THE CIRCUMCISION PROBLEM:
James L. Snyder, M.D., F.A.C.S.
INERTIA OF THE SCIENTIFIC COMMUNITYPresented at The First International Symposium on Circumcision, Anaheim, California, March 1-2, 1989.
The events that galvanized me into becoming active in this question were the children I encountered in my urologic practice who had had a bad result from circumcision.
During my time as a medical student, intern, and surgical resident, I performed a number of infant circumcisions, in spite of my general reluctance to do them. Many circumcisions are done by young doctors in training because this is often considered within the range of surgical skills that can be acquired quickly. In most cases, there is a period of direct supervision by a senior physician but, especially in our large teaching hospitals which care for indigent patients, much of this work is thereafter unsupervised or reviewed only after the fact. These young physicians then bring to this task the previously acquired notions on what a circumcised penis should look like and, with varying degrees of skill, try to achieve that end. The vast majority, it must be admitted, achieve reasonable success. The failures, unfortunately, are often recognized only years later, when there is no way to reproach either the surgeon or others involved.
Now I will show you some slides which illustrate the problems arising when the result is poor. These slides are the kind loan of a colleague (Boyd Winslow, M.D., FACS). One child in this series is a child for whom I was called as a consultant within 24 hours of his injury.
The first three slides represent the treatment of epithelial bridges. These are adhesions between the glans penis and the skin of the penile shaft, usually at the circumcision scar. They occur when the raw edges of the circumcision scar stick to the raw surface of the glans in the first few days after circumcision. If recognized early, they can be broken down with a slight amount of pain to the child but, if allowed to remain, will mature into a dense scar which requires separation by an incision. These bridges are the site of accumulation of dead tissue debris and inflammation which, after all, is what circumcision is supposed to prevent.
The second series of slides represent a major complication which occurred when an overzealous surgeon removed an excessive amount of skin during a circumcision. Fortunately, the skin was saved, but the child required a second operation to reapply his own skin as a split thickness skin graft. The resulting graft, however, did not have the texture and mobility of normal skin because of the limitations of what can be achieved in skin grafting. I was called to see a similarly injured child in 1976 who was less fortunate because the skin had been discarded and the entire shaft of the penis was left without a skin covering.
The third series represents a child who was subjected to multiple attempts at circumcision, none of which achieved the desired goal of exposing the glans penis. At surgery, the foreskin was opened and used as a covering for the shaft of the penis.
The fourth series of slides represents a child whose skin edges separated after circumcision with a Gomco clamp. As is usual in this procedure, no sutures were used during the circumcision; but closure of the separation requires insertion of sutures, most often performed in the operating room and under general anesthetic.
The fifth series of slides demonstrates a fistula, or abnormal opening of the urethra, created by improper application of a Gomco clamp and removal of a part of the glans penis and the urethra. This required plastic surgical reconstruction of the urethra and glans.
The sixth series presents a child I first saw 24 hours after he was circumcised with a Gomco clamp and electrocautery. Within a short time, the entire glans and shaft of the penis became gangrenous and separated at the scrotum. He was transferred to a major medical center and required several major surgical operations to construct a skin tube which serves the function of urination. There is, of course, no erectile tissue and no genital sensation beause of loss of nerve structures. I would like to point out that there are no photos available of the initial stages of this truly disastrous event, first because the persons caring for the child felt that it would be an invasion of the child's and the family's privacy, and second because it was feared the pictures could be used in litigation. There was an eventual out-of-court settlement of $1 million, but the loss to the child cannot be measured in terms of dollars.
Many of the people who attend or view these proceedings will be aware of the reports that, on the same day in September 1985 in Northside Hospital in Atlanta, two infants suffered major injuries during a circumcision. One of these children later underwent sex reassignment surgery because the extent of the damage to the child's penis made future function as a male unlikely or impossible. Among the literature available at this seminar, I was surprised to come across an account of a similar injury to a Louisiana child which occurred in February 1984 at the W. O. Moss Regional Hospital.
In summarizing these events, I would like to say that circumcision accidents are not uncommon. Because of their sensitive and confidential nature, however, they are usually unrecognized by outside parties and they have not been seriously studied in the medical literature except on an occasional or anecdotal basis. I suspect that the cases I have presented in this paper represent only the tip of the iceberg in terms of the size of this problem.
More to the point is that the reasons given for routine newborn circumcision in the United States have varied since its widespread popularization in the United States after 1940. In the early days of scientific medicine and before the antibiotic era, circumcision may have been advocated as a means of preventing or controlling masturbation, insanity, or warts. More disturbing is the fact that, in the face of advances in scientific and social knowledge as these justifications for the practice of circumcision crumble, new rationales emerge, usually advocating circumcision as a preventive remedy for the newest dread disease in the public consciousness.
In the 1960's when I was a medical student, I and my peers were instructed that, among other benefits, circumcision was the means of preventing cancer of the cervix in the later female consorts of the newborn child. The rationale for this has withered under more recent evidence that cancer of the cervix in women is related to multiple factors including early onset of sexual activity, multiple sexual partners, sexually transmitted viruses, and other factors unrelated to circumcision. Almost no medical authority today regards male circumcision as a prevention for female genital cancer. And yet, people with respected medical credentials continue to bring forth a litany of medical conditions for which circumcison should be considered a prophylaxis.
In the past year (1988), the California Medical Association adopted a resolution advocating newborn circumcision as a public health measure (overriding the recommendation of their own scientific committee). Among the diseases said to be prevented by this surgery were herpes infections, syphilis, gonorrhea, chancroid, lymphogranuloma venereum, genital warts, and others. Each of these diseases has a known viral or bacterial etiology and I have treated circumcised American males for every one of them, using appropriate antibiotics or other treatment to cure what circumcision did not prevent. In the past year, I treated a young man who had large viral warts on the scar of his neonatal circumcision. Recently the scientific press has been stirred by the speculation that the incidence of urinary tract infections in newborn males could be reduced by circumcision. It was overlooked that well over 95% of male children never have these infections, and that the treatment is anti-biotics - not surgery.
Most cruel is the recent speculation that circumcision would have some benefit in preventing infection with Human Immunodeficiency Virus, the suspected causative agent of the disease AIDS. When this disease appeared, it was first recognized in American homosexual males, most of whom were caucasian, middle class, and circumcised. The major epidemiologic factors were rapidly recognized as promiscuous sexual behavior and, in a separate group of patients, the reception of infected blood by transfusion or the sharing of intravenous needles by drug users. Public health education has rapidly caused a decrease in dangerous sexual behavior in male homosexuals with a resulting decline in the incidence of AIDS in this group. Intravenous drug use continues to be the major source of new AIDS infections. None of this has any relation to circumcision, and there are thousands of American men whose circumcision offered no protection from the AIDS infection.
Finally, we have been told that newborn circumcision will prevent cancer of the penis. While this may be true, it is an overrated risk. Cancer of the penis is a rare disease in this country, constituting perhaps 1/2 of 1% of all malignancies in males (less than 1 per 100,000 population per year, according to United States cancer statistics. Some have argued that the low incidence of cancer of the penis in this country is due to the fact that we do large numbers of newborn circumcisions. Further examination, however, discredits this view. The Danish Cancer Registry reported an incidence of penile cancer of 1.7-;2.7 cases per 100,000 population per year for the ten-year period from 1943-1953, (representing less than 0.003% of the population). Lest it escape anyone's notice, I would like to point out that in Denmark, as in the rest of Europe, the non-religious practice of circumcision is unknown, and more than 80% of adult European men remain uncircumcised throughout their lives.
An overlooked fact in the argument over penile cancer is that the average age of onset of penile cancer is 55 years. In the United States we have been performing large numbers of newborn circumcisions only since about 1940. Therefore, we have a large population of men over the age of 50 who were never circumcised. Yet, this group of men who are the population at risk for cancer of the penis shares the same low incidence of cancer of the penis as those men in Denmark and Europe. Clearly, other factors besides circumcision are at work here, and I would like to suggest that the practice of personal hygiene together with the ready availability of water and plumbing to facilitate this are significant factors in the reduction of this risk as compared to conditions in China and India where penile cancer is 20-30 times more common.
The use of circumcision to prevent cancer of the penis is the only instance of prophylactic surgery to prevent disease which has gained any credibility. In contrast, consider that in absolute numbers over a ten-year period (1943-1953), the Danish Cancer Registry reported 251 cases of penile cancer and for the same period reported 10,000 cases of breast cancer in women. Yet, no one seriously advocates removing the breasts of female infants to prevent this more common malignancy.
In our seminar, we have heared a number of cultural, religious, and anthropologic motivations for circumcision, many of which are of ancient origin. But the vast majority of circumcisions performed in the United States today are not done for any of these reasons. They are done out of habit and misinformation which have been implanted in the American culture only over the time of the last two generations. If circumcision were to be governed by the usual standards of medicine and government - if it were a drug such as Thalidomide - the data available in today's newspapers and the scientific literature on the damage inflicted upon children would be sufficient to cause its immediate withdrawal from the market and to prohibit its distribution. For this reason, I am grateful that the members of this symposium have gathered. As individuals, we have little chance of success in changing the practice of a nation. But as an organization, we can hope to make an impact. I have watched the efforts of the contributors to this symposium with growing admiration. Each one of you is a point of light.
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