Ch. 3: Alleged Medical Benefits of Circumcision (DOC Genital Integrity Statement)

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This is Chapter 3 of a statement available at http://www.doctorsopposingcircumcision.org/DOC/statement0.html

Click here to view/download the complete statement in PDF form: GenitalIntegrityStatement.pdf, also available at http://www.doctorsopposingcircumcision.org/pdf/GenitalIntegrityStatement.pdf

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Chapter Three: Alleged Medical Benefits of Circumcision

An infant boy is born with a healthy foreskin. Consequently, there are no medical indications for circumcision in the newborn period.1,2

Infant circumcision is a painful, stressful, and traumatic procedure that leaves the infant exhausted and debilitated to the extent that some are unable to suckle at the breast.3 Medical authorities accordingly recommend that circumcision be performed only on healthy and stable infants. In the absence of any medical indication, and with the surgical operation being performed only on healthy and stable infants, the Council on Scientific Affairs of the American Medical Association (AMA), therefore, properly describes elective infant circumcision as a “non-therapeutic” procedure.4 (Infant circumcision was downgraded from routine to elective in 1997, in a joint statement issued by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.5)

Claims for any health or medical benefit are restricted to a possible prophylactic benefit in later life. Circumcision of the newborn, in the opinion of a few, may prevent phimosis, infection with sexually transmitted diseases, urinary tract infection in the first year of life, penile cancer, and cervical cancer in sexual partners. These claims date from the era of opinion-based medicine, when, in the absence of any scientific evidence, medical doctors relied on the opinions of one another rather than on evidence. (e.g.6) We shall examine each of these claims.

Phimosis

Phimosis is the term used to describe the condition of being unable to retract the prepuce (foreskin).

Almost every newborn infant boy has a non-retractile foreskin. The condition of non-retractability occurs because 1) the foreskin is fused with the glans penis in the newborn, 2) because the foreskin of the newborn is too narrow to retract over the glans penis, or 3) frenulum breve. Non-retractable foreskin is not a disease but a normal developmental physiological stage in boys. The foreskin gradually becomes retractable between infancy and 18 years of age.7 About 1 percent of males, aged 18 and older, still have a non-retractile foreskin. The fusion of the foreskin with the glans penis spontaneously separates and no treatment is necessary. Frenulum breve, a rare condition, may be relieved by a minor incision in the frenulum (frenuloplasty).

Phimosis is not a life-theatening condition, and usually requires no treatment. When treatment is deemed necessary, phimosis may be treated by application of topical steroid ointment without surgical risk.8,9 Older boys and men may treat non-retractile foreskin with manual stretching to accomplish permanent tissue expansion.10,11 (See Chapter Seven)

Neonatal circumcision frequently results in a phimotic condition as the cicatrix caused by circumcision may contract in front of the glans penis, trapping it behind a phimotic ring. Blalock et al. (2003) report that phimosis occurs in 2.9 percent of circumcision patients.12 This exceeds, by a factor of three, the incidence of non-retractile foreskin reported by Øster (1968) at the end of puberty. It is clear, therefore, that circumcision cannot be recommended to prevent phimosis. The AAP statement of 1975 correctly noted that incomplete removal of the foreskin can result in post-circumcision phimosis.13 The AAP statement of 1989 misleadingly reported that circumcision “properly performed” prevents phimosis.14 By properly performed, the task force meant that sufficient skin must be removed to make it impossible for a circular scar to form in advance of the glans penis. Unfortunately, when that much tissue is removed, the patient is likely to suffer painful erections because insufficient skin is left to accommodate the expansion of the penis with tumesence. Circumcisions frequently are improperly performed because they are delegated to the most junior members of the staff.15 Also, knowledgable physicians are aware that skin tissue must be left to accommodate erections, so post-circumcision phimosis is not an uncommon complication. The use of male circumcision to prevent/cure phimosis is outmoded.

Sexually Transmitted Diseases

Abraham Leo Wolbarst, M.D., was an ardent defender and promoter of the practice of circumcision. After Holt (1913) criticized ritual circumcision because of the large number of cases of tuberculosis resulting in death acquired through infection of the open wound,16 Wolbarst (1914) came to the defense of ritual circumcision by extolling the alleged sanitary benefits of circumcision.6 Wolbarst did this by collecting opinions from other medical doctors, which he then published in an article in the Journal of the American Medical Association. He solicited opinions that circumcision prevented the venereal diseases of syphilis and chancroid. He then cited these opinions as evidence of the value of circumcision. Controlled studies were not available in that long-ago day. The United States military services, on the basis of such flimsy evidence, circumcised large numbers of men to prevent sexually transmitted diseases during two world wars.

Modern evidence-based medicine, however, is unable to support Wolbarst’s overblown claims. Cook et al. (1994) were unable to show a definite benefit for circumcision—finding a slight tendency for non-circumcised men to have more syphilis and gonorrhea, but less tendency to have genital warts.17 Donovan et al. (1994) reported no significant difference between non-circumcised and circumcised men.18 Van Howe (1999) found circumcised men may be slightly more likely to have urethritis and uncircumcised males may be more prone to genital ulcer disease (GUD).19 Dickson et al. (2008) found more STD in circumcised men but the difference was not statistically significant.20 The Fetus and Newborn Committee of the Canadian Paediatric Society found that “circumcision had no significant effect on the incidence of common STDs.”21 The AAP Task Force (1999) reported that “behavior factors appear to be far more important than circumcision status.”22 The medical evidence does not support the practice of neonatal circumcision to prevent STDs.

de Vincenzi & Mertens (1994) performed a meta-analysis of the then-existing literature, regarding circumcision and HIV infection. They concluded, at that time, there was insufficient evidence to recommend male circumcision to prevent HIV transmission.23 The Council on Scientific Affairs of the AMA (1999) concluded that “behavioral factors are far more important risk factors for acquisition of HIV and other sexually transmissible diseases than circumcision status, and circumcision cannot be responsibly viewed as “protecting” against such infections.”4 The Cochrane Library review of the medical evidence (2003) concluded that there is insufficient evidence to recommend circumcision to prevent HIV infection.24 Thomas (2004) found no evidence that circumcision is protective against HIV in a U.S. Navy population.25Talbott (2007) reports that it is the percentage of female sex workers in the female population, not the incidence of male circumcision, that determines the level of HIV infection.26 Dowsett & Couch (2007) examined the results of three randomized controlled trials (RCTs), but they still found insufficient evidence to recommend circumcision to prevent HIV infection.27 Green et al. (2008) reviewed the evidence regarding circumcision to prevent HIV infection and found “insufficient data” as well as countervailing data. They concluded:

“The world community must cautiously review and carefully consider the long-term consequences of mass circumcision campaigns, from the risk of increasing deaths and infections to human rights violations. In the rush to save lives, many may instead be lost and human rights trampled in the stampede. Circumcision is not the panacea the world has been waiting for in the battle to stem the HIV crisis.”28

The Lancet published two coordinated randomized controlled trials (RCTs) on February 24, 2007.29,30 One should note that the lead authors of these RCTs are natives of Australia, Canada, or the United States, all of which, now or formerly, are or were circumcising cultures. These men may well have suffered circumcision as infants. Siegfried et al.(2003) comment that such men are likely to carry “strong beliefs and opinions” in favor of circumcision.24 They may be compelled, therefore, to produce literature to support their culture of origin. (See Chapter Six for discussion of the effect of circumcision upon medical literature.) These authors wrote papers advocating male circumcision to prevent HIV infection prior to undertaking these RCTs. The severe criticism that these papers have received suggests that something other than pure medical science is at work. Researcher bias cannot be ruled out.

The epidemic of HIV infection in the United States is concentrated among men who have sex with men (MSM). Two studies find that male circumcision is ineffective at preventing HIV among MSM.31,32

Moreover, RCTs carried out among adults in Africa are not relevant to children in North America. Even if the African RCTs were accurate, the incidence of infection and the risk of infection in North America are many times less than in Africa. Moreover, children do not engage in sexual intercourse so they are not at risk of HIV infection by sexual transmission. The African RCTs are not applicable to North America. Moreover, the RCTs have been shown to have such severe methodological flaws as to make them useless for formulation of public health policy. Van Howe & Storms (2011) show that male circumcision increases the incidence of HIV infection.33 Boyle & Hill (2011) report numerous fatal methodological flaws and say the use of the three RCTs by the World Health Organization to establish public health policy recommendations is inappropriate.34 Both teams of researchers report a higher incidence of HIV infection among circumcised men than among non-circumcised men in numerous sub-Saharan African nations.33 34

Condoms are an effective means of preventing sexually transmitted disease, including HIV.35

Urinary Tract Infections

Ginsburg & McCracken (1982), who studied urinary tract infection (UTI) in male infants at Parkland Hospital in Dallas, noted that 95% of the infant male UTI patients were not circumcised.36 They speculated that lack of circumcision may have contributed to the infection in some way. However, Parkland Hospital, a public hospital, did not perform neonatal circumcisions, even if patients demanded it,37 so most of the client population at Parkland must have been noncircumcised—a fact apparently overlooked by Ginsburg & McCracken.

This flawed observation prompted Wiswell et al. to produce retrospective studies regarding UTI in circumcised infant males as compared with uncircumcised males. The studies all have serious methodological flaws, including failure to control for confounding factors, which include maternal infection, perinatal anoxia, high or low birthweight, prematurity of birth, rooming in, method of urine sample collection, type of hygienic care, and breastfeeding. The Fetus and Newborn Committee of the Canadian Paediatric Society (1989) examined data provided by Wiswell et al. and reported that they found Wiswell’s data to be “not sufficiently compelling to justify a change in their existing policy that circumcision is unnecessary and should not be performed.”38 Altshul (1990) pointed out that the studies had only shown association, not cause and effect.39 Thompson (1990) found that “unequivocable proof that lack of circumcision is a risk factor for increased urinary tract infection is currently unavailable.”40 Chessare (1993) compared the alleged advantage of preventing UTI with the disadvantages of complications and found that, even if Wiswell was correct in his claims, non-circumcision would still produce the highest medical utility.41

Evidence from Israel establishes a compelling association between ritual circumcision on the eighth day and immediate post-circumcision UTI.42-44

Mueller et al. (1997) reported no difference in the incidence of UTI in circumcised and non-circumcised boys with normal urinary tract anatomy.45

To put this matter into perspective, a Swedish study by Mårild et al. (1998), where infant circumcision is not practiced, found that, in the first six years of life, the incidence of UTI in boys was 1.8 percent, but in girls it was 6.6 percent.46 UTI infection in boys was rare after the first year of life. When UTI does occur, it is easily treated medically. McCracken (1989) and Larcombe (1999) report UTI infections respond rapidly to anti-microbial therapy.,47,48

The Task Force on Circumcision of the American Academy of Pediatrics, in their “evidence-based” statement, reported serious methodological flaws in all existing studies, and declined to recommend circumcision to reduce UTI.22The Royal Australasian College of Physicians (RACP) says routine non-therapeutic circumcision “cannot be justified on the basis of preventing a UTI.”49

The consensus of medical opinion is that circumcision is of little, if any, value in reducing UTI. Risk, complications, an disadvantages of circumcision outweigh any reduction in UTI. The notion that neonatal male circumcsion can prevent UTI increasingly is being viewed as a medical myth – one started by Ginsburg & McCracken’s failure to recognize that the client population at Parkland Hospital in Dallas was mostly noncircumcised.

Medical authorities now recommend breastfeeding, not circumcision, to reduce UTI in infancy.50,51 Moreover, Hansen (2004),52 and Mårild & others (2004)53 report that breastfeeding continues to have a protective effect even after weaning.

Kwak et al. (2004) report that circumcision after anti-reflux surgery to prevent UTI is not effective. 54

Penile Cancer

Abraham L. Wolbarst, the noted early 20th-century circumcision promoter, started the myth that neonatal circumcision absolutely prevented penile cancer, at a time (1932) when the etiology of cancer was not well understood.55His claims were accepted as fact, and unfortunately, one still finds such statements in the medical literature today. It was not long, however, until doctors started to report cases of cancer in circumcised men that did not fit with Wolbarst’s inflated claims.56 Wolbarst’s report was incorrect. Maden et al. (1993) reported 41 cases of penile cancer in circumcised men.57 Certainly, it was becoming clear that circumcision did not prevent penile cancer.

True risk factors did not emerge until the 1980s. DNA from human papillomavirus (HPV) was identified in penile cancer cells.58 Infection with HPV (which is contracted by sexual intercourse) is an important risk factor. The use of tobacco is another important risk factor.59

Maden et al. (1993) improperly claimed that lack of circumcision was a risk factor,57 but Cold et al. (1997) discovered that Maden had not adjusted his data for age.60 When Maden’s data were properly adjusted for age, there was no difference in the risk for circumcised and non-circumcised men.60

Circumcision is ineffective for the prevention of penile cancer. Bissada et al. (1986) report that penile cancer forms on the circumcision scar.61 The American Academy of Family Physicians (AAFP) says 600 to 900 circumcisions would be necessary to prevent one case of penile cancer.62 The AAP says the risk of penile cancer in a non-circumcised man is “somewhat” higher than a circumcised man but remains low.22 The AMA says, because the disease is rare and occurs later in life, the use of circumcision as a preventive measure is not justified.4

Cancer of the Cervix in Partners

The risk factors for cervical cancer are infection with human papilloma virus (HPV)63 and smoking.64 Risk of infection with HPV is increased by early onset of sexual intercourse and multiple sex partners.65 There is no clear evidence that male circumcision decreases the risk of infection.

Male circumcision cannot be shown to prevent cervical cancer in female partners. The Royal Australasian College of Physicians (RACP) points out that vaccines are being developed to prevent infection with HPV. The RACP found no data to suggest that circumcision would be of additional benefit.49 When HPV vaccine comes into general use, it should nearly end the threat posed by cervical cancer.

Human papillomavirus vaccine to protect against HPV cervical cancer is now a reality and is being given to pre-teen girls.66

Conclusion

The claims of “potential benefits”, allegedly provided by medically unnecessary, non-therapeutic circumcision, lack any real support from medical science. United States medical literature, as compared with the medical literature of other nations, is highly biased in favor of male circumcision.67 The word “potential” means to exist in possibility but not in actuality. The scientific literature that supports such “potential” benefits is written mostly by doctors who were reared in circumcising cultures.68,69

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