Abstract
Male circumcision has confirmed health benefits. Male circumcision also affects health of women. The discussion of male circumcision should be scientific, not emotional. Studies do clearly indicate that male circumcision has essential health benefits. Circumcision/genital mutilation/cutting of fe-males is harmful and globally condemned.
Introduction
Contemporary research
Current research strongly indicates that male circumcision has health benefits. We Jews circumcise only our sons – we are firmly against female genital mutilation/cutting/circumcision. In a personal communication to me (2016), Harald zur Hausen (Medicine Nobel Prize 2008) states that the effect of male circumcision in protecting against sexually transmitted diseases (STDs) is at best moderate. Morris et al. [1] evaluated in their systematic review 140 published relevant papers regarding early infant male circumcision – the risks versus the benefits. Early infant male circumcision protects against urinary tract infections (UTIs), phimosis and painful erections. It is also protective against inflammatory skin diseases as well as sexually transmitted infections (STIs) in females and in males. Infant male circumcision has a protective effect against cancer of the cervix, penile cancer and cancer of the prostate gland – it improves penile hygiene.
The Second Vatican Council has stated that God’s agreement with Jews is in effect and has never been cancelled – it does include circumcision of infant males which is not condemned as genital mutilation. Current research indicates that infant male circumcision gives benefits of health. (Jones 2018). According to Schenker (2018), circumcision of males is executed for religious and medical grounds – it could cut the heterosexual transfer of human immunodeficiency virus (HIV) infection by more than 60%. This very fact has been confirmed in several studies. It is calculated that Operation Abraham is able to prevent at least 500,000 cases of HIV infections in Africa by the year 2030. In sub-Saharan Africa, a multinational programme intends to circumcise 27 million men by the year 2021 – in this effort Israel is co-operating with Senegal and South Africa. Voluntary medical male circumcision is a highly imposing operation in order to globally stop HIV infections.
Human papillomavirus (HPV) and male circumcision
General considerations
Castellsagué et al. [3] underline that male circumcision is linked to a decreased risk of HPV infection of penis and also to reduced risk of cervical cancer in the female sexual partners of the men in question. The role of HPVs in the development of anogenital cancer is discussed in detail in the exceptional 2011 book of Harald zur Hausen [4]. This volume has a very special place in my personal collection of medical writings. In Sweden, I confered with Harald about HPV infections and their complications. His knowledge in this important subject has been many years highly impressive. Morris et al. [5] do refer to the statement of the Cancer Council of Australia on infant male circumcision and prevention of cancer. The encouragement of HPV vaccination of boys as well as male circumcision will together maximise the prevention of genital cancer. Li (2017) discusses HPV infection as well as male reproductive health. The author states that this very infection is globally one of the sexually transmitted diseases (STDs) existing in genitalia of both women and men. The author also writes that male HPV infection is linked to tumours in the reproductive organs, infertility and infection in sexual partners. Male circumcision, the use of condoms as well as fewer sexual partners are essential steps in order to fight HPV infections. The systematic review and meta-analysis of Zhu et al. (2017) including 30 published papers does indicate that male circumcision cuts the prevalence of genital HPV infection. Wei et al. (2018) evaluated the effect of male circumcision on the natural history of HPV infection in genitalia. The authors found that the clearance of HPV infection in 113 circumcised men was significantly higher compared to 560 uncircumcised ones. All the patients were followed up two times – the interval of the investigations was six months. During the examination, genital specimens were picked up as well as typed for HPV DNA.
Penile intraepithelial neoplasia
HPV DNA is found in 70 to 100% in cases of penile intraepithelial neoplasia – infant male circumcision decreases the risk of penile cancer 3-foldly (Dillner et al. 2000). Wollina et al. (2018) do describe a case of phimosis with penile carcinoma in situ in a 68 years old man. The patient was treated with success by using circumcision.
Self-testing & low-risk HPVs
I discussed [6] HPV self-testing in 2008 and in the year 2013 the low-risk HPVs in the development of malignant tumours in the anogenital tract five years later. The above paper of Zhu et al. (2017) regarding male circumcision is highly important.
Human immunodeficiency virus (HIV) and male circumcision
The 2007 declaration of World Health Organization (WHO)
WHO supports male circumcision in order to prevent HIV infections – to be uncircumcised is a risk factor.
The statements of Glick & the Tobian team
Glick (2013) underlines that controlled investigations show the significant health benefits of infant male circumcision in reducing the number of HIV infections. Tobian et al. (2014) point out that male circumcision is an underutilised method in order to prevent sexually transmitted infections (STIs). In an earlier paper (2010), Tobian et al. stated that circumcision of infant males did cut the acquisition of HIV by 53–60% – as well as the prevalence of human papillomavirus (HPV) by 32 to 35%.
HIV in sub-Saharan Africa
George et al. (2014) stress that the more effective voluntary medical male circumcision in areas with high prevalence of HIV infection could result in substantial reduction of HIV incidence in South Africa. Peltzer et al. (2014) found in their study acceptability of high degree regarding male circumcision in South Africa. The self-reported prevalence of male circumcision was 42.8%. It is essential to inform about the health benefits of male circumcision in the prevention of HIV infection. Abuelazam et al. (2016) do state that widespread male circumcision in South Africa has resulted in a 21% reduction in the incidence of HIV infection. Grund et al. (2017) declare that male circumcision does diminish the risk of obtaining HIV infection as well as some other STIs in heterosexual relationships, and is vital in order to prevent HIV. In Uganda, voluntary medical male circumcision does cut the risk of HIV infection. In sub-Saharan Africa, the participation is not optimal in some age groups as well as areas. It is important to inform about the benefits of medical male circumcision regarding the prevention of HIV infection (Gilbert et al. 2018).
In Uganda and South Africa, the programme of preventing HIV infection does include medical circumcision, antiretroviral treatment as well as prophylaxis given before exposure. Suppliers working in health care do need training as well as help in order to understand the details of the discordant HIV infection (Greener et al. 2018).
Hinkle et al. (2018) write that male circumcision decreases the risk of HIV transfer from females to males by roughly 60%. In Uganda, voluntary medical male circumcision is encouraged as a method to prevent HIV infection. It is essential to follow up the quality of this operation as well as to improve the teaching of those workers who are involved in the HIV prevention programme (Broughton et al. 2018).
HIV in western Kenya
In western Kenya, the participation in voluntary medical male circumcision has increased from 45% in the year 2008 to 72% six years later. This increasing involvement has cut considerably the HIV incidence between the years 2011 and 2016 in Siaya County (Borgdorff et al. 2018).
The statement of the Kabwama group
Kabwama et al. (2018) point out that male circumcision does save from HIV infection. This fact is well accepted.
The statement of the Carrasco team
Carrasco et al. (2018) state that voluntary medical male circumcision is a successful method in the prevention of HIV infection.
Women and HIV
Greevy et al. (2018) underline that women do have an essential responsibility in order to reduce the transfer of HIV infection. In South Africa, male circumcision is encouraged in programmes of HIV prevention. In Rakai (Uganda), all 27 the interviewed women did favour circumcised men regarding the decreased risk of HIV infection and of other STIs, as well as of better penile hygiene and of more intense sexual pleasure (Nakyanjo et al. 2018).
Safer conception
Davey et al. (2018) write that in sub-Saharan Africa, safer conception programmes for heterosexual husband and wife do include voluntary medical male circumcision, prophylaxis before exposure for HIV infection as well as antiretroviral therapy. The authors evaluated in their systematic analysis 41 acceptable surveys – 15 quantitative & 26 qualitative reviews published after the year 2007 in sub-Saharan Africa. In this study, the couples stated that they wanted to get more information about plans regarding safer pregnancy. In Africa, these strategies in question are not so far widely obtainable.
Complications following male circumcision
The risk of complication is low
El Bcheraoui et al [7] analysed 41 complications possibly caused by male circumcision. Totally, 1 400,920 patients were studied – 93.3% of them were newborn males. The authors do underline that the risk of complications following male circumcision is low. The incidence was vaguely below 0.5% in their study. It is important to note that the risk incidence rose ten-fold to twenty-fold when this very operation was performed after infancy. Brian Morris (2015) does state that the risk of adverse events following circumcision is low when infant males are operated. According to Sneppen & Thorup (2016), the risk of complications before the age of 18 is 1.7%. A group of 235 male patients were circumcised by using a new disposable ring. These patients were compared with the same number of males circumcised by using the suture device method. Post-operatively, no case of infection was observed – however, three cases of splitting of the wound were recorded in the total group of 470 circumcised males (Zhao et al. 2017).
Indistinct prevalence of complications
In the study of Adekanye et al. (2017), the prevalence of harmful events following circumcision of Nigerian primary school boys is 15.4%. This prevalence does include both excessive remainding and abolition of skin, as well as skin bridges and stenosis of meatus. My opinion is that meatal stenosis is a true complication following male circumcision – but not the harmless damages of skin.
Ethical questions
Ethical questions are essential to discuss
The discussion on male circumcision should be scientific, not emotional. One striking example of blurred writing is the paper of Kassab et al. (2018) evaluating factors linked to pain severity of in-fants undergoing immunisation. The authors found that the presence of parents in the room did essentially cut the total time of crying – circumcised infants cried longer than the uncircumcised ones. Jacobs [8] points out that circumcision on infant males is ethical to perform when the parents ask for it – this operation should be executed by a physician. Jacobs & Arora (2015) write that the ritual circumcision of male infants may violate local rules but never human rights. Earp [9] asks whether the benefits of male circumcision are greater than the risks and critisizes the interim guidelines of the Centers for Disease Control and Prevention (CDC). Earp [10] underlines that children should have their sexual organs undamaged. Genin (2017) does stress that the discussion regarding male circumcision has been and will be deeply intense – medically as well as politically. Svoboda (2017) concludes that ritual circumcision of infant males is common removing working and protective penile tissue. The author argues that this very operation violates the autonomy of the male child and it should be postponed until he can perform his own analysis. Di Pietro et al. (2017) claim that newborn male circumcision does cut in a very limited way the incidence of urinry tract infections (UTIs) and sexually transmitted infections (STIs) – Tobian et al. (2010) and Alkherizan & Elabd (2016) do have an opposite opinion. Harald zur Hausen (2016), as earlier mentioned, states that the effect of male circumcision in protecting against sexually transmitted diseases (STDs) is at best moderate.
Cultural considerations
In South Africa, traditional male circumcision is a cultural tradition indicating the progress from child to adult. Medical male circumcision and the traditional one should be integrated in order to improve the collaboration between members in local communities (Siweya et al. 2018). In Judaism, male circumcision is a religious and cultural tradition – and also a medical one.
Benefits and harms of ritual circumcision
Danish register
In Denmark, the Danish Minister of Health initiated in the year 2013 a register which collects information on all religious circumcisions of male children in the country. It makes future research possible focusing benefits as well as harms of ritual circumcision in childhood (Ploug & Holm 2017). In my opinion, the Danish register is important to obtain scientific information about benefits and complictions regarding this very operation.
New essentials discussing male circumcision
Male circumcision in South Africa
In South Africa, medical male circumcision is introduced in order to cut the incidence of human immunodeficiency virus (HIV) infection. A selected programme of intervention targets men in ages 25 to 49 years and has been valuable (Grund et al. 2018).
Male circumcision in Zambia
Jones et al. (2018) state that voluntary medical male circumcision is estimated to inhibit 3.4 million cases of HIV infection in 10 years in Africa. In Zambia, about 80% of uncircumcised males are not interested to be circumcised. It is essential to increase the acceptability as well as the uptake of this preventive operation.
Male circumcision in Zimbabwe
In Zimbabwe, voluntary medical male circumcision is taken up as the most important programme in order to prevent HIV infection since 2007. It is calculated that voluntary medical male circumcision will significantly affect the HIV epidemic in the country and save money (McGillen et al. 2018).
Circumcision and chronic prostatitis
According to Franco et al. (2018), early male circumcision does in all likelihood vaguely lessen the symptoms of chronic prostatitis, and is safe.
Cells of Langerhans
In sub-Saharan Africa, male circumcision is practised as a vital part in preventing HIV infection. It does give men protection against HIV in heterosexual relationships – the effect of this barrier is about 60%. Inside the foreskin, there are numerous Langerhans cells which decrease the local vulnerability of HIV infection. The second factor is that the inflammatory anaerobic milieu around the preputium is removed (Davis et al. 2018).
Male versus female circumcision
Manipulation of facts
Health care professionals do manipulate facts regarding Jewish cirumcision. They do indicate that we circumcise also our females. This trend is alarming. Contemporary studies clearly indicate that male circumcision has essential health benefits which is described in the preceding pages. Female circumcision/genital mutilation/cutting is a very harmful operation. It is globally condemned.
Female circumcision in Nigeria
A total of 8,111 men participated in the study of Titilayo et al. (2018). In one group, 29% of males stated that their religion demanded female circumcision. In a second one, 89.4% wanted to stop it – their religion did not ask for female genital cutting. The authors conclude that religious beliefs are essential when we want to fight female genital cutting.
Early deaths following neonatal male circumcision
About early US deaths
Only 200 early US deaths were found following neonatal male circumcision during the years 2001 to 2010 among 9 833,110 patients – i.e. 1/49,166 operations. Newborns who died after circumcision had probably other related severe conditions – cardiac, pulmonary or fluid & electrolyte disorders, or coagulopathy as the cause of death (Earp et al. 2018).
Young circumcised men are safer sexual partners
Circumcision should be performed early
Voluntary male medical circumcision is very effective in order to prevent human immunodeficiency virus (HIV) infection in men. According to reliable studies, circumcised men are safer sexual part- ners than uncircumcised ones. This fact, however, is not relevant when older males (aged 40 years or older) are discussed – male cirumcision should thus be performed in early ages.(Rosenberg et al. 2018).
Prophylactic treatment & voluntary medical male circumcision
Two methods to prevent human immunodeficiency virus (HIV) infection
According to Reed et al. (2018), oral prophylaxis before exposure to HIV infection and voluntary medical male circumcision have much the same challenges – both methods are effective.
References
- Morris BJ, Kennedy SE, Wodak AD, Mindel A, Golovsky D, et al. (2017) Early infant male circumcision: Systematic review, risk-benefit analysis, and progress in policy. World J Clin Pediatr 6: 89–102. [crossref]
- Jones DA (2018) Infant Male Circumcision: A Catholic Theological and Bioethical Analysis. Linacre Q 85: 49–62. [crossref]
- Castellsagué X, Bosch FX, Munoz N, Meijer CJ, Shah KV, et al. (2002) Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. N Engl J Med 346: 1105–1112. [crossref]
- Zur Hausen H (2011) Infections Causing Human Cancer. Wiley-VCH Verlag & Co. KgaA.
- Morris BJ, Mindel A, Tobian AA, Hankins CA, Gray RH, et al. (2012) Should male circumcision be advocated for genital cancer prevention? Asian Pac J Cancer Prev 13: 4839–4842. [crossref]
- Rubinstein E (2008) [Women positive to HPV self-test]. Lakartidningen 105: 467–468. [crossref]
- El Bcheraoui C, Zhang X, Cooper CS, Rose CE, Kilmarx PH, et al. (2014) Rates of adverse events associated with male circumcision in U.S. medical settings, 2001 to 2010. JAMA Pediatr 168: 625–634. [crossref]
- Jacobs AJ (2013) The ethics of circumcision of male infants. Isr Med Assoc J 15: 60–65. [crossref]
- Earp BD (2015) Do the benefits of male circumcision outweigh the risks? A critique of the proposed CDC guidelines. Front Pediatr 3: 18. [crossref]
- Earp BD (2016) In defence of genital autonomy for children. J Med Ethics 42: 158–163. [crossref]