Whither circumcision?

It seems certain that the Government of Iceland is shortly to outlaw non-therapeutic child circumcision, and that other Scandanavian countries are likely to follow suit. The BMA is considering its position on the matter, with regard to its advice on female genital mutilation. A British judge has observed that removal of the male foreskin seems analagous to ‘stage one FGM’ (removal of the labia minora). However, what should a practising urologist think of this?

Very few body parts have no evolutionary benefit, but data on the function of the foreskin are scanty. The presumed function of the foreskin is to protect and moisturise the glans, and it contains sensitive nerve endings which may be of importance in sexual stimulation. Conflicting and conflicted data exist on this argument from numerous poor quality studies.

So I ask two questions: Are there health benefits or risks for non-therapeutic circumcision, and can we ethically perform it in adults or children?

Potential Benefits

Almost 90% of boys with phimosis will be cured by the use of steroid cream. Only a small minority of men or boys develop resistant phimosis or need circumcision: and by the age of 16 it has been estimated that only 0.6% of English boys need circumcision for scarring and narrowing of the foreskin,1 while possibly two percent of men overall will have a medical need for surgery.  Thus the number of children needed to treat to avoid one adult circumcision is around 50.

STD protection is commonly used to justify circumcision. Data from sub-Saharan Africa suggests a significant reduction in the risk of HIV for men who have prophylactic circumcision and then have unprotected heterosexual sex in areas of endemic HIV. However this was not compared to the use of condoms. Any benefit for boys growing up in the West would be immeasurably small, even without allowing for some boys who go on to have unprotected gay sex having access to PREP. Nor is there proof regarding reduction of sexually acquired non-HIV infection with circumcision,2 although there may be a small benefit. Studies have different findings: again this has never been compared with safe sex and condom use in at risk patients.

Penile cancer is a very rare, nearly always in uncircumcised men, and is associated with HPV infection and poor hygiene as an adult. Ignoring simpler ways of preventing penile cancer, thousands of boys would need circumcision to prevent one case.

A weak asociation between circumcision and protection of women against cervical cancer may exist, and this has peen proposed as a reason for circumcising baby boys. Confounding factors exist, and in any case we are moving to an era of HPV immunisation.  However, the ethics of non-therapeutic paediatric surgery, to try to protect others from future illness, need little discussion.

There is an association between young boys with intact foreskins and urinary tract infections, but to prevent a single urinary tract infection would need in excess of 100 boys to be circumcised.3 For boys with congenital urological abnormalities, or recurrent urinary infections, circumcision may well be a medically indicated procedure.

Although our group has published on genital self image problems in adult men,4 I am not a psychologist. There is no evidence that men who are circumcised benefit from circumcision. However, the number of websites, help groups and charities for men who feel they have been harmed attests to a serious problem for at least some men.

Improved penile hygiene is often cited as a reason to circumcise boys but is entirely spurious – normal bodily hygiene is all that is required. The bacterial count in an uncircumcised male penis is usually lower than either the female genitalia, or the mouth of either sex. While circumcision may reduce bacterial counts on the penis in babies, this effect has not been shown to be of clinical importance in healthy boys, and the effect is gone by one year of age.5 Preference of female partners is sometimes cited as a reason for circumcision – using this to justify surgery on infants is an argument identical to those made for female genital mutilation.

Complications

In general, about five per cent of boys will suffer a significant complication after circumcision6 with about one in fifty needing emergency treatment for bleeding.7

Scores of case reports and series in the medical literature attest to rare but catastrophic complications such as glans amputation, penile necrosis and death. Deaths are very rare but occur in Europe every year. Penile necrosis is also very rare, but loss of the whole penis has been described many times with a number of reconstructive techniques proposed for its management. Glans amputation is still rare but commoner and well reported – I have seen many boys (including two brothers on one day after Plastibell circumcision) and men who have suffered partial or complete amputation of the glans. Management of these disasters requires complex multiple plastic surgical operations, with poor results.

Poor cosmetic results are common but underreported: revision circumcision is not a rare operation. Circumcised boys are more likely to develop meatal stenosis.8

Lack of sensation is commonly reported but hard to prove– there is clear evidence of the skin of the head of the penis changing to become thicker with time. In a recent study, circumcision was linked to decreased senstitivity;limited metaanalysis shows little or no overall effect.10 Current research in this area is unreliable11– many studies are of poor quality and fail to correct for bias including patient expectations of HIV related benefit and cultural pressures. Circumcision does increase the time taken to ejaculate, which logically suggests that sensitivity is decreased12.

What should the urologist do?

If I am asked if there is a good reason for a normal boy in the West to be circumcised then my answer has to be that I can propose no benefit. I will therefore not carry out the surgery.

I am not an ethicist, but clearly were a new religion or social group to emerge which demanded amputation of a child’s body part of any kind, urologists would rightly refuse to take part, even were it not a criminal offence. FGM is now, rightly, criminalised in most Western countries. Non-therapeutic circumcision seems likely to go the same way, and one must ask if the fact it has been carried out for thousands of years outweighs the right of the child.

Circumcision done by a skilled surgeon is an excellent treatment for the right reasons. I will continue to offer the procedure for medical reasons. I will also offer it to mentally competent adults who seek circumcision for either socio-religious reasons, or any of the purported benefits discussed above. For now, it is for urologists to decide if they are happy to circumcise babies and children, who are unable to consent, without evidence based medical reasons.

References

1. BJU Int. 1999 Jul;84(1):101-2. The incidence of phimosis in boys. Shankar KR, Rickwood AM.
2. ISRN Urol. 2013 Apr 16 Sexually transmitted infections and male circumcision: a systematic review and meta-analysis. Van Howe RS.
3. Arch Dis Child. 2005 Aug;90(8):853-8. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Singh-Grewal D, Macdessi J, Craig J.
4. Am I normal? A systematic review and construction of nomograms for flaccid and erect penis length and circumference in up to 15 521 men. Veale D, Miles S, Bramley S, Muir G, Hodsoll J. BJU Int. 2015 Jun;115(6):978-86.
5. J Pediatr. 1988 Sep;113(3):442-6. Effect of circumcision status on periurethral bacterial flora during the first year of life. Wiswell TE, Miller GM, Gelston HM Jr, Jones SK, Clemmings AF
6. Dan Med J. 2013 Aug;60(8):A4681. Complication rate after circumcision in a paediatric surgical setting should not be neglected. Thorup J, Thorup SC, Ifaoui IB.
7. J Pediatr Urol. 2013 Oct;9(5):634-7. doi: 10.1016/j.jpurol.2012.06.019. Epub 2012 Aug 1. The impact of electrocautery method on post-operative bleeding complications after non-newborn circumcision and revision circumcision. Harty NJ, Nelson CP, Cendron M, Turner S, Borer JG.
8. Br J Urol. 1995 Jan;75(1):91-3. Clinical presentation and pathophysiology of meatal stenosis following circumcision. Persad R, Sharma S, McTavish J, Imber C, Mouriquand PD.
9. BJU Int. 2013 May;111(5):820-7. doi: 10.1111/j.1464-410X.2012.11761.x. Epub 2013 Feb 4. Male circumcision decreases penile sensitivity as measured in a large cohort. Bronselaer GA, Schober JM, Meyer-Bahlburg HF, T’Sjoen G, Vlietinck R, Hoebeke PB.
10. J Sex Med. 2013 Nov;10(11):2644-57. Does male circumcision affect sexual function, sensitivity, or satisfaction?–a systematic review. Morris BJ, Krieger JN.
11. J Sex Med. 2014 Dec;11(12):2847-64. A review of the current state of the male circumcision literature. Bossio JA, Pukall CF, Steele S.
12. Int J Impot Res. 2014 Jul-Aug;26(4):121-3. Does circumcision have a relationship with ejaculation time? Premature ejaculation evaluated using new diagnostic tools. Alp BF, Uguz S, Malkoc E, Ates F, Dursun F, Okcelik S, Kocoglu H5, Karademir AK

 

Comments (22) Add yours ↓
  1. Dominic Hodgson Urologist

    Thank you for an important and timely article. In the United States the right to bear arms is constitutionalised but the right to choose whether to bear a foreskin is lost. Perhaps if homunculus man was ever shown with a foreskin, parents would have a simple tool to give them the opportunity to weigh up the seemingly limited benefits of subjecting their baby boys to a potentially dangerous procedure with the deprivation of sensation that will inevitably ensue.

    March 12, 2018 Reply
  2. Brian Morris Professor Emeritus in Medical Sciences

    This is a one-sided appraisal of the latest medical evidence, which has advanced even further since that used by the American Academy of Pediatrics (AAP) and Centers for Disease Control and Prevention is developing their affirmative policy statements released in 2012 and 2015, respectively. The AAP concluded that benefits exceed risks and that unbiased education be given to parents early in infancy, as well as other recommendations clearly designed to encourage this highly beneficial procedure. The CDC recommendations support male circumcision in infancy as the best time, and later for those not circumcised at birth.

    The benefits of infant male circumcision exceed the risks by over 100 to 1. Over their lifetime, half of uncircumcised males suffer a medical condition caused by their foreskin. See article in Mayo Clin Proc in 2014:
    http://www.ncbi.nlm.nih.gov/pubmed/24702735
    and article in World J Clin Pediatr in 2017:
    https://www.ncbi.nlm.nih.gov/pubmed/28224100

    Many men will die as a result of their foreskin, as will their sexual partners …. from genital cancers, HIV/AIDS and syphilis. Penile cancer occurs in approx. 1 in 1000 uncircumcised men. It is only ‘very rare’ in circumcised men. Large studies in the US and Canada show a 15-50 lower prevalent of prostate cancer in circumcised men. Prostate cancer is common and the protection afforded by circumcision means many men will be spared. As for cervical cancer, the evidence is now compelling — See systematic review by Grund et al in Lancet 2017: http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30369-8/abstract

    Given the benefits and very low risks early infant male circumcision is in many ways similar to vaccinations. In fact, it would be unethical now not to recommend the procedure to parents of baby boys:
    http://www.circinfo.net/pdfs/Rivin_IntJChildrensRights_2016.pdf

    MULTIPLE large systematic reviews and a meta-analysis have shown that circumcision has no adverse effect on sexual function, sensation or sexual pleasure. See systematic reviews and meta-analyses in the USA, Denmark, Australia and China, all published in peer-reviewed journals:
    http://www.ncbi.nlm.nih.gov/pubmed/?term=morris+bj+2013+sexual
    http://www.ncbi.nlm.nih.gov/pubmed/?term=tian+circumcision+meta-analysis
    https://www.ncbi.nlm.nih.gov/pubmed/?term=circumcision+2016+dan+med+j
    https://www.ncbi.nlm.nih.gov/pubmed/28653427

    Men circumcised as sexually experienced adults report better sex after being circumcised. This was the finding of two large high quality randomized controlled trials in Africa and Central America:
    http://www.ncbi.nlm.nih.gov/pubmed/?term=krieger+2008+circumcision
    https://www.ncbi.nlm.nih.gov/pubmed/28258953

    Sexual sensation resides in the head of the penis, not the foreskin:
    http://www.ncbi.nlm.nih.gov/pubmed/?term=cox+g+2015+circumcision

    All well-designed unbiased research studies, including high quality randomized controlled trials, find that the overwhelming majority of women prefer a circumcised man for sexual activity and pleasure. Women with male sexual partners who are circumcised have lower risk of cervical cancer, various common STIs and infertility: https://www.ncbi.nlm.nih.gov/pubmed/?term=morris+bj+2017+lancet

    A study of 1.4 million males by CDC researchers found adverse events from infant circumcision in the USA to be 0.4%, virtually all being minor and easily treated with complete resolution:
    https://www.ncbi.nlm.nih.gov/pubmed/24820907
    But circumcision of OLDER boys and men means 10-20 fold higher risk of an adverse event.

    Failure to recommend circumcision is akin to failure to recommend vaccination.
    http://booksandjournals.brillonline.com/content/journals/15718182/24/2

    For confirmation of the latest scientific evidence on male circumcision go to PubMed.com or reputable sources such as the website of the Mayo Clinic for reliable advice, not anti-circumcision websites and opinion pieces in the lay news media.

    Brian Morris, DSc PhD FAHA, Professor Emeritus in Medical Sciences, Sydney Medical School, University of Sydney, Sydney, Australia

    March 13, 2018 Reply
    • Hugh Young Independent researcher

      As usual, many of Professor Morris’s impressive number of citations are to articles he himself has written, or co-authored with fellow male genital cutting advocates. Unfortunately, he is not to be relied on. His publications are full of many exaggerations and distortions, absurdities and innumeracies.
      http://www.circumstitions.com/morris.html
      His figure of “100 to 1” for example is taken by using the most optimistic outliers of studies of benefits and risks. He has never seen a reason he did not like for cutting off foreskins, even including prevention of “bathroom splatter” and zipper injury. (http://www.circinfo.net/pdfs/CircBioEssays07.pdf)

      The 2010 AAP policy has now expired. It was criticised as “culturally biased” at the time by 38 top paediatricians representing 17 non-US paediatric associations. http://pediatrics.aappublications.org/content/early/2013/03/12/peds.2012-2896

      The CDC’s draft policy, which was primarily based on the AAP’s, has not yet been ratified. It was criticised by some 3000 responses, many well argued and referenced. Here is one of the best:
      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4364150/

      March 16, 2018 Reply
      • Stephen Moreton Scientist

        And many of his citations are to works by others. Interestingly the AAP’s 2012 (not 2010) statement did not cite Morris at all. So a case can be made for circ without even mentioning him.

        I find it is intactivists’ works that are full of exaggerations etc. 20,000 nerves, 15 square inches, 16 functions, 117 deaths ….

        Since when did AAP position statements come with expiry dates? Until superseded the 2012 one stands.

        The CDC’s policy was subject to a concerted social media campaign by intactivists, hence the many hostile responses it attracted. There has been a round of critique and counter critique in the literature. The one you cite is just a part of that from a known biased intactivist.

        March 24, 2018 Reply
    • Gordon Muir consultant urologist

      I come to this late but I am afraid I would look on this as an odd critique.
      As a surgeon who does many circumcisions I am not sure how I can be accused of being “one sided” particularly as I do reference the potential benefits.
      My sources are however current and from peer-reviewed publications.
      The concept that half of men will have serious problems with their foreskins if left intact is nonsense, Probably half of men have transient conjucntivitis at some time in their lives (I am not an ophthalmologist ) but that isnt an argument for removing their eyes,
      And whether or not it is ethical to operate on babies for the benefit of third parties, we now have HPV vaccination which makes arguments over female HPV disease spurious.
      A very bilious and odd reply to what I thought was a balanced little review.

      July 25, 2018 Reply
  3. Matthew Bultitude Consultant Urologist

    Nice article. I remember my surprise on my fellowship in Melbourne when one of the American Fellows whisked their child off to the hospital to have a circumcision at 7 days old. The reason … “he would look strange compared to his friends in the locker room when he grows up” !!

    NNT of 50 definitely isn’t a worthwhile justification to circumcise everyone … nor in my opinion are the the other reasons you carefully explain. Fortunately I don’t do paediatric circumcision so am never in the situation where I might be asked to do it.

    However, given that male religious circumcision is so common, the problem will come when the entire practice is driven underground with less skilled practitioners undertaking the procedure in secret. Complication rates will surely go up leading to increased referrals to the stretched NHS services for ‘botched’ procedures. This doesn’t justify it but is a consideration in this argument.

    March 13, 2018 Reply
  4. Stephen Moreton Scientist

    A disappointing article. So much data left out, and some weak data included.

    Reported cure rates for phimosis with steroid cream are variable. A recent meta-analysis found 84.26%, but without long term follow-up we cannot know how many reverted later (pubmed/26725071). Also, males with more severe cases, or a pathology, may have received surgery instead, so will not be included. Any estimate of efficacy will therefore be an overestimate.

    What is the source for 2% of men overall needing surgery? Bear in mind it is not just phimosis that can necessitate it. So can lichen sclerosis and persistent inflammatory conditions.

    Re HIV, the latest meta-analyses indicate 70 or 72% relative risk reduction: pubmed/25942703 & pubmed/29232046. Given what is known of the mechanisms by which circumcision protects, it is a biological effect, related to the presence or absence of a foreskin. So it should not matter in what country the foreskin is resident, and the virus certainly won’t care.

    Condoms are only 80 % effective according to a Cochrane review (pubmed/11869658), or 71-77% according to the latest meta-analysis (pubmed/26488070).

    There is excellent proof that circumcision protects against a range of viral and ulcerative STIs. That the author should refer to a discredited meta-analysis by well-known circumcision-opponent Robert S Van Howe (ref. 2) is disappointing. I contributed to the critique, in which the authors concluded that Van Howe’s meta-analysis was so bad it ought to be retracted (the same recommendation was made by the Catalan Institute of Oncology regarding an earlier meta-analysis by Van Howe, and his first became, literally, a text-book example of how NOT to do a meta-analysis). See pubmed/24944836
    HPV vaccines protect against only two of the 15 or so oncogenic strains of HPV (albeit the most common two), uptake is poor, and long term efficacy remains to be proven.

    Penile cancer is not “very rare”. The lifetime risk is very roughly 1 in 1000 non-circumcised men for developed countries (much higher in developing ones). Early age circumcision is highly protective, but not adult (pubmed/21695385). Risk factors include phimosis and smegma. And it will not do to blame it on hygiene, when hygiene is hard to maintain with phimosis. NNT is given as “over 900” on the website of the American Cancer Soc., not “thousands”. That 900 would also avert 8 infant UTIs, and many more adult ones, not to mention many cases of phimosis, balanitis, lichen sclerosis, STIs …. Also, that early age circumcision is protective, but not adult, indicates that whatever is causing many cases of penile cancer, it starts in childhood, even if it takes decades to manifest.

    Re UTIs: A NNT of 100 is not bad, and better than many vaccines. Considering that UTIs are increasingly antibiotic resistant (pubmed/26980184) circumcision may have more to offer than the author appreciates. I certainly don’t want a return to the pre-antibiotic era when UTIs accounted for 20% of infant mortality. Circumcision also provides lifetime protection against UTI: pubmed/23201382
    The plethora of “websites, help groups and charities for men who feel they have been harmed” attests to the success of anti-circumcision activists (“intactivists”) at spreading misleading propaganda tricking men into believing they are missing something wonderful. It does not mean their dupes actually have been harmed.

    Whilst it would be good if all males would practise hygiene, it is a fact, horrible but true, that many don’t bother. As for changes in the penile microbiome, it happens in adults too, and is of relevance to HIV transmission, as the anaerobes found under the foreskin set up a chronic inflammatory response that, in turn, increases ease of HIV transmission: pubmed/20066050

    Complications: the rates the author cites are far higher than those indicated by the largest study to date, with n =1.4 million (pubmed/24820907). That study found just 0.4%, mostly minor things, easily remedied. Similarly low rates were cited by the AAP in their 2012 Technical Report which concluded that the risks exceeded the benefits, and the procedure should be made available to parents who requested it. The CDC have also concluded that the benefits exceed the risks and the procedure should be available. Both put the proverbial cat amongst the pigeons, with accusation of “cultural bias” thrown in both directions, and the debate is still grumbling on. The Canadian Pediatric Soc. considered it “closely balanced”. No other body has attempted a systematic up-to-date review of the evidence. High time they did. That 2 of 3 bodies attempting to do this should come out in favour, and a third relatively neutral, cannot be ignored. The European bodies have not attempted this, and the Dutch & Nordic positions seem to be ideology, rather than science based.

    How many disasters occur as a result of foreskin-related conditions that circumcision would have prevented? We need more risk/benefit analyses. Some have appeared finding that circumcision wins comfortably (e.g. pubmed/24702735 & pubmed/27705739). Will our own British Medical Assoc. dare attempt one of their own?

    “there is clear evidence of the skin of the head of the penis changing to become thicker with time” Evidence please! This is an oft-cited claim, but one which is never accompanied by actual measurements. In short, one of those pieces of received wisdom that just gets copied over and over again, without any attempt to check if it is actually true. The only study to look for this found no difference: pubmed/10845974

    The most recent meta-analysis on meatal stenosis (MS) found it to occur in 0.656% of circumcised males. Although higher than in non-circumcised ones, the difference was not statistically significant, and may be explained by confounding (MS is strongly associated with lichen sclerosis for which circumcision is a common treatment) or by diagnostic bias (it is easier to see when there is no foreskin in the way): pubmed/28826876

    Sensation: again the author cites a discredited study (his ref 9). See pubmed/23578245. It was a cross-sectional survey-based study, with clear evidence of selection bias (22.6% of its sample were circumcised as opposed to 15% of the Belgian population). Further criticism followed from Chinese authors who pointed out that 12.1% of the sample were gay, leaving one wondering just how unrepresentative it was (pubmed/23759015).

    There is actually a good body of evidence that sensitivity of the penis is unaffected by circumcision. This includes various forms of sensory testing, as well as studies on men circumcised as adults. I summarise it on the circfacts.org website in the “Function & sensation” section – go take a look!

    March 13, 2018 Reply
  5. Michael Glass Retired teacher

    Good article!

    Just one problem: the question of circumcision won’t be decided by medical considerations. Instead there is likely to be a contest between two opposing positions: those who believe that God ordered it; and those who believe that boys – like girls – are entitled to decide for themselves what to do with their bodies. As these two positions are diametrically opposed, we may need to fall back on something we use when large numbers of people insist on doing what is not approved: harm minimisation.

    Here are several suggestions that will help to minimise some really bad outcomes of circumcision without stopping it completely.

    Because circumcision is surgery and there are always risks, juvenile circumcision will always be questionable, because the owner of the foreskin cannot give his own consent to the surgery. 

    This ethical question cannot be resolved by these proposals but some common sense rules could reduce the risks of this surgery.

    1  Unqualified people should be banned from circumcising anyone!

    2  Qualified but incompetent circumcisers should be banned from circumcising anyone else! 

    3  Dangerous traditional practices such as metzitzah b’peh (oral suction of the circumcision wound) should be discouraged by public education and other suitable measures.

    4  Before anyone is circumcised, an independent doctor must certify in writing that the person is free of any bleeding disorders and any other contra-indications and is strong enough to withstand the surgery.

    5  If a child is to be circumcised, both the mother and the father must give informed and written consent to the surgery. No child should be circumcised against the objection of a parent.

    6  If a man or an older child is forcibly circumcised against his will, this should be treated as a sexual assault, and the perpetrator prosecuted accordingly.

    These rules won’t interfere with most circumcisions, but they would, if implemented, give some protection to those who are circumcised.

    March 14, 2018 Reply
    • Stephen Moreton Scientist

      Michael Glass: I must disagree with your first statement. It is a poor article, for reasons explained in my post above. Your second paragraph has some truth, but I feel there is an element of the false dichotomy in it. There is a third position, the one to which I incline – namely that circumcision is preventative medicine which just happens to have religious/cultural significance for some. In this position the matter should be decided by the medical scientific evidence. If, on the basis of that evidence, it is clear that the benefits exceed the risks, and it is therefore in the recipient’s best interests, then it should be available. This aspect is being overlooked in the current debate, which seems to revolve around religious freedom vs consent.

      Your other suggestions are, as is usual for your posts on this topic, eminently sensible and pragmatic.

      March 15, 2018 Reply
      • Michael Glass Why my suggested reforms are so necessary

        Stephen Moreton,

        Thank you for both your comments.

        You are correct in drawing attention to a third position, that circumcision is preventive medicine. Obviously, medical bodies in different countries come to different conclusion about circumcisions: generally favourable in the USA, evenly balanced in Canada, less enthusiastic in Australia, New Zealand and the United Kingdom and hostile in Scandinavia.

        As official positions are at variance, the evidence cannot be clear-cut one way or the other. If there was a clear difference, it might show up in life expectancy, but the male life expectancy in Israel (82.5 years) is topped by the male life expectancy in such non-circumcising countries as Japan (83.7), Switzerland (83.4), Spain (82.8), Italy (82.7) and Iceland (82.7) http://gamapserver.who.int/gho/interactive_charts/mbd/life_expectancy/atlas.html

        Similarly, if infant circumcision made a difference to mortality it might show up in the male infant death rates but Israel’s rate (3 per thousand births) is topped by Finland (2), Iceland (2) Ireland (2) Japan (2) Luxembourg (2) Portugal (2) Singapore (2) and Sweden (2).
        Male Infant Mortality Rate by Country, ChartsBin.com, viewed 16th March, 2018, .

        My guess is that official views about circumcision in different countries are at variance because the evidence about circumcision is not decisive. However, that is not the point. Whether my guess is right or wrong, no-one should want:

        a child bleeding to death because of circumcision https://www.independent.co.uk/life-style/health-and-families/health-news/newborn-bleeds-to-death-after-doctor-persuades-parents-to-have-him-circumcised-in-canada-a6710061.html

        or suffering a lifelong disability because of a circumcision gone wrong;
        https://www.youtube.com/watch?v=Qw9AH0FBOoU

        We can do without knock down, drag out fights between parents over circumcision https://www.theguardian.com/society/2016/jul/24/male-circumcision-the-issue-that-ended-my-marriage

        https://www.weinbergerlawgroup.com/blog/newjersey-child-parenting-issues/parents-disagree-circumcision/

        and we should definitely take a stand against the forced circumcision of adults and older men

        https://www.theatlantic.com/international/archive/2011/08/in-kenya-forced-male-circumcision-and-a-struggle-for-justice/242757/

        That is why the reforms I have outlined above are so important.

        March 16, 2018 Reply
        • Stephen Moreton Scientist

          Outside of high-HIV settings it is indeed less clear cut, which is why I am reluctant to get on a soap box and advocate for it. But equally I cannot deny that there are benefits too. So I am just as reluctant to go against it. Regulation is certainly merited, but not prohibition.

          There are so many factors involved in life expectancy that, outside of extreme situations (like HIV epidemic settings) I doubt very much if the relatively modest benefits of circ would show up in the overall statistics. It would be lost amongst all the other factors. Although I have seen one study that indicated that infant mortality was higher in non-circ’d babies because of UTIs.

          Regarding complications, such as the (thankfully rare) ones you cite, they can be countered by cases of foreskins gone wrong, or diseases a circ would have prevented. The Metro recently carried a sad story of a 25 year old English chap with terminal penile cancer. Had he been circ’d as a baby he almost certainly would never suffer that dreadful disease.

          When parents start feuding over whether their son should be circ’d my advice would be don’t do it. Unless living in a high-HIV country, It is not that big a deal, and certainly not worth falling out over.

          Incidents of forced circ in Africa by lynch mobs are deplorable, but have nothing to do with medical circ. They are related to tribal rivalries (a circumcising tribe dominating a non-circumcising one) or entrenched cultural traditions (youths being coerced into initiation ceremonies). As far as I am concerned, circ has to be done to a high medical standard and consent given without duress, whether by the individual being circ’d, or by the parents or legal guardian, if a minor.

          March 24, 2018 Reply
          • Michael Glass Forced circumcision should be treated as indecent and sexual assault

            Forced circumcision is not just something that occurs in tribal settings in Africa. Examples can be found in Indonesia, the Middle East and during the breakup of Yugoslavia. Details can be found in my article in the Journal of Medical Ethics Michael Glass, “Forced circumcision of men (abridged)” Journal of Medical Ethics (J Med Ethics doi:10.1136/medethics-2013-1…

            The only way to deal with this abuse is to treat forced circumcision as the sexual assault that it is. Treating forced circumcision as a sexual and indecent assault will help to educate people about the seriousness of this crime.

            March 24, 2018
  6. Ben Challacombe Consultant urologist

    Along with organ donation and politics this is one of those subjects never to raise at a dinner party. Unless you want an argument or too finish early!
    I support Gordon’s standpoint fully and would operate on those adults with clinical need but not for cosmetic reasons.
    Regarding children, Doing something that you can’t justify only because it might be done by someone else with no medical training isn’t a valid argument. Perhaps the parents might stop and think once made aware of the risks and benefits.
    Cultural circumcision as in the USA is certainly the weakest reason out there and I too remember looking aghast at my colleague that Matt mentions when we were in Australia.
    I think urologists should step up and educate our population to preserve the normal foreskin.

    March 14, 2018 Reply
  7. David Wilton Attorney at Law

    Brian Morris is well-known for circumcision advocacy. He is also quite selective in his citations, often citing himself. So I would take his appended rebuttal to this article with a handful of salt.

    Stephen Moreton is also cast from the same mold as Morris. He also should be read with caution.

    The article is well-reasoned and persuasive. I agree with another commenter and the author that a child’s right to to his own body takes priority over speculative or marginal benefits when more effective or less invasive alternatives are available.

    March 15, 2018 Reply
  8. Rebecca Tregunna Specialist Registrar

    The child will become a man one day and at that point can be allowed to choose if he wants to have a circumcision for the ‘prophylactic’ reasons listed. Surgery is not without risk and in my mind this ritual practice is outdated and unnecessary. Circumcision in a child should be for medical reasons only.

    March 15, 2018 Reply
    • Stephen Moreton Scientist

      “Medical reasons” can include prophylaxis, and many of those prophylactic benefits are lost if one waits until adulthood. The procedure is also riskier, costlier and more unpleasant as an adult (this may be difficult for a lady, but try to visualise an erection held together by a dozen to twenty stitches – ouch!) The result is that many adult males would be deterred from circumcision even if they wanted it. This is a major issue in high-HIV settings where it is imperative to get the circumcision rate as high as possible. One can do this easily, cheaply and safely with infant/child circumcision, but it is much harder with adult circumcision. Taking the “wait until adulthood” approach and applying it in these settings will mean millions more HIV infections in decades to come. This is not ethical. See my recent reviews of the extensive literature on this topic:

      http://circfacts.org/general-information/#med3

      http://circfacts.org/general-information/#med4

      In light of this I am deeply disturbed by developments in Iceland. What sort of message is being sent to Africans when they see developed nations turning their backs on circumcision? Already, in Malawi, myths are being spread that the circumcision program there is a western plot against Africans. Circumcision proponents would “save” a few 1000 Icelandic boys from being circumcised and put at risk the welfare of millions of Africans.

      March 15, 2018 Reply
  9. Culley Carson Professor of Urology

    Great article and trail of comments. The issue of circumcision remains controversial. But, typically when government gets involved, there are emotional not evidence based decisions made that change behaviors with out considering science or research studies. The Mayo Proceedings article is a great one that should be reviewed by legislators to give them some science to temper the emotion.

    In the US, a California judge has ruled that all coffee should bear a warning that coffee might cause cancer. There are NO DATA!! I think lawyers, judges and legislators should be required to take a course in science, statistics and evidence based medicine before legislating without knowledge.

    April 4, 2018 Reply
    • Gordon Muir consultant urologist

      Thanks Culley. In fact for prostate and breast cancer there is now moderate evidence that coffee is protective.

      But all I wished to do was to point out that, unless there are massive reasons for personal benefit, carrying out surgery on infants and children is not something I feel comfortable with. We rarely vaccinate children when there is no plausible benefit to the individual and significant potential harm.

      I remain to be convinced that childhood circumcision for the average western patient has any quantifiable benefits. My duty is to my patients, not to one or other pressure group.

      July 25, 2018 Reply
  10. Michael Glass Retired teacher

    Gordon Muir said, “It seems certain that the Government of Iceland is shortly to outlaw non-therapeutic child circumcision, and that other Scandanavian countries are likely to follow suit.”

    That was in mid March. By now, in early April, this is not so certain. Two important Icelandic organisations have come out against the proposed legislation.

    The government agency for child protection does not support the legislation. https://grapevine.is/news/2018/03/29/agency-for-child-protection-in-iceland-also-speaks-up-about-circumcision/

    The Foreign Ministry is also concerned about the effect of this legislation on Iceland’s image abroad. https://grapevine.is/news/2018/04/04/proposed-child-circumcision-ban-in-iceland-prompts-diplomatic-row/

    It remains to be seen what will happen with the legislation.

    April 4, 2018 Reply
    • Gordon Muir consultant urologist

      I agree. But if not Iceland then other Scandinavian countries will follow suit. FGM is illegal and non-therapeutic male circumcision will go the same way unless an argument for benefit can be made. I can see no good argument but let the debate continue.

      July 25, 2018 Reply
  11. Michael Glass Retired teacher

    Hello Gordon,

    I wouldn’t hold your breath waiting for other Scandinavian countries to ban childhood circumcision. Those in favour of circumcision are very adept at stopping such measures from succeeding. Jewish religious authorities have been fighting off challenges to circumcision since the time of the Maccabees, more than a century before the time of Jesus. Iceland was a good example of this in action.

    Therefore if you want to do something practical about circumcision, look at measures of harm reduction such as the ones that I have outlined in other postings here.

    July 26, 2018 Reply
  12. gordon muir consultant urolpogist

    I think itself evident that only experts should do surgery and as stated I am happy to offer religious circumcision to adults who have decided that is the right thing to do. It is a criminal offence to “circumcise” a girl in most European countries and avoidance of traditional practitioners is no defence. So I do not see the difference in boys.

    July 26, 2018 Reply

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