|Circumcision and infectious diseases revisited|
Robert Van Howe dissects Gerald WeissThis is pediatrician Robert Van Howe's reply to G.N. Weiss's bizarre outburst, "Prophylactic neonatal surgery and infectious diseases", Pediatric Infectious Diseases Journal, Vol. 16, 1997, pp. 727-34
Circumcision and infectious diseases revisited
Robert S. Van Howe MD
(Department of Pediatrics, Marshfield Clinic-Lakeland Center, Minocqua, WI.)
Accepted for publication Oct. 24, 1997.
Address for reprints: Robert S. Van Howe, M.D., Marshfield Clinic-Lakeland Center, 9601 Townline Road, P.O. Box 1390, Minocqua, WI 54548. Fax 715-358-1156
Pediatric Infectious Diseases Journal, Vol. 17, January 1998, pp. 1-6
The role of the prepuce in infectious diseases
Revising history to support a modern agenda
Relying on the standard circumcision myths
Where are the primary references?
The recently published Opinion and Analysis piece by Gerald Weiss  invites rebuttal. On the basis of his previous publications, Weiss is unabashedly pro-circumcision. [2-4] He has made unsubstantiated claims in the past and as recently as 1994 still believed that neonates do not feel pain. [2, 5] Although Dr. Weiss is entitled to his viewpoint, the editorial structure of well-respected and mainstream medical journals such as The Pediatric Infectious Disease Journal should permit factual refutation of what I believe are the many erroneous statements and assumptions in Weiss's article.
HyperboleThe opening paragraph by Weiss, pointing out the prevalence and mortality of infectious diseases, has very little to do with infectious diseases involving the penis. He tries to create an urgency to intervene where no intervention is needed. To make this argument cogent, he would need to demonstrate that the penis is a common focus of serious infection and disease. He never does. While "half the people on this globe live in fear of plagues," only a small percentage of males ever have penile-associated infections.
Weiss describes the preputial cavity as a "cesspool," demonstrating his ignorance of this cavity. The wetness found in this space is made up of prostatic, seminal vesicular and urethral secretions. The prostatic and seminal vesicular secretions are rich in lytic material, which have an immunoprotective function.  Weiss mentions Tyson's glands, which we today know do not exist, [7-11] and propagates the notion that a male with a foreskin must clean his preputial cavity at least three times daily or have odoriferous consequences.  Actually the penis with a foreskin can be self-cleaning with micturition, because sterile urine flushes out the preputial cavity before the urine is eliminated.  Weiss repeatedly refers to "the foreskin allowing for a pooled pocket of infected water to harbor" various pathogens. There is no research to support such a claim. The normal newborn phallus is equipped with a prepuce that contains smooth muscle arranged in a whorled pattern near the tip that acts as a muscular one-way valve, which allows urine out, but does not allow contaminants in. [12, 13] This pattern of smooth muscle fibers gives the distal infant prepuce its typical puckered appearance. Attempts to retract the prepuce prematurely violate the integrity of this natural valve and allow the influx of bacteria. While Weiss et al.  failed to find Langerhans cells in the mucosa of the newborn prepuce, these immunoprotective cells are present in older males.  Because boys are born with the preputial mucosa and the penile glans mucosa fused and because the uterus is a sterile environment, immunoprotection is initially not an issue at this location.
The role of the prepuce in infectious diseasesAlthough Weiss is correct in pointing out the role of human papillomavirus (HPV) as an etiologic factor in the development of genital cancers, he fails to point out that circumcised males are significantly more likely to have genital warts [16, 17] or that the foreskin is not a factor in other clinical HPV-associated lesions.  Citing a 1947 paper as evidence that horse smegma was carcinogenic in mice, he ignores the studies that attempted to replicate this result and failed, [19-21] or that horse smegma differs significantly from human smegma.  Intuitively it does not make sense that a natural body secretion produced in normal amounts would be carcinogenic. The rate of collected smegma in the preputial cavity is low, given that only 6% of men with preputial stenosis have collected smegma.  If smegma were carcinogenic, one would expect men circumcised later in life to have lower rates of penile cancer than those never circumcised, but several studies have demonstrated the opposite. [24-26] Although several studies have suggested a role of "phimosis" in the development of penile cancer, [24, 26-28] until a clear definition of phimosis emerges it is difficult to interpret this finding. Eighty percent of patients circumcised for phimosis have normal histology. [29-34] It is difficult to hypothesize how the removal of histologically normal tissue can lead to later malignancy. The remainder have balanitis xerotica obliterans, the cancer potential of which is unclear. [30, 35] Of the etiologic factors for penile cancer, smoking [26-28] and HPV infection [26, 27] emerge as the greatest risk factors, not the prepuce.
Perhaps the most egregious and potentially damaging statement made by Weiss is, "No patient circumcised at birth in the United States has been reported to have developed carcinoma of the penis." There have been at least 39 such cases reported in the medical literature and untold cases that have gone unreported. [26, 36-50] Weiss listed a study with 22 such cases as one of his references,  demonstrating his unfamiliarity with the materials cited.
The author provides a laundry list of infections and problems prevented by neonatal circumcision without providing any supporting evidence. The entire premise of the article rests on the notion that neonatal circumcision has a prophylactic benefit in preventing infectious diseases. A careful review of the medical literature demonstrates that it does not. Although some studies have found that circumcision lowers the incidence of urinary tract infections, significant factors such as rooming-in,  breast-feeding, [52-54] parental education and social status, hygienic practices, [55-58] race, [59-61] urine collection method  and diagnostic criteria  have never been controlled for. Any one of these factors could explain the less than 1% difference in urinary tract infections between boys with and without a prepuce seen in these studies. More importantly the incidence of asymptomatic bacteriuria is between 0.7% (95% confidence interval, 0.2 to 1.64%)  and 2.0%.65 This rate of "background noise," which is nearly identical with the urinary tract infection rate in non-circumcised boys, makes assessment of the significance of these findings difficult. Hoberman and Wald  found that in the absence of pyuria, a positive urine culture most likely represents incidental bacteriuria. Nearly one-half of the infants diagnosed with urinary tract infection in past studies did not have pyuria, [66-68] implying that all of these studies are either invalid or require reanalysis.
There is strong evidence in four studies from Israel that neonatal circumcision increases the incidence of urinary tract infection. [69-72] A prospective study of 603 non-circumcised Japanese boys failed to find any urinary tract infections where 6 to 24 would have been expected.  Based on this, it is unclear whether the foreskin has a prophylactic effect on urinary tract infection.
Although it has been speculated that circumcised males are less likely to develop sexually transmitted diseases, five studies in the past 5 years have found circumcised males to have an overall greater incidence of sexually transmitted diseases. [16, 74-77] Likewise previous studies have found no difference in the rates of penile infection or inflammation between males with and without foreskins, [78-79] but comparison of data from prospective studies [73, 80] strongly suggests that young circumcised males are more likely to develop balanitis. This has also been demonstrated in adults.  Finally the data regarding HIV infection have been inconsistent, but large random cross-sectional studies, which have the least degree of bias, have found that circumcised men are more likely to develop or transmit HIV infection. [77, 82-85]
Surgical prophylaxisThe lamentations of Weiss over Americans' reluctance to circumcise are misplaced. The current rate of neonatal circumcision continues to be more than 90% in the midwest. [80, 86] Weiss blames the separation of church and state for the lack of acceptance of "medical" circumcision in the United States. This does not explain why in Europe, where state religions are the norm, circumcision rates approach zero, with no measurable difference in penile problems.
He bemoans our inability to embrace the surgical prophylaxis concept but fails to note that no one is willing to initiate surgical prophylaxis unless there is a compelling risk or medical factor. Indeed the only exception to this is the American fixation with altering male genitalia.  Recently the value of prophylactic oophorectomy and mastectomy in women with genetic mutations of BRCA1 and BRCA2 was evaluated. Although removal of the breasts and ovaries at 30 years of age in women without increased risk would increase life expectancy by an average of 8 months, the authors concluded that "Prophylactic surgery is obviously unreasonable for these women." Removing healthy tissue in women at increased risk is considered a "highly personal decision" made only after clear discussion of the effects of prophylactic surgery on medical outcomes takes place. 
When the cost utility of neonatal circumcision is calculated, it has an overall negative effect on health  or little effect at all.  All analyses published have found neonatal circumcision to be cost-ineffective. [90-92]
Strabo, the 1st century B.C. Greek geographer, documented that Jews circumcised girls as well as boys.  If the Egyptians were right about the males, they might also be right about the females. Because females have a greater incidence of fungal infections, urinary tract infections, genital cancers and smegma production, they are more likely to benefit from prophylactic surgical alteration of their genitalia than are males.
If Weiss is truly interested in expanding the surgical prophylactic paradigm, a number of other possibilities exist. All breast tissue can be excised from males at birth. More men die of breast cancer than penile cancer  and breast tissue has no useful purpose in males. The left testis can be removed at birth, cutting the incidence of testicular cancer and testicular torsion by more than half. Toenails can be unsightly and can ingrow and become infected, so they too should be dispensed with. All of these would decrease disease risk without altering function: which is Weiss's stated goal. To paraphrase Weiss's hero, John Arderne, "What's holding us back? This will help people!"
Revising history to support a modern agendaMost of Weiss's paper is taken up with a justification that the ancients instituted circumcision for its health benefits. There is no direct evidence that this occurred. To make his case Weiss cites a number of speculative pieces written around the turn of the century. During that era the medical profession was promoting circumcision as a preventive and treatment for masturbation, which was thought to be the source of a long list of maladies.  To convert circumcision from a religious blood ritual to a medical practice, many physicians were compelled to speculate that circumcision had a medical intent since its inception. When one looks at the primary sources, there is no evidence that it does. Although both the Old and New Testaments make numerous references to circumcision, none relates to health. In keeping with this Rabbi Moses Maimonides (1135-1204), the famous physician and philosopher, does not mention any medical purpose to circumcision, although he was 800 years closer to the source than any 20th century speculators. The only benefit Maimonides could find for circumcision was that it weakened the penis and made men more temperate sexually. He stated that the non-circumcised penis was so sexually superior that if a Jewish woman had intercourse with a non-circumcised man, she would not separate from him.  By contrast American women have little chance of having intercourse with a complete penis.
Relying on ancient scholars such as Philo of Alexandria (1st century A.D.)  and Herodotus (ca. 484 to 425 B.C.)  is ill-advised because their writing represent opinions and impressions from an era that predates the development of the scientific method.
Wallerstein points out four elements of circumcision that suggest that it was never thought of as a medical procedure.
(1) If a child dies before it is 8 days old, the corpse must be circumcised before it can be interred in a Jewish cemetery. The ritual takes place at the cemetery, just prior to burial. (2) If a child is born without a foreskin or if no blood is shed during circumcision (both exceedingly rare occurrences), a drop of blood must be drawn from the glans as a symbolic circumcision. (This is known in Hebrew as hatafath dam berith.) The nicking of the glans may be done "with a knife, a needle or even the sharpened fingernails." (3) Such a symbolic circumcision is also performed when a convert to Judaism has been previously circumcised. Reform rabbis have tried to abolish this practice. (4) Up to a century or two ago, the linen cloth used in circumcision, presumably stained with blood, was retained and exhibited at the boy's Bar Mitzvah and wedding as proof of his circumcision. 
Although Jews have been reassured and comforted by attempts to attribute health benefits to the rite, it is purely a religious exercise. The Jewish practice influenced non-Jewish acceptance of circumcision, which reinforced the Jewish ritual.  Erich Isaac stated, "Its presumed medical and physiological advantages are said to be at best unproven and at worst illusory." 
The section on schistosomiasis is irrelevant and unfounded. The author admits that there have been no studies linking the foreskin to schistosomiasis. Weiss makes the assumption that circumcision was a health measure before it was transformed into a religious blood ritual. To make this statement convincing, he needs to demonstrate that the ancient Egyptians had the wherewithal to notice the small differences in health between men with and without foreskins that we have not been able to document consistently in the modern era. If it was a health measure, why is there no documentation of it as such? Why should we consider circumcision "surgical prophylaxis" in the ancient setting when no one at the time thought of it as such? Making the leap from the Egyptian Code of Cleanliness to ascribing a medical significance to a blood ritual is unfounded historically and scientifically. Weiss's reasoning then takes a circular turn. After assuming that the Egyptians instituted circumcision as a medical intervention, he uses this "fact" to prove that circumcision had medical origins.
There are several historical facts inconsistent with Weiss's interpretation that he fails to address. It is not clear from the Bible whether Moses was circumcised. Some have speculated that the reason Zipporah circumcised their son was that Moses was not circumcised and like most genitally intact males did not want his son circumcised. [101-103] If Moses had been circumcised on the eighth day, he would have been killed by the Egyptians instead of being allowed to be raised in the palace. Speculating that Abraham had preputial problems that affected his ability to procreate is inconsistent with his siring Ishmael.
The ritual cutting as begun by Abraham was markedly different from what is performed today. Originally the operation consisted of cutting off only the very tip of the prepuce. This fact seriously undermines Weiss's speculation about decreasing the amount of mucosa through which schistosomes could pass. This practice persisted until the Hellenistic period (ca. 300 B.C. to 1 A.D.), which may explain why David, as depicted by Michelangelo, has most of his foreskin. To fit in with the Greeks, Jews obliterated the evidence of their circumcision by blistering the tip of what remained of their foreskin to enlarge it. This practice became so popular that the rabbinate altered the surgery to make it impossible for a circumcised male to appear non-circumcised. Thereafter the entire foreskin was to be ablated, and the inner lining and frenulum excised by the mohel's fingernail, specially sharpened for this purpose. The next change, Metzitzah, occurred during the Talmudic period (ca. 500 to 625 A.D.) and consisted of moistening the lips with wine and taking the bleeding penis into the mouth and sucking the blood.  If circumcision was seen as a health measure, why were these unsanitary elements added?
If Weiss wishes to be taken seriously, he needs to address these issues and attempt to refute them.
Relying on the standard circumcision mythsWeiss would like to blame operator inexperience for the horrific complications of neonatal circumcision. Although many have expressed this opinion,  it has never been proved. To the contrary a retrospective study found no difference in complication rates seen among physicians of differing experience levels. 
"Speed is essential in eliminating pain," is also espoused by Weiss. Nothing eliminates the pain of neonatal circumcision.  A poster presentation has suggested that crying is decreased when the Mogen clamp is used,  but the adhesions still must be broken, and postoperative pain has yet to be addressed adequately.
Weiss, citing a number of opinion pieces, states that later circumcision has increased mortality and morbidity than neonatal circumcision. This is not true. Reported retrospective complication rates include 2.0%,  3.1%  and 6.4%.  The only prospective study documented hemorrhage after 9.9% of neonatal circumcisions.  These rates are higher than those documented in retrospective studies of circumcisions performed later in life (1.7%). [111, 112]
Where are the primary references?An examination of the references used by Weiss is revealing. Of the 91 references cited 27 were pro-circumcision opinion pieces, 17 were textbooks(mostly outdated) and 12 were secondary articles. The 5 World Wide Web sites Weiss refers to cannot be considered serious resources. The majority of the citations are more than 10 years old. More than one-third are from before 1980. Instead of citing ancient sources, turn-of-the-century opinion pieces are used. The standard for review articles is to avoid citing opinion pieces, review articles or textbooks. Readers should expect review articles to be written by knowledgeable individuals who have taken the time to research primary sources of information.
ConclusionWeiss is correct. Schistosomiasis, HPV and HIV do have something in common: none has been clearly shown to be reduced by circumcision. A careful examination of the medical literature would have revealed his faulty premise. He never establishes the premise that circumcision is effective or that any of the ancient authorities considered circumcision to be medical. He fails to acknowledge or address dissenting information. His arguments are disjointed, illogical and difficult to follow. For these reasons it is very difficult to take his call for neonatal prophylactic surgery seriously.
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