CANADIAN ACADEMIC JOURNALS
(in reverse chronological order)
Newborn circumcision: an economic perspective
DAVID CADMAN,*† MD, MSc, FRCP[C]
AMIRAM GAFNI,‡ DSc
JANE MCNAMEE,† MA
Canadian Medical Association Journal
Dec. 1, 1984, vol. 131, pp. 1353-1355.
A B S T R A C T
The purpose of this study was to analyse the hypothesis that prophylactic circumcision of male newborns is economically beneficial to the health care system in Canada. The minimal dollar benefits that would justify this conclusion were determined. The cost of the procedure was calculated in three Hamilton, Ont. hospitals and found to average about $38. Tbe health benefits of circumcision are uncertain, but a review of the literature suggested that penile carcinoma is the most serious (and costly) disease potentially prevented by circumcision. Published estimates of the incidence rates, age at onset and costs incurred as a result of this disease were used in calculations of the per-case cost of prevention: $13.6 million. The authors conclude that the monetary benefits of circumcising newborns will not exceed this cost. It is proposed that the procedure be regarded as cosmetic surgery and be paid for by parents who wish the procedure carried out rather than by taxpayer-funded health insurance plans.
R É S U M ÉOn analyse ici la question de savoir si la circoncision du nouveau-né, considérée comme mesure prophylactique, est économiquement rentable dans le régime sanitaire du Canada. On détermine d'abord le profit monétaire minimum qui justifierait une réponse affirmative. On constate ensuite que dans trois hôpitaux de Hamilton (Ont.) le coût moyen de l'intervention est de quelque 38$. Malgré l'incertitude quant aux avantages sanitaires de la circoncision, une revue de la littérature donne à penser que parmi les maladies susceptibles d'être prévenues par cette intervention, la plus grave est le cancer de la verge. À partir de données déjà connues sur l'incidence de ce cancer, l'âge de son début et les coûts qu'il entraîne, on arrive à un coût de prévention de 13,6 millions de dollars par cas. Les auteurs concluent que les avantages monétaires de la circoncision du nouveau-né ne depasseront pas cette somme. Ils proposent donc de la considérer comme une intervention esthétique dont le coût serait à la charge des parents qui la désirent plutôt qu' à celle des contribuables du régime d'assurance-maladie.
From the departments of *paediatrics and †clinical epidemiology and biostatistics, McMaster University, Hamilton, Ont., and ‡the Leon Recanati Graduate School of Business Administration, Tel-Aviv University, Tel-Aviv, Israel.
Routine neonatal circumcision (letters)
Canadian Medical Association Journal
Nov. 15, 1983, vol. 129, p. 1082.
Although at Fredericton's Dr. Everett Chalmers Hospital requests for routine neonatal circumcision are decreasing, the circumcision rate is still 20% (Can Med Assoc J 1983; 128: 814-817). Obstetricians, who condone routine circumcision, apparently have greater authority than pediatricians, who do not.
There should no longer be difficulty in persuading parents, or anyone else, that routine circumcision is undesirable. The definitive statement on the matter has been made. It is logical and comes from an even higher authority than an obstetrician. Recently unearthed at Nag Hammadi, along with a collection of other fourth-century scrolls, was the Gospel of Thomas II. It reports the answer given by Jesus to his disciples' question "Is circumcision beneficial or not?" He said to them: "If it were beneficial the father would beget them already circumcised from their mother."
ANDREW B. MURRAY, MB, FRCP (EDIN), FRCP[C], DCH
1982 - Jul. 1
Canadian Medical Association Journal
Jul. 1, 1982, vol. 127, p. 17-18.
To the editor: Every year approximately 1.3 million male infants are circumcised in the United States. Assuming a physician's fee of $50, this amounts to an expenditure of $65 million. Certainly neonatal circumcision is in complete opposition to sound medical-surgical practice: a normal structure is operated on, no anaesthesia is used, the patient does not give his consent, there are no legitimate surgical indications, the patient and the part operated on are subject to a host of complications and the resultant penis is abnormal, less sensitive and less functional.
Apparently many physicians are not aware that the prepuce is a normal structure with a definite function. Like a shoe or a glove it protects the underlying structurein this case, the glansfrom the environment. The normal prepuce at birth is always tight, adherent, and nonretractable. Because of this the glans and meatus of the normal penis never contact feces, urine or diapers. Circumcision makes it impossible to prevent this contact. Full glans exposure and complete retractability are usually not possible until the child is 3 to 6 years of age and is learning to wash himself.
By the age of 6 years practically all boys are able to retract their foreskin. This is guaranteed by three natural occurrences: erections, smegma and masturbation. Erections begin in utero and continue well into old age. During erection there is a disparity in the expansile qualities of the enveloping penile skin and the underlying erectile bodies. Smegma is not a dirty, nasty substance but in infancy serves a distinct and useful function: it helps to dissect the space between the incompletely developed glans and foreskin, and it also prevents readherence. Masturbation is universal among males. The infant soon learns that touching his penis is pleasurable, and by moving the loose penile skin back and forth over the underlying glans he eventually exposes the glans. Added to this list is, I would hope, solicitous washing of the penis by the parent.
Thus, the glans is advantageously and appropriately exposed only when urinating, washing and engaging in sexual activities.
Circumcision not only entails many risks and complications, including death, psychic trauma, haemorrhage, infection, urethral damage and excessive removal of skin, but also represents a subtraction: about 25% of sensitive penile skin is lost forever. Assume that the circumcised erect adult penis is a cylinder approximately 15 cm in length and 4 cm in diameter, an area of approximately 60 cm2. The normal uncircumcised penis has a preputial cuff at least 5 cm longer (from the corona to the free edge of the prepuce, and then back to the coronal sulcus), which represents an additional area of 20 cm2. In circumcision this cuff, an area richly supplied with nerves and receptive to sexual stimulation, is removed.
The foreskin facilitates sexual dalliance. The tremendously loose skin covering the normal penis can be moved readily without recourse to extraneous lubrication. In masturbation a man readily moves this sheath himself. In sexual intercourse this "sheath-within-a-sheath" becomes a perfect mechanical arrangement for genital stimulation. Circumcision completely destroys the male's sheath.
The constantly exposed circumcised glans is subject to a host of desensitizing abrasive traumas throughout life: in infancy to feces, urine and diapers, and for the rest of life to abrasive clothing. The infant's meatus often changes from the normal slit-like aperture to a tight hole, and the glans develops a layer of keratin and becomes skin-like, dry, less purple-red, less smooth, less expansile and less sensitive. In the event of genital burns the exposed glans is more liable to injury.
Peer pressure is no sensible reason for continuing to perform circumcision. Binding of feet, piercing of noses and lips, biding of skulls, knocking out of teeth, infibulation of the female's genitals, and burning and excision of the clitoris have all been perpetuated on the basis of peer pressure.
Male infants will continue to be born with a prepuce. Anatomy books must show the prepuce as normal, and statues and paintings will depict the naked male with a prepuce. The male with a normal penis need feel no reticence. He knows that he possesses a normal, sensitive structure that did not have to be surgically altered, and that he possesses enough intelligence to master washing the prepuce.
In the Western world, only English-speaking people (especially in the United States) practise routine neonatal circumcision. Even then, many groups, including the Canadian Paediatric Society, are opposed to it.
People function best with complete and normal faculties of hearing, sight and smell. Who presumes to improve upon what is normal?
THOMAS J. RITTER, MD
1982 - Mar. 15
Canadian Medical Association Journal
Mar. 15, 1982, vol. 126, pp. 594,603-604.
To the editor: Since the authors of the review article Benefits and risks of circumcision (Can Med Assoc J 1981; 125: 967-976, 992) refer to my contributions on this topic[1,2] as "extreme" and "harsh," perhaps I may be permitted a few comments in response.
Following publication of my article The rape of the phallus I was accused of being a Nazi. I also received numerous abusive letters and phone calls, and, horror of horrors, the approbation of the John Birch Society, an organization anathema to me. Despite the abuse from a minority, most persons who read my small efforts took them for what they were intended asa little lighthearted satire leavened with hyperbole, an ancient ploy not unknown to Aristophanes, Juvenal, Voltaire and Swift. Fortunately, in Canada moderation and tolerance seem to be more in evidence.
Drs. Warner and Strashin's data suggest to me that circumcision becomes more prevalent with closer geographic and cultural proximity to the United States. Perhaps the religious affiliations of the physicians in each province also have an effect. Even in Canada there are those who feel one has to "lop it off" to keep up with the Joneses south of the border. In this instance I prefer to keep apart from the Joneses. Having spent 20 years in the United States I can assure Drs. Warner and Strashin that the strongest indication for circumcision there, other than religion, is the presence of Blue Shield insurance. Circumcision is much less common in groups for whom medical services are paid for in advance than it is in those who have insurance that is based on fee-for-service payments. While a few aspiring plumbers carry their enthusiasm over and circumcise children born to ghetto inhabitants, for the most part there is very little proselytizing for circumcision in the indigent noninsured as compared with middle-class whites. In the US medical schools with which I was recently associated, circumcision was at one time routinely carried out unless the parents expressly forbade it. This continued until the son of an obstetrician underwent a routine circumcision, then bled sufficiently to require a transfusion, and had a reaction to the transfusion, with temporary renal failure and jaundice. Since that time circumcision has no longer been routine.
Warner and Strashin's statement that circumcision is associated with a lower prevalence of genital herpes is probably true; however, all this shows is that in the United States and other countries genital herpes, along with gonorrhea and tuberculosis, is more common in the lower socioeconomic groups. The authors also state that the relation of circumcision to cancer of the cervix is unclear. This is far from correct. There are problems with the data on which certain studies have been based, especially those from the United States, where it seems that the circumcision status of husbands is unknown to most wives. In the two or three well designed studies that have been published, circumcision has not been shown to prevent cancer of the cervix.[4-6]
It is difficult to dispute the authors' third conclusion regarding the subjective nature of sexual satisfaction. Nevertheless, there are special receptors in the subcutaneous tissue of the glans that appreciate certain pleasurable sensations, and there are those who feel that these receptors lose their sensitivity when the glans is constantly exposed.
The statement that circumcision facilitates penile hygiene seems a peculiarly inept argument. The ear also collects dirt and wax: Do the authors recommend that the external ear be removed as a means of improving hygiene? While it is true that circumcision prevents cancer of the penis, although not completely, this statement needs to be put in perspective. Marshall has shown that "if a surgeon would perform one circumcision every ten minutes, eight hours a day, five days a week, he would seem able to prevent one penile cancer by working steadily between six and twenty nine years. Since a significant number of penile cancers are curable, still more time and labor might be required to prevent a fatality from this disease." Think what might happen if the surgeon worked on Saturday as well! Marshall then goes on to state that if cancer prevention is to be an end in itself, then bilateral simple mastectomy in women might be an even more effective measure.
I freely concede that there are certain indications for circumcision, but there are also complications, including death, hemorrhage, meatal stenosis, staphylococcal sepsis and permanent damage to the penis.[8,9] To deny this is to bury one's head in the sand. And do not tell us that all male infants are routinely screened for hemorrhagic diathesis prior to circumcision. Perhaps Warner and Strashin would do well to remember Gairdner's estimate of 15 deaths a year from circumcision in Britain at a time when only about 30% to 40% of male babies were being circumcised. Since the decline of this operation in Britain the number of associated deaths has probably fallen. Circumcisions in the United States are mostly carried out by inexperienced and uninterested house staff who have been led to believe that the operation is without danger. Following publication of "The rape of the phallus" I received numerous letters and reports of serious damage following circumcision, including complete destruction of the penis due to overenthusiastic use of electrocautery. Please do not tell me that a sizzled and ineffective penis does not cause severe psychologic problems.
In their closing remarks the authors recommend circumcision because of its medical and economic advantages. What economic advantages? Is it likely that Nature is so entirely lacking in wisdom and pragmatism that every male child comes into the world with a useless appendage, the presence of which is likely to have serious consequences to his health?
I was educated in Britain, did my house appointments there and also spent some time there in the Royal Army Medical Corps. I rarely saw an adult male who required circumcision. Since during my military service I dealt almost entirely with young men, surely I might be expected to have seen the dread consequences of preservation of the foreskin. It is interesting to note that in those parts of the world where circumcision originated and continues to be popularnamely the Near and Middle East, Australia and South Africathe climate is dry and arid, and water is often at a premium. A medical colleague who fought in the Western Desert during the last war maintains that the only valid reason for circumcision is that in a sandstorm his colleagues who had been circumcised were slightly less uncomfortable.
W.K.C. MORGAN, MD
/We showed Dr. Morgan's letter to Drs. Warner and Strashin, whose reply follows. Ed./
To the editor: It's encouraging to see that Dr. Morgan's talent for satirical writing has not faded. Unfortunately, although his style adds refreshing spontaneity to the barren facts and figures of most of the medical literature, he runs the risk of sacrificing objectivity. No doubt Aristophanes, Juvenal, Voltaire and Swift were similarly criticized.
It seems rather unlikely that the Yukon Territories lead the provinces in circumcision rates because of their close proximity to Alaska. Certainly the influence of the Joneses south of the border is less likely there than in the Maritimes, where there is a relatively low circumcision rate. In the United States circumcision does not differ from any other aspect of medical care, including prophylactic immunization, in being less prevalent among the indigent. It is fortunate that the son of the obstetrician to whom Dr. Morgan referred did not have subacute sclerosing panencephalitis (SSPE) after a measles vaccination or perhaps that medical school would have abandoned routine immunization.
The higher incidence of gonorrhea found by Taylor and Rodin in men with a foreskin was not likely to have been biased by a disproportionate number of people of lower socioeconomic status in the uncircumcised group. If this bias existed, one would expect a higher incidence of all types of venereal disease in this group.
From an excellent study by Terris and associates there is good evidence that circumcision may protect against cancer of the cervix: carcinoma of the cervix was found less frequently among women whose husbands had less than one third of a foreskin (as determined by a physician) than among women of the same race and age whose husbands had more than two thirds of a foreskin (P = 0.1); although this association is not statistically significant it is certainly strong enough to warrant further study.
If the difference in sexual satisfaction obtained with a circumcised and an uncircumcised penis were all that substantial, women would be well aware of the circumcision status of their husbands, and Dr. Morgan admits that they are not.
Unreasonable as it may be, studies have shown that mothers are much more likely to teach their little boys to wash behind their ears than beneath their foreskins.
While prevention of cancer of the penis in itself would not justify circumcision, it is an additional benefit when put in context with the other benefits. Dr. Morgan's comments about the female breast have taxed our Canadian "moderation and tolerance" to their limits. Suffice it to say he is obviously completely unaware of the firm stance the medical profession is now taking in favour of breast-feeding.
The complications of circumcision and its negligible mortality were discussed in detail in our review. We closed with the statement that the risks are significant enough that an informed parent's refusal to have his or her son circumcised is valid. We hope that our article, together with Dr. McKim's editorial, will encourage better teaching and supervision of those who perform the procedure, thereby decreasing the morbidity even further.
Nature has brought us into the world with another useless appendagethe appendix. If the benefits outweighed the risks, we would advocate prophylactic appendectomy as well.
Dr. Morgan will be surprised to hear that when we originally began our review of the literature on this topic we were quite sure the evidence would lead us to condemn neonatal circumcision. We were amazed when we were forced to conclude the opposite. Perhaps if we had led the anticircumcision crusade for 15 years we too would have been less willing to accept the facts.
ELLEN WARNER, MD
To the editor: I admired and enjoyed the first-class, thorough review of circumcision by Drs. Warner and Strashin. Circumcision is fascinating in its mythologic and historic aspects, and it was epochally influential in the story or our civilization.
My short essay in the Journal "Circumcision? Cutting out the routine cut," (1980; 122: 834) led me to review the literature and to present a paper on Oct. 8, 1980 to the World Conference on Family Medicine in New Orleans entitled "Four thousand years of foreskin or circumcisioncircumspection." It was marginally against the surgery. To be honest, I could not strongly convince myself one way or the other (i.e., for or against routine circumcision). Eventually I got bored and tired of the controversy.
To me it seems, from a dogmatic surgical aspect, that circumcision is still unnecessary surgery, though with minimal risks. However, those who advocate circumcision may have an advantage when they stress prevention and practicability (in relation to later surgery under general anaesthesia).
Being against fanaticism of any kind, I suspect anyone who crusades fervently either for or against circumcision of being ignorant of the opposing arguments or personally prejudiced.
Let's hope that the physicians who circumcise know what they are doing and do it carefully, and that the physicians who don't circumcise teach hygiene and refer the small percentage of their patients to the circumciser in time.
I suspect that the rest of us will still more or less vacillate. We will teach and inform neonates' parents and eventually leave their personal decision to tip the scale. And there isn't too much wrong with that.
ZDENEK S. PRUCHA, MD, CCFP
1982 - Mar. 1
Canadian Medical Association Journal
Mar. 1, 1982, vol. 126, p. 466-467.
To the editor: In 1975 Taylor and Rodin reported an association between genital herpes simplex and the absence of circumcision. Although the authors of the Journal's recent review article on circumcision (1981; 125: 967-976, 992) cited this study they failed to mention its two critical weaknesses. Taylor and Rodin's study was purely retrospective, and in one critical variable, the use of condoms, the study subjects were significantly different (P < 0.02) from the controls. Since genital herpes is spread by direct contact and barrier contraception may impair viral transmission we should be sceptical about a single retrospective report claiming a reduced incidence of genital herpes in circumcised men.
IAN S. TUMMON, MD
/We showed Dr. Tummon's letter to Dr. Strashin, whose reply follows. Ed./
To the editor: As coauthor of the review article on circumcision I challenge Dr. Tummon's criticisms. He complains that Taylor and Rodin's study was "purely retrospective" and, admittedly, it was. Since he has read the study he will note that only cases confirmed by culture were included and that Taylor and Rodin were careful to define those circumcised or uncircumcised. For a more controlled study one might expose two randomly selected populations of circumcised and uncircumcised males to known female carriers. But, considering the bleak prospect so far for treatment of genital herpes, such a study would hardly be acceptable.
Dr. Tummon also implies that the higher proportion of condom users among the circumcised may account for the lower incidence of genital herpes. In fact, the incidence rates of gonorrhea and nonspecific urethritis were not significantly lower in the circumcised group despite their greater use of condoms. In order to eliminate the possibility of condom use as a bias in the study, I excluded all condom users and retested the hypothesis. The incidence of genital herpes was significantly lower (P < 0.02) in the circumcised group.
Thus, it is our opinion that Taylor and Rodin do offer good evidence that circumcision does, in some way, offer protection against genital herpes.
ELLIOT STRASHIN, MD
To the editor: I enjoyed the article Benefits and risks of circumcision. I suspect that it will once again stir up controversy on this issue. I would like to make two points.
First, I always suggest to mothers of newborn infants when discussing this issue that they should not take the advice of any male physician unless they know his bias (please excuse the expression). I suggest to them that this is such an emotionally loaded issue that they cannot evaluate the advice of any male physician without knowing about the presence or absence of his foreskin.
Second, in one respect I am in agreement with the authors. It is the result of an unfortunate experience during the last unpleasantness (World War II) when I was commanded by the senior medical officer at Petawawa to do 700 short-arm inspections of young men. While it is perfectly true that most adult men do have a retractable foreskin, the level of penile hygiene in this group was appalling.
W.G. GREEN, MD
To the editor: I read with interest the article by Drs. Warner and Strashin in the Nov. 1, 1981 issue of the Journal. It was a comprehensive review and the authors should be congratulated. I do however, object to the way the authors interjected their own views at various stages in the review. The article is cleverly slanted towards recommending this unnecessary surgical procedure.
I put male circumcision on the same level as the horrifyingly barbaric practice of circumcising females. There could be some justification, though not in my opinion, for circumcising males where water is scarce, but in most parts of the world it hardly seems logical: a little soap and water is all one needs.
If Jews and Muslims and some of the tribes in Africa want to chop off the foreskins of their sons, for whatever reasons, that is their business. But at no time should the medical profession be duped into a false belief that it is medically good for their male patients to be circumcised. This same logic could be applied to the female breast (where cancer is a real problem). We would be recommending prophylactic neonatal mastectomy (without anesthesia) because of the medical and economic advantages and because the known benefits outweigh other risks.
Apart from the gut reaction I have to people recommending routine circumcision I do not think that any surgical procedure should be carried out without clear-cut indications. Neonatal circumcision certainly does not meet this requirement.
T.R. VERMA, MD, FRCS
To the editor:I believe you made a great mistake in allowing the emotional issue of routine infant circumcision to be resurrected, and I question whether the subject is worth a long review article citing 83 references. As it is unlikely that the question will ever be decided on medical grounds, doctors should confine their attention to answering parents' questions in an unbiased and objective way. In the event that parents are unable to decide whether to authorize circumcision, a coin can always be tossed.
I should like to quote from a letter contributed to The Bulletin of the Vancouver Medical Association. Any thoughtful person, especially if he believes that he is resident in "God's own country," must find it difficult to believe that the Creator could have made such a botch of the organ par excellence, that about 90% of these finished members should require correction, yet in Vancouver this percentage of circumcisions is being carried out on infant boys, not always with wholehearted parental approval.
I have spoken to numerous parents in Vancouver whose baby boys were circumcised, not because they wished this to be done, but because they were led to believe that it was desirable, and to a few who have incurred the displeasure of their doctors by refusing to allow the operation to be performed.
These observations were based on experience in well-baby clinics in Vancouver from May 1952 to October 1953.
W. BRUCE LAING, MB, DPH
To the editor: I was startled to read in the article Benefits and risks of circumcision that the authors recommend prophylactic circumcision for the general male population. They base their argument on the premise that this prevents cancer of the penis and is associated with a lower prevalence of genital herpes in later life.
Genital herpes is now reaching epidemic proportions in both sexes and among both circumcised and uncircumcised men. However, the major concern is its effect on neonates of women with the infection. My feeling is that most physicians have failed to educate patients regarding genital hygiene from childhood onwards. Yet, until we have better agents to control the herpes type 2 virus, we can expect the incidence ,of genital herpes to continue to rise.
My recommendation to parents is that they use a cotton swab with 3% hydrogen peroxide to wipe the glans and prepuce in a gyrating motion whenever they feel that their baby's penis needs cleaning. I instruct adults able to clean themselves to retract the prepuce during bathing and wash well with soap and water every day, andmost important of allto dry the area properly after cleaning and urination. Couples who already have genital herpes should use a condom during intercourse. The condom will not be 100% effective but will be at least as effective as circumcision in preventing spread of the disease.
Penile cancer is very rare and usually only affects elderly men. If we argue that circumcision prevents this condition we might equally argue for prophylactic mastectomy or colectomy to prevent cancer.
Drs. Warner and Strashin have stated most of the common risks of circumcision. I personally have treated two babies with systemic infections linked to circumcision. The first case was in a baby circumcised 6 days earlier who screamed every time his diaper was changed. Septic arthritis developed in the left hip. The second baby had osteomyelitis of the distal left femur. Both patients were crippled from the complications. How would you feel about recommending a "good" surgical procedure for a baby that can lead to such disastrous results? We are dealing with the human body, and I think cost-benefit arguments are only for politicians.
There is one way we can reduce health costs. Circumcision could be categorized as elective cosmetic surgery if there are no medical indications. Then whoever wanted it could pay for it. This would result in significant savings for the medical plans.
M.K. SZE, MD
To the editor: At the 1976 General Council meeting of the Canadian Medical Association a resolution condemning circumcision was overwhelmingly defeated following a debate in which I played a prominent role.
It was therefore with some satisfaction that I read the review article Benefits and risks of circumcision. I believe the conclusion that "for the individual the known benefits usually outweigh the risks" is valid. However, the statement that "neonatal circumcision does not appear to be helpful in preventing sexually transmitted disease although it may be associated with a lower prevalence of herpes genitalis" is incorrect. I base this on three important studies unfortunately overlooked by Drs. Warner and Strashin.
In an article published in 1855 Jonathan Hutchinson noted that about one third of his outpatient practice at the Metropolitan Free Hospital in London, England consisted of Jewish patients. He was, of course, only estimating the racial mix of his clinic population but, by using as controls the patients definitely exposed to venereal disease (those that had contracted gonorrhea), he came up with a clear and rather staggering statistic: Jewish patients exposed to venereal disease were over 15 times less likely to contract syphilis than non-Jewish people similarly exposed.
In 1949 Eugene Hand reported a markedly higher incidence of syphilis in uncircumcised as opposed to circumcised naval personnel. In contrast to Hutchinson's patients, Hand's series contained circumcised patients who were not Jewish. Hand also documented a significantly higher incidence of venereal diseases in uncircumcised patients.
However, the best and most scientific study was reported in CMAJ in 1947 by R.A. Wilson. Wilson, a pediatrician, was a medical officer in the Canadian Army during World War II. He examined 1000 recruits at an army reception centre and found that 52% were circumcised and 48% were not. He then studied the circumcision status of 1304 consecutive patients in a Canadian Army venereal disease centre. His findings for syphilis corroborated those of Hutchinson. Of 100 cases of syphilis, 90 were in uncircumcised men. Of 869 cases of gonorrhea, 640 were in uncircumcised men.
It is interesting that Warner and Strashin and the overwhelming majority of other authors of the subject have completely overlooked the three articles cited above. Today, when venereal disease continues in an uncontrolled, endemic fashion, the argument for neonatal circumcision as sensible, preventive medicine merits serious consideration.
L.J. GENESOVE, MD
Benefits and risks of circumcision
ELLEN WARNER, MD*
ELLIOT STRASHIN, MD†
Canadian Medical Association Journal
Nov. 1, 1981, vol. 125, p. 967-976.
A B S T R A C T
Circumcisions are performed either prophylactically in the neonatal period or therapeutically at a later age. About 10% of males not circumcised at birth will eventually require circumcision. The present neonatal circumcision rate is about 80% in the United States and 40% in Canada. The single most important determinant of whether a newborn will be circumcised is the attitude of the attending physician.
The literature was reviewed to determine the proven benefits of circumcision and to compare these with the known risks. Circumcising the newborn facilitates penile hygiene, prevents cancer of the penis and decreases the incidence of genital herpes in later life. Whether it decreases the incidence of cancer of the cervix is still uncertain. More important, neonatal circumcision is associated with much lower morbidity and mortality and with lower costs than therapeutic circumcision. Thus prophylactic circumcision is recommended for the male population as a whole.
R É S U M ÉLa circoncision est pratiquée soit dans un but prophylactique durant la période néonatale, soit dans un but thérapeutique plus tard dans la vie. Environ 10 % des hommes qui n'ont pas été circoncis à la naissance doivent éventuellement l'être. Le taux de circoncision néonatale est de 80 % aux États-Unis et de 40 % au Canada. Le plus important facteur qui va déterminer si un nouveau-né sera circoncis est l'attitude du médecin traitant qui préside à l'accouchement.
On a procédé à une revue de la littérature afin de mettre en évidence les bénéfices démontrés de la circoncision et de les comparer aux risques connus. La circoncision du nouveau-né facilite l'hygiène, prévient le cancer du pénis et baisse l'incidence de l'herpès génital plus tard dans la vie. Il n'est pas encore sûr qu'elle puisse réduire l'incidence du cancer du col. Ce qui est encore plus important est que la circoncision néonatale entraîne une morbidité et une mortalité beaucoup plus faibles que la circoncision thérapeutique, et ceci à un coût plus faible. En conséquence, la circoncision prophylactique est recommandée pour l'ensemble de la population mâle.
Circumcision? Cutting the routine cut
ZDENEK S. PRUCHA, M.D.*
Canadian Medical Association Journal
Apr. 5, 1980, vol. 122, p. 834.
As happens from time to time, medical journals on both sides of the Atlantic are reviving the arguments against circumcision. But parents still lack any real knowledge when deciding whether their baby should be circumcised.
There have always seemed to be as many medical reasons for circumcision as against it, and none of them has been especially strong or convincing. Those in favour may have been loosely influenced by a feeling that wise forefathers in the Judeo-Christian tradition had some important reason for this ritual, a reason presumably based on some notion of pioneering hygiene or sanitary measures. And possibly this illogical, atavistic belief has tilted the scale so that, certainly in my own practice and, I suspect, in most practices these days, an overwhelming majority of parents demand circumcision for their new-born boys.
While this procedure was a religious practice known in Egypt before being introduced to the Hebrews by Abraham, and is best known as prevailing among those of Jewish and Moslem faith, it has been practised by peoples from every continent. As well, the rather brutal and barbaric custom of circumcision and ritual clitoridectomy of baby girls is known in Islam and is extensively performed in certain African tribes and nations.
When, according to the Old Testament, Jehovah promised to make Abraham's descendants His chosen people and to place them under His protection in the promised land of Canaan, there was a stipulation that His chosen people must be circumcised on the eighth day after birth or upon conversion to the faith, "even the homeborn slave and the one bought from an outsider who is not of your seed."
Then, in about 1200 BC, the God of Abraham commanded an exiled Egyptian prince, Moses, to return to Egypt and to lead the Jews to freedom. He gave the Israelites the Ten Commandments and the other Mosaic laws, imposing the same covenant with Moses that He had made with Abraham, including the same rite of circumcision.
In the first century AD, the Roman philosopher Seneca was alarmed by the prevalence of Jewish customs and feared a loss of the Roman way of life. The actual conversions were numerous and would have been even greater but for the necessity of circumcision and the strict dietary laws.
Then a Jew named Saul was cured of blindness by the laying on of hands of another Jew of the Ananias sect and converted to Christianity. Later he changed his name to the Roman Paul and broke from the Apostolic church of Jerusalem, because of arguments regarding the procedure of converting pagans.
Saint Paul felt that pagans should become Christians directly, without first being converted to Judaism. He also stated that man should know God only through Christnot, as the Jews believed, only through the word of God as revealed in the Torah (Old Testament). He abandoned Jewish dietary laws and the rite of circumcision to make conversion easier.
Circumcision for religious beliefs remains a riteand a rightbut otherwise the question of desirability of routine circumcision has to be answered on biologic and pathophysiologic grounds. And, if this is not decisive, then strictly on the basis of medical economics and priorities, since medicare at present covers routine circumcision.
The only definite indication for circumcision (or simpler dorsal slit) is phimosiscongenital or acquired narrowing and constriction of the distal portion of the foreskin.
With newborns, you can never be sure if circumcision is essential since the future growth of the penis and prepuce usually provides adequate circumference of foreskin for easy retractibility, and only a percentage of boys or men develop phimosis and have to be circumcised.
Simple hygiene with soap water should prevent accumulation of foreskin secretions (smegma from which infection and ulceration can occur, and which can be factors in penile carcinoma, a rare disease.
Should we routinely remove appendices and tonsils because of the respective dangers of appendicitis or hypertrophy? I don't think so. Yet every GP or pediatrician will gladly perform circumcision.
Is it worth it?
I consider the advantages and disadvantages of routine circumcision rather marginal and the risk either of removal or of preservation of foreskin to be minimal. But many recent reports in medical journals stress that possible complications of this procedure (mutilation, haemorrhage, septicemia and neonatal sepsis) outweigh by far its possible advantages as a preventive measure.
While I don't remember having seen any of these complications in my 27 years of family practice, I probably did not associate some neonatal sepsis or severe, infected diaper rash with bacterial entry at the site of circumcision.
The history of these few millimetres of skin is utterly epochal and fascinating. Yet since this procedure in Canada rests mostly in the hands of family practitioners, we should try to restrict this practice by advising parents, rather than letting them decide in arbitrary fashion. To do that, we need a full awareness of the seriousness of complications as pointed out by cases our pediatricians describe.
T. L. FISHER, M.D.*
Canadian Medical Association Journal
Nov. 25, 1967, vol. 97, p. 1345.
More often than ever before, a doctor working in any field of medicine is liable to be or is hoist with his own petard; going or gone are the days when a doctor might comfort himself with the knowledge that if his treatment did no good it would at least do no harm. It is more than ever a truism that a doctor should never claim that anything he proposes doing to or for a patient is certainly effective or invariably safe. New methods of performing old procedures, though they be improvements, often seem to increase the risks of procedures sanctified by long usage and considered from time immemorial to be minor.
Circumcision is such a minor procedure. It is commonly effective and it is rarely harmful, yet complications can occur that produce bad results which range from wholly unimportant to catastrophic. One such bad result after a circumcision done by a doctor might have been tragic without the skilled help of some of the doctors' colleagues.
Some two or three years ago a doctor was consulted by an adult patient because of balanitis and phimosis for which circumcision was the only treatment that could reasonably be expected to be effective. The doctor advised it and the patient consented.
The doctor used the "sleeve" method in an effort to circumvent the thickened foreskin and the possible infection of the suture line postoperatively. What the "sleeve" method is has never been made clear. None of the consultants whose opinions were sought knew this method. They agreed only on one thing, that it would be their wish to be reminded never to use the method. The result was startling. So little skin was left that erection was painful, that with erections the penis was bent downwards and to the right, that ejaculation was blocked, that the scrotum was pulled forward, and that intercourse was not possible.
The patient's doctor referred him to a plastic surgeon who, when enough time had elapsed to allow subsidence of infection and inflammation, replaced some of the missing skin with a graft which, fortunately, took. There was marked improvement, but there still was undue tension with an erection. Two more small grafts were done, as office procedures. Final results were good; there was adequate tissue to allow normal erection and normal function.
The patient served notice early that he would be making a claim and that if settlement satisfactory to him was not reached he would bring legal action. Although it is a reasonable inference that the claimant's lawyer persuaded the claimant not to make his claim until the results of treatment could be known and tried to persuade him not to make an unreasonable claim, the patient seemed to regard the mishap as a heaven-sent opportunity to acquire a large amount of money. A fair settlement, therefore, was not possible and the claim had to be allowed to proceed to court. During trial the judge, in chambers, suggested to the doctor that it would undoubtedly be desirable if a settlement could be reached and to the plaintiff that he should be realistic in the amount of damages he sought.
The patient reduced the amount of his claim and settlement was made for $5000 inclusive of special damages.
*Secretary-Treasurer, Canadian Medical Protective Association, Ottawa, Ontario.