British Medical Journal, Issue 6172: Page 1163-1164, 5 May 1979.
[An unsigned editorial.]
Part of the North American way of life is removal of the foreskin within a few hours of birth. Nearly two million boys are born each year in the United States and in some centres 80%-90% are circumcised,1 using vast amounts of medical and nursing time and costing parents equally vast amounts of money. In Scandinavia, on the other hand. routine circumcision is almost unknown,2 and in Britain it is becoming unusual. In the 1930s about one-third of British boys were circumcised,3 but by 1949 the proportion had fallen to one-fifth,4 and by 1963 only 10% of schoolboys in Rochdale had been circumcised.5 In hospitals in England and Wales in 1975 the rate was about 6%6; this represents some 20 000 circumcisions a year. The mortality is negligible.
Practice in Britain may have been affected by Gairdner's important paper,4 published in the BMJ in 1949. He showed that while 90% of boys have an unretractable foreskin at birth by the age of 3 the proportion has dropped to only 10%. Other studies have confirmed this natural development. In over 9000 schoolboys examined in Denmark7 phimosis was found in 8% of 5-year-olds but in only 1% of secondary pupils. Among 152 teenage English boys only one had a non-retractable foreskin, although full retraction was prevented by an adherent prepuce in 22.
Most circumcisions performed on the newborn are therefore unnecessary - in the sense that in time nearly all boys become able to retract their foreskin and wash underneath it. The North American arguments in favour of mass circumcision are that many uncircumcised men do not perform this toilet, that they run a risk of developing carcinoma of the penis, and that their wives may run an increased risk of developing carcinoma of the cervix. These last two arguments could be weighty ones, but some careful studies8,9 have failed to show any difference in the incidence of cervical carcinoma in the wives of circumcised and uncircumcised husbands. Circumcision in infancy does virtually prevent penile carcinoma - there are only six recorded examples of this neoplasm in circumcised Jews.10 Even in the uncircumcised, however penile carcinoma is rare. In Sweden, which has a male population of 3.7 million (few of whom are circumcised), there are but 15 deaths from carcinoma of the penis in a year.2 Some 5600 men die each week in England and Wales but only two of these deaths are due to penille carcinoma - only 0.14% of all deaths for malignant disease in men.11
Modern research has established the role of the human papilloma virus and smoking in the etiology of carcinoma of the penis and of the cervix. The foreskin has been cleared of blame.
Surgeons who work in areas where ritual circumcision is not available are sometimes asked to don rabbinical robes on the eight day to circumcise a Jewish baby, and they may have been impressed by the lack of distress as the baby sucks on a teat containing some brandy. There is however a big difference between these rites and routine circumcision of newborn boys. Too often this is seen as an uninteresting chore to be passed to inadequately trained junior staff, which evidently is not without risk. There are many reports of removal of most of the skin of the penile shaft, injuries to the glans, circumcision of hypospadiacs, and the need to perform a second circumcision on as many as 10% of babies because inadequate removal of mucosa has been followed by secondary phimosis.1,12 The present day hospital nursery, often colonised by antibiotic-resistant organisms, is a dangerous place for a newborn baby with a raw penile wound - as is shown by two recent papers.13,14 These record three babies who developed staphylococcal septicaemia (one fatal) and one with spreading septic gangrene of the scrotal skin after circumcision in the first week of life. Haematogenous osteomyelitis and lung abscess have also been reported as complications. Furthermore, all babies who lose their foreskin lose the natural protection of the glans penis, which prevents it being burnt by ammoniacal urine on the wet nappy. Meatal ulceration is a painful condition and meatal stenosis a serious one.
Presumably most Americans are satisfied with their present practice, and some justify it most forcefully.15 Others, however do have misgivings,16 in so far as there is really no rational case for general neonatal circumcision. On the other hand, surgeons and urologists know that many men conceal a dirty mess beneath the foreskin and that in some the discomforts of phimosis make circumcision necessary, and that this is an embarassing and uncomfortable procedure in adult life. These problems can be forestalled. Examination of the penis, as well as the testes should be a standard part of school medical inspections. This would allow the few boys with true phimosis to be treated early, and at secondary school would provide an excellent opportunity to back up or amplify parental instruction in personal hygiene.
Many surgeons who are not willing to perform circumcision much before three years of age accept that after that age operation is justified for phimosis and recurrent balanitis. The parents' wishes, both for and against the operation, must be taken into account; but the operation between 3 and 5 is probably the best compromise since it avoids the discomforts of circumcision later in life. Unfortunately only one-third of the operations in England and Wales are before 5 years.6. Nevertheless the circumcision rate of about 6% is probably the correct proportion in a Western countrytoday.
This editorial expresses the view that about 6% of men need circumcisions. The BMJ, in a later editorial published on 2 January 1993, expressed the view that "overall between 1% and 2% of boys need circumcision for medical indications. Since this was before the development of alternative effective conservative treatments for phimosis and balanitis, presumably the editors of BMJ would put the rate much lower today, perhaps 0.1% to 0.2% or 1 or 2 per 1000 boys. This would make the arguments expressed in this paper apply with even greater force.
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