Medical aspects of male circumcision
BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39385.382708.AD (Published 06 December 2007) Cite this as: BMJ 2007;335:1206
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It is generally agreed among Paediatric Surgeons that Balanitis
Xerotica Obliterans (BXO) is the only absolute medical indication for male
circumcision.
Most of the Primary Care Trusts (PCT) across UK stopped funding for
cultural circumcisions. Lot of babies end up being circumcised in
community by individuals not properly trained. The National Health Service
(NHS) have to put up with their complications, the cost of which I think
is significant.
The babies circumcised in the community receive a dorsal penile block
which I think is cruel. The cost of circumcision under general
anaesthetics as a private patient is around £1500 which is beyond the
reach of many.
Competing interests:
None declared
Competing interests: No competing interests
The authors of this clinical review have undertaken the important
task of educating BMJ readers about male circumcision and they have
provided much valuable information. However, the article is somewhat
misleading and omitted some important information:
1) In the summary points, the authors stated that “Controversy
continues about the health risks of preserving an intact foreskin because
of lack of evidence and of clear randomised trials.” Although
circumcision should be only one component of an AIDS-prevention strategy,
there is no longer any serious controversy about the protection that
circumcision provides to HIV-negative men at risk of heterosexual
acquisition of HIV. The authors did not cite a third randomized trial
that was conducted in the Republic of South Africa (Auvert, 2005), nor did
they cite the joint WHO/ UNAIDS expert meeting in March 2007 (WHO/UNAIDS,
2007) where it was recommended that “…male circumcision [should] now be
recognized as an additional important intervention to reduce the risk of
heterosexually acquired HIV infection in men.”
2) The authors neglected to mention the value of the perinatal
administration of vitamin K for preventing bleeding after circumcisions of
newborns. Vitamin K is routinely given in most developed countries to
prevent early vitamin K deficiency bleeding of the newborn (also known as
hemorrhagic disease of the newborn), occurring from birth to 2 weeks of
age. An additional benefit of vitamin K is that it significantly reduces
bleeding and related complications from circumcisions performed shortly
after birth (Vietti, 1960). In developed countries, vitamin K is usually
given to newborns immediately after birth, either intramuscularly or
orally. For more information on vitamin K administration to newborns, see
the American Academy of Pediatrics’ policy (AAP, 2003) or the Cochrane
review of this subject (Puckett, 2000). While it is probably the policy in
most developing countries to give vitamin K to all newborns, it is likely
that a smaller proportion of infants in developing countries than in
developed countries actually receive vitamin K.
3) The title implies a general review of male circumcision, but the
authors do not discuss adult circumcision. The WHO has drafted a useful
training manual with guidance on the most common surgical techniques for
adult circumcision (WHO/UNAIDS/JHPIEGO, 2006). Adult circumcision is
significantly more difficult than infant circumcision.
References:
Auvert, B.; Taljaard, D.; Lagarde, E.; Sobngwi-Tambekou, J.; Sitta,
R., and Puren, A. Randomized, controlled intervention trial of male
circumcision for reduction of HIV infection risk: the ANRS 1265 Trial.
PLoS Med. 2005 Nov; 2(11):e298.
WHO/UNAIDS. Who and Unaids Announce Recommendations from Expert
Meeting on Male Circumcision for HIV Prevention. Press release, Paris, 28
March 2007, available at:
http://data.unaids.org/pub/PressRelease/2007/20070328_pr_mc_recommendati...
Vietti, T. J.; Murphy, T. P.; James, J. A., and Pritchard, J. A.
Observations on the prophylactic use of vitamin K in the newborn infant. J
Pediatr. 1960 Mar; 56:343-6.
AAP. Controversies concerning vitamin K and the newborn. American
Academy of Pediatrics Committee on Fetus and Newborn. Pediatrics. 2003
Jul; 112(1 Pt 1):191-2. Available at:
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;112/1/191.
Puckett, R. M. and Offringa, M. Prophylactic vitamin K for vitamin K
deficiency bleeding in neonates. Cochrane Database Syst Rev. 2000;
(4):CD002776, available at:
http://www.nichd.nih.gov/cochrane/Puckett/Review.htm.
WHO, UNAIDS, JHPIEGO. Manual for Male Circumcision with Local
Anaesthesia, 2006 (draft v2.2)
Competing interests:
None declared
Competing interests: No competing interests
While debating the relative merits of circumcision, it is very
important to acknowledge that DEATH is a rare but nasty side effect that
was not mentioned in the review article and which still occurs despite the
procedure being performed by competent physicians. In Canada there have
been 2 deaths of infants following circumcision in the past 5 years - one
in Ontario and one in British Columbia. It is worth noting that there are numerous cases of deaths following ritual circumcisions in South Africa each year - see this report from the BBC http://news.bbc.co.uk/2/hi/africa/3069491.stm
To try to justify
routine circumcision as an HIV prevention strategy in countries such as
Canada or Great Britain with low HIV prevalence is ill-advised and
dangerous, as the cost will be death for some infants who will die to
avoid a theoretical risk in the distant future. Primum non nocere
Paul Thiessen
Clinical Professor
Department of Pediatrics,
University of British Columbia,
Vancouver, B.C., Canada
Competing interests:
None declared
Competing interests: No competing interests
The Kenyan writer Ngugi Wa Thiongo, in his land mark novel The River
Between on the Kikuyu tribal ritual of circumcision (both male and
female), in the 1960s highlighted that any medical centred discussions on
the pros/cons of circumcision that the christian missionary hospitals and
doctors introduced into the Kenyan tribes of 1950s failed because it did
not appreciate the anthropological, cultural and social impact of the
practice on the psychology and mental well being of the person being
circumcised.
So it is that 50 years on we are at the same gates and discussing the
issues in the same vein as the missionary doctors. Even those recommending
that the practice should carry on through safe methods of "clinical and
painfree" circumscison have failed to appreciate that it is not the
foreskin/labia on or off that is the main concern but the depth and impact
of the practice on the mental health and well being of a person when
carried out in coming of age, bonding to a "kiri" (age-group) or even
attaining "warrior -moran" status (masaai tribes) that is the real issue
here.
Like the tragic heroine Muthoni of Ngugi's book, many a child will be
torn between the two worlds leading to psychological problems if the do or
don't circumcise.
We need this debate to be carried out in conjunction with community
leaders and other disciplines. That is the true head to head.
Competing interests:
None declared
Competing interests: No competing interests
Padraig Mallone and Henrik Steinbrecher's comprehensive article [1] interested me very much. Based purely on tribal and geographical epidemiology I was able in the early stages of the AIDS pandemic to gather much information just by asking the questions Who? Where? Which? How? When? What? and Why? as I travelled the length and breadth of Africa to study the AIDS phenomenon at the grassroots. I was indeed the first ever to suggest there needed to be research into whether there might be an association with male uncircumcision or circumcision: "In other tribes in Africa where AIDS has proceeded from the introduction phase to the propagation phase and men have developed the disease" I said, "data need to be collected on circumcision state..." [2].
It is a known fact that in west Africa more than 70% of tribes circumcise their males and the rest forbid the practice, while the reverse is the case in east and central Africa - more do not practise circumcision than do [3]. I suggested that the inordinately greater AIDS burden in East/Central Africa could be related to the paucity of circumcised men in that region [4]. There was then hardly any AIDS in South Africa.
I have had patients who, hearing about the 'rumour' that circumcision was beneficial sought where this could be performed quietly outside the tribe "against custom". Coming back to HIV and circumcision, I have advised not a few, that they should not rely on 'rumours' to dictate their sexual behaviour and that they should not tafracher, tafracher [5] push their phallic luck too far lest they get AIDS. However, as it is becoming increasingly clear in Africa, sex is not the only thing spreading HIV/AIDS on the continent.
But I get back to the front cover splash of this week's BMJ which asked whether circumcision was right or wrong. The question itself is wrong, surely. I myself was circumcised because all males of the Krobo tribe must be circumcised. The traditional healer of the tribe knew about haemostasis with herbs and I understand I hardly bled after he used the blade which he had sterilized in a flame. A few miles from my tribe beyond the Akwapim hills males must not be circumcised. Who is to say the Krobos are right or wrong, and the Akwapims wrong or right? Was godly Abraham wrong in circumcising Isaac?
Scientific and medical "proofs" are often the exhibition of hidden prejudices, notwithstanding chi-squares and p-values!
I declare that I have no competing interest.
1 Malone P, Steinbrecher H. Medical Aspects of male circumcision. BMJ 2007; 335:1206-1209. (December 8)
2 Konotey-Ahulu FID. Clinical epidemiology, not seroepidemiology, is the answer to Africa's AIDS problem. BMJ 1987; 294: 1589-1594.
3 Konotey-Ahulu FID. Some thirty features of AIDS in Africa. Annales universitaires des sciences de la sante 1987; 4: 541-544.
4 Konotey-Ahulu FID. What Is AIDS? Watford 1989 Tetteh-A'Domeno Co, pages 47, 50, 92, 165.
5 Konotey-Ahulu FID. Tafracher (Personal View - An invaluable Ghanaian devulgarizing word) BMJ 1975, February 8, p 329
Competing interests:
None declared
Competing interests: No competing interests
Malone and Steinbrecher’s¹ thoughtful and detailed review of
circumcision will provide an authoritative guide for medical practitioners
and parents. However there is still reluctance by surgeons to approach
Balanitis xerotica obliterans (BXO) on a multidisciplinary basis. This
disorder is histologically indistinguishable from Lichen sclerosus et
atrophicus which dermatologists treat successfully with topical steroids.
Of course phimosis prevents access for this treatment. The report from
Sheffield² of 17 cases (now extended to over three times that number³)
shows that BXO can be treated by preputioplasty and submucosal injection
of the depot steroid triamcinolone. I have confirmed the success of this
work in 11 cases aged between 6 and 11 with histological confirmation of
BXO. Follow up at 6 months showed no clinical evidence of the disease and
a fully retractable foreskin and some loss of pigmentation in a few
patients as the only residual abnormality.
This treatment should be offered where parents prefer their son to
remain uncircumcised, and clinical and histological details should be kept
for future review. This should tell us whether successfully treated BXO
in childhood continues to be a risk factor for penile cancer.
¹ Malone P, Steinbrecher S. Medical aspects of male circumcision.
BMJ 2007;335; 1206-9. (8 December)
² Godbole P, MacKinnon A E, BXO – don’t cut it off! Ann R Coll Surg Engl
2003;85;287
³ MacKinnon A E, (Personal communication)
Competing interests:
None declared
Competing interests: No competing interests
One situation where circumcision is clearly beneficial is infants
with vesicoureteric reflux (VUR). Those with milder grades of VUR (I-III)
may be subjected to this procedure to prevent urinary tract infection
(UTI). This may preclude antimicrobial chemoprophylaxis. Such infants
could be managed with general measures and UTI surveillance.
Competing interests:
None declared
Competing interests: No competing interests
Re: Medical aspects of male circumcision
Are there general neurological effects? Medieval writers do mention calming effects, and would not removing a very significant number of nerves from an infant change brain development, and possibly change development of other systems, for example, balance?
Competing interests: No competing interests