Monday, 11 April 2011

In Defense of Male Circumcision

Circumcision of the male refers to the surgical removal of the foreskin (prepuce) of the penis. A fifth of the world’s men – seven hundred million altogether – have been circumcised and in the time it takes to read this post a few hundred more will be added to the global figure. Some estimates go to as high as one third of the world’s population. For Muslims it is regarded as a Sunnah or even an obligation, and no further justification for the practice is necessary. We hear and we obey (Sami’na wa ata’na).

I just want to highlight, from the medical point of view, the health benefits of circumcision and dispel some of the perceived disadvantages or dangers. In the world at large, every segment of society has an opinion regarding circumcision. In the internet especially, there is a plethora of opinions against it, with websites showing gory pictures of the operation itself or of the complications arising from circumcision. These are from small but vocal groups and recent medical opinion has swung more and more in favour of circumcision after finding increasing evidence of its health benefits.

In the United States, the majority of male infants are circumcised for non-religious reasons. Overall male circumcision rates of up to 85 % have been reported in some studies. In a survey done in California, it was also found that parents of uncircumcised infants were more likely to be unhappy with their initial decision than parents of circumcised infants. In Britain, circumcision is less common, about a fifth of the population. Most male members of the royal family are amongst those circumcised, but Diana, Princess of Wales is said to have abandoned the practice when it came to her own sons. Nearer home, the majority of Filipinos have their male children circumcised, though as Christians, they are not required to do so on religious grounds.

Benefits
Circumcision has been associated with a quite a number of medical benefits such as lower rates of urinary tract infection (UTI), inflammation of the penis, penile skin problems, cancer of the penis and sexually transmitted infections.

Urinary tract infection in infants can result in bacterial infection which causes inflammation of the kidney and pelvis (pyelonephritis). This requires hospitalization and may lead to septicemia and death, though this is rare. In other cases there may be scarring of the kidneys and lifelong renal insufficiency. Studies consistently show that circumcised male infants have significantly fewer UTIs than uncircumcised (3 to 12 fold higher). Adult circumcised men also have a lower rate of UTI than uncircumcised men.

The risk of getting penile cancer (squamous cell cancer) is three to six-fold higher in uncircumcised men. Circumcision also reduces the risk of the sexual partner from cervical cancer. Women who have sex with uncircumcised men increased their risk of cervical cancer four fold. Case control studies have also suggested that circumcised men have a lower rate of prostate cancer than uncircumcised men.

Inflammatory disorders of the penis (meatitis and balanitis) are extremely rare in circumcised men and are commoner in the uncircumcised. So is balanoposthitis, an inflammation of the glans and foreskin with pus which usually requires surgical intervention.

Uncircumcised men are also at a greater risk of acquiring sexually transmitted infections. This is because the warm, moist environment under the foreskin provide more favourable conditions for infection. It may be argued that having a low number of sexual partners and consistent and correct use of condoms are more important preventive measured, but unfortunately, there is no evidence that any public health or educational programme has had any impact on the hygienic practices of adolescent or adult males. There is strong evidence that circumcision protects against acquisition of aids, human papilloma virus (which predispose to cervical cancer) and trichomonas but not gonorrhea or syphilis. Circumcision significantly reduces HIV (AIDS) infection because the inner aspect of the foreskin appears to be richer in cells with HIV-receptors than the head of the penis (glans) .

In those parts of Africa where there is a lack of uncircumcised men, the spread of AIDS has been facilitated considerably. The World Health Organisation has recommended that circumcision be considered as part of a comprehensive HIV prevention programme.

Women can benefit from male circumcision as well. It has been found in a randomized trial that partners of circumcised men had lower rates of genital ulceration, trichomonas infection and bacterial vaginal infection than partners of uncircumcised men. The possible explanation is that circumcised men are more resistant to infection/colonization with these organisms, or that the circumcised penis is less likely to transmit these harmful organisms.

Complications and Risks
The risk of complications arising from circumcision done in a proper clinical setting is approximately 0.2 to 0.5%. Most problems like bleeding and local infection is easily treatable with no long term effects. Unsatisfactory cosmetic results like too much or too little skin removed has also been reported. Rare complications include life-threatening sepsis or death, buried penis and amputation of the head of the penis. Obviously having it done by a competent and experienced person reduces the risk of complications considerably.

The foreskin contains specialized sensory mucosa and some studies suggest that if it is removed during circumcision, sexual sensation may be decreased. However, most circumcised males do not experience decreased sexual function or sensation as a result of the procedure. I have also done thousands of circumcisions on adult males and the general impression on questioning the patients is that there is no decrease in pleasurable sensations and some even report an improvement. Their sexual partners were also not affected and most women preferred the cleanliness after circumcision. Elsewhere, surveys have also shown that American women still claim to find a circumcised organ preferable on aesthetic grounds. This in no small way perpetuates the popularity of circumcision in America.

Conclusion
The benefits of circumcision include reduction in the rates of urinary tract infection, penile cancer, some sexually transmitted disease, penile skin infections and inflammation as well as easier hygiene. Female partners of circumcised men also benefit by reduction in cervical cancer and acquisition of some sexually transmitted infections. These benefits, it must be emphasized, extend over a lifetime and far outweighs the potential risks of the circumcision procedure which are often short term.

References are too many to list but are available upon request.

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