CIRCUMCISION OF MALE INFANTS RESEARCH PAPER,
Queensland Law Reform Commission, Brisbane.
December 1993.


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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. (a) Hygiene 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 disease. * Five major reported series of cases between 1932 and 1989 in which not one victim of penile cancer had been circumcised neonatally.83 * 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): 407-410.] (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 protection. 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 parade: 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 syphilis.96 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 sores.100 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 intercourse.104 Hirst reports:105 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 males. 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 less significant. Notes: 70 Russell T. The Case for Circumcision. Medical Observer, 10 October 1993. 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 murder! 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 states: 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 399. 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 circumcision. 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. 98 Ibid. 99 See Appendix 3 for summaries of recent research findings. 100 Ibid. 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. 103 Ibid. 104 Ibid. 105 Hirst G Controversies Surrounding Circumcision Patient Management September 1984 16.

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Cite as:
(File prepared 3 June 1998, Revised 14 January 1999)