Male Circumcision - Research Paper Example

Male Circumcision Introduction The debate on whether male circumcision without consent of the child should be terminated is a debate that has been ongoing since the mid-20th century. Male circumcision has been part of ritualistic practices in parts of Africa for over 500 years while in the Middle East, it has been in existence for around 3000 years. In the US and Canada, this practice was only accepted among mainstream populations in the late 19th century and early 20th century. By the 1960s and 1970s, approximately 40% of Canadians and 80% of Americans were being circumcised soon after birth. However, in 1971, as a result of inconclusive evidence on the health benefits of this practice, the American Academy of Pediatrics took a position against circumcision of newborns, hence the rates of the practice dropped to around 60% by the mid-1980s. In 1989, due to new evidence associating certain health risks to the lack of circumcision, the American Academy of Pediatrics adjusted its position to one of a neutral status- that of neither supporting nor objecting the practice. Evidence from clinical data showed an increased rate of circumcision among infants (to over 80%) by 1990. The renewed circumcision number stemmed from clinical evidences including the confirmation of an association of lack of circumcision and urinary tract infection (UTI). The association had previously only been postulated with no confirming evidence. Besides, this period saw the association of the practice with other infectious agents such as HIV. A study by Schoen (1310) concluded that circumcision of the newborn could be compared to immunization in terms of the lifetime health benefits. Not all communities have always embraced circumcision in the United States. Indeed, evidence suggests that the practice has been most common only among Anglo-Celtic whites and African Americans. While some opponents of male circumcision assert that the practice should not be done without consent, many men who opt to require circumcision later in life have to undergo significant and more costly medical procedures that would have been required had it been done at the infantile stage. Moses, Bailey and Ronald (372) mention that at least 15% of males not circumcised at birth will require the procedure later in life. Although a number of randomized trials carried out around the world have confirmed that male circumcision has several health benefits, the misinformation that resulted into a downtrend of the practice in the 1970s still persists among some physicians and proponents of the practice who hail from the 70s, and their students. In fact, there have been reports of harassment among new mothers by medical practitioners who are not well informed on the benefits of circumcision. There have also been attempts by medic and pediatric bodies to skirt the truth from the public in what can be viewed as a fear of legal action in case of a rare surgical accident. Policy statements by professional pediatric bodies have also been viewed by critics as attempts to appeal to authority to support the practice. Consequently, the debate on male circumcision is not one to end soon even in the face scientific evidence seeming to attribute the practice with numerous health benefits. In fact, close to 18 states have recently eliminated Medicaid insurance for male circumcision, a move that is seen as one of the initiatives to ban the practice (Tobian & Gray 1471). Why the Foreskin Increases Infection Risk As a prelude to discussing the health benefits of circumcision, one needs to first understand the anatomy of the male organ. The foreskin is made up of two layers: an outer layer that is keratinized and an inner layer that has a mucus-like lining. The inner layer therefore bears resemblance to other mucosal epithelia such as those found in the cervix and nasal airway. Although it was previously thought that the foreskin protected the glans from drying out and becoming keratinized, studies have shown otherwise (Moses et al. 372). The inner layer of the foreskin forms a sac that accumulates urinary residue, dead cells, and secretions. It also forms a favorable environment for the growth of bacteria and other disease-causing organisms. During an erection, the inner layer of the foreskin becomes exteriorized exposing the glans to infections during sexual intercourse. It has also been hypothesized that the foreskin produces certain secretions. The increased risk of infection among the uncircumcised has been attributed to the following: The foreskin increases the surface area under which infection can occur; The moist inner lining of the foreskin is thinner than the rest of the penis including the outer surface of foreskin or the glans and this increases the risk of infection; During sexual intercourse, the foreskin can lead to greater microtrauma hence acting as an entry point for disease causing microbes; The inner layer of the foreskin forms a sac that accumulates urinary residue, dead cells, and secretions that form a favorable environment for the growth of disease-causing organisms. Health Benefits of Circumcision Dr. Thomas Wiswell, once a strong critic of circumcision, found unequivocal evidence for circumcision and later switched sides after conducting his own research and looking at other research findings. In his final report, he noted that "as a pediatrician and neonatologist, I am a child advocate and try to do what is best for children. For many years I was an outspoken opponent of circumcision ... I have gradually changed my opinion" (Wiswell, 649). In making his final decision to support male circumcision, Wiswell analyzed the complication rates of having or not having circumcision using a sample of 136,000 boys in the US. Out of these, only 193 (0.19%) had complications, most of which were minor and with no reports of deaths. However, among the 36,000 boys who had not undergone circumcision, the problems were ten times higher with two reported deaths (Wiswell & Hachey, 132). A study conducted among 11,000 circumcised boys at New York’s Sloane Hospital had similar findings as above; only 6 complications arose, none of which were serious (Wiswell & Hachey, 132). Besides, there have been no cases deaths from medical circumcisions in developing nations. Health conditions involving the penis are reported regularly in pediatric practice. In a retrospective study involving boys aged between 4 months and 12 years, it was observed that uncircumcised boys reported penile problems at a significantly higher frequency than those who were circumcised (Tobian & Gray 1472). One conclusion coming out of these studies is that although circumcision is not absolutely safe, its long-term benefits outweigh the risks by an incomparable magnitude. Several benefits are attributed to this practice as discussed below: HIV Infection Various types of epidemiological studies across the globe, particularly in developing countries, have found an association between human immunodeficiency virus and male circumcision. These study types range from cross-sectional, prospective, and ecological studies and are drawn from countries such as India, the United States, Kenya, Tanzania, and Côte d’Ivoire (Mertens & Carael 107). Although some of these studies have shown no relation between the two variables, the majority have shown overwhelming evidence making epidemiologists to accept the hypothesis that male circumcision decreases the risk of HIV infection by up to 60%. However, proponents have suggested that different sexual practices or hygienic practices can confound the association between circumcision status and HIV infection. For instance, human groups that practice ritual circumcision may have different sexual practice from those that do not circumcise. This could result into varying risks of becoming infected not necessarily associated to circumcision (Mertens & Carael 105). Sexually Transmitted Diseases (STDs) The association between circumcision and STDs excluding HIV is multifaceted and varies with the individual STD. However, there is overwhelming research evidence to support the association between ulcerative STDs and circumcision. The STDs include genital herpes, gonorrhea, chlamydial, non-gonococcal, or other types of urethritis. Findings from studies instigating the nature of association between circumcision and the prevalence of these diseases have been mixed, however, there is a general agreement on increased risk of contracting chancroid, genital herpes and gonorrhea among the uncircumcised (Moses, Bailey and Ronald 370). Studies have further reported an association between uncircumcised persons and the presence of anaerobes that might enhance chances of contracting STDs (Serour, Samra, & Kushei 288). Women with one lifetime sexual partner have also been found to report instances of herpes simplex virus type 2 at a higher frequency than those whose husbands are circumcised (Maden, Sherman, & Beckmann 22). Penile Carcinoma A 1989 report by the American Academy of Pediatrics reported that all men with penile carcinoma were not circumcised at birth (Moses, Bailey and Ronald 372). Similar findings have been made in Africa and other recent case-control studies in North America. More recently, a cross-sectional study conducted in France established that penile intraepithelial neoplasia (PIN), which may be an antecedent to penile carcinoma in some men, was significantly higher among uncircumcised men (Maden, Sherman, & Beckmann 22). Although it has been suggested that enhanced hygiene will lower the risk for penile carcinoma, there is no scientific evidence to prove its validity. It is estimated that between 750 and 100 cases of the disease occur annually in the US, basically all are men who have not been circumcised at birth, and mortality may be as high as 1 out every 4 persons. In addition, persons circumcised at birth are ten times less likely to have penile carcinoma as compared to the uncircumcised. Cervical carcinoma Cervical carcinoma has been confirmed to be an STD caused by oncogenic genes of the human papillovirus. Findings of association between cervical carcinoma and male circumcision are mainly ecological since the disease is comparatively rare among populations where most men are circumcised. However, in a case-control study in India, it was observed that among women with one lifetime sexual partner, instances of the disease were more common among women who had uncircumcised husbands (Agarwal et al. 1667). Urinary Tract Infection (UTI) UTI is a common infection among children and can result into death. The younger the infant, the higher the risk and severity of the infection and hence this increases the threat of morbidity. The prevalence of UTI has been found out to be significantly high among male uncircumcised infants and adults (Wiswell & Hachey, 132). The findings arise from the fact that the inner layer of the foreskin forms a sac that accumulates urinary residue, dead cells, and secretions that form a favorable environment for the growth of bacteria. Although the infection can be treated, failure to detect it early enough can result into expensive and sometimes invasive medical procedures, at times leading to renal injury. Due to the low prevalence rates of UTI, it has been argued that the risk of injuries arising from neonatal circumcision outweigh the benefits. However, due to the several health benefits associated with the circumcision, male circumcision is the best alternative to preventing UTI (Wiswell & Hachey 134). Although it has been shown that early breastfeeding might also lower the risks of UTI, this intervention is much less effective as compared to circumcision and cannot be advocated for as a replacement of the latter. Studies investigating an association between UTI and male circumcision have been extensive for the past 25 years and have provided undeniable evidence to confirm the association. Chlamydia in Women According to various studies, women with one lifetime sexual partner who is uncircumcised have been found to be almost 6 times more at risk of infection with chlamydia trachomatis than those whose husbands are circumcised. Chlamydia is the second most reported STI and is caused by bacterial strains. The WHO approximates that 92 million new cases of this infection are reported annually. Most infections occur between 13 and 24 years, most of whom are women. The number is proportional to the number of uncircumcised men in this sexually active age bracket (Mertens & Carael 107). Chlamydia results into pelvic inflammation causing infertility, ectopic pregnancy and pain in the pelvis. It has been suggested that the association between circumcision and chlamydia may be that the foreskin traps and accumulates infected secretions from the cervix and vagina during sexual intercourse, thus increasing the risk of penile urethral infection and transfer to partner (Mertens & Carael 105). So far, research to investigate this association is ongoing but from the evidence collected so far, circumcision greatly reduces the risk of getting chlamydia. Various reports discussed in this paper and elsewhere support the premise that male circumcision has numerous health benefits to males and females alike. The practice reduces the risks of HIV and STD infection, penile and cervical carcinoma, urinary tract infection and chlamydia in women. Throughout the research, there was little scientific evidence of adverse effects linked to circumcision. In contrast, there was unequivocal evidence supporting the practice, linking it a host of health benefits some of which were not discussed in this paper. Although the final decision on whether to circumcise or not lies on sociocultural values rather than scientific evidence, people’s perceptions can change as new information comes to the fore. Consequently, it is hoped that research into this subject will continue and that male circumcision will finally be accepted among all human groups due to its innumerable health benefits. Works Cited Agarwal, Shyman S, Sehgal, Aashok, and Sardana Sarita. Role of male behavior in cervical carcinogenesis among women with one lifetime sexual partner. Cancer, 72(9): 1993, 1666–9. Maden, Christopher, Sherman, Karen J., and Beckmann, Anna Marie. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. Journal of National Cancer Institute, 85:1993, 19–24. Mertens, Thierry E. and Carael Michael. Sexually transmitted diseases, genital hygiene and male circumcision may be associated: a working hypothesis for HIV prevention. Health Transition Review, 5:1995, 104–8. Moses, Stephen, Bailey, Robert C., and Ronald, Allan R. Male circumcision: assessment of health benefits and risks. Sexually Transmitted Infections, 74(21):1998, 368–373. Schoen Edgar J. The status of circumcision of newborns. New England Journal of Medicine, 322:1990, 1308–12. Serour, Francis, Samra, Zahra, and Kushei Zind. Comparative periurethral bacteriology of uncircumcised and circumcised males. Genitourinary Medicine, 73:1997, 288–90. Tobian, Aaron AR., and Gray, Ronald H. The Medical Benefits of Male Circumcision. Journal of the American Medical Association, 306(13): 2011, 1479-80. Wiswell, Thomas E. and Hachey, Wayne E. Urinary tract infections and the uncircumcised state. Journal of Clinical Pediatrics, 32: 1993, 130–4. Wiswell, Thomas E. The circumcision debate. Pediatrics, 79(18):1987, 649–50. Read More