Sunday, July 22, 2007

What other benefits does male circumcision confer?

Before the emphasis becomes solely fixed on the HIV protection it may be good to summarise the other benefits which accrue through male circumcision.

Below is a letter listing these benefits and challenging the Australian RACP to review and update their policy with regard to neonatal male circumcision.

RACP's policy statement on infant
Male circumcision is ill-conceived


Objective: To conduct a critical peer-review of the 2004 Policy
Statement on routine male circumcision produced by the Royal
Australasian College of Physicians ( RACP).

Method: Comprehensive evaluation in the context of the research field.

Results: We find that the current Statement downplays the wide-ranging
life-long benefits of circumcision in prevention of urinary tract
infections (UTls), penile and cervical cancer, genital herpes and
Chlamydia in women, HIV infection, phimosis and various penile
dermatoses, and at the same time overstates the complication rate. We
highlight the many errors in the RACP Statement and note that it
sidesteps making a conclusion based on circumcisions well-documented
prophylactic health benefits by instead referring to the status of the
Foreskin at birth. In the era of preventative medicine we view this as

Conclusion: The RACP's Statement on routine male circumcision is not
evidence based and should be retracted.

Implications: In the interests of public health and individual
well-being an extensive, comprehensive, evidence-based revision should
be conducted so as to provide scientifically accurate, balanced
information on the advantages, and also the low rate of mostly minor
complications, associated with this simple procedure, which for
maximum benefits and minimal risk should ideally be performed in the
neonatal period.

(Aust NZ J Public Heath 2006 30: 16-22)

Brian J. Morris
School of Medical Sciences and Institute for Biomedical Research,
University of Sydney, New South Wales

Stefan A. Bailis
Research and Education Association on Circumcision Health Effects,
United States of America

Xavier Castellsague
Servei d'Epidemiologia i Begistre del Cencet, lnstitut Catah d'Oncologia
UHospitalet de Llobregat, Spain

Thomas E. Wiswell
Department of Paediatrics, State University of New York, United States
of America

Daniel T. Halperin
AIDS Research lnstitute/Center for AIDS Prevention Studies,
University of California, United States of America

The Royal Australasian College of Physicians (RACP) Division of
Paediatrics & Child Health (formerly the Australian College of
Paediatrics [ACP]) has produced a Policy Statement on circumcision in
which the summary states (in bold) that "there is no medical
indication for routine male circumcision", i.e. the foreskin of an
infant as it presents at birth has no medical condition that would
mandate its removal." This is often misinterpreted by professional and
lay bodies as saying that the RACP is opposed to circumcision. An
"appeal to authority"' may be the only position they might fall back
on, given their lack of training or time to study the evidence.

Other, now somewhat dated, position statements on circumcision by
paediatric bodies elsewhere have similarly been criticised by academic
experts, including in the case of the American Academy of Pediatrics
(AAP) Statement the former Chair of the AAP Task Force on Circumcision.

The RACP Statement is marred by references to opinion pieces by
extremist anti-circumcision organisations. As an example, in section
2, in the same sentence it lumps misconceptions from Victorian times
in with recent hard scientific evidence, referring to the latter as

When the Statement says that it concurs with a previous conclusion by
the ACP it should be recognised that the 1996 ACP Statement was a
substantially watered-down document emanating from a credible review
of the medical by a working party which reported in 1995 emphasising
the considerable medical benefits at the time in a fair and balanced
manner. In the decade since this somewhat neutral statement the
evidence in favour of circumcision has continued to increase. Yet in
its next Statement in 2002, the RACP failed to address this
adequately, and very few of our substantive criticisms to the RACP
were addressed in devising its 2004 Statement, which remains a non
peer-reviewed internet document.

In this article, we point out the multiple errors in the current
Statement, many of which have serious public health ramifications.

Cervical cancer

A large international collaborative study confirms the lower incidence
of cervical cancer in women with a circumcised male partner. Although
monogamous women whose male partners had six or more sexual partners
and were circumcised had a [5.6-fold] lower risk of cervical cancer
than women whose partners were uncircumcised, the Statement neglects
to mention that women whose partner had an intermediate sexual
behaviour risk index were also protected (OR 0.50). In an accompanying
editorial it was suggested that these findings were probably an
underestimate of the true risk to women.

The RACP Statement goes on to recommend use of condoms in lieu of
circumcision "to inhibit sexual transmission of HPV" (the Causative
agent), despite there being no significant difference in Protection
against cervical cancer between condom users (OR 0.83) and non-users
(OR 0.67). Hunan papillomavirus (HPV) is a highly infectious skin
virus transmissible during foreplay. A more specific study on condom
use per se is, nevertheless, needed.

When the Statement mentions an "increased risk of [HPV] infection in
uncircumcised men who indulged [!] in high-risk [?] behaviours" it may
be referring to uncircumcised men who don't use condoms or perhaps men
who have had sex with more than one woman in their life, either
concurrently or sequentially. The latter casts normal men as
'high-risk', which is unreasonable.

The Statement's speculation on future immunisation against HPV is
premature, despite recent success in Phase III trials of HPV16 and
HPVl8 vaccines. Fifty of the 200 types of HPV are ano-genital.
Although vaccination against the 8 most common is predicted to prevent
89% of cases [XC, unpublished], vaccination could lead to their
replacement bt rarer types not vaccinated against. Vaccination has to
occur prior to sexual debut, and availability, cost, or extent of
participation may also limit effectiveness. HPV vaccines can,
moreover, increase tumour invasiveness.

Herpes and Chlamydia in women

History of intercourse with an uncircumcised man ( ever) is also a
risk factor for herpes simplex type 2 infection in women (OR 2.2, 9 5%
CI 1.4-3 6), and Chlamydia trachomatis (OR 5.5, 95% CI 1.7-20).


The RACP Statement dismisses universal neonatal circumcision as an
AIDS prevention strategy in countries like Australia, saying that
circumcision to reduce transmission is more relevant in Third World
countries. Although lower, lack of circumcision is likely to account
for at least some HIV infections in Australasia. Moreover in a highly
mobile global society, risk cannot be ascribed parochially. In
contrast to what the RACP Statement asserts, the role of the foreskin
in HIV transmission is now compelling. This includes a detailed
meta-analysis, fastidious matching of case and control groups to
eliminate confounding factors, absolute protection in a 30-month study
of men with an infected female partner, 6.7-fold reduction in adjusted
relative risk (0.14; 9 5% CI 0.04-0.62) in another, in agreement with
the 8.2-fold reduction seen in an early prospective study, and
biological data showing that the inner, mucosal lining of the
foreskin, unlike the outer layer and rest of the penis, lacks a
protective keratin barrier, meaning that, for an otherwise healthy
penis, the foreskin is the route of infection of HIV which has been
demonstrated to accumulate rapidly in the abundant Langerhans and
other immune system cells in the inner foreskin epithelium. A Cochrane
review recommended waiting for the outcome of three randomised,
controlled trials. The first results from one of these showed a 76%
reduction, i.e. was more effective as any hoped for HIV vaccine.

Condoms, when always used, reduce infection by about 80-90%. Although
important, they are far from a panacea for HIV prevention and the
foreskin can be exposed to infected fluids prior to condom
application. This also applies to homosexual men, who engage in
'docking',' a source of sexual pleasure rendered impossible by

Since heterosexual transmission was the initial, and still is the
major, mode of transmission world-wide, lack of circumcision would
appear to be a major contributing factor to the AIDS epidemic. Even
though other modes of transmission have taken over in the west,
heterosexual transmission to the male may be reduced by lowering
foreskin prevalence among men, many of whom will visit countries in
which HIV abounds. Moreover, in some, but not other, studies the
effectiveness of circumcision in AIDS risk reduction was greater when
performed prior to puberty or sexual debut.

Penile cancer

The RACP Statement makes penile cancers seem much rarer than jt really
is - to wit, its citing of annual incidence rates of penile cancer of
1 in 100,000. The annual incidence of fatal heart attack -200 in
100,000 also seems small, yet it accounts for 22% of all deaths.
Actual lifetime risk of penile cancer in an uncircumcised man is 1 in
400 to 900, as in Australia. It represents 1-2% of cancer deaths in
men in developed nations and 10-22% of all male malignancies in some
developing countries. Presentation is split equally between carcinoma
in situ and invasive penile cancer. The latter is lethal and the RACP
Statement fails to point out that its incidence is 22 times higher in
uncircumcised men. Notably, men circumcised early in life are afforded
greater protection than if circumcised in adulthood. HPV is the
culprit in basaloid and warty carcinomas, most of which are HPV
positive. Similarly half of all vulvar carcinomas are HPV-positive
(cf. the 99.7%' HPV positivity in cervical cancer).The rate of HPV
infection is, moreover, lo er in circumcised men (OR 0.37). High-risk
HPV is found more frequently in verrucous carcinomas than giant
condylomas (which are caused by low-risk HPV) and keratinising and
verrucous carcinomas are HPV positive in one-third of cases.

As is the case for breast cancer, the sex-related organ is often
surgically removed, so adding to the devastating physical and
emotional impact of penile cancer. And the five year survival rate is

Prostate cancer

The lifetime risk of prostate cancer is 1 in 11 and not mentioned in
the RACP Statement, it is twice as common in uncircumcised men.

Urinary tract infections

In contrast to what the RACP Statement says, infections of the urinary
tract are regarded as common in the paediatric population. Rather than
the increased rate in uncircumcised boys being 3-12 fold it is really
5-89 fold (95% CI 11-14), averaging 12-fold in a large meta-analysis.
The RACP's underestimate (' 5-fold') arises from inappropriate
averaging of small and large studies.

The >90% effectiveness of newborn circumcision in preventing UTI makes
it as protective as vaccination of children in disease prevention.

By way of biological support, the strains of Escherichia coli and
Proteus mirabilis present are fimbriated, which facilitates their
adherence to the inner lining of the foreskin and subsequent colony
formation; these are pathogenic to the urinary tract and
pyelonephritogenic. Pathogenic bacteria were found in the periurethral
region of 64% of boys, without phimosis, prior to circumcision, but in
only 10% 4 weeks afterwards; for the glanular sulcus these figures
were 68% and 8% respectively. This study concluded that the
periurethral flora originate from deeper preputial regions and
emphasised the beneficial role of circumcision.

The RACP Statement says UTI incidence in uncircumcised boys is 1-2%.
It then presents a trade-off analysis using the lowest end of this
range (l%) against an inflated figure for serious complications
(haemorrhage and infections) of 2% to say there would be 2.5
complications for every UTI prevented. However, more credible analyses
involving 100,000 and 325,297 US male infants each found the
complication rate was 0.2%.

The latter then calculated that 6 UTIs could be prevented for every
circumcision complication. The RACP Statement cites this reference,
but not these data, merely saying that "other figures can be used to
come to a different conclusion".

A study in western Sydney by the Statement's co-author J.C. noted a
UTI rate of 6% in uncircumcised boys aged 0-5 years.

The RACP Statement does not mention that the highest prevalence and
the greatest severity of UTI' is prior to six months of age. It is,
moreover, misleading for their Summary to state that, "In Australia
and New Zealand the circumcision rate has fallen considerably in
recent years and it is estimated that currently only 10-20% of male
infants are routinely circumcised. In reality, the fall from 90% to
10% took place 30 years ago and is now reversing. Medicare statistics,
which relate only to rebate claims for circumcision, and are thus
underestimates, show a circumcision rate of 17% Australia-wide,
implying an actual rate higher than this. For boys aged <6>100: l. Even more
when conditions caused in women are taken into account.


The RACP Statement cites a rate of circumcision in the USA of 60%,
whereas National Center for Health Statistics (NCHS) data for the past
20 years exceed this value, the most recent being 65.3%. NCHS figures
are based on hospital records, but many US hospitals do not record
circumcisions. Moreover, the rate amongst the traditionally
non-circumcising Hispanic groups is increasing (not decreasing as the
Statement asserts in section 2) as subsequent generations adopt local
practice. Among Anglo-Celtic whites and blacks the rate is close to
90%, any lower overall figure being a dilutional effect o Hispanic,
Asian and European immigrants. Moreover, the newborn rate is
increasing by 6.8% per year in the US.

In the UK, a rate of 6% is suggested. However, publications give:
7-10% for boys aged <15 n =" 1,874,">6 months there
were 5,455 claims, of which 2,064 were for boys aged 6 months to 4
years. Thus most involve younger infants. As stated earlier, the
actual rate is higher than Medicare claim data. Only physical
examination would reveal this. Doing so in adults showed 62% of
attendees at Sydney STI Centre were circumcised being similar in older
and younger men. In Adelaide rate was 63% and 55%, respectively in
each, and in Dunedin was 40% in a 1973 birth cohort. Moreover, in
contrast to the comment in the RACP summary it is for religious
reasons in only 3% of cases.

Although the RACP Statement mentions that either a local or a general
anaesthetic can be used, it fails to alert the reader to the latter
being the norm after 6 months of age. Thus risk from general
anaesthetic must be emphasised should circumcision be delayed.


Curiously, even though circumcision in the newborn period is more
common than later, the Statement only discusses the free-hand or
sleeve-resection technique used in older children – including mention
of sutures, blood vessels, etc. It is imperative that the relatively
easy methods used for newborn circumcision are included, i.e. the
Plastibell, Gomco and Mogen procedures. Training in these, as well as
safe, easy, effective local anaesthetic methods involving EMLA cream,
dorsal penile nerve block or ring block is imperative. Vigilance for
abnormal anatomy or bleeding disorders, necessitating referral to a
paediatric urologist, should also be mentioned.


The RACP Policy Statement on circumcision is marred by many serious
errors. Far more accurate accounts can be found in recent extensive
reviews and credible websites such as by the former AAP Task Force
Chair. There are so many benefits of circumcision that the RACP should
be taking a leadership role in promoting awareness of these, as well
as fostering good surgical technique in conjunction with the RACS.
Just as with childhood immunization there is an overall benefit to
public health and individual well-being accompanied by a very low risk
of any serious adverse consequence (Table 1). Parents also have a
legal right to authorise it.

Thus, to summarise the RACP's "Where we stand: Paediatric policy on
circumcision is misleading, inaccurate and, in places, incorrect. It
amounts to thinly disguised propaganda. A new Statement that has as
its basis evidence-based medicine, not lip service to the same, needs
to be produced as a matter of urgency to assist medical practitioners
in giving accurate advice to parents, as well as in clinical
decision-making. The Statement should contain a conclusion that we the
authors see as being in harmony with the medical literature: "The net
benefits of routine infant male circumcision in prevention of a wide
range of medical and health problems over the lifetime, together with
the small risks associated with this procedure should be explained by
medical practitioners to all parents of infant boys in order to assist
them in arriving at an informed decision about what is best for their
newborn son".

Table 1 can not be included in this document to read it see at: