Letters

To the Editor

Advantages and Disadvantages of Neonatal Circumcision

The article by Dr Laumann and colleagues¹ supports the conclusions of the 1988 American Academy of Pediatrics (AAP) Task Force on Circumcision (of which I was the chair) that newborn circumcision has potential benefits as well as risks. The authors present new information that indicated that circumcised men had slight benefit in terms of sexual satisfaction and less likelihood of sexual dysfunction. This complements a 1988 survey of women that demonstrated female sexual preference for circumcised men.²

Although the subjective survey method reported by Laumann et al is valid for the issue of sexual satisfaction, it is not applicable for studying sexually transmitted diseases (STDs). As the authors point out, self-reported STDs will be underreported because patients with STDs may be asymptomatic, and the diagnosis carries a social stigma. Relying on the memories of men ranging in age from 18 to 59 years on this sensitive topic is not justified. Further it is not valid to group all 7 listed STDs. The mechanism of infection of the individual STDs can vary (eg, tranfusions and intravous drug use as well as sexual transmission for hepatitis B and human immunodeficiency virus [HIV] infection). The incubation period before symptomatic drug symptoms are apparent vary widely among the individual STDs (eg, days f or gonorrhea, monhs or years for HIV), which can make recall unreliable. Moreover, laboratory testing usually is required for diagnosis. The risk of drawing conclusions on STDs from this study, which has a relatively small sample size (353 uncircumcised men) and lack of objective data, is exemplified by the paucity of the HIV data. Epidemological studies during the past decade indicate that uncircumcised men have significantly greater risk of acquiring HIV infection than do circumcised men.^3-6 These studies as well as published devidence on other STDs, are unjustifiably trivialized by the unwarranted general conclusion that there is no significant difference in risk for STDs between circumcised and uncircumcised men.

Edgar J. Schoen, MD
Kaiser-Permanente Medical Center, Oakland, Calif

Appreciation expressed to the Medical Editing Department, Kaiser Foundation Research Institute, who provided editorial assistance.

To the Editor

Dr. Laumann and colleagues¹ conclude that circumcision provides no preventive medical benefit, thus reviving an ongoing controversy. While issues related to the risk of childhood urinary tract infection with or without circumcision may be debatable, the authors have been blinded to the medical benefits of circumcision. for adults. Indeed only 1 week following the report by Laumann et al, Royce et al² reported that male circumcision consistently shows a protective effect against HIV infection, with an 8-fold increased rate of HIV disease among uncircumcised men.² Royce et al further report a greater incidence of HIV in sexual partners of uncircumcised men and speculate that the abundance of Langerhans cells in the foreskin may be a contributing factor and that the presence of a foreskin actually may increase infectiousness.

Periodic arguments against circumcision have been supported by a variety of evidence, much of which has been directed toward the inhumanity of such procedures. While data from studies such as Royce et al² should help to restore this paper-churning debate to its proper perspective, the findings of Laumann et al that sexual dysfunction was less common in circumcised men inadvertentlyadds weight to the medical argument.

Irvin R. Berman, MD
Southeast Georgia Regional Medical Center, Brunswick

To the Editor

Dr. Laumann and colleagues¹ conclude that with respect to STDs there is no evidence of a prophylactic role for circumcision and a slight tendency in the opposite direction. However, the authors did not consider one important aspect of the relationship, if any, between male circumcision and the risk of STDs including cervical cancer in their female partners. Hunter et al.² found that women whose partners are uncircumcised are at increased risk of STDs, including HIV. Human papillomavirus (HPC), which plays an important role in the pathogenesis of cervical cancer³ also is sexually transmitted, although men are frequently asymptomatic. Several studies have shown that women whose sexual partners are uncircumcised are at increased risk of cervical cancer secondary to HPV.^4-5 These findings deserve further examination and, if confirmed, would be important information for parents and physicians to consider in deciding whether to circumcise or recommend circumcision of male infants.

Lainie Friedman Ross, MD, PhD
University of Chicago, Chicago, IL

To the Editor

Circumcision depends upon the perpetuation of American cultural beliefs that support it. One way to justify inflicting pain and harm on others is to believe that otherwise more pain and harm will follow. Using this strategy to defend circumcision requires minimizing or denying the harm caused by circumcision and producing medical claims about protection from potential future pain and harm. Circumcision advocates claim that the surgery has prophylactic benefits. Laumann et al¹ provide another response to thisbelief.

For some people, claims of medical benefits are sufficient justification for circumcision partly because circumcision is a surgical procedure that is done on someone else. Using medical claims and studies to defend circumcision may be an unconscious way for some physicians to avoid the emotional discomfort of questioning their own circumcision. A survey of primary care physicians showed that circumcision was supported more often by physicians were older, male, and circumcised.²

Full and open debate on the circumcision issue is necessary, particularly regarding long-term effects and ethical considerations, but this debate has not yet occurred. Even with full debate, the overwhelming pain and harm of circumcision cannot be proven to many circumcision advocates because people tend to avoid new information that strongly conflicts with their beliefs.

Thus far, the feelings of those who must live with the decision - the infants - generally have been ignored. The fact that infants can't physically resist or stop the procedure makes it easy to dismiss their feelings. Of course adult feelings are not so easily dismissed. A preliminary survey of 75 men suggests that the more men know about the important functions of the prepuce, the more likely they are to be dissatisfied about being circumcised.³ Now that an increasing number of men are learning about the prepuce and expressing this dis-satisfaction, clinicians must acknowledge that is impossible to predict how a male infant will feel when he is older. A prudent course of action would be to allow men to make the decision about circumcision themselves when they reachadulthood.

What prevents the adoption of such a new policy is the reluctance to acknowledge such a mistake and all that it implies. This avoidance of guilt helps to explain the tenacity with which some people defend existing circumcision policies,³ and the ongoing denial requires the continued acceptance of cultural beliefs. More than new studies, clinicians will need courage to change.The children of the future are depending on it.

Ronald Goldman, PhD
Circumcision Resource Center, Boston, Mass

To the Editor

Dr. Laumann and colleagues¹ conclude that data from the National Health and Social Life Survey do not lend clear support to either side in the circumcision debate. However, by demonstrating that circumcision does not reduce the risk of contracting STDs, the authors may have knocked another prop out from under a medical procedure that already depends on the frailest of support. Moreover, their finding that removal of the foreskin alters patterns of sexual behavior over a lifetime casts further doubt on the appropriateness of circumcising infants too young to give informed consent.

Circumcision is an invasive procedure that is not essential to an infant's welfare and virtually always can be deferred with little or no risk. The finding that circumcision has significant impact in later life adds further credibility to the view that a decision regarding circumcision should be postponed until a man can choose for himself. In 1995, the AAP Committee on Bioethics² stressed the importance of involving children in decisions concerning their health care. The committee counseled physicians to view children as persons in their own right, with interests distinct from those of their parents.

Neonatal circumcision subjects male infants to an operation that they may well reject if they were old enough to consider its advantages and disadvantages. A number of studies, such as that of Taylor and colleagues,³ have provided evidence that the foreskin is a complex structure that performs important sensory functions. The summary ablation of this structure prior to the age of consent infringes on one of the most basic human rights, namely, the right to physical integrity.

Although the courts have traditionally emphasized the importance of the family, the rights of parents to govern their children are by no means unrestricted. In a society founded upon respect for the individual, it is clearly in the interest of a child to participate whenever possible, in decisions concerning his or her own body.

Circumcision is an irreversible procedure that confers few, if any, prophylactic benefits and appears to have long-term effects on sexual behavior. Hippocrates advised his followers to treat patients conservatively. Perhaps it is time that infant males born in America were once again treated in accordance with a principle that has formed a cornerstone for the practice of medicine since ancient times.

Dennis Harrison
Vancouver, British Columbia

To the Editor

I read with great anticipation the article on circumcision in the United States¹, after hearing the press release about this article on the news. However, I not only was sorely disappointed int he results and conclusions in this study, but must say that I have never read an article that had so many generalities, such as slight tendency, slightly less likely, may have, it seems unlikely, results escape easy interpretation, cast doubt, and may reflect attitudes. I found the article to be highly unscientific and probably more suitable for publication in a journal of sociology or perhaps psychology than in a medical journal.

Perhaps the most obvious example was a comment by the authors that Results may also have been affected by the possibility that some respondents did not know whether they had been circumcised. I rest my case.

John E. Pipas, MD
Syracuse, NY

To the Editor

That the article by Dr. Laumann et al¹ documented differences in the sexual practices of men with regard to circumcision status is not surprising. Surgical removal of the prepuce results in the loss of the majority of fine-touch neuroreceptors found in the penis,² leaving only the exposed nerve glans, which is innervated with free nerve endings that can only sense deep pressure and pain.³

A hypothesis is needed to explain the findings of Laumann et al in the light of the known neurohistology. We suggest that a penis with foreskin and its full complement of neuroreceptors may make heterosexual coitus more satisfying, thereby making the man less likely to seek out alternate forms of stimulation. The only portion of the prepuce remaining in a man with surgically altered genitals is the remnant between the corona and the scar. While there are some fine-touch receptors in this tissue, the most sensitive portion of the prepuce at the tip is removed in even the most moderate circumcision.² The remaining prepuce and any remaining portions of the frenulum can be preferentially stimulated by masturbation and oral sex, whereas the sensation of deep pressure dominates during hetero-sexual coitus. The imbalance from not having the input from the missing fine touch receptors may make the experience less satisfying, causing a man with an incomplete penis to supplement his sexual experiences with other forms of stimulation.

To date the effect of circumcision on sexual function has not been carefully studied. In rodent studies, removal of the prepuce resulted in marked changes in the mechanics of copulation,⁴ the hormonal response of the female partner, and aggressive behavior. In humans, behavioral alterations have been demonstrated in the pain response of circumcised infants.⁵ Unfortunately, studies of men circumcised as adults have had too few subjects or differences in sensation were not well documented. Testing penile vibratory thresholds has demonstrated that men experience increasing thresholds with age, while those with premature ejaculation have low thresholds regardless of age.⁵ Application of this technique could be used to demonstrate if a sensation differences exists between circumcised and uncircumcisedmen.

Robert S. Van Howe, MD
Marshfield Clinic-Lakeland Center, Minocqua, Wis

Christopher J. Cold, MD
Marshfield Clinic, Marshfield, Wis

In Reply

Collectively, the letters commenting on our article on circumcision are a microcosm of the highly contentious state of opinion on the wisdom of mass neonatal circumcision in the United States. Most of the authors make useful reference to other studies that bear on evaluating the impact of circumcision on such issues as penile sensitivity, sexual satisfaction and transmission of other diseases to sex partners (eg, cervical cancer) that we could not examine because of the limitations of clinical data gathering imposed by a broad-based population survey such as ours. However, we take strong exception to Dr. Schoen's observation that the survey method is simply inapplicable because of its invalidity for studying STDs. We acknowledged in our article the limitations of self-reported STDs from a lay population, especially with respect to under reporting because of selective recall, lack of awareness and of diagnosis of asymptomatic disease, and the avoidance of social stigma. We found that 17% of the men reported that they had been informed of medical diagnoses of specific STDs, and that such experiences were associated with risk factors, such as numbers of partners, condom use, and military service, that the literature would lead us to expect.^1,2 Moreover, lacking a plausible mechanism that links the presence or absence of a foreskin with a differential ability to recall and report medically diagnosed STD experiences, we fail to see the significance of Schoen's remarks regarding our findings.

Drs. Berman, Ross, and Schoen refer to studies claiming a prophylactic effect of circumcision against HIV transmission in African populations as inconsistent with our findings for the United States. Our study, however, does provide evidence that there are strongly associated social and behavioral co-variants with circumcision status that include social background characteristics, such as age, education, race/ethnicity, and sexual practices and preferences. In short, circumcision is a marker for a complex array of social and behavioral characteristics that are known to be implicated in STD transmission. It is certainly the case that circumcision in Africa also is heavily influenced by social factors, such as tribal affiliation and religion (eg Islam),³ and these factors have important implications for sexual practices and partner choice. Without rigorous, systematic control for cofactors relevant to the particularities of the African context, the prophylactic status of the presence or absence of the foreskin remains an open question.

Edward O. Laumann, PhD; Christopher M. Masi, MD; Ezra W. Zuckerman, MA
University of Chicago, Chicago, IL

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