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Circumcision
Written by Dr John Dean, specialist in sexual medicine
Circumcision to prevent future disease
Prevention of disease is the second most commonly given reason for circumcision after religious reasons, although the evidence that it has any beneficial effect on future health is very poor. The practice is, more likely, rooted in cultural traditions, although western societies may find this an uncomfortable conclusion.
Poor personal hygiene, smoking and exposure to wart virus (human papilloma virus) increase the risk of developing penile cancer at least as much as being uncircumcised.
Circumcised men are more at risk from penile warts than uncircumcised men, and the risk of developing penile cancer is now almost equal in the two groups. Therefore, routine circumcision cannot be recommended to prevent penile cancer.
Sexually transmitted diseases
Yeast infection (caused by candida or thrush) is equally common in circumcised and uncircumcised men, although circumcised men are less likely to have symptoms with this infection so they are more likely to unknowingly pass on thrush to their sexual partners.
Far more effective and reliable methods than circumcision exist to reduce the risk of contracting sexually transmitted diseases, such as the use of condoms and adoption of safer sexual practices. Thus circumcision cannot be recommended to prevent these infections.
Human immunodeficiency virus (HIV) infection
Circumcision may be appropriate as a routine preventive measure only in regions that have a high rate of HIV infection, such as sub-Saharan Africa. The existing evidence is inadequate to recommend circumcision as an HIV-preventive measure in the UK.
Cervical cancer
Further studies over the past 50 years have had contradictory conclusions, with experts enthusiastically championing the case for and against circumcision. The evidence is inadequate to recommend it as a preventive measure against cervical cancer.
Urinary tract infection (UTI)
A UTI is not usually a great risk to health, so it does not seem reasonable to perform a surgical procedure on 100 infants to reduce the risk of one developing UTI.
Circumcision as an act of religious dedication
An increasing number of committed Jewish and Muslim people reject circumcision on ethical grounds, although they are certainly the minority at present. Attitudes to circumcision may provoke fierce hostility within families and among communities. In the past, wars have been fought, and thousands have died, to preserve the right to circumcise when rulers from other cultures forbade it.
Traditional religious circumcision is performed by a mohel (pronounced mo-hell in Hebrew or moyle in Yiddish). It is usually carried out on the eighth day after birth, unless there is a danger to the child's health, in which case it should be delayed until that danger has passed. In the UK, mohelim attend 40 to 50 circumcisions and have to pass practical and theoretical examinations during their training before performing circumcision alone.
Islam
All Muslims agree that these are the three sources of Islamic law, but different groups interpret their application in different ways. Circumcision is not mentioned in the Koran, but has the status of sunnah. Only the Shafiite school of law regards circumcision as obligatory (wajib), while the Hanafite, Jafarite, Malikite, Hanbalite and Zaidite regard it as only recommended, because it is sunnah.
Even those who consider circumcision an obligatory duty for themselves do not see it as an essential requirement for others to become a Muslim. However, the procedure is very commonly practised and is certainly seen as an important external symbol of submission to God's will.
Should we avoid circumcision?
Adult males that were circumcised as infants do not usually report sexual problems linked with their circumcision, perhaps because they have never experienced sexual sensation with a foreskin. However, men circumcised as sexually active adults quite frequently complain of sexual problems arising from either reduced or altered penile sensation.
How is circumcision performed?
It is difficult to justify subjecting infants to this experience when pain could be avoided with a brief general anaesthetic. Anaesthetic injections that numb the penis or the whole genital region are not a reliable substitute for general anaesthesia. If circumcision is important for religious or cultural reasons, then the mohel, or other ritual circumciser, can still perform the procedure and prayers with the assistance of an anaesthetist and surgical team at hand. This practice may not be the traditional family gathering associated with circumcision, but would fulfil religious obligation without causing unnecessary suffering.
When circumcision is necessary for an immediate medical reason, the surgeon would be prudent to try to preserve as much of the foreskin as possible, through some form of preputioplasty (a plastic surgery procedure that alters the shape of the foreskin but minimises the amount of skin removed). Preputioplasty may preserve sexual sensation, although its advantage over circumcision is not yet established.
Complications of circumcision
Can circumcision be reversed?
Female circumcision is not required by any religious group and is a traditional practice prevalent in Africa, Southeast Asia and South America. It is far more disfiguring, disabling and potentially dangerous than male circumcision so cannot be viewed in the same light. The author fully supports the World Health Organisation's policy that this procedure should cease throughout the world.
Conclusions
Male circumcision is vitally important to some religious and cultural groups. Hopefully, the use of general anaesthesia for infant circumcision will increase. Medical and religious authorities should work together to promote this change.
Very few absolute medical reasons exist for circumcision, and no reasons exist to justify routine circumcision of infants outside areas with a high rate of HIV infection. Far too many circumcisions are performed without good reason in Europe and the USA. The best advice is 'if it isn't absolutely necessary, don't circumcise'.
Author's note
Sexually transmitted infections that cause ulcers on the genitals (syphilis, chancroid, herpes simplex) are more common in uncircumcised men. However, urethritis or inflammation of the tube that carries urine through the penis (caused by gonorrhoea and non-gonococcal urethritis) is more common in circumcised men, as are penile warts.
Views conflict on whether circumcision can prevent HIV infection. A recent review in the
A study in 1947 reported that Jewish women rarely developed cervical cancer and the author attributed this finding to the fact that their sexual partners were circumcised.
Since 1987, several studies have suggested that uncircumcised male infants are up to 10 times more likely to contract a urinary tract infection . One in 100 uncircumcised infants will develop a UTI, compared with 1 in 1000 circumcised infants.
The circumcision of male children is a central feature of both Judaism and Islam. It is also important in many African and New World cultures.
The divine law or sharia defines every aspect of Muslim life. It is based upon the Holy Koran, the hadith (the sayings of the Prophet Mohammed) and the sunnah (Prophet's tradition).
The foreskin is not simply a useless piece of skin, to be disposed of without careful thought. It forms the covering of the head (glans) of the penis in men and the clitoris in women. It is very rich in nerves responsible for touch and the movement of the foreskin backwards and forwards over the glans provides some of the pleasurable sensation experienced during sex.
Although religious and cultural circumcision is frequently performed without anaesthetic as part of an important ritual act, it is an intensely painful procedure, even in newborn babies. Adults can testify to the pain for themselves and can give informed consent to the procedure. Infants, however, cannot. Physiological research has repeatedly shown bodily responses that indicate infants experience severe pain during circumcision.
Happily, complications of circumcision are relatively rare, although they may be under-reported following religious or cultural circumcision. For this reason, figures on the rate of complications may not be reliable. Complications include:
Attempts have been made to restore the foreskin following circumcision since ancient times. Unfortunately, no procedure had satisfactory results. Modern surgical procedures may have more success, but they are still experimental and the long-term results are unknown. If foreskin restoration is being considered, a urologist should be consulted.
Circumcision remains a controversial procedure, as it has been for thousands of years.
The author wants to emphasise that he holds a deep respect for all religions, including Judaism, Islam and the many other religious groups that practise circumcision as an important feature of their faith. He regrets any distress that this article might cause but hopes that it might be a useful stimulus to thoughtful reflection on such a long-established traditional practice.
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