CIRCUMCISION OF MALE INFANTS RESEARCH PAPER,
Queensland Law Reform Commission, Brisbane.
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7. PROPHYLACTIC REASONS FOR REMOVAL OF PREPUCE
There are those who argue strongly in favour of routine
circumcision. For example, a Brisbane general practitioner,
Dr T. Russell states:70
The evidence of the benefits of neonatal circumcision
is now so strong that it may be unethical or even
negligent not to recommend circumcision.
A United States medical practitioner, much relied upon by
pro-routine circumcision lobbyists, Dr Edgar Schoen states:71
The benefits of routine circumcision of newborns as
a preventive health benefit far exceed the risks of
the procedure ...
A number of arguments have been promoted for routine male
circumcision on the basis of preventive health.
It is important for uncircumcised males to retract and clean
beneath the foreskin to avoid infections. The need for regular
cleaning is often used as an argument in favour of circumcision.
Of course hygiene is widely regarded as a preventative health
measure to a wide range of illnesses and disease. Cleaning the
uncircumcised penis has been likened to cleaning the intact
labia of females - both of which could be regarded as a
commonsense preventative health measure.72 Circumcision
reduces the need for males to practice genital hygiene.
But, as Dr Hirst states:73
One frequently hears the argument that `my father had
to have it done in the Middle East in World War II' or
my brother in Vietnam ... so let's prevent that risk'.
Is is not facetious to suggest that removal of an organ,
however small it might be, is the appropriate way to
obviate a problem of cleanliness?
Obviously, if girls can be taught genital and menstrual hygiene,
boys can be taught penile hygiene, although some may reject this
analogy. Dr Russell has written:74
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 under the prepuce)?
Many groups which have traditionally practiced routine
circumcision, such as Jews, Muslims, Australian Aborginals -
originally lived in dry, arid conditions where facilities for
personal hygiene were not optimal. Circumcision may therefore
have had appeal as a prophylactic measure against balanitis.
(b) Risk of Cancer
There is some evidence that circumcision may reduce a man's risk
of developing cancer of the penis.
Carcinoma of the penis is exceptionally rare. In countries
where circumcision is not routinely performed, such as Denmark
and Japan, the rates of penile cancer are similar to those found
in countries like the United States where the majority of males
have been circumcised.75 The incidence of cancer is much
lower in the uncircumcised when associated with good hygiene.
Dr J S Black notes:76
Studies have shown that in uncircumcised cultures with
good hygiene the incidence of cancer of the penis is
low, but in circumcised cultures with poor hygiene the
incidence is high. Clearly it is good hygiene, not the
presence or absence of the foreskin that matters.
Dr M L Sorrells notes:77
All studies report almost total absence of hygiene in
all victims of the cancer ... the relationship of
circumcision to cancer of the penis seems real, but
even minimal hygienic standards are probably just as
effective in prevention.
Cancer of circumcised penises has been reported:
Dr Schoen reports:78
There are 750 to 1000 cases of penile cancer annually,
in the United States; however in the past twenty years
only 3 cases of penile cancer have been reported in men
who had been circumcised as newborns. There have been
six major studies of cancer of the penis in the United
States since 1932, and none of the more than 1600
patients studied had been circumcised in infancy.
Marshall determined the incidence of carcinoma of the penis in
the United States to be 0.2 to 0.9 per 100,000 uncircumcised
males. Using this data, he estimated that between 111,000 and
500,000 circumcisions needed to be performed to prevent one case
of penile cancer.79 Hirst80 refers to older United Kingdom
figures suggesting that such a number of circumcisions might
result in in more than 20 neonatal deaths "although recent
papers quote lower mortality rates."
Other studies have reported:81
* Of 150 patients with carcinoma of the penis treated at
the University of Michigan Medical Center - all were
uncircumcised. One third died as a result of the
* Five major reported series of cases between 1932 and
1989 in which not one victim of penile cancer had been
* Fifteen cases of penile cancer arising in circumcision
scars in Saudi Arabia - although as is the custom, all
had been circumcised as teenagers.84
* In Australia there were 78 deaths from carcinoma of the
penis between 1960 and 1966. In the same period there
were 2 reported deaths from circumcision.85
There has been the suggestion of a link between lack of
circumcision and the incidence of cancer of the prostrate.(sic)
There is no evidence for this assertion.86
It has been suggested that a lower-than-usual incidence of
carcinoma of the cervix in Jewish women is due to the universal
circumcised state of their sexual partners. There is no
scientific basis for this suggestion.
It has been noted however, that Muslim women, whose husbands are
circumcised in infancy, have a much higher rate of cervical
cancer than Jewish women. Parsees of India, who do not
circumcise, have a much lower rate of cervical cancer than their
Muslim neighbors who do circumcise.87 Complete circumcision
is found about as frequently in husbands of patients with cancer
of the cervix as in husbands of controls.88
The strongest predisposing factors in cervical cancer are a
history of intercourse at an early age and multiple sexual
partners, sexual hygiene, parity,89 contraceptives, coitus
interruptus, and frequent intercourse.90
For each of these cancers, it appears that more factors are
involved than circumcision and non-circumcision. Personal
hygiene seems to be the most consistently relevant factor.91
The incidence of breast cancer in women and prostrate (sic)
cancer in men are far more common in Australia than cancer of
the penis, yet it is rare to hear learned arguments in favour of
routine mastectomies for women and routine prostatectomies for
men in order to prevent such cancer from developing.
[CIRP Note: Recent research has firmly established the role of
both the Human Papiloma Virus and smoking in the aetiology of
both cancer of the penis and cancer of the cervix. Circumcision
cannot prevent either HPV or smoking and so cannot prevent
penile cancer. For a more recent discussion of this subject see:
Cold CJ, Storms M, Van Howe RS. Carcinoma in situ of the penis
is a 76-year-old circumcised man. J Fam Prac 1997; 44(4):
(c) Urinary tract infections
Such infections are said to be more common in uncircumcised
male babies. The evidence for this is scientifically suspect as
it all comes from hospital-based retrospective studies.92
Bacterial infection of the glans and prepuce are relatively
uncommon in the child where there is no known aetiological
factor, whereas in adults it usually occurs as a result of
phimosis or poor hygiene.93
(d) Sexually Transmitted Diseases
Unless men are sexually active and in a risk group for
contracting sexually transmitted diseases, circumcision will not
offer protection against such diseases. Boys, whether
circumcised or uncircumcised, are at far less risk of
contracting sexually transmitted diseases including the Human
Immunodeficiency Virus prior to becoming sexually active or
adopting a high-risk lifestyle. Presumably, at that point,
they would be old enough to consent on their own behalf to
circumcision if they believed that would offer them some
The risk of transmitting or contracting certain sexually
transmitted diseases including the HIV virus may be increased
for men already in a risk group who have uncircumcised penises
although other factors may be relevant.94
In 1947 a Canadian study on the incidence of circumcision
amongst soldiers with venereal disease found on that
uncircumcised men were nine times more likely than circumcised
men to have syphilis and almost three times more likely to have
gonorrhoea. It was observed however that cleanliness of the
genitals was commonly neglected among the soldiers. Further,
tears and abrasions of the prepuce were often noticed on sick
Small abrasions of the delicate coronal membrane must
be very common during brothel intercourse. Both
provide a portal of entry for the spirochaete.95
In a 1983 Western Australia study of men attending a special
treatment clinic it was estimated that uncircumcised men were
twice as likely as circumcised men to have herpes genitalis or
gonorrhoea, and five times as likely to develop candidiasis or
No attempt was made in the study to measure the socioeconomic
status of the subjects - it had previously been suggested that
uncircumcised men tend to come from lower socioeconomic
backgrounds and to have poorer personal hygiene and a greater
chance of exposure to infection.97 Another possibility
canvassed by the researchers is that circumcised and
uncircumcised men have similar rates of disease but that
uncircumcised men are more likely to develop and thus, to seek
medical attention. This was considered most likely to be so in
the case of candidiasis.
The authors concluded:98
The evidence at presence certainly does not warrant
the recommendation of circumcision on the ground that
it prevents Sexually Transmitted Diseases. If these
findings are confirmed in other studies, it would seem
that attention should be directed to the improvement
of personal hygiene among uncircumcised men.
The most recent available research findings on the relationship
between lack of circumcision and HIV infection indicate that,
for men involved in a high risk lifestyle, circumcision may
offer some protection from HIV infection, although not all
studies reveal such a link.99
The protective effect of circumcision may be reduced when other
factors are taken into account such as history of genital
In a 1988 study in Nairobi of 340 men attending a sexually
transmitted disease clinic uncircumcised heterosexual men were
found to be 2.7 times more likely to have HIV infection than
uncircumcised men.101 Genital ulcers may increase men's
susceptibility to HIV, or they may increases the infectivity of
women infected with HIV. The researchers conclude that the
intact prepuce may operate to increase the susceptibility to
HIV. One suggested explanation given by Nairobi researchers for the
link between lack of circumcision and HIV infection is:102
The presence of an intact foreskin provides a warm,
moist, environment that allows a longer time for
viral survival and penetration.
Further, the cornified skin covering which develops on the
circumcised penis may protect it from the microabrasions which
facilitate HIV entry.103
The prepuce may also be subject to trauma during
Symptomatic monilial balanitis, usually resulting
from sexual contact, is a common problem seen almost
exclusively in the uncircumcised, particularly in a
population where oral contraceptives are in widespead
use. Treatment of both parties usually eradicates
the infection, but occasionally circumcision is
necessary to effect a cure.
[CIRP Note: For a more recent discussion of the relationship
between incidence of circumcision and the incidence of HIV see:
Nicoll A. Routine male neonatal circumcision and risk of
infection with HIV-1 and other sexually transmitted diseases.
Archives of Disease in Childhood (London) 1997; 77(3):194-195.]
(e) Psychological and Sociological
There may be an argument that for a child to be uncircumcised in
a family or country where most males have been circumcised will
place the child in an uncomfortable and embarrassing position.
This may be more so when the community within which he lives has
a religious or strong cultural reason for circumcising the
As the majority of boys in Australia are now uncircumcised, it
is less likely than it was a few years ago, that a boy will be
made to feel out-of-place amongst his peers for being
uncircumcised. This should also be the case within families
when the majority of fathers are uncircumcised. Presumably the
old argument of fathers wanting their sons to look like them is
70 Russell T. The Case for Circumcision. Medical Observer, 10
71 Schoen E. The Status of Circumcision of Newborns. The New
England Journal of Medicine, May 3 1990: 1308, at 1311.
72 Milos MF and Macris D. Circumcision. A Medical or a Human
Rights Issue? Journal of Nurse-Midwifery, Vol 37(2) (1992)
877, at 905.
73 Hirst G. Controversies Surrounding Circumcision. Patient
Management, September 1984: 12, at 14.
74 Russell T. The Case for Circumcision. Medical Observer 1 Oct
1993. In that article, a study of British School boys is
referred to which showed that penile hygiene as such does not
exist. An obstetrician and gynaecologist writing in Patient
Management March 1992 at p. 70 notes:
The operation came into existence thousands of
years ago in Middle Eastern desert lands where
to get sand under one's foreskin must have been
75 Arnold EP. If anyone asks: `Should I have him circumcised?'
Patient Management, November 1990: 15, at 16.
76 Patient Management, March 1992: at 71.
77 Still More Criticism Paediatrics Vol 56, (1979): at 339.
78 Schoen E. The Status of Circumcision of Newborns The New
England Journal of Medicine. May 3 1990: 1308, at 1309.
79 Marshall VF. Should circumcision of newborns be routine?
Medical Record Annals Vol 48, (1954): 790.
80 Hirst G. Controversies surrounding circumcision Patient
Management, September 1984: 12, at 16.
81 Leitch IOW. Circumcision - A Continuing Enigma Australian
Paediatric Journal Vol 6 (1970): 59, at 62, reports:
Moslems are circumcised between the age of 4 and 12 years,
and comparisons of the incidence in Moslems and Jews show
a lower incidence in Jews, who are circumcised on the
eight post-natal day. However Jewish circumcision demands
the removal of more prepuce than the Moslem ritual.
Carcinoma of the penis in the Chinese accounts for 18.5
percent of all carcinomata, compared with 2% in the U.S.A.
... There are wide geographic variations, and the disease
is associated with a congenitally tight and long redundant
foreskin. The disease is rarely seen among the more
well-to-do, whole level of personal hygiene is higher.
Circumcision has been thought to provide complete
protection from carcinoma of the penis, but recently two
cases have been reported in Jews circumcised in infancy
... and five cases of carcinoma of the penis in non-Jews
circumcised in infancy.
Carcinoma of the penis seems to be associated with lack of
circumcision which by no means affords absolute
protection. Also associated are a long redundant
foreskin, and a congenitally adherent foreskin, while good
personal hygiene appears to decrease the incidence.
82 Dagher R, Selzer ML, Lapides J. Carcinoma of the Penis and
the Anti-Circumcision Crusade Journal of Urology Vol 110
(1973): at 79-80. Approximately 70 percent of the patients
underwent surgical procedures, including local excision of
the lesion, circumcision, partial penectomy, radical
amputation of the penis and lymphadenectomy.
83 American Academy of Pediatrics. Report of the Task Force on
Circumcision Paediatrics Vol 84(4) (1989):388-391.
84 Swadey JG. Letter to the Editor Southern Medical Journal, Vol 80(4)
(1987):537-538. But see Dagher R, Selzer ML, Lapides J in
Carcinoma of the Penis and the Anti-Circumcision Crusade
Journal of Urology Vol 110, (1973): 79-80 state:
Our evidence leads us to believe that circumcision at any
age will virtually prevent the onset of squamous cell
carcinoma of the penis if the neoplasm is not present at
the time of circumcision and the prepuce is completely
removed. We do not agree with the concept that
circumcision after the neonatal period is ineffective in
preventing epicermoid neoplasms of the penis. Many adult
patients with phimosis, condyloma acuminata and
leukoplatia have been circumcised at this medical center
and none has reappeared with penile neoplasm.
85 Leitch IOW. Circumcision - A Continuing Enigma Australian
Paediatric Journal, Vol 5 (1970): 59-65.
86 Id at 62 and Hirst G. Controversies Surrounding Circumcision
Patient Management, September 1984, 12, at 16. Demetrakopoulos GE
A Different View of the Facts Paediatrics Vol 56 1970 339 at 340.
87 Leitch IOW. Circumcision - A Continuing Enigma Australian
Paediatric Journal, Vol 6, (1970): 59, at 62. Note also that
the human papiloma virus type 16 has been found in 50% of
males with carcinoma of the penis. and this virus, among
others, is also implicated in the aetiology of carcinoma of
the cervix in female partners. - See Arnold EP. If anyone
asks: `Should I have him circumcised'? Patient Management,
November 1970:339, at 340.
88 Demetrakopoulos GE. A Different View of the Facts
Paediatrics, Vol 56 (1979): 339, at 340.
89 The condition of having borne children.
90 Ibid. See also Demetrakopoulos GE. A Different View of the
Facts Paediatrics, Vol 56 (1979): 339, at 340, and Sorrells
ML. Still More Criticism Paediatrics. Vol 56 (1979): at 339
The level of hygiene in both male and female indeed
seems to be a factor in the aetiology of cervical
cancer but that circumcision increases hygienic
standards is patently not true.
91 Leitch IOW. Circumcision - A Continuing Enigma Australian
Paediatric Journal, Vol 6, (1970): 59, at 62. The US Task
Force on Circumcision Paediatrics, Vol 84(4) (1989):388, at
92 Arnold EP. If anyone asks `Should I have him circumcised?'
Patient Management, November 1990: 15, at 16 notes that in
adults, if a catheter is passed and the patient subsequently
develops a urinary infection, the organism is usually
identical to that found on the culture of the urethral meatus
or preputial sac at the time the catheter is passed. "There
is support, therefore, for the belief that infections arise
from the ascending route."
93 Hirst G. Controversies Surrounding Circumcision. Patient
Management. September 1984: 12, at 14 notes that recurrence
of these infections may be a medical indication for
94 Many of the studies which are relied upon to substantiate the
increased risk are not well-controlled and do not eliminate
variables such as geographic location, hygiene, life-style,
race, socioeconomic factors or access to medical care. See
Report of the Task Force on Circumcision Paediatrics, Vol
84(4) (1989): 388, at 389.
95 A bacterium.
96 Parker SW, Stewart AJ, Wren MN, Gollow MM, Straton JAY.
Circumcision and Sexually Transmitted Disease Medical
Journal of Australia, Vol 2 (1983):288-289.
97 See Schoen E. The Status of Circumcision of Newborns (1990)
The New England Journal of Medicine: 1308 who observes:
From the early 1940s until the mid-1970s ... educated
middle class parents almost always had their newborn sons
circumcised to [to prevent cancer of the penis and
cervical cancer in sexual partners, as well as to prevent
phimosis and to promote genital cleanliness]. Those
middle-class parents were willing to pay for the procedure
(there were few insurance programs in the 1940s and
1950s). The infant sons of poor parents were usually
uncircumcised because their parents were unaware of the
benefits and could not afford the cost.
99 See Appendix 3 for summaries of recent research findings.
101 Simonsen JN, Cameron DW, Gakinya MN, Ndinya-Achola JO,
D'Costa LJ, Karasira P, Cheang M, Ronald AR, Plot P, Plummer
FA. Human Immunodeficiency Virus Infection Among Men with
Sexually Transmitted Diseases New England Journal of
Medicine Vol 319(5) (1988): 274.
102 Id at 277.
105 Hirst G Controversies Surrounding Circumcision Patient
Management September 1984 16.
[Back to Contents]
- Circumcision of Male Infants Research Paper. Queensland Law
Reform Commission. Brisbane 1993.
(File prepared 3 June 1998, Revised 14 January 1999)