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Written by Dr John Dean, specialist in sexual medicine
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What is circumcision?
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.
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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.
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In Korea, more than 90 per cent of men have been circumcised,
usually in their teens and twenties.
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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:
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for an immediate medical indication
-
to prevent future disease
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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
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stinging or pain on passing urine (dysuria)
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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:
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reduction in penile sensation (an almost universal
experience)
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bleeding
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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'.
Author's note
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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Last updated 12.09.2005
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