Circumcision: Myths, facts and fiction

Dr Sebastian Ndlovu
There are many myths and assumptions surrounding circumcision, and history has a sure way of repeating itself — rearing its head in the present.
After the studies we discussed in the previous article “established” the “protective” effect of circumcision, scientists were in a race to come up with the most logical explanation as to why. Maybe it was an attempt to get a Nobel Prize towards the most compelling, anatomically reasoned out explanation as to the basis of the alleged benefit.
That led to the “common knowledge” that the process of circumcision removes a lot of cells that could be responsible for the initial infection with HIV.
This reasoning is based on anatomical knowledge not proper scientific studies or more importantly physiology (that is the study of the function) of the foreskin. No studies as of yet have proven with absolute certainty that circumcision per se reduces the risk of contraction of any STI, let alone HIV.
People, in an attempt to explain the supposed benefit, came up with the “reasoning” that probably it was due to the removal of cells that act as a portal for HIV entry, the now popular — Langerhans cells. In essence this was mere reasoning without any laboratory evidence to substantiate the claims and it still remains that – an educated guess!
The reasoning may be noble but since it is not backed by solid evidence, it should not be force fed down the throats of a gullible populace with colossal implications. The art and science of public health policy is not based on anatomical conjectures and reasoning based on laboratory analysis of severed foreskins! It however should be based on demonstrable statistically significant benefits conferred by the practice or evidence that takes into account both anatomy and physiology.
Current studies on the function of the foreskin and the glands found in the prepuce suggest a benefit of having a foreskin. I will have to concede that this knowledge does not mean that having a foreskin is protective as much as not having one may not be protective at all.
We are currently informed that the glands in the prepuce may be responsible for something that is called – local mucosal immunity. In simple terms a local mechanism mounted by the body to fight an infection at a specific site.
The skin of the prepuce secretes various substances that can have an effect of “neutralising HIV”. The inner prepuce contains apocrine glands which secrete cathepsin B, lysozyme, chymotrypsin, neutrophil elastase, cytokines (non-antibody proteins that generate an immune response on contact with specific antigens).
Some physiologists report that secretin, IgA, and mucin are also released, all these are protein molecules which may attack any infectious pathogens thereby making up a first line of defence which severing the foreskin effectively removes.
Others argue that circumcision prevents contraction of other STIs, the evidence however is also not convincing at all. Cook et al (1994) were unable to show a definite benefit for circumcision — finding a slight tendency for non-circumcised men to have more syphilis and gonorrhoea, but less tendency to have genital warts.
Donovan et al (1994) reported no significant difference between non-circumcised and circumcised men. Van Howe (1999) found circumcised men may be slightly more likely to have urethritis and uncircumcised males may be more prone to genital ulcer disease (GUD).
Dickson et al (2008) found more STIs in circumcised men but the difference was not statistically significant. The myth, therefore, that circumcision might have a protective effect towards contracting STIs must be dispelled with the contempt it deserves. A higher rate of STIs in circumcised males in some studies might well be the result of the loss of preputial immunoprotective structures.
The loss of the protective, self-lubricating, mobile, double-layered prepuce might expose the glans penis and meatus to direct friction, abrasion, and trauma.
There are also those that when all seemed to have been lost came with a whole new benefit. The kind that got female chauvinists and feminists I presume, leaping with joy demanding some form of conciliatory action from the males!
The case of circumcision preventing cervical cancer in females. It is now known that the major risk factors for cervical cancer are smoking, infection with Human Papilloma Virus (HPV) and also HIV coinfection.
HPV is a large group of viruses that may cause genital warts, and are implicated in the genesis of genital cancers.
The Ugandan study showed less HPV infections in partners of circumcised males than their uncircumcised counterparts in groups corrected for age, status and so on.
However, what should be noted is that the majority of those men had one faithful partner, only a minor 4 percent had more than one partner.
It is evident that this “protective effect” cannot be different from the one found in uncircumcised faithful partners. Risk of infection with HPV is increased by early onset of sexual intercourse and multiple sex partners and as we will see there is no evidence that circumcision protects males from HPV but high risk behaviour is a predisposing factor.
A recent large-scale study at the University of Washington found no difference in the incidence of HPV infection between circumcised and uncircumcised male college students.
The new study confirmed previous research which showed that the location of the virus differed between circumcised and uncircumcised men: circumcised men tend to carry the virus on the shaft skin of the penis, while intact men are more likely to carry it on the glans.
The study also found that circumcised men have more sexual partners. In a previous study the researchers found that for college females the circumcision status of their partner was NOT a risk factor for HPV infection in women.
The authors say the African Random Clinical Trials, which seemed to show that uncircumcised men were more likely to carry the HPV virus, were seriously flawed because they took samples only from the glans (not from the shaft skin, where the virus is concentrated in the circumcised).
This highly unpublicised study which was carried out from 2006 to 2009 and published in 2011 concluded that “circumcision does not lower the risk of infection with Human Papilloma Virus. People who claim that uncircumcised men are more likely to develop or communicate genital cancers are ignoring the facts and spreading misleading information.”
Some argue that the seriousness of cervical cancer in Third World countries justifies desperate and heroic methods of treatment. But the severity of a problem does not necessarily demand severe or heroic methods at all: what it demands is effective methods. This brings us to the vaccines that prevent infection with HPV. These vaccines are given to pre-pubertal girls and currently the costs are said to be a barrier.
In this matter it seems very dishonest for the pro-circumcision zealots to fund a method whose benefit is contentious and act out of depth to fund one whose benefit is definite. In other words, these donors are insinuating that the effective methods that work in the developed world will not work in the Third World.
Or they believe that we deserve the barbaric cutting of foreskins rather than modern science of vaccination and humane behavioural change! I am sorry but that seems very racist and degrading, yet we are accepting it as gospel.
It is 19th century quackery to circumcise the whole male population to prevent an infection that can be effectively prevented by a simple injection. And in this case the vaccine is given to the very individual at risk. It is highly unethical and legally impermissible to circumcise anyone on this account because there is no benefit, even if there was, the person bearing the loss and risk is not the person reaping the benefit.
The suggestion is also highly sexist: imagine the outrage if it was suggested that women should have part of their genitals excised in order to reduce the risk of disease in men!
For those who think circumcision is the panacea for the prevention of penile cancer, please note that the risk of cancer of the penis is one in 100 000.
If circumcision could prevent cancer of the penis performing 100 000 circumcisions on normal males to possibly prevent one cancer of the penis in an elderly man is not only unethical but also highly insane.
Nowhere else in medicine is this type of prevention practiced and it should not be.
It is reported that circumcision was virtually unknown in the United States, during the early years of the republic, doctors began to promote it, beginning in the 1850s, as a cure for masturbation.
When it was discovered that masturbation could not be prevented in this manner, they sought something else. In the 1950s it was cervical cancer (amazing, this is where we are in Africa). Now it is Aids. All these alleged “medical reasons” are simply excuses.
It, therefore, appears that a lot of funding is going towards an exercise which has no definite benefit.
These funds could be used towards the future of HIV prevention and treatment! The “unfortunate” researchers whose studies found that the procedure could increase the risk of HIV infection in South Africa concluded:
“The world community must cautiously review and carefully consider the long-term consequences of mass circumcision campaigns, from the risk of increasing deaths and infections to human rights violations. In the rush to save lives, many may instead be lost and human rights trampled in the stampede. Circumcision is not the panacea the world has been waiting for in the battle to stem the HIV crisis”.

Dr Sebastian Ndlovu is a qualified medical doctor. He writes in his personal capacity and opinions expressed here are his personal opinions in an attempt to create public discourse on health matters and improve public health policies. You can contact him at [email protected]