Canadian Medical Association Journal, Volume 126: Page 1399, 15 June 1982.
The review by Warner and Strashin1 clearly presented the arguments for and against circumcision and the contraindications. However, the most important reason for favouring circumcision - that is, preventing carcinoma of the penis - is not completely established. In addition, Warner and Strashin overly minimized the risks of circumcision. They also did not include the cost of complications of neonatal circumcision in their cost benefit analysis.
While the literature suggests that circumcision may protect against carcinoma of the penis, the case is not entirely proven. There are, for example, wide differences in the incidence of penile carcinoma among African tribes that do not practise circumcision.2 In Sweden, where circumcision is rare, the incidence of penile carcinoma is low.3 It is possible that there are genetic or environmental factors that influence the incidence of this carcinoma and, by coincidence, are associated with circumcision. Warner and Strashin do recognize that the protective role of circumcision is not completely established. In their conclusions they stated that "cancer of the penis may be prevented by circumcision", but in the abstract of the article the crucial word "may" is omitted.
Warner and Strashin discussed the literature on the incidence of early complications, including the report by Gee and Ansell4, which noted one life-threatening hemorrhage, four cases of septicemia and one case of complete penile denudation, as well as circumcision in eight cases of hypospadias among 5000 circumcised boys. Then they concluded that "hemorrhage, infection and other immediate complications..... are easily treated; those that are not are very rare". The potential for meningeal spread from septicemia and the hospital costs for these complications were ignored. Neither did they discuss problems resulting from inappropriate management of the prepuce that can result in the need for later circumcision. Phimosis commonly follows infantile balanitis, which occurs when premature and energetic attempts are made to break down the incorrectly named "preputial adhesions" the epithelial tissue that has not yet separated into planes. This lack of separation is normal in newborns and may not be completed until the age of 16 or 17 years.5 Øster5 reported that among 1968 schoolboys examined annually for 8 years the incidence of phimosis was 8% at age 6 to 7 years but only 1% by the age of 16 to 17 years. How many physicians recommending and carrying out circumcision in schoolboys know this? A survey of 60 pediatricians in the United States revealed that 78% did not know at what age the prepuce might normally be retracted.6 Øster5 found that only 3 (0.15%) of the 1968 boys required circumcision. Thus, the true need for later circumcision may be greatly exaggerated.
McKim's editorial on circumcision also minimized the risks of this operation in the newborn period.7 The risks should indeed be minimal; however, because circumcision is not always carried out by "experienced, skilful surgeons", surgical complications are regularly seen and are not "extremely rare", as McKim stated.
Certainly the good teaching and supervision of neonatal circumcision McKim pleaded for are vital.
In the past we made many errors when therapeutic approaches were developed in the absence of adequate proof of efficacy.8 Silverman8 has emphasized our need not only to learn from past experiences but also to ensure that we use the correct methods to evaluate our interventions.
Several years ago the fetus and newborn committee of the Canadian Paediatric Society carefully reviewed the pros and cons of circumcision; the conclusions were published in a statement in 1975.9 The intentions of this statement was to reduce the number of unnecessary circumcisions and the complications that might result. (Incidentally, Warner and Strashin did not refer to this review.) The present fetus and newborn committee sees no reason for modifying the statement of the previous committee and is concerned that a completely balanced view be available to the physician asked to decide upon the necessity for circumcision.
Canadian Paediatric Society
c/o Children's Hospital of Eastern Ontario
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