (suppl 69): 181-6 - Kirby PK, et al. The challenge of limiting
the spread of human immunodeficiency virus by controlling other
STDs. Arch Dermatol 1991; 127: 237-42 - Kochen M, McCurdy S. Circumcision and risk
of cancer of the penis. A life-table analysis. Am J Dis
Child 1980; 134: 484-6 - Kreiss JK, Hopkins SG. The association between
circumcision status and human immunodeficiency virus infection
among homosexual men. J Infect Dis 1993; 168: 1404-8 - Kunanusont C, et al. HIV-1 subtypes
and male-to-female transmission in Thailand. Lancet
1995; 345: 1078-83 - Lafferty PM, et al. Management of foreskin
problems. Arch Dis Childhood 1991; 66: 696-7 - Maden C, et al. History of circumcision,
medical conditions, and sexual activity and risk of penile cancer.
J Nat Canc Inst 1993; 85: 19-24 - Marx JL. Circumcision may protect against
the AIDS virus. Science 1989; 245: 470-1 - Moses S, et al: Geographical patterns
of male circumcision practices in Africa: association with HIV
seroprevalance. Int J Epidemiol 1990; 19: 693-7 - Moses S, et al: The association between
lack of male circumcision and risk for HIV infection: a review
of the epidemiological data. Sexually Transm Dis 1994;
21: 201-9 - Niku SD, et al. Neonatal circumcision
(review). Urol Clin N Am 1995; 22: 57-65 - Ohjimi H, et al. A new method for the
relief of adult phimosis. J Urol 1995; 153: 1607-9 - Osborne JE: HIV: The more things change, the
more they stay the same. Nature Med 1995; 1: 991-3 - Oster J. Further fate of the foreskin: incidence
of preputial adhesions, phimosis and smegma among Danish schoolboys.
Arch Dis Child 1968; 43: 200-3 - Parker SW, et al. Circumcision and
sexually transmissible diseases. Med J Aust 1983; 2:
288-90 - Pepin J, et al. Association between
HIV-2 infection and genital ulcer disease among male sexually
transmitted disease patients in The Gambia. AIDS 1992;
6: 489-93 - Prual A, et al. Sexual behaviour, AIDS
and poverty in Sub-Saharan Africa. Int J STD AIDS 1991;
2: 1-9 - Roberts JA. Does circumcision prevent urinary
tract infections? J Urol 1986; 135: 991-2 - Rushton HG, Majd M. Pyelonephritis in male
infants: how important is the foreskin? J Urol 1992;
148: 733-6 - Russell T. The case for circumcision.
Med Observer 1993 (1 Oct issue) - Sandeman TF. Carcinoma of the penis. Australasian
Radiol 1990; 34: 12-6 - Schlosberger NM, et al. Early adolescent
knowledge and attitudes about circumcision: methods and implications
for research. J Adolescent Hlth 1992; 13: 293-7 - Schoen EJ. The status of circumcision of newborns.
N Engl J Med 1990; 332: 1308-12 - Schoen EJ. Circumcision updated?implicated?
Pediatrics 1993; 92: 860-1 - Schoen EJ et al. AAP Task Force on
Circumcision. Report of the Task Force on Circumcision. Pediatrics
1989; 84: 388-91 - Simonsen JNM, et al. HIV infection
among men with STDs. N Engl J Med 1988; 319: 274-8 - Spach DH, et al. Lack of circumcision
increases the risk of urinary tract infections in young men.
J Am Med Assoc 1992; 267: 679-81 - Stull TL, LiPuma JJ: Epidemiology and natural
history of urinary tract infections in children (Review).
Med Clin N Am 1991; 75: 287-97 - Taylor PK, Rodin P. Herpes genitalis and circumcision.
Br J Ven Dis 1975; 51: 274-7 - Whittington WL, et al. HIV-1 in patients
with genital lesions attending a North American STD clinic: Assessment
of risk factors. Int Conf AIDS 1989; 5: 409 - Wilson RA. Circumcision and venereal disease.
Can Med Ass J 1947; 56: 54-6 - Wiswell TE. Do you favor routine neonatal
circumcision? Yes. Postgrad Med 1988; 84: 98-104 - Wiswell TE. Circumcision - an update.
Curr Problems Pediat 1992; 10: 424-31 - Wiswell TE, Geschke DW. Risks from circumcision
during the first month of life compared with those for uncircumcised
boys. Pediatrics 1989; 83: 1011-5 - Wiswell TE, Hachey WE. Urinary tract infections
and the circumcision state: an update. Clin Pediat
1993; 32: 130-4 - Wiswell TE, Roscelli JD. Corroborative evidence
for the decreased incidence of urinary tract infections in circumcised
male infants. Pediatrics 1982; 69: 96-9 - Wiswell TE, et al. Declining frequency
of circumcision: implications for changes in the absolute incidence
and male to female sex ratio of urinary tract infections in early
infancy. Pediatrics 1987; 79: 338-41 - Wiswell TE, et al. Effects of circumcision
status on periurethral bacterial flora during the first year of
life. J Paediat 1988; 113: 442-6
