Cultural Bias and the Urinary Tract Infection (UTI) Circumcision Controversy

Recently much discussion in the circumcision controversy has centered on the issue of infant urinary tract infections (UTI). This is largely a technical question but it has some bearing on the larger ethical and social issues of routine newborn circumcision.

In order to discuss infant UTI intelligently, it is first necessary to understand the childhood UTI is in general a difficult and confusing diagnosis. If a careful physician and an adult patient have a telephone conversation that leads to the diagnosis of UTI, the diagnosis will usually, though not always, be correct. But if the same conversation passes between the physician and the parent of a healthy pre-school girl, the UTI diagnosis has, in my experience, an 80% chance of being wrong. The comparable figures for a pre-school boy approaches 95%.

Even if the child is examined and a urine specimen is obtained, UTI misdiagnosis rates are still substantial because of the difficulty in obtaining clean urine specimens from small children. The physician who wishes to avoid mistakes must be prepared to make the best possible initial diagnosis (UTI or not UTI) and then mistrust his (her) first impression sufficiently to make the correct diagnosis in the end. This caveat applies both to individual clinical cases and to research projects.

This brings us to newborn circumcision, a surgical procedure that is now alleged to prevent UTI. Until recently the state of medical common knowledge regarding infant male UTI was as follows:

In all age groups except early infancy, females have a much higher rate of UTI than males. Male infants are more likely to be born with abnormalities of the urinary tract. Although such abnormalities are rare, they are the predominant cause of infant UTI. Infant UTI is therefore a serious condition that often requires surgical correction of an underlying cause.

Now enter Dr. Thomas Wiswell, Army pediatrician who did a prospective study of UTI in infants, targeting the role, if any, of circumcision. The result, which drew widespread attention both inside and outside the medical community, was that the uncircumcised boys appeared to have twenty times as many UTIsas the circumcised ones (4% vs. 0.2%).

Obviously, this result does not fit with our common knowledge. A condition with 4% incidence is no longer rare. And perhaps more disturbing, the crucial connection between UTI and urinary birth defects is broken. Circumcision could conceivably prevent UTI but it cannot prevent birth defects without violating Einstein's Law of Relativity. Because of these concerns and others of a similar technical nature, a controversy erupted over Wiswell's result, and Wiswell responded with more data by doing an indirect review of all available hospitalized Army cases. This review also showed a twenty-to-one ratio between the two groups of boys but with different rates (1.0% and 0.05%). I then did a similar review in Northwest Permanente Hospitals. I found not a single confirmed case of UTI in a normal male infant. All of the confirmed cases occurred in infants who had clear-cut urinary birth defects.

Not only is my result dramatically different from Wiswell's, my result is perfectly consistent with common knowledge. Now common knowledge can be wrong---flat earth and so on. But we should never jump to the conclusion that it is wrong without hard evidence. In the present case, we have some unconfirmed evidence of infants with bacteria in their urine. The evidence that the infants were actually harmed by these bacteria is practically nonexistent. Indeed, if Wiswell's 4% figure was correct, there would have been 80 uncircumcised infant boys with UTI in my study. What happened to these patients if they never got diagnosed? They didn't die, they didn't turn up with sepsis (blood poisoning) or meningitis, they didn't have kidney transplants. It might be supposed that the undiagnosed babies turn up as adults with urinary problems, but neither scientific evidence nor common knowledge supports this notion.

It is common knowledge that girls who have recurrent UTI in childhood and are lost to follow-up in adolescence sometimes turn up in adulthood with serious kidney problems. The closest we get to this in the medical lore of the male is that middle-aged men often suffer urinary problems due to teen-age gonorrhea.

We are a long way from understanding the relationship, if any, between infant UTI and circumcision.

The incidence of UTI seems to vary widely depending on whether the investigator passively collects cases or goes fishing for them. How then can this confusing and ambiguous scientific question be factored into the larger social and ethical controversy over the legitimacy of routine newborn circumcision. I believe one must start by establishing a basis for discussion that is free of cultural bias.

Although the numbers vary somewhat, the US is about 75% circumcised in the post-war period. However, white middle-class baby-boomers are almost all circumcised. It is not so long since the routine circumcision was Routine with a capital R, done without discussion or parental consent. Many parents still expect it to be done this way. Also, the (male) physicians in the US who discuss this issue are almost all circumcised. It is therefore inevitable that these circumcised physicians have an I'm OK, you're OK attitude about the state of being circumcised. I can vividly recall seeing a Hispanic boy with an intact foreskin exactly 30 years ago. I thought he had a weird abnormal growth. Bible stories notwithstanding, it took me a couple of years to figure out the truth. In an attempt to escape this bias, I have put newborn (male) circumcision on a list of primitive cultural practices that can be discussed together.¹ Starting with the most obnoxious:

1. Castration
2. Foot binding
3. Radical female circumcision or infibulation
4. Scarification
5. Ubangi lip stretching
6. Limited female circumcision
7. Male circumcision
8. Mayan head deformation
9. Maori tattooing
10. Ear and nose piercing

It takes a while for the white middle class American physician to digest the fact that newborn (male) circumcision fits on this list. It also takes a while to digest the fact that circumcision was introduced into this country not as a physical hygiene measure but as a mental hygiene measure to prevent masturbation. In this context, male circumcision was promulgated in the same breath with with clitoridectomy (removal of the clitoris) and frontal lobotomy.

When an American physician says that circumcision prevents UTI or cancer of the penis, he is sincere. But, it is like a medieval Chinese physician saying that foot binding prevents flat feet. If someone asks me, What rate of preventable UTI would justify male circumcision? I respond by asking, What rate of preventable UTI would justify routine female circumcision? The second question is patently absurd unless one's cultural bias allows a sympathetic view of female circumcision. Therefore, the first question can be only slightly less absurd.

To put it another way, if newborn circumcision were introduced as a new procedure, it would have to be proven safe and effective. It is conceivable that circumcision could be proven effective, i.e. that the significant UTI prevented might exceed the significant complications of the procedure. But to prove safety, it is necessary to prove that circumcision does not interfere with the sexual functioning of the penis. In the I'm OK, you're OK, culturally-biased discussion, this point is easily overlooked. For example, one hears the following argument:

The foreskin may have been useful to early man who ran naked through the brambles but modern man wears clothes and has no need of the thing, so he might as well get rid of it and cut down the cancer risk.

My response to this argument is a slight change in the wording:

Breasts may have been useful to early woman who had no choice but to suckle her babes. But modern woman has many infant feeding options and therefore has no absolute need of breasts. She might as well get rid of them and cut down on the cancer risk.

Incidentally, breast cancer is 5,000 times more common than foreskin cancer. Ounce for ounce, the rate might be the same.

Finally, what is the relationship between the cultural bias in this country and the religious aspect of circumcision? The history of religious circumcision contains some positive elements. It appears that circumcision spread in the early Hebraic period as part of a campaign of religious reform that suppressed pagan religions that practiced human sacrifice. Medieval Jewish writings specifically denied any hygienic function for circumcision. Jewish physicians were forbidden by law to perform secular circumcision of gentiles. Therefore the promulgation of secular circumcision in this country from 1880 to1950 cannot have been a Jewish activity.

On the other hand, the modern secular Jew likes to explain religious law as a reflection of practical considerations:

The eating of pork was forbidden because pigs carry Trichinosis.

This statement probably does not contain a grain of historical truth, but its tidy logic is appealing. So we may just as well say:

Biblical circumcision was performed in order to improve penile hygiene and prevent venereal disease.
~ (1930 version)

or:

Biblical circumcision was performed in order to prevent wicked masturbation and the mental illness that it causes.
~ (1890 version)

Any day now I expect to see the following update in print:

Biblical circumcision was performed in order to decrease the risk of contracting AIDS.
~ (1990 version)

It is a mistake for Jews, Christians, or Moslems to buy into the notion that these secular arguments are a legitimate part oftheir cultural heritage.

Martin S. Altschul, MD received his doctorate in medicine from the  Johns Hopkins University Medical School; an M.S. in statistics from the  Massachusetts Institute of Technology; and is currently a staff pediatrician at the Northwest Region Kaiser Foundation Hospital, Salem, Oregon.

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