 Prof Brian Morris This article was originally on the University of Sydney website. Prof. Brian Morris now maintains a site called "Benefits of Circumcision", www.circinfo.net, that is still hosted by the University (whois shows: Name Server: PHOENIX.PHYSIOL.USYD.EDU.AU; Name Server: PLEXUS.PHYSIOL.USYD.EDU.AU) |
[This article, while taking the form of a scientific paper, does not seem to have appeared in any peer-reviewed scientific journal. The rebuttal below is a partial review - which makes clear the many reasons for that non-appearance. [REBUTTAL TO]
Morris produces a vast amount of data, much of it from obscure sources. The fact that a claim goes unanswered here does not mean it can not be answered.]
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MEDICAL BENEFITS FROM CIRCUMCISION [Part 1 of 2] 12/98
 ] and up-to-date coverage of the circumcision issue. To find out more about this recent publication click here.
Circumcision is the removal of a fold of loose skin [ ... and muscle, and nerves... ] (the foreskin) [For its structure, see Anatomy, for its action see How the Foreskin Works, for its size, see "Not just a flap".] that covers the head (glans) 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. [Most men, of course, have a moderate amount, covering the glans and a little more, the acroposthion.] 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. [Many passionate circumcisionists avoid that central fact.] (Compare, for example, ear piercing. [Healthy tissue is not removed by 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 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. [This seems improbable: why did the doctors not just refuse to do it? One answer is that the parents then sometimes threaten to do it themselves.] Such attitudes are a far cry from the situation years ago when baby boys were circumcised routinely in Australia. [ ... and mothers who wanted to leave their babies intact were harassed...] But over the past 20 years the rate has declined to as low as 16-19% [81]. 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 Paediatrics in August 1995 and adopted by the College in May 1996 [6]. In this document medical practitioners are now urged to fully inform parents of the benefits of having their male children circumcised. [This is false. Certainly that was not how the Australian Medical Association saw the policy: The AMA will discourage circumcision of baby boys in line with the Australian College of Paediatrics' Position Statement on Routine Circumcision of Normal Male Infants and Boys. The statement, released in June and supported by the AMA's November Federal Council meeting, includes: * The Australian College of Paediatrics should continue to discourage the practice of circumcision in newborns. * Educational material should be available to parents before the birth of their baby and in maternity hospitals. * Some parents after considering medical, social, religious and family factors will opt for circumcision. It is then the responsibility of the doctor to recommend this is performed at an age and under circumstances which reduce hazards to a minimum. A M A Australian Medicine is the national news publication of the Australian Medical Association Limited. (ACN 008626793) ] 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 [37]. [False again: The American College of Pediatrics has moved far closer to an advocacy position [False again. The AAP's 1997 statement said circumcision "has potential medical benefits and advantages" 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. [Beware of the person who boasts of their lack of bias!]
It has been suggested [18] that the increased risk of infection in the uncircumcised [...begging the question that there is such an increased risk...] 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 glans of which develops a thick stratum corneum layer [Which further reduces the sensitivity of the glans.]), and the presence of a prepuce is likely to result in greater microtrauma during sexual intercourse [This neglects the rolling, gliding action of the prepuce.], 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 favours growth of micro-organisms (discussed later). [The whole surface of the human body is a teeming mass of micro-organisms. Disinfectants and the like only reduce the number, and only for hours at most. The natural flora of the foreskin are similar to those of the sides of the lips. Everything that may be said about the natural history of the foreskin is very much more true of the labia.] The preputial sac has even been referred to by Dr Gerald Weiss, an American surgeon, as a ‘cesspool for infection’ [142], [- which says a great deal more about Dr Weiss than the prepuce. An analysis of the works of Dr Weiss is a high priority for these pages...] 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. [No, because the infant foreskin is fused to the glans and cleaning is both impossible and unnecessary.] Even if optimal cleansing is performed there is no evidence that it confers protection [152][153].[ - except the mute testimony of the vast number of intact men worldwide who have never had any problems.]
Circumcision has been practiced widely in Western countries this century. In the USA it increased from 8% in 1870 to 56% in 1910 [98]. In Britain it rose from 19% for those born in 1914 to 22% for 1924 and 30% for 1930 [98]. From at least the mid-1940s to mid-1970s over 90% of boys in the USA and Australia were circumcised soon after birth. [It then went out of fashion in those countries, but no foreskin-related plagues followed.] The major benefits at that time were seen as improved lifetime genital hygeine [sic throughout], 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 Paediatrics Committee for the Newborn stated, in 1971, that there are ‘no valid medical indications for circumcision’ [19]. However, in 1975 this was modified to ‘no absolute valid ... ’ [134], which remained in the 1983 statement, but in 1989 it changed significantly to ‘New evidence has suggested possible medical benefits ...’ [3]. A new statement is to appear in 1998. [This statement, which did not appear until 1999, perhaps because of internal controversy within the committee, did not recommend circumcision, but left it once again to the parents. The AAP would be putting its members at legal risk if it condemned circumcision as harmful or unethical.] Dr Edgar Schoen, Chairman of the Task Force on Circumcision of the American Academy of Pediatrics, [In 1987 and 1995, but not in 1999] has stated that the benefits of routine circumcision of newborns as a preventative health measure far exceed the risks of the procedure [115]. During the period 1985-92 there was an increase in the frequency of postnewborn circumcision and during that same time Schoen points out that the association of lack of circumcison and urinary tract infection (UTI) has moved from ‘suggestive’ to ‘conclusive’ [115]. [This claim is mainly due to the work of Wiswell on children born in military hosptials. The difference in the very small incidence of UTIs can be accounted for by the practice, encouraged by the medical profession, of pulling back intact boys' foreskins, and by the presence of urethral abnormalities: having such abnormalities was one reason to be spared circumcision. Another factor is that premature babies are more likely to be catheterised - encouraging UTIs - and less likely to be circumcised. UTIs were only proposed as a reason for circumcision in the 1980s, long after circumcision had become routine, only the most recent case of circumcision being a solution looking for a problem. UTIs can readily be treated non-surgically, as they always are in girls.] 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’ [115]. [Drs Schoen, Wiswell and Weiss are notable enthusiasts for infant circumcision. Benefits included: a decrease in physical problems involving a tight foreskin [92], lower incidence of inflammation of the head of the penis [32][33][36][138], 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 [This is false. Circumcised men can contract penile cancer, and in fact the belief that they are immune has dangerously delayed diagnosis.] and a decrease in urological problems and infections [reviewed in 3,6,37,69,110,113]. Therefore the benefits are different at different ages.
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. [Circumcision is frequently allocated to house-surgeons (interns) for training in "minor surgery".] However, urologists who see and have to treat the problems of uncircumcised men cannot understand why all newborns are not circumcised [113,115]. [This is of course a wild overstatement.] 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 circumcison, led Schoen to state ‘Current evidence concerning the life-time medical benefit of newborn circumcision favours an affirmative choice’ [115].
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. [At its worst, Male Genital Mutilation (circumcision) is worse than the least severe form of FGM. As a human rights issue, the right to bodily security, autonomy and freedom of choice, they are exactly the same.] 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’. [Or perhaps the circumcisionists are exporting their efforts to Africa... The rate is now low in Australia and falling.] 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. [We certainly hope so!] 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." [Taken out of context as it is, it is hard to see what this message was really about. As to psychological harm, it can certainly be devastating to learn what one has lost through circumcision, but the Intactivist movement can hardly slacken its efforts in order to protect men from the truth about their loss.] 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 is false, it is subjected to peer review - unlike this one...] This propaganda vehicle should really be titled ‘Anti-circumcision’. The Editor of this ‘journal’ is an outspoken critic of circumcision. His writings appear superficailly convincing to the naive. However, various authorities have shown how he [Someone called "johnd" has deleted a reference [137] here:] <!-- commented out by johnd [137] " ---> distorts, misquotes, and misrepresents the bulk of the literature he claims support his opinions and even misconstrues his own published findings (on balanitis) [154]. ["Various authorities" prove to be Dr Thomas Wiswell, who has contributed 12 of the 161 references to this paper. The deleted reference is an article by Dr Robert Van Howe, which certainly does not attack the Journal of Circumcision.] 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. [This raises the question of relevance and personal attack.] Another of these groups is ‘UNCIRC’, [Morris may mean RECAP, now NORM] which promotes procedures to reverse circumcision, by, for example, stretching [actually stimulating growth by tension] the loose skin on the shaft of the retracted penis or the use of surgery. This has led to genital mutilation [140]. [ "Led to"? [It is not clear how the men who underwent psychiatric examination were selected. If men restoring their foreskins are typically unhappy about being circumcised, should we be surprised? This is a most elaborate attempt to "blame the victim".
Dr Tom Wiswell, a respected authority in the USA [in the opinion of Dr Morris; indeed any circumcision advocate seems in his opinion to be a "respected authority"] 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 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" [149,150]. 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! [He may say this now, but evidence of his opposition is hard to find. If he was an opponent, he seems to have had a road-to-Damascus experience and now expresses the characteristically excessive zeal of the convert.] Wiswell looked at the complication rates of having or not having it performed in a study of 136,000 boys [It is a fallacy that a huge sample size guarantees great accuracy] born in US army hospitals [which biasses the sample, compared to babies in general] between 1980 and 1985. 100,000 were circumcised and 193 (0.19%) had complications [depending on how complications are defined], with no deaths, but of the 36,000 who were not circumcised the complication rate was 0.24% [What is a complication of not circumcising?] and there were 2 deaths [156]. [Deaths from what? This is scare tactics.] 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 [This is, literally, incredible.], none of which were fatal [110]. An early survey saw only one death amongst 566,483 baby boys circumcised in New York between 1939 and 1951 [125]. (There are no deaths today. [Absolutely false: tell that to Ryleigh McWillis's, Dustin Evans Jr's or Jerome Sweet's parents.]) [For more about complications, see Williams and Kapila, or the complications page on this site and its references, or the gallery of circumcisions.] 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 [51] [One reason for this would be greater parental anxiety and insecurity about intact sons.]
[This site has a page devoted to the pain of circumcison.] No adverse psychological aftermath has been demonstrated [if one defines "psychological" too strictly to include the work of Lander or the work on breastfeeding][112]. It must be recognised that there are many painful experiences encountered by the child before [?], during and after birth [79]. Circumcision, if performed [with or] without anaesthetic is one of these. [It is one of the few that can be simply avoided.] Cortisol levels have registered an increase during and shortly after the procedure [131,132], indicating that the baby is not unaware of having had something painful done in its unanaesthetized state. ["Not unaware"!! Morris's little joke conceals agony for millions.] Neverthless, some babies show no signs of distress at all. [Yes, some appear to sleep through the procedure, but in fact this is a shock reaction.] 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. [The Lander study found two out of 12 babies stopped breathing, vomited, etc. Taddio et. al showed that the trauma of circumcision manifests itself for months afterwards. More data on the pain continues to come in, since circumcision is commonly used as a benchmark for pain in neonates. The AAP has just produced a new report on pain. The trauma of circumcision may adversely affect the bonding required for breastfeeding.]
The proponents of not circumcising nevertheless stress that lifelong penile hygeine is required. [Yes, washing with water, like any other part of the body, nothing special.] This acknowledges that something harmful or unpleasant is happening under the prepuce. [Rubbish. No more than in the mouth or vulva.] Studies of middle class British [57,110] and Scandanavian [95] schoolboys concluded that penile hygeine, as such, is at best poor and at worst nonexistant. [Schoolboys are traditionally, "dirty". A preoccupation with "hygiene" is peculiarly American. The intact penis is no "dirtier" than the labia.] Furthermore, Dr Terry Russell, an Australian medical practitioner states ‘What man after a night of passion is going to perform penile hygeine before rolling over and snoring the night away (with pathogenic organisms multiplying in the warm moist environment under the prepuce)’[110]. 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 odour. [This preoccupation with bacteria is beginning to seem obsessive. Do women get up to wash their genitals after sex?] 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? [They should leave it alone. The foreskin naturally adheres to the glans for months or years after birth, and trying to separate it prematurely is the cause of a lot of phimosis. The boy will roll it back by himself when he and it are ready.]
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 [30]. [Williamson and WIlliamson found - in a survey with a low response rate - that women in one Iowa hospital tended to have their sons circumcised to suit their own sexual preference, and apparently see no ethical or moral problems in this practice.] The main reason may have more to do with hygeine and apearance, 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% [88]. [More recent figures indicate a decline, especially in the western states. Morris's figures seem high, throughout - wishful thinking?] The actual rates are higher than indicated by this data, as they represent only the numbers reported, whereas not all are [44] 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% [91]. [Conversely, where parents refuse circumcision, they are sometimes charged for it, and it may be recorded as having been done in order to claim reimbursement, or from force of habit.] 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.)
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 [by whom?] 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 ot stroke. [This is scare-tactics. "Ballooning" of the penis on urination is normal, though it is a frequent excuse for circumcision.] Paraphimosis (where the retracted foreskin cannot be brought back again over the glans) is a very painful problem, relieved by circumcision or slitting the dorsal surface of the foreskin. [...or by lubricating the glans with, say olive oil, and applying gentle pressure to reduce its size. This has to be done before circumcision can be performed, anyway. It is yet another example of the "If in doubt, circumcise" attitude that Morris promotes.] To paediatric surgeons, the most obvious medical reasons for circumcision are balanitis (inflammation of the glans) and posthitis (inflammation of the foreskin), which are very painful conditions virtually limited to uncircumcised males. In babies, balanitis is caused by soiled diapers, playing and sitting in dirty areas, antibiotic therapy, as well as yeast and other micro-organisms. The incidence of balanitis is twice as high in uncircumcised boys [40,52] and is greater than 5-fold higher in uncircumcised adults [36]. [What other inflammation is relieved by cutting off the affected area? Naturally, only intact boys can suffer from posthitis, just as only non-amputees can suffer from athlete's foot. As far as soiled diapers are concenred, the prepuce protects the urethra from faeces entering and causing meatal ulcers, which are almost entirely confined to circumcised boys.] Balanitis caused by the group A haemolytic variety of streptococcus is present exclusively in uncircumcised boys [93]. [Dr Morris is trying to frighten you with big words.] Balanoposthitis (inflammation of the foreskin and glans) is common in uncircumcised diabetic men owing to a weakened, shrunken penis [36] and such men also have more intercourse problems. Diabetes is common [...not all that 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 [And the glans of a circumcised boy can not In elderly men, infections and pain from balanoposthitis, phimosis and paraphimosis are seen and carers report problems in achieving optimal hygeine 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. [We really are scraping the bottom of the barrel here, aren't we? Cutting off their penises would mean they wouldn't leave the seat up, either....] Foreskin problems also mean intercourse is painful. [So do lack-of-foreskin problems - especially for the woman.] 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 [47]. 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 inabilitiy to have sexual relations. [And what puts a ring of scar tissue right around the penis? Circumcision!] This problem can be solved by excising the frenulum during a circumcision. Frenoplasty (removing just the tight frenulum) is also possible. [This may well cause frenular chordee.] 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 [128,129]. The study showed that parents had nothing to fear for their son’s psychological well-being from circumcision.
In 1982 it was reported that 95% of UTIs in boys aged 5 days to 8 months were in uncircumcised infants [45]. This was confirmed by Wiswell [157] 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 [158]. 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 [155]. 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 [159]. Reviews by others in the mid-80s concluded there was a lower incidence in circumcised boys [74,107]. 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 [156]. The number was equal for boys and girls [Really? Every other study shows the incidence is several times higher for 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% [148]) is reported in uncircumcised children [109,130]. These and other reports [e.g., 23,45,51,109,120,130] all point to the benefits of circumcision in reducing UTI. [The 1989 AAP Taskforce on Circumcision report condemned Wiswell's work prior to that date as "methodologically flawed."] 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 [156]. The average was 12-fold higher and the range was 5 to 89-fold, with 95% confidence intervals of 11-14 [156]. 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 [22]. [The UTI rate among girls is greater than that of any boys - yet nobody has ever suggesting using surgery to protect girls.] 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 [124]. 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 [41,46,58,59,130,159,160]. 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 [41,46,160]. Circumcision prevents such colonization and subsequent ascending infection of the urinary tract [107]. A recent report found that swabs were taken of the periurethral 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) [119]. Since these organisms are common inhabitants of the female genital tract, aquisition 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 [119]. 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. [To et al. give a figure of 195 circumcised to prevent one UTI. You can see that graphically demonstrated.] 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 hygeine 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 [95,115], not performing circumcision would appear to be far less effective than having it done in the first instance [115].
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 [147]. Work in the mid-70s showed higher chancroid, syphilis, papillomavirus and herpes in uncircumcised men [133]. 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 [97]. Others have reported higher rates of nongonococcal urethritis in uncircumcised men [123]. 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 [20]. 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 [30]. 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 gonnorrhea, syphilis, chlamidia, nongonoccocal urethritis, herpes and HIV (which is more often aquired intravenously) [72], although some under-reporting by uncircumcised men was likely as they tended to be less educated [This is just bigotry. The intact men's mothers were less likely to have finished high school - that hardly makes the men less likely to know if they've had the clap.]. Also, circumcision at birth was assumed, so that the number who sought circumcision later in life for problems, such as STDs [Circumcision is not a treatment for 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 [The Laumann study found chlamydia only in the circumcised.], 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 hygeine, availability of running water and socioeconomic group being studied. In some more recent studies in developed nations, in which hygeine is good, no difference was apparent. [...nullifying this whole section.]
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% [66,76]. It represents approximately 1% of all malignancies in men in the USA. [This is false. The American Cancer Society's "Cancer Facts and Figures-1996" gives figures indicating penile cancer amounts to less than 0.18% of all malignancies of men in the USA - and not of all of that would be on or near the foreskin.] 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 [This is false], 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. [A classic example of assuming what you want to prove.] In a study in Melbourne in 1990, although 60% of affected men were over 60 years of age, 40% were under 60 [111]. In 5 major series in the USA since 1932 [161], not one man with penile cancer had been circumcised neonatally [76], i.e., this disease is almost completely confined to uncircumcised men and, less commonly, in those circumcised after the newborn period. [The claim that neonatal circumcision protects against penile cancer, but later circumcision does not, while it suits those promoting neonatal circumcision, is magical rather than scientific. No mechanism for this supposed protective effect has ever been found. ] 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]. [They are the subject of published case reports because the belief that "circumcised men never contract penile cancer" is so widespread. Maden found 41 cases in circumcised men.] 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 [151,152]. 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 [114], 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 [66]. In Denmark (circumcision rate = 2%), penile cancer has been decreasing steadily [39] in parallel with an increase in indoor b athrooms. 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. [Climatically? How,one can only wonder, does climate make a difference? What are the genetic factors at work across the whole USA that make intact men more suxceptible to penile cancer than Danes? And what is the difference between US and Danish culture - apart from the US's love-affair with circumcision - that could account for this difference?] The statistics for Denmark have been used by anti-circs to draw a sweeping and fallacious conclusion about lack of circumcison [We prefer to call it a whole penis...] 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, [Even that is a risk reduction of 50% through being intact - it certainly demands a better explanation than this] as stated above [66]. In underdeveloped countries the incidence is higher: approx. 3-6 cases per 100,000 per year [66]. 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 [87]. In Uganda it is the most common malignancy in males, leading to calls for greater circumcision in that country [29]. 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 [78], 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 [90]. 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 [62]. 93% of men whose female partner was positive for early signs of cervical cancer (cervical intraepithelial neoplasia, CIN) had the male equivalant, penile intraepithelial neoplasia (PIN) [8]. 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 [8]. Moreover, the rate of PIN was 10% in uncircumcised men cf. only 6% in circumcised men [8]. Other factors, such as smoking, poor hygeine and other STDs have been suspected as contributing to penile cancer as well [14,76], 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 [49]. 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 [because the circumcision rate has fallen. Duh.].) 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 [24,111]. 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. [Breast cancer in men is more common than penile cancer, yet no-one has ever suggested neonatal mastectomy to protect against this scourge, and a man's breasts are of far less use to hm than his foreskin. The American Cancer Society does not promote circumcision as a preventative of penile cancer.]
Prostate cancer accounts for 27% of new cancers in males and 7% of deaths [89]. Uncircumcised men have twice the incidence of prostate cancer compared with circumcised [5,35], and this cancer is rare amongst Jews [2]. No association has been seen between rate of prostate cancer and rate of cervical cancer in different geographic localities [108]. 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) [28]. For HPV16 the increased risk was 2.4-fold.
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 [42]. 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 [1]. 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 [25]. 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 [55]. 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 [139]. 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) [11]. A study in 1994 found that in women with CIN, PIN was present in the male partner in 93% of cases [8]. 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 [101], but not in another [106]. Thus the epidemic of cervical cancer in Australia, and indeed most countries in the world, would appear to be contributed, at least in part, [When some studies say one thing and others say another, the answer is not to say the truth is "at least in part" one thing, but to make more studies.] by the uncircumcised male and would therefore be expected [...by those who want to expect such a thing. Only time will tell.] 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. |
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[M.S. El-Bahnasawy and M.T. El-Sherbiny, Paediatric penile trauma BJU International, vol 90 issue 1, July 2002, p 92
"The cause of trauma was circumcision in 43 (67%), human hair-tie strangulation injury in 10 (16%), an animal attack in four (6%), a bicycle accident in four (6%), a zipper injury in two (3%) and electrical injury in one (2%)." ]