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Circumcision Debate
- Daniel Polowetzky (7 December 2007)
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Circumcision, hygiene and emasculation
- Antonio Lopez San Roman (7 December 2007)
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Circumcision is harmful
- John P Warren (8 December 2007)
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Kirsten Patrick makes a valiant effort to do an impossible task.
- George Hill (8 December 2007)
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The medical profession's role in cultural circumcision
- Richard A Crane (8 December 2007)
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HIV prevalence
- Sharon V Cuthbert (8 December 2007)
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Prevalence rates of HIV
- Shrikaanth Krishnamurthy, Walsall, WS2 9XH (9 December 2007)
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Circumcision can wait until puberty - let the child decide
- Sam Richmond (9 December 2007)
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Still like Russian Roulette
- Hugh P Young (9 December 2007)
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Declaring a foreskin as a conflict of interest.......
- Phillip J. Colquitt (9 December 2007)
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Head against Brick
- J D Poff (11 December 2007)
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Role of the physician in male circumcision: Balancing the risks and benefits
- Shailendra Kapoor (11 December 2007)
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Scalpel-Like Words
- Rood Andersson (11 December 2007)
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male circumcision should be a choice for adults
- Rain Song (11 December 2007)
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Circumscision-relevance to HIV
- debra meerkotter (12 December 2007)
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Male Circumcision for hygienic health reasons
- N Yale Zelvin (12 December 2007)
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Turning Our Backs On A Horrible Legacy
- Martin S. Morris (12 December 2007)
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no more brutality, stop circumcision
- david j garbacz (12 December 2007)
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Let's here from the religions
- Neville W Goodman (12 December 2007)
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Must be evaluated as a whole-life issue
- Cynthia Virtue (13 December 2007)
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Patrick fails to make the argument
- Robert S Van Howe (13 December 2007)
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A powerful way of morally assessing the issue
- Marwan Daar (13 December 2007)
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Circumcision is Good
- Joel .O AKANDE (13 December 2007)
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Informed consent
- Marion Drage (15 December 2007)
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Glad to know
- Scot Anderson (15 December 2007)
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Re: Glad to know
- Scot Anderson (17 December 2007)
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Daniel Polowetzky, Registered Nurse Mount Sinai School of Medicine, New York, New York
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The issue of male circumcision is not on a par with so-called female circumcision, even when performed for non-medical, religious or societal reasons. The differences in anatomy of the human external genitalia and differences in the commmonly performed procedures referred to as "circumcision" are important in clarifying the debate. Excision of the clitoris in "female circumcision" likens it to penectomy. Hence, female circumcision is a far worse violation of the rights of children than male circumcision. As for the notion that male circumcision may result in a boy's perception that he has been "assaulted", despite, as is certainly universally true in procedures performed shortly after birth, not having any memory of the event, this would have the same credibility as the Freudian notion of the Elektra Complex in girls. As for motivation for male circumcision in populations with high circumcision rates, conformity rather than true religious belief may be in play. Of course, this does not avoid the moral debate. Competing interests: None declared |
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Antonio Lopez San Roman, Staff Physician, Gastroenterology Hospital Ramón y Cajal, E28005 Madrid
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Circumcision may have health benefits, but this does not compensate the fact that it is, indeed, a form of mutilation. I agree, that in areas where religious beliefs are strongly in favour of circumcision, health care providers should offer a healthier and more controlled way to have it done. But to stimulate circumcision as a genital therapeutic panacea might even lead to the false belief in circumcised men, that they are immune to STD's. Non-circumcised men have to adopt some hygienic measures, both daily and after engaging in sexual activity. I believe that it is the failure to comply with such measures, rather than the foreskin itself, that makes uncircumcised men more susceptible to some health problems. If we look only at health benefits, it is clear that emasculation (severing of the penis) will be more protective from STD's than circumcision, but fortunately no one is supporting it (yet). Competing interests: None declared |
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John P Warren, Retired consultant physician CM17 0DX
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As Chairman of the registered charity NORM-UK, I have heard from many men dissatisfied that their foreskins were removed without their consent, and often without therapeutic necessity. Many have never complained to their doctors for several reasons: 1 they know the doctor can't give them back the lost foreskin, 2 they feel ashamed of their mutilation, 3 they are afraid of a hostile response from the doctor, 4 it may be decades after the operation that the full effects are understood by the patient. Indeed, some of those who have complained have faced hostility from the medical profession. In my experience men who were circumcised as children may complain of
some of the following problems:
Comparing circumcision with immunisation is not appropriate. Immunisation takes nothing away, and leaves little or no visible mark. In most cases it provides a high level of protection against an infectious disease with a very low risk of complications. Kirsten Patrick states 'no robust research exists examining the long term psychological effects of infant circumcision. Most evidence of psychological trauma is anecdotal.' This may be true, but lack of evidence to show that something occurs is not evidence that it does not occur, but merely evidence of our ignorance. In fact, although we may have been circumcising for more than 15,000 years, we still don't know what we are doing. We do know that the pain of neonatal circumcision alters pain responses in the infant months later (Taddio A. et al. Effects of neonatal circumcision on pain responses during vaccination in boys. Lancet 1995; 345: 291-2). Competing interests: Chairman NORM-UK |
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George Hill, Vice President for Bioethics and Medical Science Doctors Opposing Circumcision, Suite 42, 2442 NW Market Street, Seattle, Washington 98107-4137
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Competing interests: None declared |
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Richard A Crane, F2 doctor, Accident and Emergency Queen's Medical Centre, Nottingham, NG7 2UH
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The recent WHO statement that circumcision has a role in the prevention of HIV is a bandwagon that many of the pro-circumcision lobby have seized upon in recent months as justification for the practice worldwide. Kirsten Patrick, I see, is no exception. The data is based purely on studies in Africa and the statistical significance of these studies is unlikely to be reproduced in western countries, where the prevalence of HIV is low. Evidence for any other health benefit is tenuous, and would apply equally to a self-consenting child circumcised at puberty as to one circumcised as an infant. Whilst researching an article on the subject of cultural circumcision, earlier this year, I was astonished to learn of the barbaric practice of ritual circumcision without any anaesthetic, carried out by medically untrained members of certain religious groups. If those same infants were to present to an emergency department with deliberately inflicted wounds elsewhere on their bodies, the repercussions for the child’s guardians would be significant. Fear of accusations of religious intolerance are the reason, I am sure, why these spectacular double standards remain unchallenged. Reluctantly, I agree therefore, that whilst this practice remains legal, it would be unwise for the medical profession to turn its back on medically unnecessary circumcision completely. Competing interests: None declared |
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Sharon V Cuthbert, F2 (GP) Oxford Deanery Didcot Health Centre, Britwell Road, Didcot, OX11 7JH
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Kirsten Patrick's defence of male circumcision includes the assertion that 'South Africa’s prevalence of HIV infection is one of the highest in the world, second only to India’s.' The statistics from UNAIDS have recently been revised, but even so, the most recent report indicates that although the prevalence of HIV in South Africa is indeed very high at 18.8%, this is below a number of other sub-Saharan African countries including Swaziland (33.4%) and Botswana (24.0%). In India, the prevalence is in fact only 0.9%. Patrick also states that of those infected in 2006 only a third were in sub-Saharan Africa. The 2007 report describes a peak of new infections in the late 1990s at over 3 million, declining to 2.5 million in 2007 of whom over 2/3 (1.7 million, 68%) were in sub-Saharan Africa.1 1. UNAIDS. 2007 AIDS epidemic Update. Geneva: UNAIDS/WHO, 2007. (Available at http://www.unaids.org/en/HIV_data/2007EpiUpdate/default.asp) Competing interests: None declared |
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Shrikaanth Krishnamurthy, Associate Specialist in Psychiatry Dorothy Pattidon Hospital, Walsall, WS2 9XH
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In his article "Is infant male circumcision an abuse of the rights of the child? No" (BMJ 2007; 335: 1181), Kirsten Patrick claims "South Africa’s prevalence of HIV infection is one of the highest in the world, second only to India’s." This is an erroneous and misinformed statement on 2 counts. Neither does India have the highest prevalence of HIV infection, nor is South Africa's prevalence second highest in the world. In epidemiology, prevalence is the "overall proportion of the population who suffer the disease".[1] According to the UNAIDS statistics, the number of people living with HIV in South Africa is 5.5 million[2] with an estimated average prevalence rate of 18.8% between the ages 15 and 49.[3]] From the same source[3], the corresponding figures for India are 2.5 million and 0.36% respectively. The countries with the highest prevalence of HIV infection in the world are Swaziland, Botswana, Lesotho, Zimbabwe and Namibia, in that order. South Africa stands sixth. In terms of total numbers, South Africa is the country with the largest number of HIV infections in the world. [1] Trisha Greenhalgh. How to Read a Paper. BMJ books, 2001 [2] UNAIDS: Regional data. (Available at http://www.unaids.org/en/Regions_Countries/Countries/south_africa.asp ) [3] UNAIDS & World Health Organization. 2007 AIDS epidemic update: December 2007. Geneva UNAIDS/WHO, 2007 (Available at http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf ) Competing interests: None declared |
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Sam Richmond, Consultant Neonatologist Sunderland Royal Hospital, SR4 7TP
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All of the alleged advantages of circumcision mentioned by Kirsten Patrick, with the single exception of the dubious protection from urinary tract infections, only become of any possible importance after puberty. Why not wait until the child is older and then, having clearly delineated to him the advantages and disadvantages, allow the child himself to decide? The answer is that this practice is essentially a religious one and for some curious reason the world turns a blind eye on this outrageous mutilation of the child because the belief of the parents in an imaginary being and the parents apparent need to enforce this delusion on their children has to be 'respected'. Competing interests: None declared |
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Hugh P Young, independent researcher 3 Haunui Way, Pukerua Bay, NZ, 5026
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It is no longer true that most males in the English-speaking world outside the US are circumcised, since the rates fell below 50% about 30 years ago, and are now residual in New Zealand and the UK - with no epidemics of foreskin-related complaints. It is not true that circumcision was medicalised in the 1940s and 50s to prevent urinary tract infections - the first medical reference to that "circumstition" was in 1982. Before that, it was to protect against cancer, STDs and of course masturbation and the ills believed to follow from it. The New Zealand study of STIs gained headlines of the form "Circumcision protects against STIs" worldwide; a subsequent proviso, that the Number Needed to Treat was more than 20 for a minor infection, went almost unreported. The randomised clinical trials for HIV in three African countries were not double blinded, and there is evidence of various experimenter effects (notably more counselling for the circumcised experimental groups), as well as various unexplained anomalies, such as HIV seroconversion in men reporting no sexual activity. Cutting the experiments short increased their uncertainty. 137 of the control groups seroconverted, compared to 64 of the circumcised experimental groups, but at least 340 of the experimental groups dropped out of the studies, their seroconversion status unknown. Differential loss from study, by men disillusioned when they learnt their serostatus, is a serious consideration. Yet "60% protection" has become such a mantra that an Israeli paper reported that six out of ten circumcised men are immune to HIV! We never hear the large Numbers Needed to Treat that the studies imply in Africa, nor the much larger in the North. It is inevitable that any effect on men circumcised in mass campaigns will be less than in scientifically controlled and monitored studies, and diminish over time. In 2000, UNAIDS said "Relying on circumcision for protection is ... a bit like playing Russian roulette with two bullets in the gun rather than three." That has not changed, and circumcision campaigns will divert scarce resources and attention away from measures that have been shown to work. It seems prevention of HIV is now going to be used as a wedge to prop up flagging rates of neonatal circumcision. Thanks to the Internet, the men who are outraged at what was done to them are now finding a voice. Sooner or later, a court is going to take notice. When will the medical profession start to listen? Competing interests: None declared |
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Phillip J. Colquitt, RN/Technician Independent Comment
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......I mean, it is isn't it? How can you comment objectively on the immorality of removing the foreskin, if you, the commenter, possess one? And how can you comment objectively on the positives of removing the foreskin if you, the commenter, don't possess one. Competing interests: No other respondents declared theirs. Why should I? |
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J D Poff, researcher Auckland 0629, NZ
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To quote Strategies and Analyses from the ICCL Working Conference on Women's Rights as Human Rights (Dublin, March 1997 [1]), "Children have the right to bodily integrity". At what point does Kirsten Patrick situate the departure of male children from the protection of this statement? Nothing in her defense of male genital mutilation outweighs the fundamental natural right of all people to security of person. No modern western medical ethics committee would allow a comparable procedure on any other healthy organ, whatever the putative prophylactic benefits; so why this organ? Isn't it suspicious that, after all these millennia, it remains the poor penises and vulvas that are so wayward and unclean they need to be cut and scarred for social acceptance? Some of us who were circumcised as children feel extremely angry about this mutilation of our bodies, done without our consent for reasons we now know to be inadequate, if not scurrilous. We are fully entitled to be heard on this without being belittled and patronised, because circumcision is not a trivial intervention. We also have a clear responsibility to speak out against this atavistic rite on behalf of helpless baby boys, who deserve better from civilized people. 1 http://members.tripod.com/~whr1998/documents/icclbodily.htm ______________________________________
Competing interests: None declared |
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Shailendra Kapoor, M.D. UIC, Chicago, IL 60612
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The articles by Hinchley and Patrick are highly interesting and provide contrasting opinions on the risks and benefits of circumcision. (1,2) Circumcision provides a number of benefits besides those mentioned by Patrick. For instance, circumcision has been repeatedly shown to decrease the risk for penile carcinoma as well as prostate carcinoma. In fact, penile carcinoma is nearly three times more common in uncircumcised men compared to circumcised men. (3) In addition, circumcision is associated with a decreased risk for developing conditions such as phimosis and balanitis. (4) On the other hand, circumcision has its own associated risks such as infection and bleeding. One significant fact to consider is the fact that circumcision may result in “behavioral disinhibition”. For instance, in a recent study nearly 30% of circumcised men had the false notion that because of circumcision they could engage in safe sex with multiple partners. (5) This by itself is enough to warrant concern. Circumcision is a non reversible procedure and given the wide debate about its role, the physician should present all the pros and cons to the parents in an educated and unbiased manner. The physician in the end should maintain a neutral role and respect the informed decision of the parents. 1. Hinchley G. Is infant male circumcision an abuse of the rights of the child? Yes. BMJ 2007; Dec 8;335(7631):1180. 2. Patrick K. Is infant male circumcision an abuse of the rights of the child? No. BMJ 2007; Dec 8;335(7631):1181. 3. Frisch M, Friis S, Kjaer SK, Melbye M. Falling incidence of penis cancer in an uncircumcised population (Denmark 1943-90). BMJ 1995; Dec 2;311(7018):1471. 4. Herzog LW, Alvarez SR. The frequency of foreskin problems in uncircumcised children. Am J Dis Child 1986; Mar;140(3):254-6. 5. Lagarde E, Dirk T, Puren A, Reathe RT, Bertran A. Acceptability of male circumcision as a tool for preventing HIV infection in a highly infected community in South Africa. AIDS 2003; Jan 3;17(1):89-95. Competing interests: None declared |
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Rood Andersson, Founder NORM-Phoenix, POBox 5173, Goodyear, AZ, USA 85338
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It is fascinating to discover that the BMJ issued a Clinical Review of circumcision entitled "Medical Aspects of Male Circumcision" on the same day, 8 December 2007, in which Kristen Patrick's encomium to the controversial practice of male genital mutilation was printed. A six- point summary by the Clinical Review illustrates the controversy from the viewpoint of medical indications, only, but it is interesting, nonetheless, despite its prejudicial bow to the efficacy of medical procedures: 1. 1 in 6 males in the world ends up being circumcised. 2. The medical indications to circumcise prepubertal boys are rare. 3. There are many relative indications for circumcision in childhood, but the evidence of benefit needs to be carefully appraised. 4. The medical indications to circumcise adults are similarly rare. 5. Controversy continues about the health risks of preserving an intact foreskin because of lack of evidence and of clear randomised trials. 6. Complications of circumcision are well documented and can be drastic. 7. Nearly all circumcisions are carried out for cultural or religious reasons. Kirsten Patrick downplays the "well documented" complications of circumcision, suggesting that "medically beneficial" results are worth the risk. Perhaps. Those boys who die as a consequence of the procedure would certainly object to having been genitally mutilated, had the opportunity been given them to dissent to being circumcised. The tens of thousands of men who must live with horribly ugly skin tags, skin bridges, partial and whole glans amputations, and, indeed, entire penile amputations would undoubtedly object, too. As a foreskin restorer who knows something of the difference between being intact and the brutal consequences of genital mutilation, and, as a counselor for men who spend countless years in foreskin restoration, I must object, personally, to Ms. Patrick's dismissal of our suffering. And what meager crumbs are tossed our way in partial compensation for having our genitals mutilated? We are told that cervical cancer rates are "less likely" among genitally mutilated men, nevermind that cervical cancer is a product of promiscuous behaviour. Similar statistics seemingly hold for HIV infection, too, as they relate to the prepuce. But promiscuous, intergenerational, condomless sex promotes the spread of HIV, not the lowly prepuce. Finally, the New Zealand syphilis cohort study is tossed our way, disregarding the fact that the study has been largely discredited. Ms. Patrick then dismisses psychological harm because "only a tiny proportion" of genitally mutilated men have reported experiencing distress, as a consequence of having been circumcised. Does she not know that many circumcised boys and men are unaware that they were genitally mutilated? Does she not know that having been mutilated at birth, that they have no method of comparison? Does she not know the adverse consequences of male genital mutilation to their female partners? Ms. Patrick supposes far too much. As a doctor, and as a former Roger Robinson editorial registrar, she should not attempt to force her scalpel- like words on the genitals of helpless children. Rood Andersson NORM-Phoenix Competing interests: None declared |
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Rain Song, student Langara, Vancouver, B.C.
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Arguing that males should be circumcised to prevent increased chances of HPV transmission to females, and thusly the possibility of increased incidents of cervical cancer is ludicrous. Perhaps the solution here is to remove female cervixes at birth. "Circumcising a baby boy to protect against STDs is like selling your car to make sure he's never injured in a crash. That's silly - keep the car, drive safely, and use the seat belts." - Bill Stieg. There is no reason to do this to a child, of any age. Even teens can be pressured and coerced by family members. Whether it is for religious or cultural reasons or a rite of passage, the body belongs to the person, not the parent. This procedure should only be performed on adults with their full consent. As for… “comment(ing) objectively on the immorality of removing the foreskin”, I don’t believe that I have ever had to have had one to be able to stand up for the rights of the individual, the child. It is their body; it should be their choice. For the people who wish to have their child circumcised for religious reasons, I ask you to consider this. Would your god rather have sheep come fully informed, choosing god with all of their heart and soul, performing all of god’s required rituals and sacrifice willingly, or would your god rather that someone come because of their parent’s expectations or social pressures? In circumcising your child, you are possibly robbing your child of their choice denying them the opportunity to prove their commitment, and willingness follow god’s commands. I challenge you to read the scriptures and question previous interpretations. After all, I am sure that god, like any good teacher, would appreciate an intelligent, well read, questioning student, who is thirsty for knowledge much more than a student, nodding off in the back of the class, who just goes to school because mom and dad pay for it. Finally, in reference to the comment, “Circumcision is one of the commonest surgical procedures performed on males; Rape is one of the most common crimes committed against women… let’s think about those statements for a moment. Does commonality make something any less heinous? Competing interests: I am not declaring any competing interests because I do not have any. |
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debra meerkotter, consultant radiologist Helen joseph hospital ,Johannseburg, South Africa
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Working with patients that are infected with HIV or have AIDS continually challenges me.We deal with patients that are young and are really the 'living dead'.Sometimes I think of my hospital as an AIDS Hospice.It is a daily occurence to be dealing with people with CD4 counts of less that 100 (often less than 25!) The article by Dr Patrick highlights important data regarding HIV transmission.If circumcision can significantly reduce HIV transmission we need to promote circumcision in our country.If parents can be educated on the value of circumsision in HIV transmission reduction we might alter the future of our children and in doing so the future of our country. Valid research based reasoning is brought out in this article and as a medical profession we should be able to inform and guide parents through this process. Competing interests: None declared |
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N Yale Zelvin, retired 10709
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One reason that is hardly mentioned as a reason for male circumcision is that for reasons of male personal hygiene it has benefits.. I found that in discussions with old World War 2 veterans , several told me that as teenage draftees they were circumcised by the Army without being asked because as they now say they had become infected by the collection of detritus under the foreskin. Obviously this random sampling of a handful of World War vets is not perfect validation although any uncircumscribed male can understand the reasoning and one would think it would not be difficult to ascertain the facts...but we are dealing with our government which stiil argues for abstinence rather than contraception.. . This does not have to go unchecked but perhaps a publically stated FOIL question by the media to the Pentagon or the VA or the surgeon general can clarify the point....Perhaps young mothers with sons can give their experience without the old fashioned modesty of their parents.I know as a draftee for the Korean war all men were thoroughly checked for infections those who were circumscribed had a quicker check. I think this will turn out to be difficult for the obvious reasons that have prevented the expected professional groups from opiningin the past.. Anything now that can have erotic, sexual or religious significance does not seem to simply fall under the First Amendment . Competing interests: None declared |
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Martin S. Morris, Government Relations Executive 20016
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Millions of baby boys over history must have suffered excruciatingly painful deaths from infections due to being cut so close to where the pass liquid and solid wastes. We should honor them by abandoning the practice of circumcision. Competing interests: None declared |
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david j garbacz, media 95060
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as a man who has had it both ways on his own penis i can say without any doubt that a penis with a forskin is a functioning and feeling penis. period. mucus membrane exposed is like leaving your mouth open all the time, and see what your tounge feels like. Any issue raised regarding transmission of sexual diseases very sad. If you engage is unprotected sex it makes little ultimate difference if you play russian roulette with two or one bullet. in the end you will die. foreskin or no. Competing interests: None declared |
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Neville W Goodman, Consultant Anaesthetist (retiring) Southmead Hospital, Bristol, BS10 5NB
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What an extraordinary waste of space these articles and the ensuing correspondence has been! Circumcision is done largely as an article of faith: it says we must do it and so we do. "Reasons" for following articles of faith are pointless. The "reasons" that eating pork is prohibited for Jews and Moslems are irrelevant: their scriptures tell them they must not eat and therefore they do not eat. You could say that pork is more likely to contain tapeworm cysts, but that is merely post-hoc attempted justification. The only people whose opinions are worth seeking in the discussion about circumcision are those who believe circumcision is necessary to religious identity. Ignore the medical backing for or against circumcision, what do the rabbis and imams think? Competing interests: None declared |
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Cynthia Virtue, Independent comment Massachusetts, USA 01824
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Addressing this issue is laudable, however, none of the journal articles I have read address issues much beyond childhood. As the issue concerns a sexual organ, not only should the adult male be evaluated for satisfaction with the procedure, but his partner(s) should be interviewed as well. There are significant differences in experience for the partner, between circumcised and uncircumcised men. Sadly, this sort of research, while important to the question, is missing. Competing interests: None declared |
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Robert S Van Howe, Pediatrician Michigan State University College of Human Medicine 49855
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The head to head debate of whether infant male circumcision is an abuse of rights of the child seemed unbalanced. While Geoff Hinchley discussed basic human rights principles and documents and how they apply to the practice of infant male circumcision, Kirsten Patrick fails to attempt to demonstrate that these principles do not apply to the practice. To make her point Patrick needs to establish why circumcision has to be performed on newborns rather than waiting until the child is competent and able to make the decision for himself. She does not attempt this. The only ammunition she has is to show that infant circumcision is in the infant’s best interest or that the infant would choose to be circumcision if given the choice when competent. Since very few competent males choose to be circumcised, she must make the first argument that the benefits of circumcision are sufficient to trump the rights to bodily integrity and personal autonomy. Let’s see how she does. 1. Well, I’m sorry to rain on her parade, but most circumcisions are not performed in infancy: most are performed as part the Muslim faith later in life. 2. Well, I’m sorry again, but there have been two studies that have shown a possible medical benefit to female circumcision. One found that is significantly shortened the second stage of labor,[1] while the second found circumcised women had a lower risk of HIV infection.[2] 3. Sorry, again, but male circumcision, like female circumcison, is painful, had immediate and long term medical complications, and can result in psychosexual scarring.[3] 4. Sorry, again, the pain of circumcision done under local anesthesia is not comparable to that of an injection for immunization. Heel sticks, which are more painful than injections, have been shown to be much less painful than circumcision. When neonatal personnel were asked to rate how painful procedures were for newborns, circumcision was considered the most painful procedure (tied with chest tube insertion) ahead of endotracheal intubation, insertion of gavage tube, tracheal suctioning, arterial or venous cutdown, lumbar puncture, IM injections, insertion of an umbilical artery catheter, insertion of peripheral intravenous line, heel stick, and insertion of radial or tibial arterial catheter.[4] 5. Yes, vaccines have a very low risk of side effects that include fever, anaphylaxis, but why not mention that circumcision has resulted in, to list only a few complications, gangrene,[5] amputation of the glans,[6] and death.[7] Also note that if given the choice, most adults would agree to be vaccinated. 6. Sorry, but the urinary tract infection scare took place in the 1980s not the 1940s and 1950s.[8] 7. Sorry, but the data from seven case controlled studies of cervical cancer that showed that circumcised men were less likely to have human papillomavirus (HPV) infection was deeply flawed. You see, in circumcised men with HPV infections over half will only have the virus on the shaft of the penis.[9] The study Patrick cites did not sample the shaft of the penis, so it is likely that more than half of the circumcised men with HPV were missed by not sampling the penile shaft. In a studies where the entire penis is sampled for HPV, no differences are apparent.[9-13] A systematic survey of the literature found the same result.[14] 8. Sorry, just stating that male circumcision is associated with a reduced risk of cervical cancer without giving a reference is not very convincing. If Patrick is referring to the study she cites for HPV infections, then she will be disappointed to find the study, like the many others in the medical literature,[15-27] did not find a statistically significant association. She may have fallen into the old trap of isolating a stratum in which an association had a p-value below .05, but forgetting to perform a Bonferroni adjustment. When the entire medical literature is considered, there is no convincing evidence of an association. 9. Sorry, but all three (not two) randomized clinical trials were stopped early, which only amplified their lead-time bias. These trials were also plagued by attrition bias, length bias, expectation bias (both subjects and investigators), and selection bias. The subjects may also have been financially coerced by being offered a free circumcision, money equivalent to two-weeks worth of employment, unlimited access to free condoms, and free health care for 21 to 24 months. It remains to be seen whether the results can be replicated outside of a research setting with highly motivated subjects. 10. Sorry, I have never heard of a vaccine with 50% efficacy being widely used. Most vaccines are least 85% effective. I also doubt that an HIV vaccine with 50% efficacy would be implemented for fear that a vaccine program would decrease condom usage and undermine safe-sex practices, resulting in an increase in HIV infections. This is also likely to happen if circumcision is promoted as a HIV preventive. 11. Sorry, but India and South Africa do not have the highest prevalence of HIV infection. 12. Sorry, but the number of new cases of HIV peaked in the late 1990s.[28] 13. In the absence of a vaccine, other reasonable weapons are being used. They include aggressive treatment of sexually transmitted diseases (STDs), which is more effective and less expensive then circumcision;[29] condoms, which are more effective and less expensive than circumcision; and changes in sexual mixing patterns, which is more effective and less expensive than circumcision. Should circumcision be considered reasonable when less expensive, less invasive, more effective interventions are already available? How does Patrick define “reasonable”? If circumcision is “reasonable” then why stop there? Why not advocate partial or complete penectomy? It certainly would decrease the number of sexually transmitted cases of HIV, STDs, and unwanted pregnancies. As it stands circumcision is either inadequate or redundant. 14. Sorry, but the birth cohort study from New Zealand represents an anomaly in the medical literature. A birth cohort study from another part of New Zealand found no difference in overall risk of STDs.[30] When the entire medical literature is looked at, most studies found that circumcised men have a greater risk for STDs.[30-40] This may be because urethritis infections are more common in circumcised men and urethritis is most common form of STDs.[41] 15. Sorry, but adequate anesthesia is not available for infants. In studies of topical anesthetics used for infant circumcision there is evidence that the procedure is still painful.[42] To demonstrate that these topical agents provide adequate anesthetic, a trial of circumcision with a topical agent with a control group not being circumcised would need to be performed. To date, no such study has been performed. To provide adequate anesthetic, general anesthetic would be needed. Unfortunately, the risk of general anesthetic for an elective procedure at this age is unacceptable. So this was a sorry argument that begs the question whether the BMJ has fact checkers screen articles before they are printed. Without the medical facts to support the “benefits” theory, there is not much to stand on. Even if there were medical benefits from circumcision that could not be obtained by other less invasive, less expensive, more effective means, Patrick would need to show how these benefits (which don’t exist) outweigh the right to bodily integrity and personal autonomy. So by failing to try to demonstrate this, Patrick simply fails. References: 1. Essén B, Sjöberg N-O, Gudmundsson S, Östergren P-O, Lindqvist PG. No association between female circumcision and prolonged labour: a case control study of immigrant women giving birth in Sweden. Eur J Obstet Gynecol Reprod Biol. 2005; 121: 182-185. 2. Stallings RY, Karugendo E. Female circumcision and HIV infection in Tanzania: for better or for worse?[abstract] Third International AIDS Society Conference on HIV Pathogenesis and Treatment. Rio de Janeiro, July 25-27, 2005. 3. Hammond T. A preliminary poll of men circumcised in infancy or childhood. BJU Int 1999; 83 (suppl 1): 85-92. 4. Porter FL, Wolf CM, Gold J, Lotsoff D, Miller JP. Pain and pain management in newborn infants: a survey of physicians and nurses. Pediatrics 1997; 100: 626-32. 5. Bliss DP, Healy PJ, Waldhausen JHT. Necrotizing fasciitis after Plastibell circumcision. J Pediatr 1997; 131: 459-62. 6. Sherman J, Borer JG, Horowitz M, Glassberg KI. Circumcision: successful glanular reconstruction and survival following traumatic amputation. J Urol 1996; 156: 842-4. 7. Paediatric Death Review Committee: Office of the Chief Coroner of Ontario. Circumcision: a minor procedure? Paediatr Child Health 2007; 12: 311-2. 8. Wiswell TE, Smith FR, Bass JW. Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1985; 75: 901-3. 9. Weaver BA, Feng Q, Holmes KK, Kiviat N, Lee SK, Meyer C, Stern M, Koutsky LA. Evaluation of genital sites and sampling techniques for detection of human papillomavirus DNA in men. J Infect Dis 2004; 189: 677- 85. 10. Aynaud O, Ionesco M, Barrasso R. Penile intraepithelial neoplasia. Specific clinical features correlate with histologic and virologic findings. Cancer 1994; 74: 1762-7. 11. Aynaud O, Piron D, Bijaoui G, Casanova JM. Developmental factors of urethral human papillomavirus lesions: correlation with circumcision. BJU Int 1999; 84: 57-60. 12. Svare EI, Kjaer SK, Worm AM, Osterlind A, Meijer CJ, van den Brule AJ. Risk factors for genital HPV DNA in men resemble those found in women: a study of male attendees at a Danish STD clinic. Sex Transm Infect 2002; 78: 215-8. 13. Shin HR, Franceschi S, Vaccarella S, Roh JW, Ju YH, Oh JK, Kong HJ, Rha SH, Jung SI, Kim JI, Jung KY, van Doorn LJ, Quint W. Prevalence and determinants of genital infection with papillomavirus, in female and male university students in Busan, South Korea. J Infect Dis 2004; 190: 468-76. 14. Van Howe RS. Human papillomavirus and circumcision: A meta- analysis. J Infect 2007; 54: 490-6. 15. Connon AF. Cancer detection survey gynaecological and epidemiological data. Med J Aust 1972; 1: 738-41. 16. Aitken-Swan J, Baird D. Circumcision and cancer of the cervix. Br J Cancer 1965; 19; 217-27. 17. Wahi PN, Luthra UK, Mali S, Mitra AB. Religion and cervical carcinoma in agra. Indian J Cancer 1972; 9: 210-5. 18. Zarkovic G. Alterations of cervical cytology and steroid contraceptive use. Int J Epidemiol 1985; 14: 369-77. 19. Boyd JT, Doll RA. A study of the aetiology of carcinoma of the cervix uteri. Br J Cancer 1964; 18: 419-34. 20. Kjaer SK, de Villiers EM, Dahl C, Engholm G, Bock JE, Vestergaard BF, Lynge E, Jensen OM. Case-control study of risk factors for cervical neoplasia in Denmark. I: Role of the "male factor" in women with one lifetime sexual partner. Int J Cancer 1991; 48: 39-44. 21. Brinton LA, Reeves WC, Brenes MM, Herrero R, Gaitan E, Tenorio F, de Britton RC, Garcia M, Rawls WE. The male factor in the etiology of cervical cancer among sexually monogamous women. Int J Cancer 1989; 44: 199-203. 22. Terris M, Wilson F, Nelson JH Jr. Relation of circumcision to cancer of the cervix. Am J Obstet Gynecol 1973; 117: 1056-66. 23. Agarwal SS, Sehgal A, Sardana S, Kumar A, Luthra UK. Role of male behavior in cervical carcinogenesis among women with one lifetime sexual partner. Cancer 1993; 72: 1666-9. 24. Rotkin ID. Adolescent coitus and cervical cancer: associations of related events with increased risk. Cancer Res 1967; 27: 603-17. 25. Stern E, Dixon WJ. Cancer of the cervix — a biometric approach to etiology. Cancer 1961; 14: 153-60. 26. Kmet J, Damjanovski L, Stucin M, Bonta S, Cakmakov A. Circumcision and carcinoma colli uteri in Macedonia, Yugoslavia. Results From a Field Study. Br J Cancer 1963; 17: 391-9. 27. Jones EG, MacDonald I, Breslow L. A study of epidemiologic factors in carcinoma of the uterine cervix. Am J Obstet Gynecol 1958; 76: 1-10. 28. Chin J. The AIDS Pandemic: The Collision of Epidemiology with Political Correctness. Oxford: Radcliffe Publishing; 2007. 29. Gilson L, Mkanje R, Grosskurth H, Mosha F, Picard J, Gavyole A, Todd J, Mayaud P, Swai R, Fransen L, Mabey D, Mills A, Hayes R. Cost- effectiveness of improved treatment services for sexually transmitted diseases in preventing HIV-1 infection in Mwanza Region, Tanzania. Lancet 1997; 350: 1805-9. 30. Dickson N, van Roode T, Paul C. Herpes simplex virus type 2 status at age 26 is not related to early circumcision in a birth cohort. Sex Transm Dis 2005; 32: 517-9. 31. Aynaud O, Piron D, Bijaoui G, Casanova JM. Developmental factors of urethral human papillomavirus lesions: correlation with circumcision. BJU Int 1999; 84: 57-60. 32. Dave SS, Fenton KA, Mercer CH, Erens B, Wellings K, Johnson AM. Male circumcision in Britain: findings from a national probability sample survey. Sex Transm Infect 2003; 79: 499-500. 33. Diseker RA 3rd, Peterman TA, Kamb ML, et al. Circumcision and STD in the United States: cross sectional and cohort analyses. Sex Transm Infect 2000; 76: 474-9. 34. Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States: prevalence, prophylactic effects, and sexual practice. JAMA 1997; 277: 1052-7. 35. Parker SW, Stewart AJ, Wren MN, Gollow MM, Straton JA. Circumcision and sexually transmissible disease. Med J Aust 1983; 2: 288- 90. 36. Schrek R, Lenowitz H. Etiologic factors in carcinoma of penis. Cancer Research 1947; 7: 180-7. 37. Richters J, Smith AMA, de Visser RO, Grulich AE, Rissel CE. Circumcision in Australia: prevalence and effects on sexual health. Int J STD AIDS 2006; 17: 547-54. 38. Seed J, Allen S, Mertens T, et al. Male circumcision, sexually transmitted disease, and risk of HIV. J Acquir Immune Defic Syndr Hum Retrovirol 1995; 8: 83-90. 39. Taylor PK, Rodin P. Herpes genitalis and circumcision. Br J Vener Dis 1975; 51: 274-7. 40. Urassa M, Todd J, Boerma JT, Hayes R, Isingo R. Male circumcision and susceptibility to HIV infection among men in Tanzania. AIDS 1997; 11: 73-80. 41. Van Howe RS. Genital ulcer disease and sexually transmitted urethritis and circumcision: a meta-analysis. Int J STD AIDS (in press) 42. Lander J, Brady-Fryer B, Metcalfe JB, Nazarali S, Muttitt S. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision: a randomized controlled trial. JAMA 1997; 278: 2157-62. Competing interests: None declared |
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Marwan Daar, Student Centre for Vision Research, Toronto, Canada, M3J 1P3
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A useful way to morally assess male genital cutting (MGC) is to reflect upon the aspects of female genital cutting (FGC) which are deemed minimally sufficient to cause moral outrage, and see whether they map onto MGC. MGC and FGC are certainly not identical. For one, the subjects of the procedure are of different sexes. MGC largely takes place in relatively sterile conditions, using anaesthetic and surgical technologies, while FGC is primarily associated with dangerous circumstances. MGC may offer health benefits that are not to be found with FGC. But let us imagine a procedure, thousands of years old, which involves scraping away the inner walls of the vagina, and trimming down the infant's vulva. Suppose this it has become medicalized, and is done using sterile equipment by trained professionals, and causes little to no pain. Suppose that the resulting scar tissue and loss of delicate mucosal surfaces renders the female significantly less likely to transmit and receive infectious pathogens, including HIV. Furthermore, suppose the risks of the procedure are of little significance. Imagine this procedure has taken place for thousands of years, and is an important cultural aspect, and a source of pride in the millions of women which undergo it. They consider an intact vulva to be a dirty and ugly object in need of trimming. Very few women complain about it, and much of the sexual research done, which largely involves verbal self report, doesn't show any consistent loss of sexual function. In order to be consistent, Ms. Patrick would have to concede that such a procedure is not an abuse of human rights. Others would disagree. They would claim that it is very hard to objectively measure the sexual effects of the procedure, and until physiologic measures are taken (such as measuring the strength of a cut woman's sexual response via measures such as changes in blood pressure, skin conductance, heart rate, strength and duration of orgasmic contractions, and release of hormones associated with orgasm), it would be foolish to rely on verbal self reports, which are extremely limited in their methodological power. Instead, they would argue, there is a prima facie case to be made that the removal of erogenous tissue decreases the range of sexual sensation, and that it is better to err on the side of caution and assume that it is sexually detrimental, regardless of what the vast majority of cut woman claim. They would appeal to the sound judgement that the removal of sexual tissue from a nonconsenting female, unless absolutely medically necessary, is fundamentally horrifying. The step that many have not yet taken is to understand that it is fundamentally horrifying to do so from a nonconsenting human, female or male. Competing interests: None declared |
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Joel .O AKANDE, Director (Company) . NHS: Staff Grade Chichester CRT. PO19 6GS
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Just to add my view that this argument about male circumcision is largely a distraction.
1) I was circumcised . My parents did it in the traditional African way—knife sterilised in red hot flame that is allowed to cool down. I am glad they did. I am free of hanging skin folds as an adult and more so free from balanitis and the likes. 2) Now in the UK, I have had my two boys circumcised. I am glad I did. In addition to the above, they look tidy and easy to manage, free from potential viral, fungal and bacterial infections that I may have to worry about if it had been otherwise. 3) Evidence by UN and other researchers have now proven the huge benefits of this procedure-- at least in Africa. Guess what? It is a prevention against AIDS/HIV. I do not care what the mechanism is, the fact is that it helps. 4) As a practitioner in my early days in Nigeria, I saw and had many of circumcisions done. The parents were often very happy. Regardless of what we may now conclude, we are not going to stop them or future generations. It has huge religious (Christian-Jewish) values 5) There are now simple products in the market to aid the procedure to reduce bleeding, infection and effects on urethra. If carefully done and if there is no history of bleeding in the family, there is no contra-indication for this procedure. 6) I guess the fear in the West is not knowing what to do with the foreskin. If I were a girl, I have wondered, I would have my boy friend circumcised! Joel AKANDE Competing interests: None declared |
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Marion Drage, Cataloguer NYU 10011
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Whether a family chooses to circumcise a child or not should be a matter of informed consent. I don't know th e protocols in the U.K. but in the United States parents must sign a consent form for a circumcision. I was shocked to learn that many of my co-workers didn't understand why the consent form was require because, they believed, circumcision was required by law! They got this idea because doctors tell them it is a law, and the doctors get quite hostile if you refuse this procedure or, even worse, tell them it isn't a law. My lover is NOT circumcised and I think he looks just fine the way nature made him. I would NEVER have it done on a son of mine. INFORMED CONSENT people! Competing interests: None declared |
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Scot Anderson, Physicist Clear Creek Eng. 90433 (USA)
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I am glad to know that I am anecdotal and retrospective and therefore can not enter into the debate as someone who feels their human rights were violated. Violated by the very people charged with my care. I, as a practicing physicist, am very used to interpreting and understanding data and the use of statistics to tease subtleties out of that data. When the conclusions are not clear, when there is doubt, SCIENCE not culture or religion, MUST accept the conservative hypothesis – we do not know and therefore can not make a statement. This is mirrored in the Hippocratic Oath to first do no harm – ie. Your patients are not to be subjects of experiment and treatment must be as conservative as possible and yet be effective. Circumcision is not the most conservative treatment for any of the ills it supposedly prevents; it is surgical amputation, no doctor would cut off a foot or a hand with the rapidity or arrogant self assurance that many amputate a foreskin. The data collected and published in this Journal about penile sensitivity follows from experiment directly measuring a physical quantity – the gold standard of scientific endeavor. There are no better data to be had; all other methods establish a causal relationship through statistical inference where errors and bias do creep in, especially in unblinded studies. The penile sensitivity data are partially verified by Clifford Blustein, Masters & Johnson and others who all found little or no decrease in sensitivity of the glans in intact and cut men. This is exactly what Sorrels et. al. found, little or no difference. What failed to get the attention it deserved is that the frenar band, always amputated during circumcision is 12X more sensitive than the glans. None of the other studies measured this. There can be NO DOUBT this constitutes harm. Guesses at what an individual may do as an adult, statistical studies about groups of men can not substitute for the fact that the individual is harmed by infant circumcision and therefore paying a price he did not accept for behavior he most likely will not engage in. Harm in this case is that we are all diminished by capricious amputations, how we react is a matter of personal choice. My final word is that you can not protect your rights by taking away those of another. You can not protect girls from circumcision (excision of the female prepuce) or the other more destructive genital surgeries if you do not protect boys too. The very same cultural and religious arguments can and will be applied to infant girls to justify their congruent amputations. There are even medical studies showing the benefits of female circumcision, we of course, being western are far too sophisticated to base radical amputative surgeries on such statistical studies – or are we? Scot Anderson Competing interests: None declared |
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Scot Anderson, Physicist Ckear Creek Eng, 90433
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Oops. Got the journal wrong, the Sorrels study was in British Journal of Urology, April 2007, not BMJ. My most humble appologies to both. Scot Anderson Competing interests: None declared |
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