Hygienic circumcision, a myth or a reality?

"There is no convincing evidence that circumcision is useful or necessary in terms of prevention or hygiene."

Dutch royal medical association (KNMG)

"You don’t do a hundred surgical operations to prevent a single case...” Dean Edell

Introduction

Statistically conflicting, the prophylactic results of circumcision are very debated (UTIs, cancer (ACS), STDs, AIDS). These controversies only occur in the USA. In Europe, the three national medical societies (United Kingdom, Holland, the French Conseil national du SIDA) who considered the matter condemned circumcision. Concerning AIDS, the advantage of circumcision is very debated and advocated only in high-risk-taking populations (South Africa). Whatever it may be, it must be recalled that medical ethics only allow amputation for a preventive motive in extremely rare cases with high probability (breast cancer with Ashkenazi Jewish women affected by a genetic mutation) and on no account upon children. Circumcision for religious or traditional motives encounters strong ethical and legal (International Conventions) opposition and raises the indignation of the defenders of the rights of the child.

Newborn UTIs

Winberg and his Swedish colleagues^{1, (*)} overthrew the main argument of prescribers of circumcision: the newborn being naturally immunized against family coli bacilli, infantile infection by urethral contamination (UTI) –besides easy to cure– does not occur when the intimacy of the mother-child couple is respected. Indeed, such infections mainly happen when the child, separated from his mother, is exposed to nosocomial contagion. Leboyer’s recommendations find here an unexpected echo.

Post-circumcision infections

Regarding post-operative infections, the methicillin-resistant staphylococcus aureus (MRSA) epidemic is highly deadly². It strikes circumcised newborn boys twice more^{3, 4} than others, more than HIV which does not strike children. The death rate from MRSA in the USA is 6.3 for 100 000 against 4.4 for HIV⁵. Through advertising circumcision against AIDS, the hypocritical enemies of infantile sexuality do not take into account that mortality, is still worse than that they pretend to prevent.

STDs

Anyhow, contrary to the rumour, circumcision seems globally without incidence on STDs^{6,7, 8, 9, 10, 11, 12, 13, 14} and the prophylactic alibi does not hold. According to Laumann’s survey¹⁵, upon 1 511 subjects, the sexually maimed are at markedly greater risk for two STDs; they are 25 times more prone to chlamydia and twice more to herpes. However, for these two same diseases, Cook’s enquiry¹⁶ led upon 2 776 subjects gives a neutral issue. It also indicates some protection of the circumcised against syphilis and gonorrhoea but they are more prone to genital warts. Dickson's enquiry¹⁷, led over two years upon 2,655 randomly selected subjects, concludes that circumcision has no incidence upon gonorrhoea, chlamydia and trichomonas. The third important randomized statistical study¹⁸ shows a notable indifference of STDs to circumcision status but it did not concern AIDS. Taking into account these sometimes contradictory results, it seems that towards STDs other than AIDS and herpes –which is mainly a disease of stress– circumcision is neutral. But fighting infection is today unproblematic.

Enquiries agree that the sexually maimed are relatively protected from AIDS but Talbot¹⁹ showed that prostitution, not the foreskin, is the great vector of the pandemic in Africa. Nevertheless, the appalling extent of the AIDS pandemic in this continent has, once more, favoured the guilt-making of a foreskin decidedly a favourite scapegoat for puritan phobia. For lack of integrating ethical and behavioural variables, statistic enquiries^20,21,22 that showed an important reduction of the risk thanks to circumcision (60% over 14 months, 50% over 15 months), however fascinating these results may be, are likely to be gravely misleading. The high price of the loss of all men’s foreskin is not justified by these enquiries with hasty conclusions^{23, 24}. If one adds up genetic vulnerability²⁵ and that provoked by the schistosoma mansoni²⁶, one is compelled to put the part of the foreskin into perspective. The example of Japan (first world consumer of condoms) where STDs, notably AIDS, are rare, proves that nothing replaces condoms. As confirmed by the enquiry ordered by Kenyan authorities²⁷, the circumcised’s reluctance to use condoms –because of the weaker sensitivity of their glans– is likely the great cause of the importance of the AIDS epidemic in the United States and Africa. Circumcision of the major part of the population did not protect either the USA –the developed country where the epidemic made the most ravages– or Africa from AIDS. Now, if the scar is fragile, it is an open door for infections.

Genital warts

Genital warts caused by the human papilloma virus strike around 6% of the population. A study ²⁸ indicates that the circumcised are twice more prone to them.

Penile cancer

It is extremely rare and its rate of mortality is very low: 1/100 000 in the USA²⁹ where most men are circumcised against 0.82/100 000 in Denmark where very few are. The American Cancer Society³⁰ asserts that is linked to lack of hygiene, smoking and risky practices. The loose way of living of a few ones should not provoke not only the loss of enjoyment but also the mortality and other accidents due to circumcision, of the whole population.

Cancer of the cervix

The cancer of the cervix has sometimes been ascribed to the absence of circumcision but a study showed that it is without effect upon the transmissibility of HPV³¹.

Conclusion

The hygiene argument is the leitmotiv of ignoramuses, namely, allowing for exceptions, ladies and the circumcised (the most often native of Africa and Middle East). It does not stand the fact that animals and two-thirds of humans live entire without problem. Even in the tropics, on the one hand, billions of men live with their foreskin, on the other hand, ethnic groups of circumciseds and intacts live side by side (Hutus and Tutsis, Luos and Kikuyus, Zulus and Xhosas). It would be well known if the intact were worse off for it. That argument is all the more dangerous as it appears to be founded upon empirical knowledge deriving its strength from the antiquity of the practice, which impresses a few Westerners. The myth of the grain of sand that would get into the foreskin in the desert³² seems to hint at the act of Onan, as if the dust of the soil would come up into his foreskin. Among military physicians, unlike their French, German, Italian, Japanese³³ and Vietnamese counterparts, only those from Anglo-Saxon countries, influenced by puritanism, used it in order to impose the operation to young recruits. The hygienist myth tends towards accrediting the idea that circumcision is made for the good of the child. The true reasons are much less blameless.

Ethics forbids mutilation for prophylactic motive. This rule is particularly true for an operation on a sexual organ but it is all the truer concerning children; they must not be the victims of their elders’ sexual practices. Repression of autosexuality seems to be the veritable argument, today unformulated, of proponents of circumcision. According to Kellog’s and others’ phantasy, autosexuality would be immoral, debilitating and would render troops unable for war.

1 Winberg J., Bollgren I., Gothefors L., Herthelius M., Tullus K. The prepuce: a mistake of nature? Lancet, 1989; 1: 589-96. http://www.cirp.org/library/disease/UTI/winberg-bollgren

(*) Sigismond. Letter to the Editor; BJU Int 2003, 91: 429-30.

http://onlinelibrary.wiley.com/doi/10.1046/j.1464-410X.2003.04113.x/full

2 Epidemic methicillin-resistant staphylococcus aureus: dramatically increased risk for circumcised newborn boys. http://www.doctorsopposingcircumcision.org/DOC/mrsa.html#n40

3 Thompson DJ, Gezon HM, Rogers KD, et al. Excess risk of staphylococcus infection and disease in newborn males. Am J Epidemiol 1965;84(2): 314-28.

http://www.cirp.org/library/complications/thompson1965/

4 Enzenauer R, Dotson C, Leonard T, et al. Male predominance in persistent staphylococcal colonization and infection of the newborn. Hawaii Med J 1985;44(9): 389-90, 392, 394-6.

5 National organization of circumcision information resource centers. MRSA deaths in the US exceed AIDS deaths: circumcision is a culprit. http://hivreports.com/article.cfm/id/234497

6 Laumann E., Masi C., Zuckerman E. Circumcision in the United States. JAMA 1997; 277 (13): 1052-1057. http://www.cirp.org/library/general/laumann

7 Cook L., Koutsky L., Holmes K. Circumcision and sexually transmitted diseases. Am j pub health 1994; 84: 197-201. http://www.cirp.org/library/disease/STD/cook1/

8 Van Howe R. Does circumcision influence sexually transmitted diseases? BJU int1999; 83 (suppl. 1): 56-62. http://www.cirp.org/library/disease/STD/vanhowe6

9 Dickson N. Circumcision and Risk of Sexually (sic) Transmitted Infections in a Birth Cohort. J of ped, 2008; 152 (3): 383-387.

http://www.icgi.org/2008/02/wives-more-likely-to-contract-hiv-from-circumcised-husbands/

10 Green L. McAllister R., Peterson K., Travis J. Male circumcision is not the HIV ‘vaccine’ we have been waiting for! Future HIV therapy 2008, vol. 2 (3): 193-199.

http://www.futuremedicine.com/doi/pdf/10.2217/17469600.2.3.193?cookieSet=1

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http://www.circumcisionandhiv.com/files/ajar2008garennelong_term_effect_of_male_circumcision.pdf

12 Mehta S., Moses S., Agot K., Parker C., Ndinya‐Achola J., Maclean I. and Bailey R. Adult male circumcision does not reduce the risk of incident neisseria gonorrhoea, chlamydia trachomatis, or trichomonas vaginalis infection: results from a randomized, controlled trial in Kenya. J infectious dis 2009, 200 (3): 370–378.

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13 Ferris J. et al. Circumcision in Australia: further evidence on its effects on sexual health and wellbeing. Australian and New Zealand Journal of Public Health, 2010, 34 (2), 160–164.

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15 Laumann E., Masi C., Zuckerman E. Circumcision in the United States. JAMA 1997; 277 (13): 1052-1057. http://www.cirp.org/library/general/laumann

16 Cook L., Koutsky L., Holmes K. Circumcision and sexually transmitted diseases. Am j pub health 1994; 84: 197-201. http://www.cirp.org/library/disease/STD/cook1/

17 Dickson N. Circumcision and Risk of Sexually (sic) Transmitted Infections in a Birth Cohort. J of ped, 2008; 152 (3): 383-387.

http://www.icgi.org/2008/02/wives-more-likely-to-contract-hiv-from-circumcised-husbands/

18 Laumann E., Masi C., Zuckerman E. Circumcision in the United States. JAMA 1997; 277 (13): 1052-1057. http://www.cirp.org/library/general/laumann

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20 Auvert B, Tallard D, Lagarde E, Songnim-Tambekou J, Sitta R. et al. (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Med 2 (11): e298.

http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0020298

21 Bailey C, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial. Lancet 2007; 369: 643–56.

66http://www3.niaid.nih.gov/news/QA/AMC12_QA.htm

22 Gray H, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in young men in Rakai, Uganda: a randomized trial. Lancet 2007; 369: 657–66.

23 Van Howe R. Does circumcision influence sexually transmitted diseases? BJU int1999; 83 (suppl. 1): 56-62. http://www.cirp.org/library/disease/STD/vanhowe6

24 Dickson N. Circumcision and Risk of Sexually (sic) Transmitted Infections in a Birth Cohort.J of ped, 2008; 152 (3): 383-387.

http://www.icgi.org/2008/02/wives-more-likely-to-contract-hiv-from-circumcised-husbands/

25 He W. et al. Duffy antigens receptors for chemokines mediate trans-infection of HIV-1 from red blood cells to target cells and affect HIV-AIDS susceptibility. Cell host and microbe 2008; 4: 52-62.

http://www.ncbi.nlm.nih.gov/pubmed/18621010

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28 T. Dinh. Genital warts among 18- to 59-year-olds in the United States, National health and nutrition examination survey, 1999-2004.Sexually Transmitted Diseases 2008; 35 (4): 357-360.

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29 American cancer society. What are the key statistics about penile cancer?

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30 American cancer society. Can penile cancer be prevented?

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31 Van Buskirk K. et al. Circumcision and acquisition of human papilloma virus infection in young men.Sexually Transmitted Diseases, 2011, 38 (12).

http://journals.lww.com/stdjournal/Abstract/publishahead/Circumcision_and_Acquisition_of_Human.98923.aspx

32 Darby R. The riddle of the sands: circumcision, history and myth. J Hist Med Allied Sci. Jul 2005; 60 (3): 283-319.

33 Wallerstein E. Circumcision: the uniquely American medical enigma. Urol clin North Am 1985; 12 (1): 123-132. http://www.cirp.org/library/general/wallerstein/