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Rapid Responses: Rapid Responses published:
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Retraining of American Physicians Urgently Needed
- George Hill (2 October 2000)
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BXO does not require treatment by circumcision
- John D Dalton (2 October 2000)
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"Ancient and unpleasant" reasons not to circumcise.
- Jason Stone (5 October 2000)
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Treat the fathers
- Hugh Young (23 May 2001)
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BXO, circumcision, and penile cancer
- Jake H Waskett (13 June 2005)
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Circumcision is a last resort - to be avoided, whenever possible
- George Hill (26 June 2005)
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Re: Circumcision is a last resort - to be avoided, whenever possible
- Robin J Willcourt (30 June 2005)
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George Hill, Retired
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Retraining of American Physicians Urgently NeededTo the editor: Rickwood and colleagues bring welcome news of a decline in the incidence of unnecessary post-neonatal circumcision in the United Kingdom.1 Unfortunately, the situation in the United States seems to be far worse than in the United Kingdom. Nearly 60 percent of males born in the US receive a non-therapeutic neonatal circumcision. Most of the 40 percent minority who escape neonatal circumcision are at grave risk of a post neonatal circumcision due to the profound ignorance of the normal development of the foreskin amongst American doctors. Most male doctors practicing today were born in the era of mass neonatal circumcision and have no personal experience of the foreskin. Normal development of the prepuce is not part of the curricula of U.S. medical schools. Most American doctors seem unaware of Kayaba and colleague's finding that 37.1 percent of 11-15 year old boys still have less than completely retractile foreskins.2 The helpline (415-488-9883) of the National Organisation of Circumcision Information Resource Centers (NOCIRC) receives dozens of calls every week from anxious parents whose paediatricians or family doctors have told them that their young intact son must have a circumcision because of a normal uncomplicated non-retractile foreskin which the attending doctor has mis-diagnosed as phimosis. The lack of knowledge is becoming more apparent because fewer and fewer boys now are subjected to neonatal circumcision due to of the American Academy of Pediatrics 1999 rejection of neonatal male circumcision as a beneficial therapeutic procedure.3 At the present time many members of the lay public seem to be better informed than the attending physicians! The Council on Scientific Affairs (CSA) of the American Medical Association have expressed concern over the high rate of neonatal circumcision that prevails in the U.S. and have called for better information for doctors and parents in hopes attaining a lower incidence of non-therapeutic neonatal circumcision.4 The CSA want improved training of American doctors in matters relating the foreskin and circumcision.4 NOCIRC's experience supports the CSA's conclusion that better physician education is needed. Retraining of American doctors in the normal development of the foreskin and the care of the normal complete penis is urgently needed and should be given a high priority.
George Hill
1 Rickwood AMK, Kenny SE, Donnell SC. Towards evidence based circumcision of English boys: survey of trends in practice. BMJ 2000;321:792-793.
2 Kayaba H, Tamura H, Kitajima S, et al. Analysis of shape and retractability of the prepuce in 603 japanese boys. J Urol 1996;156(5):1813-1815.
3 American Academy of Pediatrics Task Force on Circumcision. Circumcision Policy Statement. Pediatrics 1999;103(3):686-693.
4 Council on Scientific Affairs, American Medical Association. Report 10: Neonatal circumcision. Chicago: American Medical Association, 2000.
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John D Dalton, Researcher and Archiver NORM-UK
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Rickwood, Kenny and Donnell (BMJ 2000;321:792-793) are to be commended for their timely reminder that most boys circumcised in England undergo the procedure unnecessarily, at significant cost to the NHS. The evidence does not however support their contention that cicatrisation of the orifice due to balanitis xerotica obliterans (BXO) is an absolute indication for circumcision. It has long been observed that BXO is identical to lichen sclerosus et atrophicus (LSA).1 LSA on the skin of children's genitalia responds well to high-potency local steroids.2 Pasieczny showed that BXO/LSA responded well to treatment topical testosterone propionate ointment and considered it to be the "treatment of choice" for the condition.3 There is also reason to question the effectiveness of circumcision for the treatment of BXO. It may occur in those who are circumcised or those who are not.4 Some children circumcised for BXO may have residual lesions which require treatment with topical steroids.5 If medical practice were consistent with the evidence base, it seems possible that virtually all boys could be spared this ancient and unpleasant form of surgery. The continued use of circumcision in medical practice would appear to be a matter for investigation by the National Institute for Clinical Excellence. References 1.Laymon CW, Freeman C. Relationship of Balanitis
xerotica obliterans to lichen sclerosus et 2. Ryan TJ, Chapter 11, Concise Oxford Textbook of Medicine (Eds Ledingham JGG and Warrell DA), Oxford University Press, 2000, ISBN 0-19-262870-4. 3. Pasieczny TAH.The treatment of balanitis xerotica obliterans with testosterone propionate ointment. Acta Derm Venerol. 1977; 57:275-7. 4. Freeman C, Laymon CW. Balanitis xerotica obliterans. Arch Derm Syph (Chicago) 1941: 44; 547-61. 5. Bale PM, Lochhead A, Martin HC, Gollow I. Balanitis xerotica obliterans in children. Pediatr Pathol. 1987;7:617-27.
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Jason Stone, Physiology demonstrator Department of Physiology
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John Dalton's reference to the need to spare young boys "this ancient and unpleasant form of surgery" should be questioned. While it is agreed that circumcision is "ancient", it could even be accepted as "unpleasant", it does not mean that the medical profession should choose to try prevent it on these grounds. Nobody has any argument against offering a mastectomy patient reconstructive breast surgery simply for social and psychological reasons even when the procedure is not medically beneficial. Is the pschosexual development of a young boy whose penis does not look the same as his father's any less important to consider? I hope the answer is not becuse the procedure to make it look the same is "ancient, unpleasant and deemed by the 1999 American Academy of Paediatrics as a nonbeneficial medical procedure" |
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Hugh Young, Independent researcher
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Jason Stone makes an extraordinary comparison:
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Jake H Waskett, Independent researcher Manchester, England, M26 1JR
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Dalton correctly observes that some success has been noted in treating BXO with steroids.1 However, a number of authors have noted that tissue affected by BXO may become cancerous,2-10 though others express uncertainty.11 There are indications that BXO may be more common than is currently thought.12 A history of phimosis is also associated with a dramatically increased risk of penile cancer.13,14 Prompt, effective treatment must be considered essential, to minimise such risk. Although some researchers have been relatively successful in treating BXO with steroids,15 others have not.16,17 Steroid treatment is ineffective when there is minimal scarring.16 It seems inappropriate to propose that such an unreliable treatment should be considered preferable when time is of the essence. Lastly, Young suggests that there is no evidence to support the idea that a child's psychosocial or psychosexual development might be helped through circumcision.18 This is not true. Schlossberger et al. found that circumcised boys scored significantly higher on satisfaction items.19
Competing interests: None declared |
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George Hill, Executive Secretary Doctors Opposing Circumcision, Suite 42, 2442 NW Market Street, Seattle, Washington 98107-4137, USA
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Competing interests: None declared |
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Robin J Willcourt, Maternal-Fetal Medicine 158 Molesworth Street, Adelaide 5006
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Editor, Hill1 improperly dismisses the evidence cited by Waskett2, citing a review3 that not only predated some of Waskett's references, but also suggested only that it "may be the phimosis itself rather than the LS that caused it that is the true risk factor." (My emphasis.) It is also unclear why Hill chose to draw attention to extragenital LS, which would not seem to be relevant. Hill asserts that the risk factors for penile cancer are smoking and HPV.1 This is certainly true, but these are not the only risk factors. Lack of circumcision and particularly phimosis are risk factors. Harish,9 cited by Hill, reported an odds ratio of 7.4 associated with phimosis (that study did not investigate circumcision itself). Hellberg,10 cited by Waskett, reported an odds ratio of 64.6 associated with phimosis. Daling,11 again cited by Waskett, reports an odds ratio of 7.4 for phimosis, and an odds ratio of 2.3 against invasive carcinoma for those not circumcised during childhood. Velazquez reports a strong association between phimosis and penile cancer. Tseng13 found an odds ratio of 16 associated with phimosis, and - like Daling11 - suggested that prevention of phimosis may be the mechanism by which circumcision is protective. Brinton14 documented a relative risk of 37.2 associated with phimosis, but was unable to investigate the effect of circumcision during infancy. Adult circumcision, which is often performed for phimosis, was positively associated with penile cancer, suggesting that the patient remains at risk after treatment. Maden15 reported an odds ratio (adjusted for age and penile rash) of 3.5 with a history of phimosis. An odds ratio of 3.2 was associated with lack of circumcision (adjusted for age and penile tears). Schoen16 documented that among patients with invasive carcinoma, a relative risk of 22 was associated with lack of circumcision. Other data are also supportive of the connection. Many studies have noted surprisingly high rates of phimosis in penile cancer patients. Soria noted phimosis in 24.5% of patients,17 as did Maiche in 44%,18 42% in Pec's study,19 and "more than 75%" in Matsuo's.20 The evidence, as I hope I have shown, is clear. There can be little doubt that phimosis is a risk factor for penile cancer, and Waskett's review demonstrates that BXO may also be involved. Neonatal circumcision, by effectively preventing phimosis, reduces the risk of penile cancer, particularly invasive forms. The evidence shows that a mere history of phimosis is enough to increase risk, so prompt and effective treatment, as Waskett suggests, is essential. Indeed, it would seem irresponsible to expose the patient to risk for longer than absolutely necessary. Robin Willcourt MB BS
Competing interests: None declared |
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