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+CircumciSioN+

THE MEDICAL BENEFITS FROM CIRCUMCISION
by Dr. Brian J. Morris
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 harassment by medical professionals of new mothers, especially those belonging to religious groups that practice circumcision, in an attempt to stop them having this procedure carried out. Such attitudes are a far cry from the situation years ago when baby boys were circumcised routinely in Australia. But over the past 20 years the rate has declined to as low as 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 ...
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