Circumcision in Boys: Time for Doctors to Reconsider

Circumcision in boys is often - in analogy with that in girls - referred to as male genital mutilation. MGM, as it deals with the removal of part of an organ which has a highly specialized function. This term will be used here along with circumcision.

Circumcision of boys is performed on a large scale basically in the following four categories. The figures are very approximate , based on fertility rates in the respective population groups (UNICEF: State of the world's children, 2002) and assuming a circumcision rate of 80% (except for the USA where the figures can be given reasonably exact).

While the literature on neonatal circumcision in the Anglo-Saxon countries is indeed abundant it is remarkable how little is known and reported from the other target groups on this operation which must be the most frequently reported in the world.

Background

Circumcision may be dated back some 5000 years when it seems to have been practiced in Egypt. Cave paintings indicate that it was done in adults and according to historical sources¹ the operation was not done universally but was limited to high officials. The custom slowly spread from there around the Mediterrean sea.

According to Genesis 1:17 in the Old Testament (some 3000 years back) Abraham got a relevation from God with the content that the two should enter into a Covenant. The provision was that Abraham should circumcise himself ( 99 years as he was ) and all his male house. As a result he should get plenty of offsprings and become the ruler of large countries. Also his wife Sarah, 90 years, and so far barren should become pregnant and give birth to a child (which became Isaak, who is considered to be the distant origin of the prophet Mohamed who lived more than 2000 years later). Ever since, circumcision has been one of the cornerstones in the Jewish tradition, although the custom in recent years has become more of an ethnic marker and is much less rigidly upheld than it used to be².

The Moslem circumcision dates back to the time of Mohamed at the 7^th century. It is not mentioned in the Quran and is thereby not a Moslem dictum. However, in the explanations and comments to be Quran dating back the 7-8^th century, statements are made from which it may be possible to conclude that a true Moslem should be circumcised. However, as with the Jewish circumcision, it has become more of an ethnic marker than a religious must.

The origin and purpose of the MGM in the traditional African context is lost in a historical mist. In the traditional society the operation is performed prior to puberty as an initation rite -the boy has now entered into adult life. In a more urban life style the operation may be performed earlier. Again, it is a deeply rooted tradition which seems to have become also something of an ethnic marker.

The neonatal Angl-saxon circumcision was introduced some 150 years ago as a prophylaxis and treatment for masturbation. Little by little nearly hundred other conditions and ailments were added, ranging from epilepsy to asthmas to rheumatism- indeed a strange range and variety³.

The foreskin

Up to the 7th fetal week the male and the female genitals are identical. Thereafter the male hormones initiate the development of the male genitals.In the 12th week the prepuce is formed as a double pleat of skin which grows down to cover the glans. The inner layer of the prepuce and glans remain loosely attached until about 4 - 5 years and can only be separated by an instrument (which is done at circumcision).

The inner layer of the prepuce and the glans remain loosely attached until about 4 - 5 years and can only be separated by an instrument (which is done at circumcision).

The inner layer of the prepuce has a ridged band which contains large numbers of nerve endings mediating low threshold and fine touch sensations. This ridged band area starts at the frenulum (the frenulum band) and will be turned inside out when penis is erect, thus forming a highly sensitive structure during intercourse. In the same area there is an extensive plexus of venules and capillaries. Also a layer of smooth muscles bundles are oriented toward the tip of the prepuce forming a kind of sphincter which tends to close the orifice when penis is flaccid, preventing urine, sand etc from gaining access to the preputial space.

Thus the prepuce is a highly delicate organ with very specialized functions and is not just a piece of skin⁴.

The question of medical benefits

It is not possible to find out why circumcision was first introduced, whether it had to do with clearliness or with fertility or it was simply a ritual phenomenon intended to give a marker.

The medical literature dealing with Moslem and the traditional African circumcision is indeed scanty, except for occasional articles which are focusing on complications e.g. from South Africa.

There is, however, an abundant literature particularly from the USA on pros and cons regarding the neonatal circumcision. An article in the Lancet in 1932⁵ claimed that circumcision should prevent cancer of the penis in adult age. Later an overwhelming number of studies have shown that this is not the case.⁶, nor that cancer of the cervix in the partner should be less common. Other factors such as early sexual debut, many partners, papilloma virus and smoking seem to be decisive.

There seems to be a higher rate of urinary tract infection during the first few weeks in those who are intact but the difference is small. A Canadian study has concluded that it would need 195 circumcisions to prevent one admission to hospital for urinary tract infection⁷.

Lately a number of studies have claimed that the risk for contracting HIV should be lower in those who were circumcised.¹ However, conclusive evidence is still lacking, the studies have been made in African settings where it may be difficult to rule out confounding factors related to environment and lifestyle.

A number of pediatric, surgical and obstetric professional societies in the US, in Canada, England and Australia all have made statements similar to that of the American Academy of Pediatrics (AAP) namely that these data (scientific data demonstrating potential medical benefits) are not sufficient to recommend routine neonatal circumcision⁶.

Complications

Circumcision is considered to be a minor operation particularly when performed in the neonatal period and with due surgical precautions. Nevertheless the total complication rate has been found in different complications to range between 2-10%⁹. Mainly, it concerns bleedings and postoperative infections. But a review is made through 184 scientific articles (Circumcision and resource pages, CIRP, Internet home page.) lists in addition: septicemia, urinary retention, ulceration of the meatus leading to stenosis, urethra fistulas, necrosis and gangrena of the glans, amputation, and psychological sequele.

The complication rates following the circumcisions made in the traditional societies by village barbers and similar is probably considerably higher and more severe.

In addition complications from anesthesia when used may occur. Thus several deaths and near deaths have occurred in Sweden in recent years as a result of incompetent handling and overdosage of anesthesia and pain relievers¹⁰.

The long term complications are only little known. Few people are prepared to discuss their genital problems publically. Removal of too much of the prepuce up including part of the penile shaft skin has been reported repeated to cause erectile difficulties, pains and severe sexual relation problems.¹⁰.

A different long term problem relates to the fact that the circumcised penis is a (religious) marker which the victim may not necessarily appreciate. He may not wish as an adult to associate to the faith of his parents.

A number of mutilated cases have been brought to court recently mainly in the US where the doctor has been sued and sentenced to pay fines of up to 1.5 million dollars¹².

Trends

As was mentioned in the beginning a review of all forms of mutilation and circumcision is about to be made as part of the implementation of the Convention on the Rights of the Child. This is still to come about. The topic is sensitive as it concerns areas of tradition and religion which by many are considered untouchable. However, it concerns the well -being of the child.

The child has no voice and no say!

In Sweden recently there have been a number of court cases where the (Moslem) father has had the circumcision done on the son without the knowledge of or consent from the (non-Moslem) mother. Such cases are bound to become more common in times when there are more mixed marriages. However, in countries like Israel and in many Moslem countries this kind of dilution will take very long time. In Sweden, however, with some 20.000 persons who are stated by Jewish society to be included as Jews, only approximately 40 % of their boys are being circumcised, the remaining supposedly considering the operation dangerous, unnecessary ( as a religious marker) or of no importance¹⁰.

In the Anglo-Saxon countries there is a definite downward trend. In the US there was a peak of some 90 % circumcision in the 1960s. It has now fallen to about 57 % In England it is less than 5 % , partly because the operation is no longer paid by the NHS. The same trends are seen in Canada, New Zealand, and Australia¹³.

A new law

In Sweden a law has been passed by the Parliament (in 2001) intended to regulate circumcisions (about 3000) a year, nearly all Moslem, only about 40 Jewish boys). The first 2 months a Jewish mohel may perform the operation but with a doctor (or nurse) present to give the anesthesia which is now obligatory. The Board of Health has issued detailed instructions on what and how. After 2 months there has to be a doctor to do the operation after informed consent. Inspections made recently by the Board indicates that the mohels are not abiding by the Boards instructions on anesthesia and that boys up to 4 months are being circumcised, which is against the law¹⁰.

Conclusions

Female genital mutilation continues by the hundreds of thousands in many African countries (and among migrants to the US and the Europe!) in spite of strong reactions from the UN and the international community, not least from Women's organizations that is not compatible with the Child Convention.

Male genital mutilation which is performed on 100 times more victims has attracted much less attention and interest although this operation should also be listed as incompatible with the Child Convention. It is time for this medically unnecessary operation to be brought out into the light and scrutinized.

We as doctors have a clear responsibility to take a lead to start combating this medieval and brutal rite some of which may have had a religious origin but which is now much more to give an ethnic marker and a social happening. If anything it should be postponed to the late teens when the child may decide for himself. Or be transformed to a non-surgical symbolic rite.

It should be pointed out also that the tradition continues much due to strong economic incentives. It gives a good pay to be a circumciser either you be a doctor in the US or a barber in Africa! In the US some 400 dollars for a few minutes work!

Sometimes you feel ashamed of belonging to the profession!

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