Medical analysis of circumcision

Current US medical opinion about circumcision is highly controversial. All major medical groups now no longer recommend, and some even discourage, routine infant circumcision (see below), because the risks are either perceived greater than the benefits (if any), or the benefits are not believed to have been sufficiently substantiated, or to be too small to justify recommending an invasive procedure.

There are a number of circumstances where doctors sometimes recommend circumcision. An overtight foreskin can cause problems in sex, as the foreskin may become trapped behind the glans of the penis and restrict blood flow (paraphimosis). Circumcision is the recommended remedy for this condition, which typically arises in teenagers experimenting with sex. It can be treated by a program of stretching and use of topically applied steroid creams, but this is generally considered less effective and risks later relapse[?]. As a result, in the NHS of the U.K. it is only recommended to patients who wish to retain their foreskin for religious or sexual reasons. A newer, experimental, procedure is minor surgery to make a small slit in the foreskin without removing any tissue.

The use of circumcision to treat phimosis has been criticised; Rickwood et al. write in their 2000 paper "Towards evidence based circumcision of English boys" in the British Medical Journal [1] (http://bmj.com/cgi/content/full/321/7264/792):

Too many English boys, especially those under 5 years of age, are still being circumcised because of misdiagnosis of phimosis. What is phimosis? At birth, the foreskin is almost invariably non-retractable, but this state is transient and resolves in nearly all boys as they mature. Such normality, with an unscarred and pliant preputial orifice, is clearly distinguishable from pathological phimosis, a condition unambiguously characterised by secondary cicatrisation of the orifice, usually due to balanitis xerotica obliterans. This problem, the only absolute indication for circumcision, affects some 0.6% of boys, peaks in incidence at 11 years of age, and is rarely encountered before the age of 5. (...) Strictly, only some 0.6% of boys with pathological phimosis need to be circumcised, although more relaxed criteria would allow for a similar proportion affected by recurrent balanoposthitis.

Table of contents 1 Circumcision and cancer 2 Circumcision and Urinary Tract Infection[?] (UTI) 1 Circumcision and HIV/AIDS 1.1 Medical complications of circumcision 2 Long term effects of circumcision 2.1 Statements by health groups

Circumcision and cancer

Early studies by circumcision advocates have found a reduced risk of penile cancer[?] in circumcised males, or that their mates had a lower risk of cervical cancer; these conclusions are, however, no longer fully accepted. The idea that circumcision prevents penile cancer was first stated by Dr. Abraham Wolbarst in The Lancet (1932;1:150-3). According to Dr. Khalid Aziz of the Canadian Pediatric Society[?], Wolbarst

"was a prominent and influential member of the American Society of Sanitary and Moral Prophylaxis, an organization dedicated to stamping out sexual immorality. Besides the article on penile cancer, his legacy includes an opinion piece calling for sterilization of adult masturbators, and a study purporting to show that circumcision prevents epilepsy." [2] (http://www.courtchallenge.com/letters/aziz1)

Modern papers which claim a reduction in penile cancer still reference, but do not rely on Wolbarst's research. Modern studies rely on controlled medical studies. Some writers not doing original controlled medical studies still rely on Wolbarst's work, even though his research has been superseded by better studies. This tendency has been criticized by medical professionals who oppose the practice. For example, Paul M. Fleiss and Frederick Hodges[?] wrote in a 1996 letter to the British Medical Journal in response to a recent paper on circumcision that relied on Wolbarst [3] (http://bmj.com/cgi/content/full/312/7033/779/c):

Wolbarst invented this myth and was directly responsible for its proliferation; he based it on unverifiable anecdotes, ethnocentric stereotypes, a faulty understanding of human anatomy and physiology, a misunderstanding of the distinction between association and cause, and an unbridled missionary zeal. It was not based on valid scientific and epidemiological research.

Epidemiological studies disproved Wolbarst's myth long ago. In North America the rate of penile cancer has been estimated to be 1 in 100000 (...). Maden et al. reported penile cancer among a fifth of elderly patients from rural areas who had been circumcised neonatally and had been born at a time when the rate of neonatal circumcision was about 20% in rural populations. Their study also shows that the rate of penile cancer among men circumcised neonatally has risen in the United States relative to the rise in the rate of neonatal circumcision.

The American Cancer Society[?] notes in a 1998 statement [4] (http://www.cancer.org/docroot/nws/content/nws_1_1x_misleading_information.asp) that "the practice of circumcision is strongly associated with socio-ethnic factors, which in turn are associated with lessened risk. The consensus among studies that have taken these other factors into account is circumcision is not of value in preventing cancer of the penis."

Those who believed circumcision to prevent penile cancer proposed smegma as a causative agent, however, as of 1963, it was conclusively proven that smegma is not carcinogenic (by injecting it into animal wounds). Lastly, circumcision itself is not a riskless procedure, so its risks have to be compared to those of penile cancer. In the United States there are more annual fatalities from circumcision complications than from penile cancer [5] (http://www.cirp.org/library/general/gellis1/), and this simple comparison does not take into account that there remains at least some (if not the entire) risk of penile cancer after the procedure. No statistically significant difference in the incidence of penile cancer has been found between nations that circumcise and those that do not.

The claim that circumcision reduces the incidence of cervical cancer in female partners was first put forward by Wynder et al. in 1954, but later relativated because female subjects gave incorrect information about the circumcision status of their partners (even a substantial number of males in the US fail to properly identify their circumcision status). Stern and Neely disproved the hypothesis in 1962 [6] (http://www.cirp.org/library/disease/cancer/stern1/).

Circumcision and Urinary Tract Infection[?] (UTI)

Infections of the urinary tract (kidneys, ureters, bladder and urethra) can lead to kidney damage if undetected, but can generally be treated effectively with antibiotics. Recent studies find a three to seven times increased risk of uncircumcised UTIs in male infants within the first year of life. A 1998 Canadian population based cohort study by To et al. [7] (http://www.cirp.org/library/disease/UTI/to2/), for example, reported a relative risk of 3.7. The overall incidence of UTIs in infants was low, 1.88 and 7.02 per 1000 respectively.

These studies have been extensively criticized for their methodology. The American Academy of Pediatrics[?] noted in its 1999 circumcision policy statement:

Few of the studies that have evaluated the association between UTI in male infants and circumcision status have looked at potential confounders (such as prematurity, breastfeeding, and method of urine collection) in a rigorous way. For example, because premature infants appear to be at increased risk for UTI, the inclusion of hospitalized premature infants in a study population may act as a confounder by suggesting an increased risk of UTI in uncircumcised infants. Premature infants usually are not circumcised because of their fragile health status. In another example, breastfeeding was shown to have a threefold protective effect on the incidence of UTI in a sample of uncircumcised infants. However, breastfeeding status has not been evaluated systematically in studies assessing UTI and circumcision status. [8] (http://www.aap.org/policy/re9850)

UTI is usually detected through urine tests. Depending on the method of urine collection, there is a varying risk of false positives through contamination. The bacteria detected may in fact come from the foreskin itself, not the urinary tract. In spite of this, an increased risk of UTI in uncircumcised males is generally considered plausible, a higher likelihood of bacterial colonization being the proposed mechanism.

However, studies of UTI and circumcision do not classify groups of circumcised males according to their mothers' handling of the foreskin, making it impossible to infer any link with specific hygienic practices. It is generally recommended not to retract the foreskin of an infant during hygiene [9] (http://www.cirp.org/library/normal/aap/). Hodges and Fleiss claim that "it has been proven that retraction and washing of the infant foreskin can cause urinary tract infections by irritating the mucous membranes and destroying the naturally occurring beneficial flora which protects against pathogens."

If circumcision does indeed reduce the incidence of UTIs, To et al. estimate that 195 circumcisions would be needed to prevent one hospital admission for UTI in the first year of life.

Circumcision and HIV/AIDS

In 1986 Aaron J. Fink[?], a circumcision advocate, proposed that circumcision might prevent the distribution of AIDS. He hypothesized that the keratinization of the circumcised penis might prevent HIV infection. Other researchers soon investigated the question whether there is a link between circumcision and HIV infection rates.

After more than 40 studies, the evidence has remained largely inconclusive. Several studies of African populations found a significantly reduced risk of HIV transmission in circumcised males. At least 16 studies found no statistically significant link between circumcision and HIV transmission, and four studies found an increased risk in circumcised males. [10] (http://www.circumstitions.com/HIV)

This ongoing research has been extensively methodologically criticized. The main criticism is that past studies have ignored substantial confounding variables. Perhaps most notably, most studies have not controlled for different socio-sexual behaviors. In their meta-analysis of related studies [11] (http://www.cirp.org/library/disease/HIV/vincenzi/), Vincenzi and Mertens note that "circumcision is not performed randomly". Circumcision in central Africa is primarily a Muslim practice, and Islam requires ritual washing, marital fidelity and periodic abstinence from sex. Similar relationships have been found in other cultures that practice male circumcision [12] (http://violence.de/prescott/truthseeker/genpl). In addition, in many studies, the circumcision status of subjects has not been directly verified. The authors of the meta-analysis conclude that there is not sufficient evidence for a link between circumcision and HIV transmission. Similarly, Van Howe in another 1999 meta-analysis concludes that "the recommendation to routinely circumcise boys in Africa is unfounded and even dangerous." [13] (http://www.cirp.org/library/disease/HIV/vanhowe4/)

Studies have also failed to control for the specific practice of "dry sex" (vaginal lubrication is dried out by various means, presumably to heighten the male's sexual pleasure), which is common among uncircumcised males in sub-Saharan Africa. Dry sex increases HIV infection risk dramatically. Other confounding factors that have been cited as possibly relevant are regionally prevalent diseases and "female circumcision", the effects of which on HIV transmission have not been investigated. It has also been claimed that circumcision changes sexual behavior directly, either leading to more or less risky sexual behavior. Because of these criticisms and the inconclusive results, no medical body has so far accepted circumcision as a means to reduce HIV transmission.

Among industrialized nations, AIDS rates are highest in the three countries which still practice routine infant circumcision at substantial levels (table 2). However, this is due to the propensity of males in these countries to have repeated casual unprotected sex with prostitutes, and who then go on to infect their spouses. Advocates of circumcision note that circumcision only reduces the chances that one may become infected with AIDS; deliberately sleeping with multiple prostitutes, most of whom are known to be infected with AIDS, will overwhelm any benefit that circumcision could give.

Sexual behavior that leads to AIDS generally occurs not before puberty. Because of this, circumcision critics demand that any decision to be circumcised should be made later in life by the child, and not by the parents. Critics also warn that advertising circumcision as a way to prevent AIDS might be used to promote and justify the belief that safe sex practices are unnecessary.

Table 2 World Health Organization data of AIDS rates for 1995
Nation	AIDS cases per 100,000 pop.
USA	16.0
Australia	4.5
Canada	3.8
France	3.5
Netherlands	3.1
United Kingdom	2.4
Germany	2.2
Sweden	2.0
Norway	1.6
New Zealand	1.2
Finland	0.9
Japan	0.2

Medical complications of circumcision

While all benefits associated with circumcision are controversial, the procedure has risks. Complications of circumcision are rare. They range from bleeding, infections, disfigurement, scarring and sexual dysfunction through severe mutilation of the penis, to (in few cases) death. Williams and Kapila observe:

Some authors have reported a complication rate as low as 0.06 per cent while at the other extreme rates of up to 55 per cent have been quoted. This reflects the differing and varying diagnostic criteria employed; a realistic figure is 2-10 per cent. Although haemorrhage and sepsis are the main causes of morbidity, the variety of complications is enormous. The literature abounds with reports of morbidity and even death as a result of circumcision.

It has been claimed that deaths that are the indirect result of a circumcision (e.g. infections of the circumcision wound) are often not registered as a complication. The overall number of deaths from circumcision per year is unknown, but has been estimated to be over 200 per year in the United Sates [14] (http://www.cirp.org/library/general/baker1/),[15] (http://www.cirp.org/library/general/gellis1/). In countries with lower medical standards, complication rates are much higher, and historically, circumcision has been a risky procedure. The Talmud grants an exemption from circumcision if the first three sons died from it [16] (http://www.cirp.org/library/cultural/neusner1/).

Many extreme cases of circumcision complications have been documented in the scientific literature. Perhaps best known is the case of "Bruce/Brenda/David", an infant whose genitalia were amputated after a botched circumcision and who was then raised as a girl, with severe traumatic consequences. The case has been documented by John Colapinto[?] in the book As Nature Made Him.

Long term effects of circumcision

Meatal stenosis[?] is a condition that is "exceedingly rare" in intact males, yet occurs in 9-10% of males who are circumcised at birth. It is caused by exposure of the meatus to urine or by rubbing against the diaper. The disorder "is characterized by an upward deflected, difficult-to-aim urinary stream and, occasionally, dysuria and urgent, frequent, and prolonged urination. Surgical meatotomy is curative." [17] (http://www.emedicine.com/ped/topic2356.htm) Meatal stenosis usually occurs too late to be registered as a circumcision complication. Meatitis (inflammation of the meatus) is also more common in circumcised boys.

The process of keratinization after circumcision is well known and negatively affects the sexual sensitivity of the glans to stimulation. This effect of the procedure is sometimes presented as an advantage (prolonging the sexual act) or as a disadvantage (decrease in sensation). In a study of adult males who decided to become circumcised (in 84% cases due to medical conditions), 38% reported negative outcomes such as decreased sensitivity and erectile dysfunction [18] (http://www.cirp.org/library/sex_function/fink1/).

Because the foreskin acts as a natural lubricant, uncircumcised men and boys can usually masturbate without any external aids by simply sliding the foreskin back and forth over the glans. Circumcised men frequently have to resort to using a lubricant and other techniques. [19] (http://www.cirp.org/library/psych/boyle5/) With total foreskin amputation, which is no longer common, erection can become painful or even impossible as the remaining skin is stretched to its limits. This effect on masturbation and sexual behavior was alluded to in early circumcision advocacy (see below).

O'Hara and O'Hara have conducted a survey among women who had sex with both circumcised and uncircumcised males, and found that 85.5% preferred intact partners. Women reported having had more single and multiple orgasms with uncircumcised men, and less vaginal discomfort. Specifically regarding the loss of vaginal secretion in partners of circumcised men, the authors write [20] (http://www.cirp.org/library/anatomy/ohara/#n2):

When the anatomically complete penis thrusts in the vagina, it does not slide, but rather glides on its own 'bedding' of movable skin, in much the same way that a turtle's neck glides in and out of the folder layers of skin surrounding it. The underlying corpus cavernosa and corpus spongiosum slide within the penile skin, while the skin juxtaposed against the vaginal wall moves very little. This sheath-within-a-sheath alignment allows penile movement, and vaginal and penile stimulation, with minimal friction or loss of secretions.

Circumcision without anaesthesia is believed by many child psychologists and neurologists to have severe long term traumatic effects. [21] (http://www.cirp.org/library/pain/) However, circumcision is usually practiced today with local anaesthesia.

Statements by health groups

The American Academy of Pediatrics created a Task Force on Circumcision, which issued an official policy statement. The abstract of their statement reads:

"Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be provided."

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists issued a statement in 1997 that "newborn circumcision is an elective procedure to be performed at the request of the parents on baby boys who are physiologically and clinical stable."

The American Academy of Family Physicians Reference Manual states: "Current medical literature regarding neonatal circumcision is controversial and conflicting. The decision to perform neonatal circumcision should be based on the informed consent of the parents, and requires objective, factual counseling of parents by the family physician."

In recent years the American Cancer Society[?] has come out against routine circumcision. "We would like to discourage the American Academy of Pediatrics[?] from promoting routine circumcision as a preventive measure for penile or cervical cancer...Perpetuating the mistaken belief that circumcision prevents cancer is inappropriate." [22] (http://www.cirp.org/library/statements/letters/1996.02:ACS/) The American Academy of Pediatrics no longer promotes routine circumcision.

The American Medical Assocation states:

There is little doubt that the uncircumcised infant is at higher risk for urinary tract infection (UTI), although the magnitude of this risk is debatable... Despite the increased relative risk in uncircumcised infants, the absolute incidence of UTI is small in this population... One model of decision analysis concluded that the incidence of UTI would have to be substantially higher in uncircumcised males to justify circumcision as a preventive measure against this condition.

The data on circumcision status and susceptibility to HIV infection and other sexually transmissible diseases have been recently reviewed. Five of 7 prospective studies involving heterosexual transmission of HIV-1 found a statistically significant association between lack of circumcision and elevated risk for acquisition of HIV... At least 16 studies have examined the relationship between circumcision and sexually transmissible diseases other than HIV. In general, circumcised individuals appear to have somewhat lower susceptibility to acquiring chancroid and syphilis, possibly genital herpes, and gonorrhea compared to individuals in whom the foreskin is intact... Regardless of these findings, behavioral factors are far more important risk factors for acquisition of HIV and other sexually transmissible diseases than circumcision status.

(Source: American Medical Assocation, Report 10 of the Council on Scientific Affairs on Neonatal Circumcision)