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?
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.
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;9 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.
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