In recent years there has been a subtle shift in the propaganda put out by the circumcision promoters. In the past they stressed the necessity of circumcision for individual hygiene, but these days they increasingly they talk about circumcision as a vital element in a public health strategy. The reason for the shift of emphasis is as simple as it is sinister: finding that their arguments about individual health or bodily aesthetics are having little impact on parents, they are hoping that if they can whip up a big enough scare about supposed threats to public health, they will be able to pressure medical authorities, and even governments, to force parents to get their baby boys circumcised. This is what they mean when they say that the evidence for the protective effect of circumcision against certain diseases is “compelling”: sufficient, that is, for the authorities to compel people to get themselves or their children circumcised.
These arguments for widespread, and ideally mandatory, circumcision rely on the proposition that we are facing a public health crisis to which circumcision is the only answer. One circumcision promoter has gone so far as to describe circumcision as “a biomedical imperative for the 21st century”. [1] These arguments rely almost entirely on data collected in various underdeveloped and usually poverty-stricken Third World countries, all with epidemic levels of many kinds of disease, not to mention political instability, ethnic/religious violence, economic collapse and social chaos. Trying to blame the foreskin for these endemic problems reminds one of other occasions on which the innocent have been made the scapegoats.
The circumcision promoters managed to get circumcision programs going in Africa by linking it with reproductive health; now they are trying to get them going in developed countries by linking circumcision with public health.
One thing is clear: whatever the problems Africa and certain other developing nations may face, there is no evidence that any Western or developed nation, much less Australia, is threatened with any kind of health crisis. Quite apart from its air of unreality, such “ten minutes to midnight” health alarmism ignores the principles of risk management, which require that a full assessment of risk consequence, likelihood, mitigation strategies and risk tolerance be undertaken before it is possible to reach any conclusions about the degree of risk inherent in taking or not taking certain actions. Individuals have different levels of risk tolerance, and they have the right to develop their own strategies for handling health risks, and striking the appropriate balance between dangers and pleasures. The health industry is not entitled to pre-empt their options.
But leaving these ethical considerations aside, and despite the claims of the circumcision promoters, there is no proof that circumcision has ever improved child or public health outcomes in developed nations, and plenty of evidence that circumcision is, on the contrary, a menace to personal and individual health.
[1] Brian Morris, “Why circumcision is a biomedical imperative for the 21st century”, BioEssays, November 2007
Far from circumcision improving the health of South Africans, the traditional circumcision rite performed among the Xhosa people results in the death of about 100 boys each year, and many more severely injured. Last year (2009) the death toll was 91, and so far this year (10 July 2010) it stands at 47. Further details at Circumstitions
You might well expect nothing better when complex surgeries are carried out in unsanitary and primitive conditions, but a recent study has found that even in the sterile wards of United States hospitals, circumcision may kill as many as 100 boys each year. The study, by researcher Dan Bollinger, concluded that approximately 117 neonatal deaths (within the first 28 days of birth) due directly or indirectly to circumcision occur annually in the United States, or one out of every 77 male neonatal deaths. This compares with 44 neonatal deaths from suffocation, 8 in automobile accidents and 115 from Sudden Infant Death Syndrome, all of which losses have aroused deep concern among child health authorities and stimulated special programs to reduce mortality. Not so long ago the American Academy of Pediatrics issued an official warning against the risk of death by ... choking on hotdogs, estimated to cause only 5 child deaths per year (and presumably none in the neonatal period).
Bollinger’s figures have been questioned and have yet to be confirmed, but even if the death toll is half the estimate (60 deaths a year) it would still be alarming. Further details on this site
In recent years there has also been a spate of deaths in Britain, arising from ritual circumcision of boys among the Muslim community. If this level of harm were seen as a result of female genital cutting, there would be screams for action to protect girls; but since it is only boys who are affected, the response circumcision promoters is to demand yet more circumcision as a public health imperative. (See News page).
Further information at Circumstitions
There has never been a comprehensive study of adverse circumcision outcomes (euphemistically known as complications), but judging from the dozens of articles that appear annually in medical journals, all discussing the best means of repairing circumcision damage, there is reason to believe that circumcision imposes a severe burden on the health resources of countries where it is common. And the burden of repairing circumcision damage is additional to the medical resources committed to the original surgery.
Unlike in underdeveloped countries, such as Turkey, Iran or Nigeria, where the incidence of serious adverse outcomes from circumcision runs as high as 20 per cent, [1] it is clear that deaths or serious complications from circumcision are not common in developed countries. Australia has an enviable record with respect to deaths from circumcision, none having been reported since 1993. There is, however, no room for complacency. As well as good medical practice, the absence of such reports is as much a consequence of the declining and now low incidence of infant circumcision and the difficulty of attributing deaths to circumcision when they are the result of later complications, such as infection, or of long term sequelae, such as depression and suicide. As shown on the above table, several authorities agree that there is no reliable record of mortality, and the Australian Institute of Health and Welfare has admitted that their statistics cannot identify deaths due indirectly to circumcision:
“We have information on circumcision and there are external cause codes for complications of medical and surgical care. However, it is not possible to tell if the complication was a result of the circumcision. For example, the circumcision may have been undertaken in a previous admission, and the patient readmitted with a complication. If this was the case, we couldn’t tell that it was the same patient and we wouldn’t know for sure that the complication was due to the circumcision.” [2]
It is a similar picture with respect to complications, the incidence of which is the subject of wide disagreement. In 1970 Leitch suggested a rate of 15.5 per cent, including 8 per cent requiring a second operation to tidy up the mess left by the first [3], while more recently the Royal Australasian College of Physicians cites estimates ranging from an implausible 0.06 per cent to an equally unlikely 55 per cent, depending on definition. It seems to regard a likely incidence as falling within the range of 2 to 10 per cent, and it warns that “serious complications, such as bleeding, septicaemia and meningitis may occasionally cause death”. [4] If the rate of complications is 15, 10 or even only 2 per cent, it is apparent that the small number of cases that get publicly reported represent only the tip of the iceberg; this under-reporting contributes to the illusion that circumcision is a safe and “harmless” operation. [5]
References
In the United States, where circumcision remains common, the incidence of complications runs at near-epidemic levels and constitutes a serious public health problem in itself, as this comment from a pediatric surgeon indicates:
Unfortunately, 70-80% of neonatal circumcisions are performed by obstetricians, who can neither manage their complications (2-5% incidence) nor obtain proper informed consent (defined as outlining risks and benefits of a procedure, as well as alternatives-including nothing) for neonatal circumcision. Currently, the American College of OB-GYN (ACOG) have no paramenters for training (learning and performing neonatal circumcision, managing complications) of residents, who then go out and continue this practice.
In my practice, as a pediatric urologist, I manage the complications of neonatal circumcision. For example, in a two year period, I was referred 275 newborns and toddlers with complications of neonatal circumcision. None of these were “revisions” because of appearance, which I do not do. 45% required corrective surgery (minor as well as major, especially for amputative injury), whereupon some could be treated locally without surgery.
Complications of this unnecessary procedure are often not reported, but of 300 pediatric urologists in this country who have practices similar to mine … well, one can do the math, to understand the scope of this problem … let alone, to understand the adverse cost-benefit aspect of complications (>$750,000) in this unfortunate group of infants and young children. Fortunately, neonatal circumcision is on the decline as parents become educated, but the complications still continue.
Source: M. David Gibbons, MD, Associate Professor, Pediatric Urology, Georgetown University School of Medicine and George Washington School of Medicine. Posted at Men’s Health Magazine on “The debate over circumcision: Should all males be circumcised?” in the comments section
At one United States clinic, surgical operations to correct the damage done by circumcision represents 7.4 per cent of all cases seen.
Source: Rafael V. Pieretti, Allan M. Goldstein and Rafael Pieretti-Vanmarcke, Late complications of newborn circumcision: A common and avoidable problem, Pediatric Surgery International, 26 (5), May 2010
One of the most common complications of circumcision is meatal stenosis, ulceration and narrowing of the urethral opening of the penis. This is not only painful for the boy and ugly to look at, but may inhibit urination (with potentially drastic consequences). Nearly all such conditions require a further surgical operation. There is a vast medical literature on this problem; here is the abstract of one United States study.
The objective of this study was to prospectively document the incidence of meatal stenosis in boys. The study included a consecutive sample of boys whose visit with the physician included a genital examination in a private primary care pediatric practice in rural northern Wisconsin. Meatal stenosis was diagnosed in boys from 1.94 to 12.34 years of age. The diagnosis was made in 24 of 329 circumcised boys who were Tanner I development and older than 3 years of age (7.29%, 95%CI=4.48- 10.10%). Nearly all required meatotomy to resolve their symptoms. All of the boys with meatal stenosis were circumcised neonatally (exact OR=3.54, 95%CI=0.62-∞). The ratio of circumcised boys to noncircumcised boys in this study provided 80% power to demonstrate a 21.4% difference in the incidence of meatal stenosis between circumcised and noncircumcised Tanner I boys 3 years and older. Meatal stenosis may be the most common complication following neonatal circumcision. The frequency of this complication and the need for surgical correction need to be disclosed as part of the informed consent for neonatal circumcision. A careful meatal examination is indicted in any circumcised boy with abdominal or urinary complaints.
Robert Van Howe, Incidence of Meatal Stenosis following Neonatal Circumcision in a Primary Care Setting, Clin Pediatr. 2006;45:49-54
Further information on complications at Circumstitions
Further information on complications at CIRP
In addition to immediate complications, circumcision has a wide range of harmful impacts on individual psychology (shame, resentment, anger, sometimes lading to severe psychological problems, depression and suicide), and an adverse effect on body image and sexual function. These are too numerous to cover here, but details and links to further information can be found on the Injury and Harm Page of this site.
See also circumcision and sexual function.
The evidence above indicates that circumcision is a significant cause of ill-health and injury. We shall also find that there is plenty of evidence that circumcision has never contributed to improved health outcomes, neither individual nor social.
You might think, and a circumcision promoter would think, that a few deaths and mangled penises were a reasonable price to pay if widespread circumcision was producing substantially better health outcomes in the survivors. Unfortunately, a recent report by the Organisation for Economic Cooperation and Development on child health found that on many measures the United States scored so badly that it was on a par with Turkey and Mexico. The study of all thirty countries in the OECD ranked the USA 24th in overall child health and safety and 23rd in material well being. Under health and safety the OECD measured the incidence of low birth weight, infant mortality, breast-feeding, vaccination for pertussis (whooping cough) and measles, mortality in children 0-19 years and suicide. In addition, it measured the number of births to teenage girls (15-19 years). On all these indicators except suicide the USA scored very badly, and its high rate of teen births placed it right off the scale and up with Mexico and Turkey.
Such figures throw serious doubt on the claim that circumcision improves child health outcomes. On the basis of these OECD figures it is clear that the countries with the lowest incidence of circumcision (northern Europe and Japan) have the healthiest children and those with the highest incidence of circumcision (Turkey and the USA) have the least healthy.
In Australia, reports by the Australian Institute of Health and Welfare in 2004 and 2009 found substantial improvements in child health outcomes in the 20 years from 1983 to 2003. This was the very period during which circumcision all but disappeared, falling from around 40 percent of boys in the early 1980s to less than 10 per cent in the mid-1990s. If circumcision was as essential to health as its promoters claim, you would expect to find evidence in these surveys, but what these studies suggest is that as the incidence of circumcision has fallen, child health has improved.
Advocates such as Brian Morris and circumcision practitioners such as Terry Russell have predicted epidemics of genito-urinary disease as a result of Australia’s abandonment of circumcision in the 1970s to 1990s, thus setting a test for their own claims. According to the AIHW, these epidemics have not arrived, and their claims fail by their own benchmark. Nor did such epidemics occur in Britain following the abandonment of circumcision in the 1950s, in New Zealand in the 1960s, or Canada in the 1990s.
The preceding studies may perhaps be dismissed because they did not specifically cover the particular diseases that circumcision is supposed to prevent. But in January 2010 an article in the American journal Annals of Family Medicine, by Caryn Perera and other researchers in Adelaide, subjected the claims of the circumcision lobby to an exhaustive review, and concluded that its value for child health was close to zero. When the literature was considered as a whole (rather than cherry picked for papers supporting a particular thesis) there was no proof that circumcision of infants or boys provided any significant protection against urinary tract infections, sexually transmitted infections or cancer of the penis. There was evidence from Africa that circumcision of sexually active adult men provided some limited protection against sexually-transmitted HIV, but the authors of the paper pointed out that these results were irrelevant both to Australia and to children. Their conclusion was that “Current evidence fails to recommend widespread neonatal circumcision for these [health-related] purposes.”
Source: Safety and Efficacy of Nontherapeutic Male Circumcision: A Systematic Review, by Caryn L. Perera, BA, Grad Cert EBP, Franklin H. G. Bridgewater, MBBS, FRACS, Prema Thavaneswaran, BSc (Hons), PhD and Guy J. Maddern, PhD, FRACS; Annals of Family Medicine, Volume 8, Issue 1, January/February 2010
More generally, a cost utility analysis of neonatal circumcision found that even if the extreme claims of advocates were true, the associated complications and adverse outcomes would cancel out and exceed the benefit to health. Published in the US journal Medical Decision Making, the study concludes that the procedure both adds to health costs and reduces the overall health of the individual, and can therefore be justified on neither economic nor medical grounds.
Abstract: A cost-utility analysis, based on published data from multiple observational studies, comparing boys circumcised at birth and those not circumcised was undertaken using the Quality of Well-being Scale, a Markov analysis, the standard reference case, and a societal perspective. Neonatal circumcision increased incremental costs by $828.42 per patient and resulted in an incremental 15.30 well-years lost per 1000 males. If neonatal circumcision was cost-free, pain-free, and had no immediate complications, it was still more costly than not circumcising. Using sensitivity analysis, it was impossible to arrange a scenario that made neonatal circumcision cost-effective. Neonatal circumcision is not good health policy, and support for it as a medical procedure cannot be justified financially or medically.
Source: Van Howe RS. A cost-utility analysis of neonatal circumcision. Medical Decision Making 2004;24:584-601
When the circumcision promoters speak about the necessity for circumcision as a public health measure, they generally cite the high incidence of sexually transmitted infections (STIs), and follow this up with claim that circumcision greatly reduces the risk of such infections. It may be true that the incidence of common STIs is increasing in Australia, but the most likely cause of this is increasing promiscuity among young people and the falling age at which sexual activity begins. There is no proof that it has anything to do with the presence or absence of the foreskin, or indeed of analogous structures in the female genitalia.
The evidence in medical journals as to whether the presence or absence of the foreskin makes any difference to the outcome is contradictory and inconclusive; every study which claims to find a correlation has been criticised as flawed or countered by other studies that find no connection at all. Some studies find that circumcised men are more vulnerable to some STIs.
Dickson et al 2008
“These findings are consistent with recent population-based cross-sectional studies in developed countries, which found that early childhood circumcision does not markedly reduce the risk of the common STIs in the general population in such countries.”
Source: Dickson NP, Van Rood T, Herbison P, Paul C., Circumcision and risk of sexually transmitted infections in a birth cohort. J Pediatr 2008;152: 383-7.
National Health and Lifestyle Survey, USA, 1992 (N=1511)
“We find no significant differences between circumcised and uncircumcised men in their likelihood of contracting sexually transmitted diseases.”
Source: Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States. Journal of the American Medical Association 1997;277(13): 1052-7.
British National Survey of Sexual Attitudes and Lifestyles, Britain, 2000 (N=4762)
“We did not find any significant differences in the proportion of circumcised and uncircumcised British men reporting ever being diagnosed with any STI … We also found no significant associations between circumcision and being diagnosed with any one of the seven specific STIs.”
Source: Johnson AM, Mercer CH, Evans B. et al. Sexual behaviour in Britain: Partnerships, practices, and HIV risk behaviours. Lancet 2001;358(9296): 1835-42; and Dave SS, Johnson AM, Fenton KA, et al. Male circumcision in Britain: Findings from a national probability sample survey. Sex Trans Infect 2003;79: 499-500.
Australian Study of Health and Relationships, Australia, 2001-2002 (N=10,173)
“No significant protective effect of circumcision is discernible for genital warts, chlamydia, genital herpes, gonorrhoea, non-specific urethritis or pubic lice.” [4]
Source: Richters J, Smith AMA, de Visser RO, et al. Circumcision in Australia: Prevalence and effects on public health. Int J STD AIDS 2006;17: 547-54.
Further details, with links to articles, on STI page of this site
Circumcision increases risk of urethritis
Most recently, another Australian study of almost 4300 men carried out by researchers from La Trobe University, Victoria, and the University of NSW has found that circumcision does not reduce the risk of contracting most sexually transmitted infections (STI), but significantly increases the risk of non-specific urethritis (the clap) and slightly reduces the risk of penile candidiasis (an easily cured fungal infection). The observed incidences of HIV and syphilis were so low that it was not possible to conclude that circumcision had any protective against these STIs.
The authors of the study, published in the Australian and New Zealand Journal of Public Health, comment that findings from an earlier Australian survey showing slightly higher rates of sexual performance difficulties among older uncircumcised men had been used to support the procedure. It had previously been thought that uncircumcised men found greater difficulty maintaining an erection and were more likely to experience pain during intercourse. The new study found that on these measures there was no difference between circumcised and uncircumcised men in the over-50s age group.
The conclusion of the study is that that “circumcision appears to have minimal protective effects on sexual health in the Australian context.”
Source: Jason A. Ferris, Juliet Richters, Marian K. Pitts, Julia M. Shelley, Judy M. Simpson, Richard Ryall, and Anthony M. A. Smith. Circumcision in Australia: Further evidence on its effects on sexual health and wellbeing. Australian and New Zealand Journal of Public Health, Vol. 34 (2), April 2010, 160-64
Despite this avalanche of evidence, history seems to be repeating itself. Prevention of STIs has been one of the main selling points for circumcision of male infants and boys since the late nineteenth century and today. Based almost entirely on the dubious evidence of a single publication by the English syphilis expert authority Jonathan Hutchinson in the 1850s, Anglo-American doctors became convinced that circumcision would infallibly protect men from syphilis (the AIDS of that era). Beginning in the late nineteenth century, millions of baby boys in Britain, the USA and Australia were circumcised in the hope that it would overcome the health crisis then thought to be threatening the nation. As it turned out, circumcision had no impact on the incidence of syphilis at all, the prevalence of which was reduced by screening, early treatment, safe sex (especially condoms), and finally defeated when penicillin was introduced in the 1940s. The most important early measure in controlling syphilis was not medical at all but social: reducing the stigma attached to the disease so that people were no longer afraid to seek treatment.
Babies and children cannot catch venereal disease
Even if circumcision did confer significant protection against venereal disease, it would be a shameful waste of health resources, not to say grossly unethical, to circumcise babies for this reason. STIs are a problem faced by sexually active adults – and more particularly by sexually adventurous adults who pick up numerous partners and fail to practise safe sex. Anybody can catch an STI if they engage in risky sexual behaviour; nobody need get them if they play it safe. Infants and children are not at risk of STIs, because they do not engage in the kinds of sexual activity that expose them to infection. STIs are an adult problem, and if an adult male prefers to get himself circumcised instead of wearing a condom, that is his privilege. He is not entitled to impose that choice on an innocent and not-at-risk child.
It is even hard to see why circumcision would be a rational step for a sexually promiscuous adult. Nearly all STIs (with the obvious exception of AIDS) can be quickly cured with antibiotics, and the few that cannot (such as genital herpes) are mild in effect and can be kept under control by other drugs. Chlamydia, for example, can be cured with a single pill, and even a serious disease such as syphilis is still eliminated from the body by a course of penicillin. An adult may choose to get himself circumcised instead if he thinks that would be more effective, but it would be an irresponsible diversion of health resources, as well as grossly unethical, to impose that choice on sexually inactive children.
As the study by Perera et al observed, the only evidence for circumcision having any prophylactic efficacy came from Africa, where there was some evidence that adult males who got circumcised had a slightly lower risk of contracting HIV through unprotected intercourse with an infected female partner. And we are speaking of a “slightly lower risk” because a risk reduction of between 50 and 60 per cent cannot be considered impressive, particularly when compared with the 90 to 95 per cent protection offered by a condom, and the even greater assurance that would be provided by a vaccine, when that happy day arrives. Even in Africa the recommendations of the World Health Organisation have been contested, and its gung-ho approach to what it calls the circumcision roll-out has been attacked by the South African Medical Journal as costly, ineffective, a violation of accepted principles of bioethics and human rights, culturally insensitive and smacking of medical colonialism. [1] It has also been criticized by child health and human rights experts as neither medically necessary nor ethically permissible. [2] To cite the African data as an argument for circumcision of male infants and boys in Australia would be irresponsible and inappropriate.
As the authors of the paper also point out, there is no evidence that circumcision of infants or boys (neonatal circumcision) has any effect in reducing susceptibility to HIV infection in adulthood (though this point is usually taken for granted by circumcision promoters), and there is evidence that in developed AIDS is more prevalent among the circumcised: see HIV-AIDS page for details.
Africa has unique health problems. The circumcision trials were on adult men and can no more be extrapolated to children than the World Health Organisation recommendations for the underdeveloped world can be transferred to a developed country like Australia, where there is a low (even negligible) incidence of female to male transmission. In Australia, unlike Africa, AIDS is not a heterosexual epidemic, but a relatively rare disease confined to specific sub-cultures. In any case, because it is a disease of promiscuous adults, children are not at any risk of infection – unless, of course, by surgery. When they become sexually active boys are old enough to understand the issues and make their own decisions about how to manage the risks of sexual activity with others.
The Australian Federation of AIDS Organisations has stated clearly that circumcision has no relevance to Australia’s AIDS problem.
On top of all this, although wild claims were made for the protective effect of circumcision following a few clinical trials (none of which were randomised in the correct manner, and all of which were terminated prematurely), there is so far no evidence that the widespread circumcision in Africa now being funded thanks to Mr Bush and Bill Gates is having any effect in reducing the incidence of HIV. On the contrary, wherever you look (United States, Africa, Malaysia), AIDS infections seems to be soaring among circumcised populations.
Further information about HIV-AIDS on this site
Further information about AIDS in Africa on the Africa page
AIDS infections soar among circumcised populations
Doubts emerging about African circumcision trials
So let’s have no more of this ridiculous pretence that AIDS in Australia represents some catastrophic health crisis to which a drastic measure such as universal circumcision is the only answer. Such ten-minutes-to-midnight alarmism is nothing more than irresponsible scaremongering. The evidence in developed countries such as Australia is overwhelmingly that circumcision is harmful to the individuals and an unnecessary burden on health and medical resources. The less circumcision there is, the healthier (and happier) we will all be.
HIV references
1. D. Sidler, J. Smith, H. Rode, “Neonatal circumcision does not reduce HIV/AIDS infection rates”; A. and J. Myers, “Editorial: Rolling out male circumcision as a mass HIV/AIDS intervention seems neither justified nor practicable”, both in South African Medical Journal, Vol. 98, No. 10, October 2008. Both available at CIRP
2. Robert Van Howe and J. Steven Svoboda, Neonatal circumcision is neither medically necessary nor ethically permissible: A reply to Clark et al, Medical Science Monitor, Vol. 14, 2008: available on this site.