There is a divinity that shapes our ends
Rough-hew them how we will. - Shakespeare
It is currently fashionable to counsel parents against routine neonatal circumcision as an unnecessary operation. 1
There has been a strong, vocal, and emotive anti-circumcision movement which promulgated highly emotive reports using terminology such as "penile plunder" and "rape of the phallus", 2,3 Morgan's article "Rape or the Phallus", which is credited with starting the anti-circumcision crusade, contains nothing of substance.
As a result of that uninformed crusade there has been an undoubted trend against routine neonatal circumcision with decreasing rates of circumcision reported in the US, Canada and Australia, 4,5,6,7,31,48. That trend has been reversed over the last ten years.
Anyone could be forgiven for feeling that it is no longer ethical to circumcise neonates. However, the evidence of the benefits of neonatal circumcision is now so strong that is may be unethical or even negligent not to recommend circumcision.
There are medical benefits of neonatal circumcision in reducing the risks of :
- Peri-urethral bacterial colonisation 8
- Neonatal urinary tract infection, septicaemia, meningitis, renal failure and death 7,8,9,10,11
- Phimosis and balanoposthitis 1,12,13,14
- Carcinoma of the penis 15,16,17,18,19
- Gonorrhoea 20,21
- Syphilis 20,21
- Herpes genitalis 20,22
- HIV and AIDS 23,24,25,26,27,28,29,30
- Later circumcision with anaesthetic risks 31
In addition to the original papers on each of the above, several authors have summarised the state of our knowledge regarding non-circumcision and the acquisition or transmission of disease.
Edgar J Schoen, chairman of the American Academy of Pediatrics multidisciplinary task force on circumcision (1988), concludes his summary by saying : "The benefits of routine circumcision of newborns as a preventive health measure far exceed the risks of the procedure."
Dr Gavin Hart, director of the South Australian STD Control Branch, writes: "The benefits of neonatal circumcision are substantial and have been underestimated in the past." 35
A review of 136,086 boys born in US army hospitals from 1980 - 1985 showed that of 100,157 who were circumcised, 193 had complications (0.19%). There were no deaths.
By contrast, the 'complication' rate among the 35,929 who were not circumcised was 0.24%, and included two (2) deaths. 36
Another review of 10,802 neonatal circumcisions at New York's Sloane Hospital found only six (6) complications, none of which was fatal. 37
It is often argued by the anti-circumcision lobby that the benefits of circumcision can be achieved by "penile hygiene" - thus acknowledging that something harmful may be going on under the prepuce. 1
That such benefits are unlikely to be achieved by "penile hygiene" was shown by a study of British school boys, which showed that "penile hygiene" as such just does not exist. 41
And even it did, 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)?
Neonatal UTI
Wiswell et al reported from a study of 300 male children (150 uncircumcised) that uncircumcised boys had significantly higher total colony counts of uro-pathogenic bacteria at all ages prior to 12 months. 8
Neonatal UTI is more frequent in uncircumcised male infants than in females and more frequent in females than in circumcised male infants. 3,9
Wiswell et al reporting on 427,698 infants born in US army hospitals worldwide in the ten years 1975 to 1984 found that uncircumcised boys had a greater than 11-fold increase in urinary tract infection compared with circumcised boys. From 1975 to 1984 the frequency of circumcision fell from 84 to 74% and the incidence of urinary tract infection fell in the circumcised, but rose in the uncircumcised. 7
Another large series is summarised by Roberts, who found : "Urinary tract infection occurred in 4.12% of uncircumcised male infants compared to 0.4% of female infants and only 0.21% of circumcised male infants." Uncircumcised boys had a 20-times greater risk of UTI. 11
Carcinoma of the penis
The wait-and-see approach will not prevent carcinoma of the penis, which is virtually unknown in those circumcised at birth, and more common in Muslims circumcised at puberty, but almost exclusively confined to the uncircumcised 8. 1,36,37
"There are 750-1,000 cases of penile cancer annually in the United States; however, over a period of 20 years only three cases of penile cancer were reported in men who had been circumcised as newborns."33 writes Schoen.
Dagher et al reported on 156 patients with carcinoma of the penis treated at University of Michigan Medical Center. All were uncircumcised. At least a third of Dagher's series died as a result of the disease. 15
Hardner et al reported a series of 100 cases. All were uncircumcised. 16 Riveros et al reported on their series of 265 cases. All were uncircumcised.17
The American Academy of Pediatrics Task Force 1989 looked at five major reported series since 1932 and not one victim of penile cancer had been circumcised neonatally. 46
Swadey described a report of 15 cases of penile carcinoma arising in circumcision scars in Saudi Arabia - but all had been circumcised as teenagers, as is the custom.42
In Australia there were 78 deaths from carcinoma of the penis between 1960 and 1966; in the same period there were two recorded deaths from circumcision. 31
The anti-circumcision movement has claimed that cancer of the penis is a rare, relatively benign and easily treated condition, whilst decrying circumcision as a dangerous procedure. How do they reconcile that stance with the facts?
STDs
A study of 1,304 consecutive patients in a Candian army centre and comparison with a control group of 1,000 recruits showed that the uncircumcised had nine times greater risk of syphilis and almost three times greater risk of gonorrhoea. 43
Parker et al of the department of medicine, University of Western Australia, reported that "uncircumcised men are twice as likely as circumcised men to develop herpes genitalis or gonorrhoea, and five times more likely to develop candidiasis or syphilis".20
HIV and AIDS
The Most noteworthy and under-publicised findings in recent times relate to the relationship between lack of circumcision and the acquisition of HIV infection by heterosexual intercourse.
Simonsen et al reported on the heterosexual transmission of HIV among 240 men attending an STD clinic in Nairobi. Of these, 11.2% were seropositive for HIV. Men who were uncircumcised were 2.7 times more likely to have HIV infection. Uncircumcised men were more frequently infected with HIV, regardless of history of genital ulcers. Additionally, uncircumcised men had a history of genital ulcer disease more frequently than circumcised men. 23
William Cameron et al reported on 422 men who had acquired HIV from prostitutes; 2.2% of circumcised men seroconverted after one (1) exposure compared with 18.5% of uncircumcised men who became HIV-positive after a single exposure. 24
Marx summarised the African findings by stating: "They found that uncircumcised men ran a greater risk of becoming infected with the AIDS virus whether or not they had genital ulcers." A further study was done prospectively; men who were not infected by the AIDS virus were followed until they became infected. In both studies, lack of circumcision alone increased the likelihood of AIDS infection some five to eightfold. 29
Marx speculates on how lack of circumcision contributes to AIDS virus susceptibility: "One possibility suggested is that the presence of an intact foreskin provides a warm, moist environment that allows a longer time for viral survival and penetration."
He also points out that the circumcised penis develops a cornified covering similar to the skin elsewhere on the body, which may protect if from the microabrasions which facilitate AIDS virus entry.
Additionally, he said the foreskin itself is also subject to trauma during intercourse. 29
Bongaarts et al examined anthropological literature regarding circumcision practices for 409 African ethnic groups to determine whether circumcision practices play a role in explaining the large existing variation in the sizes of African HIV epidemics. The correlation between HIV infection and lack of circumcision in 37 African countries was high. 27
Fink states "When the probability (P being less than 0.001) is that circumcision is a beneficial factor in lowering the risk of acquiring an ongoing fatal disease, then the burden of proof must reasonably shift to proponents claiming those practices as important confounding correlates. This belief becomes even more persuasive when a prospective study by epidemiological experts reveals an eight times greater risk of HIV infection with lack of circumcision rising to a 43% seroconversion rate when associated with genital ulcer after only a single sexual exposure to an infected consort." 28
Increased Risk
Finally, the wait-and-see approach to circumcision exposes the child to the greater risks (including anaesthetic) attendant on later circumcision. Leitch reported on 200 circumcisions performed at the Adelaide Children's Hospital for various indications.31 The mean age of the patients was 28 months; the incidence of complications was 15.5%. Additionally, research work points to greater pain and psychological trauma the later the circumcision is performed.32
Katz has carefully studied this issue and concluded that in infants up to three (3) weeks of age, the pain and irritability that result from circumcision are restricted to immediate time of surgery. 44
At this time (1993) search of the literature leaves a few loose ends: What of Chlamydia and its acquisition or transmission - is lack of circumcision a risk factor? What of hepatitis B and the uncircumcised state? Will circumcision reduce the risk? And what of genital warts and the human papilloma virus?
Conclusion
The circumcision debate has now come full circle. The American Academy of Pediatrics committee on the foetus and newborn (1971) stated : "There are no valid medical indications for circumcision in the neonatal period."
The 1975 AAP task force on circumcision modified that to : "There is no absolute medical indication for routine circumcision of the newborn."
The 1987 AAP task force (reporting in 1989), however, found: "New evidence has suggested possible medical benefits from newborn circumcision." 46
In 1990 Edgar J Schoen, chairman of the 1987 task force, concluded : "The benefits of routine circumcision of newborns as a preventive health measure far exceed the risks of the procedure". 33
The evidence gathered is now so strong that Wiswell published this statement: "As a paediatrician 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." 1
* References on request