Health and disease

A run-down on the diseases that have been supposed to make circumcision necessary, and the reasons why these claims fail.

Introduction

From its earliest appearance in the surgical repertoire circumcision has been touted as the miracle cure for a bewildering, and unbelievable, array of diseases, bodily conditions and disapproved behaviour. In roughly chronological order it has been advocated and imposed as a preventive of or cure for masturbation, phimosis, epilepsy, syphilis, cancer of the penis, paralysis, polio, tuberculosis, bilharziasis (a tropical parasite), hip joint disease, bed-wetting, pimples, brass poisoning, "nervousness", cervical cancer in women, prostate cancer, herpes, urinary tract infections and AIDS – to name a few. One collector of medical curiosities has identified no fewer than 390 reasons to circumcise.

There is a striking continuity between the arguments of nineteenth century promoters of circumcision and those of their descendants today. You have only to compare the hysterical language and implausible claims of Peter Charles Remondino in his History of Circumcision from the Earliest Times to the Present: Moral and Physical Reasons for its Performance (1891) with Brian Morris in his In Favour of Circumcision (Sydney 1999). Morris predicts much the same dire consequences from not circumcising every boy that Remondino predicted in 1891 – consequences that continue to fail to materialise.

Health benefits of circumcision contested

Because it is a highly emotional subject, arousing deep passions on both sides, the literature on circumcision and health is vast beyond imagining. Like the Bible, you can find a quote and a statistic for any claim you care to make; and if you go back to the nineteenth century you can find medico-scientific evidence that the foreskin is complicit in, and circumcision can prevent, almost any problem - from epilepsy, tuberculosis and paralysis to bed-wetting, night terrors and pimples, as well as offering an infallible cure for brass poisoning. There may be an avalanche of evidence in favour of its benefits for health, but on closer inspection much of it turns out to be worthless rubble, containing very little gold.

Nonetheless, researchers in places where routine circumcision became established (Britain, the USA, Australia and Canada) have attempted to sift through the piles of mullock and reach an overall conclusion as to whether it is good, bad or indifferent. They have all concluded that that circumcision as a precaution is ethically questionable and medically unnecessary, and that it should not be performed unless there is an injury, deformity or disease that cannot be treated in any other way.

The most recent statement from the British Medical Association comments: “There is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research. ... The BMA considers that the evidence concerning health benefit from non-therapeutic circumcision is insufficient for this alone to be a justification for doing it.”

The most recent policy (September 2009) issued by the College of Physicians and Surgeons of British Columbia states that doctors should “Advise parents that the current medical consensus is that routine infant male circumcision is not a recommended procedure; it is non-therapeutic and has no medical prophylactic basis; it is a cosmetic surgical procedure; current evidence indicates that previously-thought prophylactic public health benefits do not outweigh the potential risks.”

The current policy of the Royal Australasian College of Physicians states: “After extensive review of the literature the RACP reaffirms that there is no medical indication for routine male circumcision. … Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure.”

Even in the United States the American Academy of Pediatrics does not consider the health benefits of circumcision to be sufficient to recommend it; and in the Netherlands the Royal Dutch Medical Association has recently (May 2010) issued a powerful statement against the operation, stating that it as a prophylactic procedure it offers no benefits at all.

Details of policies issued by medical bodies

A recent survey of the literature by researchers in Adelaide found that the value of circumcision as a health reaction was “close to zero”.

Circumcision and public health: Is circumcision a biomedical imperative for the 21st Century?

On this page we provide a run-down on the major diseases and health problems for which circumcision has been touted as the magic bullet. For full details about each one, follow the links at the end of each section.

Masturbation and spermatorrhoea

The original and principal reason for the introduction of circumcision was to discourage practices and functions that were not diseases at all. We all know what masturbation is and understand that nearly all boys and girls do it quite naturally, but the Victorians did not like it for both moral and “medico-scientific” reasons, and blamed it for a host of real problems. Spermatorrhoea was simply a name given to completely natural seminal emissions, such as in wet dreams or at moments of sexual excitement – which are not uncommon in adolescent boys.

Phimosis and paraphimosis

Phimosis is the name given to a foreskin that cannot be drawn back to expose the glans. All male infants and young boys have phimosis, and there is no definite age at which retractability should be achievable. Phimosis used to be regarded as an “indication” for compulsory circumcision, but that was an error arising from ignorance of normal genital anatomy. Even after puberty some men still have a phimotic condition, and most are not worried by it; if a man does experience discomfort he can gently stretch the foreskin opening or apply steroid cream. If that does not work he can always get himself circumcised if he really thinks it necessary: it does not have to be done for him at an age when the final condition of his penis cannot be known.

Too many boys are still circumcised between the ages of three and six because their foreskins are not easily retractable, but genuine (pathological) phimosis can rarely be identified that early. If a boy is experiencing discomfort or pain the standard treatment these days is application of topical steroid cream. Recent research shows that 85 per cent of boys with a problem phimosis respond to twice-daily applications of steroid cream within four weeks, and many within two weeks. Real (pathological) phimosis is now recognised as nearly always arising from injury or certain rare forms of infection. You can always cut the foreskin off, but once it’s gone there is no getting it back. Circumcision should always be the last resort.

Cancer of the penis and prostate

Cancer of the penis is such a rare disease that most cancer registries do not even keep figures on its occurrence. It is not only rare, but a disease of old men, rarely encountered before the age of 50. Because of cancer’s high scare value, however, cancer of the penis has always figured prominently the propaganda of circumcision advocates, beginning with Jonathan Hutchinson in the mid-nineteenth century and continuing through the efforts of the American circumcision promoter Abraham Wolbarst in the early twentieth century, whose 1930s opinion piece in the Lancet continues to be quoted. One of the most frequently repeated of the so-called pros of circumcision is that “cancer of the penis is virtually (or practically) unknown among circumcised men.” True, but it is also true that cancer of the penis is virtually (or practically) unknown among uncircumcised men. It is equally true that circumcised men get cancer of the penis. But to put the issue in perspective, men are far more likely to get cancer of the testicles or prostate, and even of the breast, than on their penis, so if you were serious about pre-emptively amputating “redundant” body parts that might later become cancerous you would begin there and leave the foreskin until last. Nobody suggests prophylactic removal of the prostate, testicles or male breast so as to reduce the risk of cancer in those body parts.

The Cancer Council of Australia has come out strongly against recent(2012) claims that mass circumcision of boys is necessary as a preventive of cancer of the penis and prostate. In a statement released on 21 June, the Council warned that cancer of the penis was a rare disease in Australia, and that the evidence of circumcision having a protective effect was not sufficient to justify the operation. As to prostate cancer, the main risk factor was nothing more than getting old - a natural process that circumcision could do nothing to arrest. The statement concluded: “Taking into account these issues, the relatively lower burden of potentially preventable disease in Australia, and the complex cultural, ethical and legal issues surrounding the practice of circumcision, Cancer Council Australia does not recommend circumcision as a routine cancer-preventive procedure at this time.”

Source: Cancer Council of Australia, Neonatal male circumcision and cancer

Information from NSW Cancer Council

Cervical cancer

Even though it is not a problem that affects males, the possibility that circumcision of boys might protect adult women from cervical cancer has been a selling point of circumcision promoters since the early twentieth century, and the notion has been heavily stressed in recent times. This is a clever tactical move on their part, since they know that women tend to be more hostile to circumcision than men and mothers more protective of their babies than the father. Cervical cancer would appear to be a powerful bogeyman to bring those obstinate anti-circumcision mothers around to the correct point of view.

In fact, it has been repeatedly shown that a male partner’s circumcision status is not a significant factor in whether a woman develops cervical cancer. Even if it was, the American legal scholar Sarah Waldeck has pointed out that Western law and medical ethics do not permit a person to be mutilated without consent in order to benefit a third party, and this is all the more impermissible if the identity, or even the existence, of the supposed beneficiary is unknown.

On top of all this, the issue is rapidly becoming irrelevant, because an effective vaccine has been developed and is being rapidly deployed.

Read the argument of Sarah Waldeck.

Urinary Tract Infections (UTIs)

Prevention of UTIs is a major selling point of circumcision advocates today, but the main reason babies get urinary tract infections (usually caused when intestinal bacteria from their mother colonise the inner surface of the foreskin and then spread up the urethra) is not because of the foreskin. The most important cause is when newborn babies are taken away from their mothers in modern hospitals before they have a chance to receive their mother’s antibodies, and thus natural resistance, to the maternal bacteria. The best solution is simply to make sure that a newborn baby stays with his mother and starts to breast feed ASAP; mother’s milk will supply the necessary antibodies and thus protect the urinary tract. (There is nothing wrong with benign intestinal bacteria on the inner foreskin surface; in fact, they probably keep out harmful bacteria.)

The main source of data for the view that uncircumcised boys are more subject to UTIs are a series of papers in the 1980s by the American army doctor Thomas Wiswell. Most of the uncircumcised boys in his studies were born in US military hospitals, where the rule was to retract their foreskins in infancy for cleaning purposes. This harmful practice is contrary to all current medical knowledge and is known to be a major cause of injury and infection. It is quite likely that the higher incidence of UTIs shown by these unfortunate boys was the result of the forcible retraction of their foreskins by ignorant doctors and nurses.

Urinary tract infections seem to be problem only in countries with a history of widespread circumcision, and where incorrect foreskin care (such as premature retraction) is thus common. In any case, UTIs are usually minor infections which clear up quickly with antibiotics; persistent infections may indicate a malformation of the urinary tract or bladder, which will indeed require surgery, but not on the foreskin.

Sexually transmitted infections (STIs)

It is hard to know what relevance protection against Sexually Transmitted Infections could have to babies. STIs – also known as Sexually Transmitted Diseases (STDs) or venereal disease (VD) 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.

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.

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 child.

HIV-AIDS

The latest argument for circumcising normal male infants is that, even if all the other reasons for circumcision have proven to be invalid, at least it will protect them from the AIDS virus. This has been a big selling point, massively promoted by the media, and has convinced many otherwise rational people that maybe circumcision is the way to go. The claim is, however, misleading because circumcision does not give immunity to HIV infection; the African experiments were on adult men, not infants or children; and the degree of risk reduction shown in the African results is not impressive.

The argument is also irrelevant because, even if circumcision did provide significant protection did, infants and boys are not at risk because they do not have sex with carriers of the virus. The main risk factor for HIV is unprotected sex with numerous partners; if the foreskin is a factor at all, it is a very minor one, and is probably no more to blame than the mucosal surfaces of the female genitals.

The argument for circumcision as a tactic against HIV is really debate about how to control AIDS in the Third World, where the disease is an epidemic mainly affecting heterosexuals, both male and female, has no relevance to conditions in developed countries, where it is a far less serious problem mainly affecting small subcultures, such as promiscuous male homosexuals and intravenous drug users. It has no relevance at all to infants and children, who are not at risk of sexually-transmitted HIV because they do not have sex with carriers of the virus. The Australian Federation of AIDS Organisation has stated that circumcision has no role to play in the prevention of AIDS in Australia.

Given that AIDS is a disease of promiscuous adults, boys should be allowed (as the RACP recommends) to make their own decision about circumcision when they are old enough to understand the issues.

Functions of the foreskin

Anatomy and physiology of the foreskin

Role of the foreskin in normal sexual function
www.cirp.org/library/sex_function

New research on the ridged band

The ridged band is a special zone of tissue on the underside of the foreskin, with probably the densest concentration of nerve endings in the human body. Until recently doctors did not even know it was there because they were too busy amputating foreskins before they had studied what they were tossing in the trash. In terms of its role in sexual responsiveness, it could be regarded as the male clitoris.

For further details http://research.cirp.org

No evidence that circumcision ever improved infant or child health ...

Circumcision of normal male infants and boys as a health precaution first appeared in the late nineteenth century, and the incidence of the practice increased steadily until the 1950s, when it peaked at about 80 per cent of boys born in Australia. If the practice had in fact improved infant or child health you would expect evidence of this to have been found by scholars who have studied this very question. But no! Over the past thirty years there has been considerable research into maternal and child health during the first half of twentieth century Australia, including major studies by Diana Wyndham, Phillipa Mein Smith, Milton Lewis and Janet McCalman. Although these scholars have scoured the records and covered the relevant issues in great detail, there is one word which makes not a single appearance in their pages: circumcision. Although its incidence was steadily increasing over this period, the authors apparently found no evidence that it made the slightest contribution to the improvements in infant survival rates and general child health observed at the same time.

Examining the remarkable fall in infant and maternal mortality that occurred roughly between 1905 and the 1930s, they note that it was a phenomenon observed throughout the developed world, in Europe as much as in Britain or Australia, and they conclude that it is largely attributable to improved nutrition (including more breast feeding), cleaner environments and the provision of sewerage systems and clean domestic water supplies. The last of these is particularly important in explaining the fall in deaths from one of the major nineteenth century killers, diarrhoea. This was usually the result of gastro-intestinal infections caught from contaminated food or water, but the final cause of death was often dehydration – a problem which many Victorian doctors completely misinterpreted. Noticing that the boy was not urinating they concluded, not that he was dying of thirst and needed water, but that "congenital phimosis" - his appropriately tight foreskin - was preventing him from urinating, and thus that the solution to the problem was surgical.

... but child health has improved as rate of circumcision fell

The reasonable conclusion, that the rising incidence of circumcision over the first half of the twentieth century made no contribution to improved child health outcomes, is confirmed by a recent report from the Australian Institute of Health and Welfare covering the period 1983 to 2003. The report, A picture of Australia’s children 2005, shows major improvements in child health over the 20 years from 1983 to 2003, and a halving of infant mortality. These are very significant dates, since 1983 was the beginning of the dramatic slide in Australian circumcision incidence, from about 40 per cent of boys in the early 1980s to less than 12 per cent in 2003. It is thus good empirical proof that “lack of circumcision” does not increase child health problems. Even more significantly, it is a decisive refutation of “scientific” predictions by various antiquated circumcision enthusiasts that the fall in the circumcision rate would lead to an explosion of genito-urinary problems in boys. No such problems are identified in this report, which does not even mention any health problems affecting the genito-urinary area.

If one were to be as unscrupulous in mixing up correlation with causation as many pro-circumcision zealots tend to be, one could reasonably conclude that Australian children have become healthier because the incidence of circumcision has fallen, not merely at the same time. But there is no need to go that far. At the very least A picture of Australia’s children is definitive proof that there is zero connection between circumcision and improved health outcomes.

The report can be downloaded from the AIHW website in several pdfs here

A further report by the AIHW in 2009 has confirmed this picture. The evidence from the AIHW in Australia and the figures in the OECD report, Doing Better for Children, make it very clear that there is no connection between circumcision and improved infant or child health. On the contrary, these data suggest that the best way to ensure better health for babies and kids is not to circumcise.

References

1. Philippa Mein Smith, Mothers and King baby: Infant survival and welfare in an imperial world – Australia 1880-1950 (London: Macmillan, 1997), p. 200

2. Diana Wyndham, Striving for national fitness: Eugenics in Australia, 1910s to 1930s (PhD thesis, University of Sydney, 1996), p. 198

3. Milton Lewis, Populate or perish: Aspects of infant and maternal health in Sydney, 1870-1939 (PhD thesis, Australian National University, 1976)

4. Janet McCalman, Sex and suffering: Women’s health and a women’s hospital – The Royal Women’s Hospital, Melbourne, 1856-1996 (Melbourne University Press, 1998)

American research shows circumcision bad for health and hip-pocket

A cost-benefit analysis of routine circumcision published in the US journal Medical Decision Making, concludes that the practice cannot be justified on either economic or medical grounds. The procedure both adds to health costs and reduces the overall health of the individual.

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.

The article concludes:

The perpetuation of neonatal circumcision cannot be justified financially or medically; therefore, any justification for the practice must be based on religion, culture, or aesthetics. A limitation of cost-utility analysis is the inability to incorporate such factors. Currently in the United States, cultural considerations trump financial and health concerns when deciding to have a newborn male circumcised. Consequently, this cost-utility analysis will have little or no impact on circumcisions performed for cultural reasons. Instead, this cost-utility analysis is aimed at the financial and medical aspects of neonatal circumcision. Should 3rd-party payers pay for the procedure? Based on this analysis, it would be in their financial interests not to. Still, insurance companies take cultural factors into account when marketing their health plans. This justification has been given by members of the insurance industry for providing neonatal circumcision benefits to their customers. It seems odd, however, that other body modifications, such as ear piercing and tattoos, are rarely covered by medical insurance plans.

The medical community faces a different set of issues. Should medical care providers perform a procedure on a newborn knowing that it is more likely to impair health than improve it? Medical ethical standards, such as "do no harm," appear not to condone such a practice. By performing circumcisions on infants, health care providers venture into the realm of being "cultural brokers." The debate whether this is the proper venue for medical services has not taken place. The analysis is clear: Neonatal circumcision cannot be justified on economic or medical grounds. If the medical community is interested in preserving health and saving money, they should refrain from promoting, encouraging, or presenting neonatal circumcision as a medical option. Third-party payers may want to reassess their current reimbursement policies and possibly consider paying physicians or parents not to perform neonatal circumcisions. Either of these options would result in an overall cost savings.

Robert Van Howe, "A cost-utility analysis of neonatal circumcision", Medical Decision Making, Vol. 24, December 2004, pp. 584-601

Full text of the article is available here

Further information on this site

Circumcision and public health (2): Is circumcision a biomedical imperative for the 21st century?

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On this page

Masturbation
Phimosis
Cancer of penis
Cervical cancer
Urinary Tract Infections
Venereal disease
HIV-AIDS
Other problems
Circumcision and child health

Health and disease

A run-down on the diseases that have been supposed to make circumcision necessary, and the reasons why these claims fail.

Health benefits of circumcision contested

Masturbation and spermatorrhoea

Phimosis and paraphimosis

Cancer of the penis and prostate

Cervical cancer

Urinary Tract Infections (UTIs)

Sexually transmitted infections (STIs)

HIV-AIDS

Other rare problems

Balanitis and posthitis

Paraphimosis (can't return foreskin after it retracted)

Frenulum breve

Balanitis Xerotica Obliterans (BXO)

Injuries to the foreskin

Non-surgical treatment of foreskin problems

Functions of the foreskin

No evidence that circumcision ever improved infant or child health ...

... but child health has improved as rate of circumcision fell

American research shows circumcision bad for health and hip-pocket