Circumcision as a Hygiene Measure

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SOME SUBJECTS DIE HARD, and of all the hairy perennials, circumcision in infancy ranks high. The subject is all too often clouded by emotional reactions and obscured by entrenched attitudes. It has recently been revived in our correspondence columns by the publication in our issue of May 22, 1971 (page 1148), of a resolution passed by the Australian Pædiatric Association that:

The Australian Pædiatric Association recommends that newborn male infants should not, as a routine, be circumcised.

Elsewhere in this issue (page 233) we publish a further letter from the Australian Pædiatric Association drawing attention to the Australian Pædiatric Journal of June, 1970 in which the question is discussed in a paper by I. O. W. Leitch,¹ and in turn commented on by R. G. Birrell and E. Durham Smith. We should also like to draw attention to three other papers in THE MEDICAL JOURNAL OF AUSTRALIA of May 27, 1967, by J. E. Wright, of Newcastle, by Mr. David St. John-Hunt, of London, and by W. K. C. Morgan, writing from the U.S.A. Though Mr. St. John-Hunt is not a medical man, his paper is of interest because he has a thorough knowledge of the extensive literature on the subject, has made a careful study of it, and approaches it in a commendably objective fashion.; the fact that he comes down in favour of circumcision is relatively unimportant, except that it demonstrates that the arguments for circumcision cannot be lightly brushed aside. Durham Smith also presents the question in a very objective fashion, and his views, as those of an experienced pædiatric surgeon, commandrespect.

The resolution of the Australian Pædiatric Association of course conforms with the weight of informed pædiatric opinion of British Medicine today—that routine pædiatric circumcision is founded partly on tradition and partly on a misunderstanding of normal anatomy, that it is hardly ever necessary in infancy and seldom in later life, and that as neonatal circumcision incurs an appreciable morbity and occasional mortality, its use as a routine measure cannot be justified. The arguments in favour of circumcision centre mainly round two points, (a) the embarrassment and inconvenience caused if circumcision becomes necessary in adult life, and (b) the question of hygiene. As regards the first, the pædiatrician might answer that the convenience of the few does not justify the indiscriminate cropping of the innocents. As regards the second, he might say that surgery is a poor substitute for good hygiene. The old argument that lack of circumcision was a handicap in desert warfare is, we trust, scarcely relevant to modern urban civilization. Of more substance is the association between cancer of the penis and cervical cancer with the uncircumcised state. In both these cases there is evidence that careful washing is just as effective as surgery as a prophylactic measure.

However, this may be over-simplifying things a bit. We can perhaps let Durham Smith have the last word:

Most of the criticisms of circumcision are really criticism of bad circumcision, done at the wrong time.

He goes on to condemn neonatal circumcision on the grounds that the circumstances are too often conductive to bad surgery. He believes that doctors should encourage people to regard the uncircumcised state as normal, but that parental wishes should be respected, as there is a case to be made out for circumcision as a hygiene measure. However, in such cases he considers the elective procedure is best performed in the second or third year of life, but he insists that this should be done with the patient in the hands of a competent anæsthetist and with strict observation of good technique which should reduce complications to neglible proportions.

This middle of the road view will certainly be assailed by extremists in both camps, which only goes to show that the question of routine circumcision (in fact, as a hygiene measure) is an issue which is still very far from settled.

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