Circumcision is a surgical procedure that involves partial or complete removal of the foreskin (prepuce) of the penis. The first evidence of circumcision comes from early Egyptian wall paintings that are more than 5000 years old.
How common is circumcision?
About one-fifth of men worldwide have been circumcised, mostly for religious and cultural reasons when the procedure is commonly performed shortly after birth or around puberty.
Although adults are occasionally circumcised as an act of religious dedication, adult circumcision is most commonly performed for medical reasons.
At present, around 80 per cent of US males have been circumcised, mostly for non-religious reasons. The frequency of newborn circumcision has fallen in the USA from 90 per cent in the 1950s to around 60 per cent today.
In Korea, more than 90 per cent of men have been circumcised, usually in their teens and twenties.
In the UK in 1948, around 20 per cent of boys were circumcised shortly after birth, more commonly among middle class families and those living in the south of England. Then, 50 per cent of grammar school boys, 84 per cent of public school boys and 60 per cent of graduates were circumcised. By 1975, only 6 per cent of boys born in the UK were circumcised.
Why circumcise?
Reasons for circumcision fall into three broad groups : -
for an immediate medical indication
to prevent future disease
as an act of religious dedication.
Circumcision for an immediate medical reason
Non-retractable foreskin in children
Contrary to common belief, the foreskin cannot be pulled back (retracted) in almost all newborn babies. Well-meaning parents do not need to try cleaning under the foreskin until it has become fully retractable of its own accord because attempts to pull back a non-retractable foreskin can result in pain and possibly injury.
About 50 per cent of one-year-old boys will have a non-retractable foreskin, 30 per cent of two-year-olds, about 10 per cent of four-year-olds and about 5 per cent of 10-year-olds.
The small percentage of adults who have a persistently non-retractable foreskin have a slightly increased chance of developing phimosis (see below), but this persistence is not a reason for circumcision.
Phimosis
In phimosis (foreskin contraction), the opening of the foreskin is narrowed, preventing retraction. Provided that the skin of the foreskin is normal and inability to retract it does not cause problems with intercourse or recurrent infections, no action is necessary.
Occasionally, the edge of the foreskin has a white, scarred, inelastic appearance and will not pucker open as it is retracted. Between 1 and 1.5 per cent of boys will develop this condition by the time they are 17 years old.
Symptoms can include : -
irritation or bleeding from the edge of the foreskin
stinging or pain on passing urine (dysuria)
inability to pass urine (acute or, rarely, chronic urinary retention).
The changes in the prepuce are known as balanitis xerotica obliterans, which can become cancerous if left untreated. Circumcision is advisable in most cases.
Acute balanoposthitis
This condition involves redness and swelling of the foreskin, together with a discharge of pus from the space between the foreskin and the glans.
Sometimes the whole penis may be swollen and inflamed. Between 3 and 10 per cent of boys will develop this condition, depending on how the condition is defined.
Balanoposthitis is very occasionally the first sign of diabetes. If there is no underlying cause, simple hygiene measures, mild painkillers and the avoidance of tugging the foreskin are the only necessary treatments. Most cases will recover without further intervention. Circumcision is only done for recurrent and troublesome cases.
Paraphimosis
This condition is caused by forcibly pulling back the foreskin behind the coronal ridge of the glans or head of the penis, without its subsequent replacement.
The foreskin then forms a tight tourniquet around the glans, causing severe pain. The condition can sometimes be treated by firmly but gently squeezing the trapped glans until the foreskin can slip over it again.
If this is not possible, the paraphimosis needs to be reduced under a general anaesthetic. Circumcision is only very rarely necessary.
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.
Penile cancer
Cancer of the penis is an extremely rare disease and, in the early part of the last century, was almost unheard of in circumcised men. However, there is some evidence that circumcision may only offer protection from penile cancer if done in childhood, and adult surgery may not offer any protection.
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
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.
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
Views conflict on whether circumcision can prevent HIV infection. A recent review in the British Journal of Urology concluded that there is no link between having an intact foreskin and HIV infection, whereas another paper in the British Medical Journal takes exactly the opposite view.
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
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.
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)
Since 1987, several studies have suggested that uncircumcised male infants are up to 10 times more likely to contract a urinary tract infection (UTI). One in 100 uncircumcised infants will develop a UTI, compared with 1 in 1000 circumcised infants.
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
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.
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.
Judaism
In the book of Genesis (17: 10-14), circumcision represents the covenant made by God with Abraham and his descendants.
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
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).
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?
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.
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?
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.
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
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 : -
reduction in penile sensation (an almost universal experience)
bleeding
damage to the urethra (urine tube in the penis)
amputation of the glans (rare)
infection in the blood or septicaemia (rare).
Can circumcision be reversed?
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.
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
Circumcision remains a controversial procedure, as it has been for thousands of years.
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'.
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