Whither The Foreskin?

A Consideration of Routine Neonatal Circumcision

Complications

Complications of circumcision may be regarded as immediate or delayed. The immediate complications fall into three categories: hemorrhage, infection, and surgical trauma.¹⁴ Hemorrhage is the most common of these immediate complications. It may be caused by inadequate hemostasis, blood coagulapathies, or the existence of anomalous vessels.¹⁵ Patel¹⁶ studied 100 consecutive male infants who were circumcised at birth and who were reevaluated 6 to 18 months later. He found 35 instances of hemorrhage of which four required sutures.

Infection of the wound in circumcision is also a fairly common complication. It is manifested by local inflammatory changes, ulceration, and suppuration.¹⁵ Occasionally infection may lead to more serious complications such as partial necrosis of the penis, or it may be a source of septicemia. Shulman et al¹⁵ have recorded a case of staphylococcal septicemia giving rise to osteomyletis of the femur, and a fatal case of septicemia and pulmonary abscesses, both of which were ascribed to infection of circumcision wounds.

A common complication of circumcision is loss of penile skin. This can result from pulling too much of the skin from the shaft up over the glans during the operation. The remaining skin slides back, leaving a denuded penile shaft. Major losses of penile skin usually occur, however, because of a complicating infection, the use of the electocautery, or improper surgical technique. Van Duyn and Warr¹⁷ reported a case of routine circumcision, performed by an experienced, competent pediatrician with use of a circumcision clamp, that resulted in wound dehiscence and required replacement by split skin grafting.

Additional complications include accidental lacerations of penile or scrotal skin, or both, incomplete circumcision with formation of adhesions and secondary penile deformity, and accidental amputation of the glans with secondary postoperative hemorrhage, and retraction of the penis into a subcutaneous position by contraction, healing, and fibrosis of the circular wound.^1,15,18

Delayed complications of circumcision are related to the newly circumcised penis being in frequent and prolonged contact with feces and ammoniacal urine. One could logically expect the de-epitheialized, edematous, bleeding glans to become inflamed, bruised, or infected, with subsequent development of fibrosis and scarring.

Meatal stenosis, with its symptoms of dysuria, increased urinary frequency, and enuresis, is not related either to the method of circumcision or to the skill with which it is performed as it is a late complication.¹ The appearance of this condition indicates the fallacy of the argument that boys should be circumcised at birth so they will have no trouble in later life. In Patel's series of 100 newborn circumcised boys who were examined 6 to 18 months later, 31 had developed meatal ulcers, 8 had meatal stenosis, 1 had phimosis (!) and 8 developed infections.

Delayed complications of circumcisions may not only be anatomic; they may also be psychologic. Settlage¹⁹ has stated, Concern for the psychologic development and future health of the child requires that events in the neonatal as well as any later stage of development be managed in such as a way as to keep tension in the child within tolerable limits. One cannot argue that structure and functions are intimately related, and at the same time shrug off with equanimity the fretful, circumcised newborn, his glans swollen and cyanotic for three to five days.

Is Circumcision Necessary?

It is interesting to note that all of the reasons advanced for routine circumcision have to do the prevention of certain conditions, not with the establishment of a condition such as strong teeth and bones or a normal cardiac reserve. Robertson²⁰ has stated: Avoidance of harm is not to be equated with provision of benefit; just because it doesn't kill, that doesn't mean it helps.

One of the reasons advanced for routine neonatal circumcision is the prevention of phimosis. Actually the presence of phimosis cannot be determined at birth because histologically the prepuce is still developing at this time and its separation is usually incomplete.^18,21 McKay²² has observed: The prepuce of the newborn infant is normally so tight and adherent that no information can be obtained as to later need for circumcision.

At birth only 4% of boys have a fully retractable foreskin; ; at 6 months of age, 15%; at one year of age 50%, and it is not until the age of 3 that 90% of boys have a completely retractable prepuce.²³ To diagnose phimosis one must find not only a nonretractable foreskin, but a small preputial opening. Ballooning of the prepuce occurs on micturation.

Recurrent infection under a non-retractable foreskin in an older child seems a more legitimate reason for recommending operation to allow drainage. The fortunate rarity of this condition is possibly the result of the persisting attachment of the prepuce to the glans.¹

Balanitis is uncommon in childhood when the prepuce is performing its protective function; in the circumcised penis the incidence of meatal ulcers is significantly increased precisely because the glans is deprived of the protection of the foreskin.^1,18,21,24 Most cases described as balanitis are nothing more than inflammation of the skin of the prepuce, which is usually due to ammonia dermititis from ammoniacal urine and circumcision is strongly contraindicated. In these cases the foreskin is carrying out its prime function of protecting the underlying glans;^{1,12,18,21,24,25} if it is removed, a meatal ulcer due to the ammonia will almost certainly result.²⁵

As to the argument that circumcision is of value in preventing the accumulation of venereal disease, Morgan²⁶ has observed:

Venereal disease is more prevalent in the lower socioeconomic groups and these are the groups that are most likely to be uncircumcised. They are also the groups in which there is a poor standard of personal hygiene. The lower socioeconomic groups are also those with a higher incidence of tuberculosis but one could be excused for doubting that the retention of the prepuce renders one more susceptible to tuberculosis. Post hoc ergo propter hoc is invalid logic.

Herskowitz²¹ has noted that Spock's⁹ argument that circumcision helps a boy to feel regular is cultural, and wonders if Spock would favor circumcision of the clitoris in a society where that is the usual practice. It is the duty of the medical profession to lead rather than follow a community's standards of health care.

Different opinions exist as to the importance of the foreskin in the act of coitus. On the one hand is Morgan's¹⁸ assertion that coitus without a foreskin is comparable to viewing a Renoir while colorblind due to the prepuce lubricating the glans and permitting easier penetration. On the other is the statement that after circumcision the glans becomes less sensitive, resulting in a more delayed orgasm, and this a lessening of premature ejaculation. Goodwin¹³ quoted a patient discussing delayed orgasm as prostatectomy as saying, It takes about 15 minutes longer, doctor, but we don't begrudge a moment of it.

As to the argument that the circumcised penis is more esthetic, one is reminded that beauty is in the eye of the beholder, and that most Renaissance works of are show the male organ, if not with a fig leaf, at least with a foreskin. Morgan²⁷ noted:

Perhaps why American mothers seem to endorse the operation with such enthusiasm is the fact that it is one way an intensely matriarchal society can permanently influence the physical characteristics of its males,

and concluded:

the argument is also put forth that the circumcised organ is more hygienic for the prepuce collects nasty secretions. So does the ear, but the removal of this rather ugly appendage is frowned upon, and in one famous instance cutting it off lead to war - the so-called war of Captain Jenkin's ear. One can be grateful that this worthy mariner did not lose his prepuce under similar circumstances, for it is rather likely the battle would still be raging.¹⁸

Circumcision and Cancer of the Cervix

Circumcision is only one of a large number of variables, many of them interrelated, which cannot be considered separately in epidemiologic studies of the etiology of cancer of the cervix. Factors known to be associated with a high degree of risk of developing cervical cancer include low socioeconomic status, early marriage, multiple marriages, extramarital relations, coitus at an early age, nonuse of contraceptives, syphilis, and multiparity.²⁸

In 1932, Hanley⁴ found only three cases of cancer among 90,000 Fijians who practice male circumcision at birth, but he found 26 cases among 70,000 Hindus who do not practice circumcision. The two populations live side by side but do not intermingle.

New data²⁹ from Fiji 25 years later, however indicated that natives of Fiji have a lower incidence of cancer in general, whereas the immigrant Hindus have a much higher incidence of cancer of all sorts. Also, while nearly 100% of the Fijians were circumcised in contrast to only 25% of the Hindus, there were 55 cases of the former with cancer of the cervix and only 101 of the latter, a ratio of 1:2 instead of the 1:9 of 25 years earlier. Perhaps this reflects improved methods on cancer detection developed over the intervening years, but in any case the data no longer retain their original significance.

Circumcision probably improves the hygienic status of the penis in circumstances where a low standard of hygiene would otherwise prevail. Kmet's³⁰ group studied circumcised orthodox Moslems, circumcised emancipated Moslems, and uncircumcised non-Moslems in Yugoslavia. They found premalignant lesions of the cervix to be 11 per 1,000 in the uncircumcised non-Moslems, 5.5 per 1,000 in the circumcised emancipated Moslems, and nil in the circumcised orthodox Moslems. This would indicate circumcision to be of questionable benefit in protecting women who live in cultures not adhering to religious rules regarding sexual hygiene, promiscuity, and genital cleanliness. A possible weakness in Kmet's study is that they were unable to obtain any data regarding the percent distribution of the circumcised males or the types of prepuces present in the uncircumcised.

Aitken-Swan and Baird's³¹ group of 54 husbands whose wives had pre-clinical and clinical cancer of the cervix included 12 who were completely and 10 who were partly circumcised, compared with 56 husbands whose wives were in a control group, of whom 14 were completely and 14 partly circumcised. Thus complete circumcision was found about as frequently in husbands of patients with cancer as in husbands of controls.

Boyd and Doll³² found the discovery rate for cancer of the cervix among non-Jewish women whose marital partners were circumcised to be no different from the rate among non-Jewish women with circumcised husbands. Jones et al³³ found the incidence of cancer of the cervix not to be related to the absence of circumcision in the spouse or other sexual partners. Circumcision was as common among the husbands of a group of women with certain cervical cancer as among husbands of a control group of women.

Khanolkar³⁴ found the cervix to be the site of origin of cancer more frequently in Moslem than in Parsee women with cancer, although the husbands of the former are circumcised and the those of the latter are not. The Parsees on the other hand, attach much greater importance to cleanliness. Additionally, Elliot³⁵ found English wives at the lower end of the socioeconomic scale to have a liability to cancer of the cervix more than ten times greaterthan those at the top.

Lack of circumcision supposedly leads to the accumulation of smegma beneath the prepuce^5,6 and smegma has been thought to be a carcinogenic substance.^2,6 If this were the case one would expect to find a difference in the rate of discovery of malignant and premalignant lesions of the cervix between groups not using such an obstructive form.

In support of such a theory, Boyd and Doll³² found that fewer patients than controls had used obstructive methods of contraception, and Baird and Aitken-Swan³¹ found that fewer patients than controls had ever used or predominantly used a sheath or cap contraceptive. Of 54 patients with cancer of the cervix, 13% had used an obstructive contraceptive as opposed to 43% of 56 controls. Stern and Nealy,³⁶ however discovered that the use of a sheath contraceptive by the marital partner was not to be associated with rate differences for cancer of the cervix betweenpatient and control groups.

To determine whether smegma is indeed carcinogenic, Heins, in a study reported by Weiss,²⁹ inoculated monkeys through the vagina one to two times weekly for three years with raw human smegma and was unable to produce any cancers of the cervix or vagina. Additionally, Fishman's³⁷ group injected smegma from old men into the vaginas of mice two to three times weekly for 12 months and was unable to stimulate the production of genital cancers, although inoculation of similar animals with a known carcinogen regularly produced vaginal cancers.

Dodge's⁷ investigations in Kenya have revealed not significant differences between the numbers of cervical cancer cases in women of tribe who men were or were not circumcised. He concluded: The tribal distribution of cases does not seem in any way related to the practice of circumcision among the tribal males ... thus it seems the role of smegma in the genesis of cervical cancer is of little importance.³⁵

Lack of circumcision as a possible etiology for cancer of the cervix received attention from Gagnon's³⁹ being unable to find a single case of cervical carcinoma among 13,000 Catholic nuns over a 20-year period. This has lead to the idea that since Catholic nuns do not have intercourse with uncircumcised men, a lower rate of cervical cancer would obtain in those cultures where circumcision is performed.

Seemingly overlooked is the idea that Catholic nuns do not have intercourse with circumcised men either. It would appear that the decisive factor in the nuns' freedom from cervical cancer is related not to the presence or absence of the foreskin but to the absence of sexual relations.

In 1964, Reid⁴⁰ suggested that penetration of the epithelium by spermatozoa could initiate the process leading to cancer, and that an obstructive contraceptive would lessen the cancer risk by preventing spermatozoa from reaching the squamous epithelium. Boyd and Doll's³² and Baird and Aitken-Swans³¹ findings in this regard and Gagnon's³⁹ data from the Catholic nuns would seem to support this proposal.

Circumcision and Carcinoma of the Penis

Lack of circumcision has been found to be associated with carcinoma of the penis. Many authors^2,3,5-7 have noted the rarity of penile cancers in circumcised men. Dodge and Kaviti⁷ have stated that cancer of the penis occurs more frequently among European an Asian populations in the uncircumcised than among the circumcised. Others^2,3 have claimed that cancer of the penis has never been recorded in men circumcised at birth.

But, does the retention of the foreskin truly cause cancer of the penis? Is smegma actually carcinogenic? Or does the accumulation of smegma beneath the prepuce indicate a more basic problem, namely, that of poor genital hygiene? Proponents of circumcision have been unable to answer these questions with certainty.

In 1960, Apt⁸ found only 15 cases of cancer of the penis, scrotum and other male genital organs (excluding cancer of the prostate and testis) in Sweden. Practically all of Sweden's 3.7 million males are not circumcised.

Anna-Munthrodo⁴¹ recorded the incidence of carcinoma of the penis amongst Jamaicans and observed that 50% of them had gonococcal infection, 55% had positive blood Wassermann reactions, and 50% of them had positive complement-fixation tests for granuloma inguinale.

The Javanese, like the Jews, regularly perform ritual circumcision, but Sampoerno, in a study referred to by Herskowitz,²¹ found seven carcinomas of the penis among 78 carcinomas of Javanese men.

Additionally, all 163 cases with cancer of the penis in Reddy's⁶ series of Indian men belonged to the low-income group who are usually credited with low personal and genital hygiene. Dodge and Kaviti⁷ found the rate of carcinoma of the penis among uncircumcised east African tribes to vary considerably and conceded that unexplored differences in personal hygiene or in dietary habits may be responsible. Lenowitz and Graham⁴² found in 1946 that cancer of the penis was 5 times more common in American Negroes than in American whites, but skin cancer was seven times more common in whites.

The facts speak for themselves. Carcinoma of the penis is uncommon in uncircumcised men with a high standard of hygiene, as in Sweden, but circumcision affords little protection in populations where personal hygiene may be minimal. In cases of penile carcinoma, lack of hygiene is always striking.²⁵ If the uncircumcised man has a foreskin which he can retract and which he keeps clean, the risk of this cancer is removed.

Circumcision and Carcinoma of the Prostate

Some investigators^3,6 have attempted to show a correlation between uncircumcision and prostatic carcinoma.

Ravich³ found that among his 1,275 Jewish private patients who underwent surgery for prostatic obstruction there were only 23 with cancer, an incidence of 1.8%. This compared with 35 cancers, or 19% in the 132 non-Jewish private patients, of whom he estimated about 5% were circumcised. Unfortunately, there are no data as to the age differences of his Jewish vs. non-Jewish patients. Since prostatic cancer is a disease associated with advanced age, the omission of this information renders his data inconclusive.

Interestingly, Ravich³ also noted there was a 67% incidence of prior venereal infections in patients with cancer of the prostate as compared with 28% of the benign prostatic cases. He found that the incidence of cancer was significantly higher in both male Jews and non-Jews when gonorrhea had been present. This in turn would indicate a lower state of personal hygiene in prostatic cancer than in benign cases.

Apt⁸ studied the cancer registers of Sweden and Israel for 1960 and found the number of prostatic cancers cases in Sweden to be 1,544 as opposed to 88 in Israel. This indicated the annual rate in Sweden to be 414 per million males in comparison to Israel's 88. Thus he concluded prostatic cancer to be 4.7 times more frequent in Sweden than in Israel. But, there were 3.7 million males in Sweden in 1960 and only 1.0 million males in Israel. Also, using Apt's own figures, 16% of the male population of Sweden was over 60 years old, as opposed to 8.3% of the Israeli male population being 60 or more years old. If one takes 16% of 3.7 million males, he finds that there were 0.592 million males over age 60 in Sweden. Taking 8.3% of 1.0 million males, one finds 0.083 million males over age 60 in Israel. There are thus seven times more men over age 60 in Sweden than in Israel, but prostatic cancer is only 4.7 times more frequent in Sweden. Would this mean that non-circumcision protects against prostatic cancer?

Comment

Circumcision is rarely performed or requested on the basis of its medical indications. Shaw and Robertson⁴³ interviewed 80 mothers of newborn male infants and found that 72% denied that a physician had ever discussed circumcision with them. The reasons for or against circumcision stated by 106 physicians questioned bore little of any resemblance to the reasons advanced by the 80 mothers. The results cast doubt on the belief that the decision to circumcise is reached in any scientific manner. Obviously, circumcision performed on the basis of religious beliefs is beyond the scope of this discussion.

Poor sexual hygiene, inadequate hygienic facilities, and venereal disease tend to increase the incidence of genitourinary cancers in ethnic groups or populations that do not practice circumcision. In these groups, then,circumcision would seem to be indicated.

However in groups where a high standard of cleanliness could reasonably be expected, circumcision at birth would not seem to be justified. Certainly phimosis, paraphimosis, balanoposthitis, and penile carcinoma are uncommon and could probably be prevented by adequate hygiene. It seems more likely that the presence of smegma in the uncircumcised is simply a sign of poor hygiene, and that this is the risk factor which increases the risk of both penile and cervical cancer.²⁸

Proponents of circumcision will agree that in theory, personal hygiene may be as effective as circumcision in cancer prevention. The critical point however, is whether the necessary standards are, or can be achieved in practice. Newhill¹¹ has stated, An uncircumcised boy has to be taught to keep his penis clean - which is likely to result in an undesirable concentration of attention on his penis every time he has a bath. A penis without a prepuce is permanently clean.

There is no question but that cleanliness must be taught. However, if a child can be taught to tie his shoes or brush his teeth or wash behind his ears, he can also be taught to wash beneath his foreskin. The foreskin is not fully retractable in 90% of males before age 3 anyway and not special attention is needed before this time. As to the boy paying an undesirable amount of attention to the genital area, most children in the genital stage of development will do exactly that. Children will play with themselves and with each other. Mere circumcision will not prevent such activity, nor is it supposed to.

In regard to the immediate surgical complications of circumcision, it is true that their incidence is small. They do however exist, and they are preventable. Such potential hazards as uncontrollable hemorrhage, lacerations, deformities, and amputations should be considered not only from the patient's and family's points of view but from a medico-legal one as well.Delayed complications of circumcision are more common, but less severe. Meatal ulcer, meatal stenosis, enuresis, and penile deformity secondary to scarring and fibrosis are potential sequelae of circumcision.

Justification of circumcision in order to save a boy later lockerroom embarrassment seems unrealistic. This is the latter half of the 20th century, a time supposedly to celebrate individuality and freedom of choice. One of the American ideals is independence and originality of expression. If being uncircumcised is embarrassing to a boy he can always be circumcised later. At any rate it will be his choice, and he will know why he chooses it.

Finally, to those physicians who would recommend the performance of untold numbers of circumcisions to prevent one case of cancer of the penis, there arises an interesting problem: The ultimate side effects and complications of the orally administered contraceptives have yet to be determined, but how many physicians who advocate circumcision as a cancer preventative continue to prescribe these anovulatory agents? How many of them still allow their patients, their wives or their children to smoke cigarettes, which are far more likely to be carcinogenic than is the foreskin?

Radiation of the thymus and routine tonsillectomy are no longer acceptable. This is because they have been found to be associated with certain dangers and to provide only questionable benefits. Perhaps routine neonatal circumcision will one day join these antiquated curiositiesin medicine's attic.

Conclusion

Routine circumcision of the newborn is an unnecessary procedure. It provides questionable benefits and is associated with a small but definite incidence of complications and hazards. These risks are preventable if the operation is not performed unless truly medically indicated. Circumcision of the newborn is a procedure that should no longer be considered routine.

Opinions expressed in this paper are not necessarily those of the Department of Defense or the Department of the Air Force.
Reprint requests to 3644-E Chamblee-Tucker Road, Atlanta, GA 30341.

Correspondence in response to this article:

• Harnes J. The foreskin saga. JAMA 1971;217(9):1241-42.

Preston's reply:

• Preston EN. Letter. JAMA 1971;218(7):1051

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