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General Introductions
by Professor Brian J. Morris, University of Sydney (Australia)

Historically circumcision has been a topic of emotive and often irrational debate. At least part of the reason is that a sex organ is involved. (Compare, for example, ear piercing.) In the USA circumcision has always been common amongst the majority Anglo-Celtic Whites and also amongst Afro-American Blacks. Australia similarly once conducted routine circumcision of all newborn boys. In both countries a down-turn took place after the mid-1970s, but is now rising again in each as the medical and health benefits are becoming better known. The misinformation that produced the downtrend years ago is still embedded in the consciousness of some medical practitioners who hail from the 70s, and their protégés. In fact there have even been reports of harassment by medical professionals (such as less well-informed midwives, nurses and doctors) of new mothers, especially those that can be more readily identified because they belong to religious groups that practice circumcision, in an attempt to stop them having this procedure carried out. There has been a trend by pediatric bodies to skirt the truth in favor of what could be viewed as "New-Age political correctness", spurious "human rights" rhetoric, or perhaps fear of litigation stemming from the rare surgical mishap. The policy statements of professional pediatric bodies have been misused by others as part of an "appeal to authority" fallacy [132] which is often used as a substitute for supplying an actual argument. The bodies themselves also see a trend and copy it so that the statements of one of them can be seen to then trigger a "bandwagon" response. Those who write the policy statements are often physicians with little or no academic expertise. Not surprisingly they have been criticized by academic experts, as discussed below. Through the 1990s and into the new millenium a reversal of the downtrend began. In the light of an increasing volume of medical scientific evidence pointing to the benefits of neonatal circumcision, the pediatric professional bodies of various countries have been forced to review the evidence and formulate more up-to-date policy statements. These documents MUST be read in their entirety to be fully comprehended. (Isolated quotes have been taken from these by anti-circ groups to fuel their propaganda.) What is stated in the details of the various Statements is much like what is presented in the present review of the medical literature. However, it is important to note that vital facts have been distorted, watered down or omitted from the various Statements of pediatric bodies, whereas the present review is very much more comprehensive and balanced. Moreover, no medical body has advocated prohibition of circumcision and arguments by opponents are weak and specious [366]. The latest Statements of the American Association of Pediatrics in 1999 [205], the Canadian Paediatric Society in 1996 [107] and the Royal Australasian College of Physicians, Division of Paediatrics and Child Health in 2004 [39] provide information on the benefits and possibility of rare or minor risks. These suffer, however, from falling short of drawing the obvious conclusion from the evidence they present, i.e., that circumcision is the best choice for lifetime health and sexual well-being. The hesitancy is undoubtedly a consequence of the sensitivity of this issue, as well as medico-legal caution and the recognition of the hysteria that this subject can provoke because of the diversity of opinion in the community, where anti-circ groups tend to bombard such professional bodies in an attempt to "win" their political cause. More on this can be found in the section "Anti-circumcision lobby groups". The British Medical Association has not even attempted to review the medical literature, producing instead a pompous paternalistic and legalistic statement in 2003 [46, 47]. By and large, the statements of most of these professional bodies tend to recommend that medical practitioners fully inform parents of the benefits and minor, rare risks of having their male children circumcised. Thus publicly most give the impression that the benefits and harms are very evenly balanced [107]. Indeed, professional bodies have carefully avoided taking sides in the polarized debate, by making noncommittal guidelines and leaving it to the medical practitioner to discuss the matter with the parents [113]. While such bland tolerance has accommodated a broad range of strong and conflicting opinions, the medical profession is now faced with a growing knowledge-base that indicates a wide range of health benefits of circumcision, meaning that the time is fast approaching when affirmative statements cannot be avoided [113]. Indeed, Prof Roger Short states "If we believe in evidence based medicine, then there can be no debate about male circumcision; it has become a desirable option for the whole world" [327]. Of course, well-informed medical practitioners only have to read the present Statements of pediatric bodies in full to be able to draw their own conclusion. In a deplorable ploy, the Royal Australasian College of Physicians" (RACP) 2002 and 2004 Policy Statement sidestepped making a conclusion by instead substituting the words there "is no medical indication for routine infant male circumcision", i.e., that the foreskin as it presents at birth lacks any medical condition that would mandate its removal. This tactic is to be condemned as inexcusably irresponsible, especially in the current era of preventative medicine and medical knowledge of the benefits of circumcision. Recognized authoritative figures in the USA in particular strongly advocate circumcision of all newborn boys. More details of what they have said in the medical literature appear later. As a prelude to this, one needs to first understand the anatomy. The foreskin is composed of an outer layer that is keratinized (as is skin generally), and an inner lining that is a mucosal surface. The inner lining thus resembles other mucosal epithelia such as constitute the cervix, nasal passages and rectum. It had been suggested that the foreskin protected the glans from drying out and becoming keratinized. However, histological examination has shown the same amount of keratin in the skin of the head of the penis irrespective of circumcision status [345]. The inner layer lines a "preputial sac", which becomes a repository for shed cells, secretions, and urinary residue that accumulates [71, 265]. It is also a hospitable environment for the growth of bacteria and other microorganisms. During an erection the head and shaft of the penis extend so that the inner layer becomes exteriorized along the distal half of the shaft. This exposes it to infectious agents during sexual intercourse. It has been speculated that the prepuce is a source of secretions, pheromones, etc, but given the dubious authorship of these reports and the absence of any research support, such suggestions should be regarded as fanciful.

It has been suggested [55] that the increased risk of infection in the uncircumcised may be a consequence of the following:
  • The foreskin presents the penis with a larger surface area.
  • The moist inner lining of the foreskin represents a thinner epidermal barrier than the more cornified outer surface of the foreskin and the rest of the penis, including the glans of both a circumcised and an uncircumcised penis, which have been found to have the same amount of keratin (i.e., similar skin thickness and protection from invasion of microorganisms) [345]. This means that the inner lining is a potential entry point into the body for viruses and bacteria. (A photograph of a histological section illustrates this later, in the section on the AIDS virus.)
  • The presence of a prepuce is likely to result in greater microtrauma during sexual intercourse, thereby permitting an entry point into the bloodstream for infectious agents.
  • The warm, moist mucosal environment under the foreskin favours growth of micro-organisms (discussed in detail later). The preputial sac has even been referred to by Dr Gerald Weiss, an American surgeon, as a 'cesspool for infection' [377], as its unfortunate anatomy wrapped around the end of the penis results in the accumulation of secretions, excretions (urine), dead cells and growths of bacteria as referred to above. Parents are told not to retract the foreskin of male infants, which makes cleaning difficult. Even if optimal cleansing is performed there is no evidence that it confers protection [392, 393]. In the late 19th century circumcision became routine as a result of pronouncements in publications by various physicians, most notably Remondino [8, 129, 290]. The procedure rapidly gained popularity and became routine. Although most of the claims in Victorian times were absurd, some have nevertheless stood the test of time, including prevention of penile cancer, syphilis, balanoposthitis and phimosis.
It was not until the early 1970s that a similar fall happened in Australia and Canada, in response to statements by the pediatric bodies in each country [18, 74]. Curiously, a similar statement by the American Academy of Paediatrics (AAP) Committee for the Newborn in 1971 that there are "no valid medical indications for circumcision" [73] had only a slight effect. In 1975 this was modified to "no absolute valid ..." [355], which remained in the 1983 statement, but in 1989 it changed significantly to "New evidence has suggested possible medical benefits" [10]. However, in the 1999 Statement [205] the AAP went backwards. Although the literature review in this was academically weak, this did, nevertheless, mention the vast array of benefits. Its major flaw was that it fell short of stating the obvious, if it had used a more balanced literature survey, in recommending circumcision. As mentioned above this is quite understandable, given medico-legal worries in the face of very hostile, politically active anti-circ groups. Interestingly, a joint response by the previous Chair of the AAP Taskforce and others more expert than those on the recent Taskforce rebutted the 1999 statement [318, 319]. Others also levelled valid criticisms [33, 196]. The various statements highlight the information that follows in the present much more comprehensive and better balanced web review. It is clear that providing a scientific and balanced statement by a pediatric body is difficult in the face of minority lobby groups whose agenda tends to be a political one rather than medical or scientific. This is not to detract from the clear scientific weaknesses in the 1999 AAP Statement and their pamphlet [33, 318]. Dr Edgar Schoen, Chairman of the 1989 Task Force on Circumcision of the American Academy of Pediatrics, has stated that the benefits of routine circumcision of newborns as a preventative health measure far exceed the risks of the procedure [312]. He has continued to this day to campaign for public education of the benefits of circumcision, publishing a very worthy book on the topic in 2005 [315]. During the period 1985-92 there was an increase in the frequency of post-newborn circumcision (to over 80% in one study [397]) and during that same time Schoen points out that the association of lack of circumcision and urinary tract infection (UTI) has moved from "suggestive" to "conclusive" [312]. Moreover, this period heralded the finding of associations with other infectious agents, including HIV. In fact he goes on to say that "Current newborn circumcision may be considered a preventative health measure analogous to immunization in that side effects and complications are immediate and usually minor, but benefits accrue for a lifetime" [312].

Some of the health benefits are:
  • Decrease in physical problems involving a tight foreskin [253].
  • Lower incidence of inflammation of the head of the penis [98, 101, 104].
  • Reduced urinary tract infections.
  • Fewer problems with erections, especially at puberty.
  • Decrease in certain sexually transmitted infections (STIs) such as HIV, HPV, chlamydia, syphilis in the male and their partner(s).
  • Almost complete elimination of invasive penile cancer.
  • Decrease in urological problems generally.(Reviewed in [2, 8, 10, 19, 107, 198, 301, 310] to cite just a few. More details appear in specific sections to follow)
Therefore the benefits are different as the human male progresses through life. Neonatologists see only newborns and thus only see the problems of the operation itself performed on infants. In fact such problems occur in only a minor proportion of baby boys, and generally because of poor technique by an inexperienced operator. However, urologists who see and have to treat the problems of uncircumcised males of all ages cannot understand why all newborns are not circumcised [310, 312]. Other health care workers in hospitals and aged care homes also have adverse comments concerning the uncircumcised penises they see and have to deal with, problems with catheters for urinary drainage, and the deranged reactions of elderly men with dementia when attempts are made to wash the genital area. The demand for circumcision later in childhood has increased, but, with age, there is an inevitable increase in worry to the boy or man in the lead-up to having this done, usually a more visible scar is left, and the cost can be 10-times as great. Such considerations, coupled with the advantages of early circumcision, led Schoen to state "Current evidence concerning the life-time medical benefit of newborn circumcision favours an affirmative choice" [312]. Dr Tom Wiswell, a respected authority in the USA was a strong opponent, but then switched camps as a result of his own research findings and the findings of others. This is what he has to say: "As a pediatrician and neonatologist, I am a child advocate and try to do what is best for children. For many years I was an outspoken opponent of circumcision ... I have gradually changed my opinion" [389, 390]. This ability to keep an open mind on the issue and to make a sound judgement on the balance of all available information is to his credit ... he did change his mind!

Wiswell looked at the complication rates of having or not having circumcision performed in a study of 136,000 boys born in US army hospitals between 1980 and 1985. 100,000 were circumcised and 193 (0.19%) had complications, mostly minor, with no deaths, but of the 36,000 who were not circumcised the problems were more than ten-times higher and there were 2 deaths [397]. A study by others found that of the 11,000 circumcisions performed at New York's Sloane Hospital in 1989, only 6 led to complications, none of which were fatal [301]. An early survey saw only one death amongst 566,483 baby boys circumcised in New York between 1939 and 1951 [240]. (There are no deaths today from medical circumcisions in developed countries.)

Problems involving the penis are encountered relatively frequently in pediatric practice [204]. A retrospective study of boys aged 4 months to 12 years found uncircumcised boys exhibited significantly greater frequency of penile problems (14% vs 6%; P < 0.001) and medical visits for penile problems (10% vs 5%; P < 0.05) compared with those who were circumcised. In infants born in Washington State from 1987-96, 0.2% had a complication arising from their circumcision, i.e., 1 in every 476 circumcisions [65]. It was concluded that 6 urinary tract infections could be prevented for every circumcision complication, and 2 complications can be expected for every penile cancer prevented [65].

The reasons for circumcision, at least in a survey carried out as part of a study at Sydney Hospital, were: 3% for religious reasons, 1-2% for medical, with the remainder suggested by the researchers as "to be like dad" or a preference of one or both parents for whatever reason [92]. The main reason may in fact have more to do with hygiene and appearance, as will be discussed later in the section on socio-sexual aspects.
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