Medical analysis of circumcision

Introduction

The evidence for medical benefits and risks of circumcision have come under increasingly close scrutiny by a number of national professional medical organizations. Their tasks have been challenging, as the subject is controversial, with many conflicting claims in the literature. Some of their conclusions may be found in the Costs and Benefits section below.

Numerous medical studies have tried to assess the effects of circumcision. These studies are discussed below.

Penile Problems

A 1988 New Zealand study of penile problems by Fergusson et al, in a birth cohort of more than 500 children from birth to 8 years of age found that:

By 8 years, circumcised children had a rate of 11.1 problems per 100 children, and uncircumcised children had a rate of 18.8 per 100. The majority of these problems were for penile inflammation including balanitis, meatitis, and inflammation of the prepuce. However, the relationship between risks of penile problems and circumcision status varied with the child's age. During infancy, circumcised children had a significantly higher risk of problems than uncircumcised children, but after infancy the rate of penile problems was significantly higher among the uncircumcised. These associations were not changed when the results were adjusted statistically for the effects of a series of potentially confounding social and perinatal factors. [1]

One point worth noting is that boys continued to be counted as "uncircumcised" if circumcised after the neonatal period, and any complications from their circumcisions were counted as problems of the uncircumcised.

Phimosis

Phimosis is the inability to retract the prepuce over the glans penis after separation from the glans has occurred. The foreskin is joined to the glans, and is naturally unretractable when a baby is born. But there are differences of opinion about how long this should continue, and how the foreskin should be treated if it remains too tight for too long. Gairdner[2] published data regarding the age of first foreskin retraction in 1949 that is now thought by some to be incorrect. However, these data still is presented in medical textbooks and taught in medical schools.[3] Many doctors, therefore, are misinformed about the natural developent of the foreskin, and this contributes to the mis-diagnosis of the normal non-retractile foreskin of childhood as pathological disease. Rickwood et al. write in their 2000 paper "Towards evidence based circumcision of English boys" in the British Medical Journal [4]:

Too many English boys, especially those under 5 years of age, are still being circumcised because of misdiagnosis of phimosis. What is phimosis? At birth, the foreskin is almost invariably non-retractable, but this state is transient and resolves in nearly all boys as they mature through puberty. Such normality, with an unscarred and pliant preputial orifice, is clearly distinguishable from pathological phimosis, a condition unambiguously characterised by secondary cicatrisation of the orifice, usually due to balanitis xerotica obliterans. This problem, the only absolute indication for circumcision, affects some 0.6% of boys, peaks in incidence at 11 years of age, and is rarely encountered before the age of 5. (...) Strictly, only some 0.6% of boys with pathological phimosis need to be circumcised, although more relaxed criteria would allow for a similar proportion affected by recurrent balanoposthitis.

A 1968 Danish study of 9,545 boys, which distinguished between phimosis and preputial adhesion, found that both conditions steadily declined with age. Phimosis was 8% among 6-7 year olds but only 1% among 16-17 year olds. Similarly, preputial adhesion was 63% among 6-7 year olds but only 3% among 16-17 year olds. The author, Jakob Øster, concluded:

"Phimosis is seen to be uncommon in schoolboys, and the indications for operation even rarer if the normal development of the prepuce is patiently awaited. When this policy is pursued, in the majority of cases of phimosis, it is seen to be a physiological condition which gradually disappears as the tissues develop." [5]

It has been observed that Øster's study may not be representative of wider populations[6]. The true incidence of phimosis is controversial. Osmond found that 14% of British soldiers suffered, and Schoeberlein noted that 9.2% of uncircumcised German men suffered from phimosis[7]. Reporting on a New Zealand study, Fergusson et al found that 3.7% of boys suffered from phimosis.[8]

Phimosis is a complication of circumcision, that can occur when too little foreskin is removed.[9]

Images of phimosis.[10][11][12][13]

Paraphimosis

The American Academy of Family Physicians says:

"Paraphimosis is a urologic emergency, occurring in uncircumcised males, in which the foreskin becomes trapped behind the corona and forms a tight band of constricting tissue. Often iatrogenically induced, paraphimosis can be prevented by returning the prepuce to cover the glans following penile manipulation. Treatment often begins with reduction of edema, followed by a variety of options, including mechanical compression, pharmacologic therapy, puncture technique and dorsal slit. Prevention and early intervention are key elements in the management of paraphimosis. (Am Fam Physician 2000;62:2623-6,2628.)"[14]

The article goes on to say that the cause is most often iatrogenic (caused by doctors). It further stated:

"Rare causes of paraphimosis include self-inflicted injury to the penis such as, piercing a penile ring into the glans and paraphimosis secondary to penile erections."

Several different techniques are mentioned of dealing with this condition, and these are listed by the article in the American Family Physician, and also in the anti-circumcision site CIRP. [15] One procedure is minor surgery to make a small slit in the foreskin without removing any tissue.[16] Another method of treating paraphimosis is called the "Dundee technique." [17] Nevertheless, many physicians recommend circumcision for paraphimosis.

Images of paraphimosis. [18][19]

Balanitis

Balanitis is inflammation of the glans penis. Balanitis involving the foreskin or prepuce is termed balanoposthitis. The most common complication of balanitis is phimosis, or inability to retract the foreskin from the glans penis.[20] Balanitis afflicts young boys generally only where a difficult to retract tight foreskin is present. Two studies found that uncircumcised boys were at approximately twice the risk of developing balanitis[21][22] and one study found that uncircumcised men were at more than five times the risk[23]

EMedicine says: "Uncircumcised men with poor personal hygiene are most affected by balanitis. Lack of aeration and irritation because of smegma and discharge surrounding the glans penis causes inflammation and edema. Adherence of the foreskin to the inflamed and edematous glans penis causes phimosis."[24]

Inflammation has numerous causes, including irritation by environmental substances, physical trauma, and infection by a wide variety of pathogens, including bacteria, virus, yeast, or fungus — each of which require a particular treatment. Good medical practice includes careful diagnosis with the aid of a good patient history, swabs and cultures, and pathologic examination of a biopsy. Only then can the proper treatment be prescribed.[25] Many studies of balanitis do not examine the subjects' genital washing habits; a 1993 study by Birley et al. did so and found that excessive genital washing with soap may be a strong contributing factor to balanitis.[26]

Escala and Rickwood, in a 1989 examination of 100 cases of balanitis in childhood, concluded: "[T]he risk in any individual, uncircumcised boy appears to be no greater than 4%." [27]. In adults, this risk rises to about 12.5%, though over a third of diabetic men are affected.[28]

Zoon's Balanitis also know as Balanitis Circumscripta Plasmacellularis or plasma cell balanitis (PCB) is an idiopathic, rare, benign penile dermatosis [29] for which circumcision will suffice for the management and treatment of. [30][31]

Images of balanitis [32][33][34][35]

Skin diseases

Researchers from the Imperial College School of Medicine, Chelsea & Westminster Hospital, London, England in a study Circumcision and genital dermatosesreported the results of their study of 357 patients referred for genital skin disease:

Most cases of inflammatory dermatoses were diagnosed in uncircumcised men, suggesting that circumcision protects against inflammatory dermatoses. The presence of the foreskin may promote inflammation by a köebnerization phenomenon, or the presence of infectious agents, as yet unidentified, may induce inflammation. The data suggest that circumcision prevents or protects against common infective penile dermatoses.

Some American military doctors have recommended prophylactic circumcision because of the difficult conditions during wartime. For example, a United States Army report regarding World War II noted that in case of penile lesions, the foreskin may "invite secondary infection". The sexually transmitted disease chancroid, now very uncommon, was also associated with phimosis, which could hardly occur in circumcised males, and "soldiers in combat were seldom able to practice personal hygiene". (Source: JF Patton, Medical Department, United States Army, Surgery in World War II, Urology , p. 64)

In a study relating to Epididymitis Epididymitis in children: the circumcision factor? demonstrated with highly statistical significance that a relationship exists between epididymitis and the presence of a foreskin. It was found that an intact foreskin is an important etiological factor in boys with epididymitis.

Prostate cancer

Early ecological studies suggested that circumcision has a protective effect against prostate cancer. Ravich and Ravich report on patients operated on for prostatic obstruction. In Jews, 1.8% of obstructions were cancerous, compared with 19% of non-Jews.[36] Apt made similar observations in Sweden, concluding that uncircumcised males were at approximately twice the risk. Although ecological studies are unreliable, later case-control studies have confirmed this association.

Ross et al. reported on two case-control studies, both in Southern California. Both studies included 142 cases. In both studies, circumcised men were at reduced risk (relative risk of 0.5 in whites and 0.6 in blacks).[37]

Mandel & Schuman reported on a case-control study with 250 cases. When compared to controls drawn from their neighborhood, circumcised men were less likely to develop prostate cancer (odds ratio 0.82).[38]

Ewings & Bowie performed a case-control study of 159 cases of prostate cancer, and found that circumcised men were at a reduced risk (odds ratio 0.62).[39]

Prostate cancer is the second most common cancer in men. The lifetime risk of developing it is 1 in 5.[40]

Penile cancer

Penile cancer is a rare form of cancer with an annual incidence of 1 case in 100,000 patient-years in developed countries.[41] The overall 5-year survival rate for all stages of penile cancer is about 50%.

A study performed in 1980 estimated that the lifetime risk of an uncircumcised man developing invasive penile cancer (IPC) is one in 600 [42]. This was more than 3 times higher than for males neonatally circumcised.[43][44][45]

Childhood circumcision has been associated with a reduced incidence of penile cancer in numerous studies. [46][47][48][49][50][51]

An absence of circumcision has been associated with a higher incidence of HPV infection in males in several studies. HPV infection is a known risk factor in the development of penile cancer.[52][53][54]

However, the American Cancer Society made this statment in their website (last revised 1 January 2005):

The large variations in penile cancer rates throughout the world strongly suggest that penile cancer is a preventable disease. The best way to reduce the risk of penile cancer is to avoid known risk factors whenever possible.

In the past, circumcision has been suggested as a way to prevent penile cancer. This suggestion was based on studies that reported much lower penile cancer rates among circumcised men than among uncircumcised men. However, most researchers now believe those studies were flawed because they failed to consider other factors that are now known to affect penile cancer risk.

For example, some recent studies suggest that circumcised men tend to have certain other lifestyle factors associated with lower penile cancer risk: they are less likely to have many sexual partners, less likely to smoke, and more likely to have better personal hygiene habits. Most public health researchers believe that the penile cancer risk among uncircumcised men without known risk factors living in the United States is extremely low. The current consensus of most experts is that circumcision should not be recommended as a prevention strategy for penile cancer. [55]

The American Medical Association and the Royal Australasian College of Physicians (September 2004) also state that the use of infant circumcision to prevent penile cancer alone in adulthood is not justified. [56] [57]

Images of Invasive Penile Cancer in Uncircumcised Men

[58][59][60][61][62]

or alternative links:

[63][64][65][66][67]

Human Papillomavirus (HPV) and Cervical cancer

According to Dr. Xavier Castellsagué, "...it would not make sense to promote circumcision as a way to control cervical cancer in the United States, where Pap smears usually detect it at a treatable stage."

The study Male Circumcision, Penile Human Papillomavirus Infection, and Cervical Cancer in Female Partners published in the The New England Journal of Medicine in April 2002 found that male circumcision reduces the risks of penile human papillomavirus (HPV) infection in the man and of cervical cancer in his female partner.

The subsequent study Condom use and other factors affecting penile human papillomavirus detection in men attending a sexually transmitted disease clinic confirmed the findings with regard to the protective effect of male circumcision against infection by penile human papillomavirus.

In predominantly non-circumcising Great Britain the incidence of cervical cancer has reached epidemic proportions. In a study published in The Lancet The cervical cancer epidemic that screening has prevented in the UK scientists from the London School of Hygiene and Tropical Medicine found that had it not been for effective cervical screening fully one in 65 of all British women born since 1950 would have died from cancer of the cervix. In 2000, cervical cancer deaths in Great Britain were 3.9 per 100,000 patient-years, compared with 3.3 in the USA, 2.8 in Canada, and 2.4 in Australia. [68]

The claim that circumcision reduces cervical cancer in female partners was first put forward by Wynder et al. in 1954, with smegma as the hypothesized causative agent. Stern and Neely's findings cast doubt on the hypothesis that smegma causes cervical cancer in female partners in 1962 [69]. Some now believe that the link between the higher incidence of Cervical cancer in female partners of uncircumcised men is through the higher incidence of penile human papillomavirus (HPV) to which uncircumcised men are prone,[70][71][72] although smegma has been shown to be weakly carcinogenic.[73]

A new HPV vaccine is expected to substantially reduce the risk of cervical cancer when it becomes available.[74]

Circumcision and Urinary tract infection (UTI)

Infections of the urinary tract (kidneys, ureters, bladder and urethra) can lead to kidney damage if undetected, but can generally be treated effectively with antibiotics. Recent studies find a three to seven times increased risk of uncircumcised UTIs in male infants within the first year of life. A 1998 Canadian population based cohort study by To et al. [75], for example, reported a relative risk of 3.7. The overall incidence of UTIs in infants was low, 1.88 and 7.02 per 1000 respectively. According to the American Medical Association, "There is little doubt that the uncircumcised infant is at higher risk for urinary tract infection (UTI)."

Some of these studies have nevertheless been extensively criticized for their methodology. The American Academy of Pediatrics noted in its 1999 circumcision policy statement:

Few of the studies that have evaluated the association between UTI in male infants and circumcision status have looked at potential confounders (such as prematurity, breastfeeding, and method of urine collection) in a rigorous way. For example, because premature infants appear to be at increased risk for UTI, the inclusion of hospitalized premature infants in a study population may act as a confounder by suggesting an increased risk of UTI in uncircumcised infants. Premature infants usually are not circumcised because of their fragile health status. In another example, breastfeeding was shown to have a threefold protective effect on the incidence of UTI in a sample of uncircumcised infants. However, breastfeeding status has not been evaluated systematically in studies assessing UTI and circumcision status. [76]

More recently, however, randomized controlled trials[77] and other studies have confirmed the protective effect of circumcision[78] [79] [80].

UTIs are usually detected through urine tests. Depending on the method of urine collection, there is a varying risk of false positives through contamination. The bacteria detected may in fact come from the foreskin itself, not the urinary tract. In spite of this, an increased risk of UTI in uncircumcised males is generally considered plausible, a higher likelihood of bacterial colonization being the proposed mechanism.

However, studies of UTI and circumcision do not classify groups of circumcised males according to their mothers' handling of the foreskin, making it impossible to infer any link with specific hygienic practices. It is generally recommended not to retract the foreskin of an infant during hygiene [81]. Hodges and Fleiss claim that "it has been proven that retraction and washing of the infant foreskin can cause urinary tract infections by irritating the mucous membranes and destroying the naturally occurring beneficial flora which protects against pathogens." More recent research has shown that in fact fewer pathogens are present in circumcised males.

UTIs in boys are most common during the first years of life[82].

Based upon their data, To et al. estimate that 195 circumcisions would be needed to prevent one hospital admission for UTI in the first year of life. The American Academy of Pediatrics recommends breastfeeding to reduce the risk of UTI in children,[83] but does not recommend circumcision for this purpose.

Circumcision and HIV/AIDS

In 1989 the Cameron studywas published and reported an 8.2 times higher risk of HIV infecttion among uncircumcised men. Since then some 38 studies have covered the issue of the protective effect accruing through male circumcision.

The USAID document Male Circumcision:Current Epidemiological and Field Evidence summarized research as at September 2002. It states:

A systematic review and meta-analysis of 28 published studies by the London School of Hygiene and Tropical Medicine, published in the journal AIDS in 2000, found that circumcised men are less than half as likely to be infected by HIV as uncircumcised men. A subanalysis of 10 African studies found a 71 percent reduction among higher-risk men. A September 2002 update considered the results of these 28 studies plus an additional 10 studies and, after controlling for various potentially confounding religious, cultural, behavioral, and other factors, had similarly robust findings. Recent laboratory studies in Chicago found HIV uptake in the inner foreskin tissue to be up to nine times more efficient than in a control sample of cervical tissue.[84]

However, the Cochrane Library for Evidence-based Medicine's review of the data (2004) reported:

We found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men. The results from existing observational studies show a strong epidemiological association between male circumcision and prevention of HIV, especially among high-risk groups. However, observational studies are inherently limited by confounding which is unlikely to be fully adjusted for. In the light of forthcoming results from RCTs, the value of IPD analysis of the included studies is doubtful. The results of these trials will need to be carefully considered before circumcision is implemented as a public health intervention for prevention of sexually transmitted HIV.[85]

Neither UNAIDS nor the Centers for Disease Control of the United States Public Health Service have accepted male circumcision as a proven method of epidemic control. The Royal Australian College of Physicians (2002) said:

There is increasing evidence, particularly from sub-Saharan Africa, which suggests an increased risk of female to male transmission of HIV in uncircumcised men. However, how much circumcision could contribute to ameliorate the current epidemic of HIV is uncertain. Whatever the future direction of this debate it can not be seen as an argument in favour of universal neonatal circumcision in countries with a low prevalence of HIV. [78] (http://www.racp.edu.au/hpu/paed/circumcision/STDs.htm)

The USAID office of HIV/AIDS said: "male circumcision should not be actively promoted for HIV prevention unless and until the RCTs (Randomized controlled trials) confirm MC to be effective in reducing HIV infection".[86] Three randomized controlled trials (RCT's) are underway in Kenya, South Africa, and Uganda over a three to five year period, with the first results due in 2006. However, other studies have found an association between circumcision and the prevalence of HIV in communities.

Anti-circumcision activists have contested all findings which indicate that circumcision reduces HIV transmission. For example, Van Howe, a leading anti-circumcision campaigner, produced a meta-analysis which presented circumcised men at a greater risk for HIV infection. He further speculated that circumcision may be responsible for the increased number of partners, and therefore, the increased risk. As reported by fellow anti-circumcision activist Geoffrey T. Falk Van Howe has subsequently acknoledged that some of his "were not as refined as they could have been" [87]. Van Howe's work was reviewed by O'Farrell and Egger who exposed fatal methodological flaws in his work.

Weiss, Quigley and Hayes carried out an new meta-analysis on circumcision and HIV and found as follows:

Male circumcision is associated with a significantly reduced risk of HIV infection among men in sub-Saharan Africa, particularly those at high risk of HIV. These results suggest that consideration should be given to the acceptability and feasibility of providing safe services for male circumcision as an additional HIV prevention strategy in areas of Africa where men are not traditionally circumcised.

There have been other studies of note. Kelly et al. reported in Age of male circumcision and risk of prevalent HIV infection in rural Uganda that where circumcision was carried out before the age of 12 it results in a reduction to 0.39 of the odds of an uncircumcised man. The degree of protection changed according to the age at which circumcision was performed, however, with those circumcised at between 13 and 20 years at an odds ratio of 0.46, and those circumcised after the age of 20 at an odds ratio of 0.78. " They concluded: "Prepubertal circumcision is associated with reduced HIV risk, whereas circumcision after age 20 years is not significantly protective against HIV-1 infection."

With regard to the effects of behaviour on infection risk Buvé in USAID funded multi-site study on behalf of UNAIDS found that "In conclusion, differences in the rate of HIV spread between the East African and West African cities studied cannot be explained away by differences in sexual behaviour alone. In fact, behavioural differences seem to be outweighed by differences in HIV transmission probability."

Bailey found in his study [88] that:

These results suggest that differences between circumcised and uncircumcised men in their sex practices and hygienic behaviors do not account for the higher risk of HIV infection found among uncircumcised men. Further consideration should be given to male circumcision as a prevention strategy in areas of high prevalence of HIV and other sexually transmitted diseases. Studies of the feasibility and acceptability of male circumcision in traditionally noncircumcising societies are warranted.

Kiwanuka et al studied the relationship between religion and HIV in Rural Uganda and [concluded: "Lower rates of HIV infection among Pentecostals appear to be associated with less alcohol consumption, sexual abstinence and fewer sexual partners, whereas the low HIV prevalence in Muslims appears to be associated with low reported alcohol consumption and male circumcision." His findings therefore reflected that among Muslims despite the lowest likelihood of abstinence and the highest likelihood of having had more than two sexual partners they still had the lowest level of HIV infection as compared to the other religious groups in the study.

Studies have also been carried out as to the acceptability of male circumcison within traditionally non-circumcising communities. Kebaabetswe found that:

Male circumcision appears to be highly acceptable in Botswana. The option for safe circumcision should be made available to parents in Botswana for their male children. Circumcision might also be an acceptable option for adults and adolescents, if its efficacy as an HIV prevention strategy among sexually active people is supported by clinical trials.

Lagarde found that "More than 70% of the non-circumcised men (NCM) stated that they would want to be circumcised if MC were proved to protect against sexually transmitted diseases (STD)." Lagarde cautioned that "Our results strongly suggest that interventions including MC should carefully address the false sense of security that it may provide."

Bailey in his study Adult male circumcision in Kenya: safety and patient satisfaction looked at the possible adverse effects of introducing male circumcision on a public health scale and the post operative satisfaction levels of 380 circumcsions on 18-24 year old consenting men. As to satisfaction; "At 30 days post-surgery, 99.3% of men reported being very satisfied and 0.7% somewhat satisfied with circumcision. None were dissatisfied." And with regard to adverse effects; "All were mild or moderate and resolved within hours or several days of detection."

In a recently published study in this regard in The Lancet,Male circumcision and risk of HIV-1 and other sexually transmitted infections in India, Reynolds and Bollinger found that male circumcision was strongly protective against HIV-1 infection with circumcised men being almost seven times less at risk of HIV infection than uncircumcised men.[89] They further state that:

"The specificity of this relation suggests a biological rather than behavioural explanation for the protective effect of male circumcision against HIV-1."

Baeten et al in a study published in The Journal of Infectious Diseases in 2005 found that uncircumcised men were at a greater than two-fold increased risk of aquiring HIV per sex act when compared with circumcised men. They conclude as follows:

"Moreover, our results strengthen the substantial body of evidence suggesting that variation in the prevalence of male circumcision may be a principal contributor to the spread of HIV-1 in Africa."

Despite the strong evidence of a significant protective effect of infant male circumcision, "male circumcision should not be actively promoted for HIV prevention unless and until the RCTs (Randomized controlled trials) confirm MC to be effective in reducing HIV infection".[90] This cautious approach is supported by the South African Cochrane Centre for evidence-based medicine. Three randomized controlled trials (RCT's) are underway in Kenya, South Africa, and Uganda over a three to five year period, with the first results due in 2006.

Complications of Circumcision

Circumcision is a surgical operation and the complications thereof are many and varied. Williams & Kapila report that "the literature abounds with reports of morbidity and even death as a result of circumcision."[91] The complications generally may be classified into immediate and delayed complications. The immediate complications may be further classified into surgical mishap, hemorrhage, infection and anesthetic risk.

Immediate Complications

Surgical mishap. Surgical mishap includes penile denudation,[92] excision of part or all of the glans penis,[93] urethral fistula,[94] and penile necrosis, resulting in loss of the entire penis.

Hemorrhage. Hemorrhage is usually minor and easily controlled, but may rarely progress to exsanguination, hypovolemic shock, and death.[95] [96]

Infection. Infections are usually be minor and local, but in rare cases may progress to urinary tract infection,[97] life-threatening systemic infections, meningitis,[98] and death.

Anesthetic risk. Anesthetic risk includes methaemglobinaemia (methanoglobinemia).[99][100]

Infection and bleeding are by far the most common complications. Other immediate complications are extremely rare.

Delayed Complications

Possible delayed complications may include urinary retention,[101] venous stasis,[102] phimosis,[103] adhesions,[104] concealed penis,[105] skin bridge,[106] and painful erections. Some suggest that the meatus may also be affected, leading to meatitis,[107] meatal ulceration,[108] and meatal stenosis.[109][110] It is believed that these are complications, as they are seen more often in circumcised boys. However, this may be because it is impossible to diagnose the condition in uncircumcised boys.[111]

Pain, stress, trauma, and inteference with breastfeeding initiation

Taddio et al. reported behavioural changes (heightened pain responses) during vaccinations in children circumcised with EMLA cream and with no anaethesia.[112] The researchers commented: "Study of the vaccination pain response of infants who had received more effective circumcision pain management (ie, dorsal penile nerve block and adequate postoperative pain management) would be interesting."

Marshall et al. report that the stress of neonatal circumcision may alter feeding behaviour and some male infants may be unable to breastfeed after circumcision.[113] They commented:

Despite differences between control and experimental infants shortly after surgery, by 24 h post-operatively no significant differences were observed between the groups. The behavioral effects of circumcision in the present study were immediate but brief. This should be comforting information to those who provide care for newborns and for their parents.[114]

Howard et al. report that neonatal circumcision without anaesthesia and using acetaminophen results in deteriorated breast-feeding immedately after circumcision.[115] They commented:

Numerous studies have shown that circumcision causes severe intraoperative pain as measured by changes in crying, heart rate, respiratory rate, transcutaneous PO₂, and cortisol levels.... Neonatal circumcision are often performed on the day of discharge with many neonates leaving the hospital 3 to 6 hours postoperatively. Thus the observed deterioration in ability to breast-feed may potentially contribute to breast feeding failure. Furthermore some neonates in this study required formula supplementation because of maternal frustration with attempts at breast-feeding, or because the neonate was judged unable to breast-feed postoperatively. This finding is disconcerting because early formula supplementation is associated with decreased breast-feeding duration.

Some professionals agree.[116], although another reported "As soon as the mohel was finished, the baby was whisked back to mom's breast for a comforting feed, with no problems at all!" [117]

Human milk is the optimum food for human infants.[118] The American Academy of Pediatrics recommends that stressful procedures should be avoided,[119].

Sexual Effects

There have been many claims about the effect of circumcision on sexual function. For example the Collins, Senkul and Laumann found no adverse effect on erectile function from circumcision while Fink and Shen did.

An analysis of a national US survey by Laumann found that uncircumcised males had a higher overall rate of sexual dysfunction[120] especially after the age of 45 years.

“Of the 7 sexual dysfunctions considered, uncircumcised older men were more likely to experience every one of these difficulties than were their circumcised peers.”

However, Laumann also found that circumcision was positively correlated with the amount of education of the mother and was more common amongst Whites than Blacks or Hispanics, This difference in social condition is a confounding factor.

Senkul in a study from Turkey reported delayed ejaculation after circumcision as did Shenin China. Senkul said that delayed ejaculation may in fact be seen as a benefit.

Shen reported:

ninety-five patients were investigated on erectile function by questionnaire before and after circumcision, respectively. Eighteen patients suffered from mild erectile dysfunction before circumcision, and 28 suffered from mild or moderate erectile dysfunction after circumcision(P = 0.001). Adult circumcision appeared to have resulted in weakened erectile confidence in 33 cases(P = 0.04), difficult insertion in 41 cases(P = 0.03), prolonged intercourse in 31 cases(P = 0.04) and improved satisfaction in 34 cases(P = 0.04). Adult circumcision has certain effect on erectile function, to which more importance should be attached.

Glans sensitivity

Most studies of the effect of circumcision on sexual sensitivity have focussed on the glans and ignored the foreskin itself. Anti-circumcision activists suggest that the foreskin may be sexually responsive. [121] [122] [123]

There is evidence that circumcision does not lead to increased keratinization as claimed by anti-circumcision activists [124] or reduction in sensitivity of the glans [125][126].

Fink in his study reported: "Adult circumcision appears to result in worsened erectile function (p = 0.01), decreased penile sensitivity (p = 0.08), no change in sexual activity (p = 0.22) and improved satisfaction (p = 0.04). Of the men 50% reported benefits and 38% reported harm. Overall, 62% of men were satisfied with having been circumcised."

Fink grouped decreased sensitivity with ejaculation taking longer than the men desired. Only one question relating to ejaculation time had a significant result; the question directly addressing sensitivity had no significant difference. It has been questioned whether this should be seen as evidence of decreased sensitivity or simply of delayed ejaculation.

Bleustein et al study tested the sensitivity of the glans penis, and found no difference between circumcised and uncircumcised men [127], confirming an earlier study by Masters and Johnson[128]. Some men who undergo foreskin restoration claim that the procedure really does improve glans sensitivy. Some have therefore argued that much of this perceived "improved sensitivity" of the glans reported by foreskin restorers is psychosexual and psychosomatic and an example of the placebo effect, with no real change in glans sensitivity.[129] [130]

Yang et al. concluded in their study into the innervated of the penile shaft and glans penis that: "The distinct pattern of innervation of the glans emphasizes the role of the glans as a sensory structure."[131]

Foreskin sensitivity

Circumcision opponents point out that studies on the effect of circumcision on sexual sensitivity have focussed on the glans and ignored the foreskin itself, citing [132] [133] [134] as studies which report great sensitivity and abundant nerve supply. While there are no studies examining whether it or any other single part of the penis is specifically sexually sensitive, they claim a sexual role based upon the presence of nerve-endings in the foreskin sensitive to light touch and fluttering sensations. Not all agree, however. Anti-circumcision activist and author Kristen O'Hara argues that the glans is the "male clitoris", with the foreskin maintaining at best a supporting role during sexual intercourse.[135]

Retired pathologist and anti-circumcision activist John R. Taylor Taylor has postulated that the highly innervated and vascularised ridged band at the end of the foreskin, which is almost invariably removed in circumcision, is erogenous and plays a role in normal sexual function. He also speculates that the gliding action possible only where sufficient loose penile shaft skin exists serves to stimulate this band through contact with the corona of the glans penis during vaginal intercourse.[136] No scientific confirmation of Taylor's speculation exists.

Partner preference

Williamson and Williamson made a 1988 survey of new mothers. They found that 71% preferred a circumcised partner for sexual intercourse, and 83% for giving fellatio. When asked why, 92% responded that it stays cleaner and 90% that it looks sexier. Although 78% of the women had not had direct contact with an uncircumcised penis, those who did expressed the same preference[137] This study was done in an area of the United States where circumcision was the norm.

Costs and Benefits

Several authors have conducted cost-benefit analysis to see if male neonatal circumcision justifies the expense and the medical risks. Cadman et al. (1984) conducted a study to see if public funds should be used to pay for circumcision. They concluded that the expense of the circumcision outweighed any money that might be saved by reducing the risk of penile cancer so circumcision should not be paid by public funds.[138] Lawler et al. (1991) examined male neonatal circumcision to weigh the benefits and costs.[139] They reported a net cost of $25.00 and a benefit of ten days of life. They concluded that there was no medical indication for or against circumcision. Ganiats et al. (1991) also examined the benefits and costs.[140] They reported that the cost of circumcision was $102 and it cost 14 hours of healthy life. They found no medical basis on which to recommend for or against circumcision. Chessare (1992) compared the preventative effect of circumcision against urinary tract infections to the risks.[141] He concluded that non-circumcision produces the “highest expected utility”, provided that the probability of developing a UTI was less than 0.29. Christakis et al. (2000) report that "Circumcision remains a relatively safe procedure. However, for some parents, the risks we report may outweigh the potential benefits."[142]

In June of 2004 the College of Physicians and Surgeons of British Columbia stated that neonatal circumcision is medically unnecessary.

"Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention." [143]

The American Academy of Pediatrics said in their 1999 policy statement:

"Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child." [144]

Clarifying their statement in 2000, the authors explained:

The Task Force found the evidence of low incidence, high-morbidity problems not sufficiently compelling to recommend circumcision as a routine procedure for all newborn males. However, the Task Force did recommend making all parents aware of the potential benefits and risks of circumcision and leaving it to the family to decide whether circumcision is in the best interests of their child. ... Circumcision falls into that group of procedures that have potential medical benefits and some risks and should be evaluated by each family in the context of their personal beliefs and values as well as their ethnic, cultural, and religious practices. The Task Force respects the role of parents as decision-makers for their newborns and recommends that physicians discuss with parents the potential benefits as well as risks of circumcision so that parents can decide whether circumcision is in the child's best interests.

See Also

Bioethics of neonatal circumcision

Circumcision advocacy

Circumcision and law

Foreskin restoration

Male circumcision

References

• American Academy of Pediatrics. Circumcision Policy Statement (RE9850). March 1999.
• American Medical Association. Report 10 of the Council on Scientific Affairs (I-99), Neonatal Circumcision. Dec 1999.
• British Medical Association. The Law & Ethics of Male Circumcision - Guidance for Doctors. March 2003.
• Canadian Paediatric Society. Neonatal Circumcision Revisited. 1996 (reaffirmed March 2002)
• The Royal Australasian College of Physicians. Policy Statement On Circumcision. Sep 2002.
• Apt A. Circumcision and prostatic cancer. Acta Med Scand 1965; 178: 493-504