Circumcision has historically been a topic of emotive and often irrational debate. At least part of the reason is that a sex organ is involved. (Compare, for example, ear piercing.) During the past two decades the medical profession have tended to advise parents not to circumcise their baby boys. In fact there have even been reports of harrassment by medical professionals of new mothers, especially those belonging to religious groups that practice circumcision, in an attempt to stop them having this procedure carried out. Such attitudes are a far cry from the situation years ago when baby boys were circumcised routinely in Australia. But over the past 20 years the rate has declined to as low as 10%. 

However, a reversal of this trend is starting to occur. In the light of an increasing volume of medical scientific evidence (many publications cited below) pointing to the benefits of neonatal circumcision a new policy statement was formulated by a working party of the Australian College of Paediatrics in August 1995 and adopted by the College in May 1996 ^[2] . In this document medical practitioners are now urged to fully inform parents of the benefits of having their male children circumcised. Similar recommendations were made recently by the Canadian Paediatric Society who also conducted an evaluation of the literature, although concluded that the benefits and harms were very evenly balanced. As discussed below the American College of Pediatrics has moved far closer to an advocacy position. 

In the present article I would like to focus principally on the protection afforded by circumcision against infections, including sexually transmitted diseases (STDs). I might add that I am a university academic who teaches medical and science students and who does medical research, including that involving genital cancer virology. I am not Jewish, nor a medical practitioner or lawyer, so have no religious bias or medico-legal concerns that might get in the way of a rational discussion of this issue. 

The increased risk of infection may be a consequence of the fact that the foreskin presents the penis with a larger surface area, the moist skin under it represents a thinner epidermal barrier than the drier, more cornified skin of the circumcised penis, the presence of a prepuce is likely to result in greater microtrauma during sexual intercourse and, as one might expect, the warm, moist mucosal environment under the foreskin favours growth of micro-organisms. 

In the 1950s and 60s 90% of boys in the USA and Australia were circumcised soon after birth. The major benefits at that time were seen as improved lifetime genital hygiene, elimination of phimosis (inability to retract the foreskin) and prevention of penile cancer. The trend not to circumcise started about 20 years ago, after the American Academy of Paediatrics Committee for the Newborn stated, in 1971, that there are ?no valid medical indications for circumcision?. In 1975 this was modified to ?no absolute valid ... ?, which remained in the 1983 statement, but in 1989 it changed significantly to ?New evidence has suggested possible medical benefits ...? ^[49] . 

Dr Edgar Schoen, Chairman of the Task Force on Circumcision of the American Academy of Pediatrics, has stated that the benefits of routine circumcision of newborns as a preventative health measure far exceed the risks of the procedure ^[48] . During the period 1985-92 there was an increase in the frequency of postnewborn circumcision and during that time Schoen points out that the association of lack of circumcision and urinary tract infection has moved from ?suggestive? to ?conclusive? ^[48] . At the same time associations with other infectious agents, including HIV, have been demonstrated. In fact he goes on to say that ?Current newborn circumcision may be considered a preventative health measure analogous to immunization in that side effects and complications are immediate and usually minor, but benefits accrue for a lifetime? ^[48] . 

Benefits included: a decrease in physical problems such as phimosis ^[36] , reduction in balanitis (inflammation of the glans, the head of the penis) ^[17] , reduced urinary tract infections, fewer problems with erections at puberty, decreased sexually transmitted diseases (STDs), elimination of penile cancer in middle-aged men and, in addition, in older men, a decrease in urological problems and infections [reviewed in: 2, 18, 30, 44, 47, 49]. Therefore the benefits are different at different ages. 

Neonatologists only see the problems of the operation itself. However, urologists who deal with the problems of uncircumcised men cannot understand why all newborns are not circumcised ^{[47, 48]} . The demand for circumcision later in childhood has increased, but, with age, problems, such as anaesthetic risk, are higher. Thus Schoen states ?Current evidence concerning the life-time medical benefit of newborn circumcision favours an affirmative choice? ^[48] . 

In a letter written by Dr Schoen to Dr Terry Russell in Brisbane in 1994 Schoen derides an organization known as ?NOCIRC? for their use of ?distortions, anecdotes and testimonials to try to influence professional and legislative bodies and the public, stating that in the past few years they have become increasingly desperate and outrageous as the medical literature has documented the benefits. For example they have compared circumcision with female genital mutilation, which is equivalent to cutting off the penis. In 1993 the rate of circumcision had risen to 80% in the USA and Schoen suggests that ?Perhaps NOCIRC has decided to export their ?message? to Australia since their efforts are proving increasingly futile in the US?. He also noted that when Chairman of the Task Force his committee was bombarded with inaccurate and misleading communications from this group. Another of these groups is ?UNCIRC?, which promotes procedures to reverse circumcision, by, for example, stretching the loose skin on the shaft of the retracted penis. Claimed benefits of ?increased sensitivity? in reality appear to be a result of the friction of the foreskin, whether intact or newly created, on the moist or sweaty glans and undersurface of the prepuce in the unaroused state and would obviously in the ?re-uncircumcised? penis have nothing to do with an increase in touch receptors. The sensitivity during sexual intercourse is in fact identical, according to men circumcised as adults. 

Another respected authority is Dr Tom Wiswell, who states ?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? ^{[56, 57]} . This ability to keep an open mind on the issue and to make a sound judgement on the balance of all available information is to his credit ? he did change his mind! 

The complication rates of having or not having the procedure have been examined. Amongst 136,000 boys born in US army hospitals between 1980 and 1985, 100,000 were circumcised and 193 (0.19%) had complications, with no deaths ^[58] . Of the 36,000 who were not circumcised the complication rate was 0.24% and there were 2 deaths ^[58] . In 1989 of the 11,000 circumcisions performed at New York?s Sloane Hospital, only 6 led to complications, none of which were fatal ^[44] . Also no adverse psychological aftermath has been demonstrated ^[46] . Cortisol levels have registered an increase during and shortly after the procedure, indicating that the baby is not unaware of the procedure in its unanaesthetized state and one has to weigh up the need to inflict this short term pain in the context of a lifetime of gain from prevention or reduction of subsequent problems. Anaesthetic creams and other means appear to be at least partially effective in reducing trauma and some babies show no signs of distress at all when the procedure is performed without anaesthetic. 

The proponents of not circumcising nevertheless stress that lifelong penile hygiene is required. This acknowledges that something harmful or unpleasant is happening under the prepuce. Moreover, a study of British schoolboys found that penile hygiene does not exist ^[44] . Furthermore, Dr Terry Russell, writing in the Medical Observer states ?What man after a night of passion is going to perform penile hygiene before rolling over and snoring the night away (with pathogenic organisms multiplying in the warm moist environment under the prepuce)? ^[44] . 

The reasons for circumcision, at least in a survey carried out as part of a study at Sydney Hospital, were: 3% for religious reasons, 1-2% for medical, with the remainder presumably being ?to be like dad? or a preference of one or both parents for whatever reason ^[16] . The actual proportion of men who were circumcised when examined at this clinic was 62%. Of those studied, 95% were Caucasian, with younger men just as likely to be circumcised as older men. In Adelaide a similar proportion has been noted, with 55% of younger men being circumcised. In Britain, however, the rate is only 7-10%, much like Europe, and in the USA, as indicated above, the rate of circumcision has always been high ^[16] . 

Neonatal urinary tract infections 

A study by Wiswell of 400,000 newborns over the period 1975-84 found that the uncircumcised had an 11-fold higher incidence of urinary tract infections (UTIs) ^[58] . During this decade the frequency of circumcision in the USA decreased from 84% to 74% and this decrease was associated with an increase in rate of UTI ^[61] . UTI was lower in circumcised, but higher in uncircumcised. In a 1982 series 95% of UTI cases were in uncircumcised ^[60] . A study by Roberts in 1986 found that 4% of uncircumcised boys got UTI, compared with 0.4% of girls and 0.2% of circumcised boys ^[42] . This indicated a 20-fold higher risk for uncircumcised boys. In a 1993 study by Wiswell of 200,000 infants born between 1985 and 1990, 1000 got UTI in their first year of life ^[59] . The number was equal for boys and girls, but was 10-times higher for uncircumcised boys. Of these 23% had bacteraemia. The infection can travel up the urinary tract to affect the kidney and higher rate of problems such as pyelonephritis is seen in uncircumcised children ^{[43, 52]} . These and other reports [e.g., 21, 43, 52] all point to the benefits of circumcision in reducing UTI. 

Indeed, Wiswell performed a meta-analysis of all 9 previous studies and found that every one indicated an increase in UTI in the uncircumcised ^[59] . The average was 12-fold higher and the range was 5 to 89-fold, with 95% confidence intervals of 11-14 ^[59] . Meta-analyses by others have reached similar conclusions. Other studies, including one of men with an average age of 30 years, have indicated that circumcision also reduces UTI in adulthood ^[51] . The fact that the bacterium E. coli , which is pathogenic to the urinary tract, has been shown to be capable of adhering to the foreskin, satisfies one of the criteria for causality [52, 62, and refs in 18]. Since the absolute risk of UTI in uncircumcised boys is approx. 1 in 25 (0.05) and in circumcised boys is 1 in 500 (0.002), the absolute risk reduction is 0.048. Thus 20 baby boys need to be circumcised to prevent one UTI. However, the potential seriousness and pain of UTI, which can in rare cases even lead to death, should weigh heavily on the minds of parents. The complications of UTI that can lead to death are: kidney failure, meningitis and infection of bone marrow. The data thus show that much suffering has resulted from leaving the foreskin intact. Lifelong genital hygiene in an attempt to reduce such infections is also part of the price that would have to be paid if the foreskin were to be retained. However, given the difficulty in keeping bacteria at bay in this part of the body ^{[38, 48]} , not performing circumcision would appear to be far less effective than having it done in the first instance ^[48] . 

Sexually-transmitted diseases 

Early studies showed higher rates of gonococcal and nonspecific urethritis in uncircumcised men ^{[39, 48]} . Recent studies have yielded similar findings. In addition, the earlier work showed higher chancroid, syphilis, papillomavirus and herpes ^[53] . However, there were methodological problems with the design of these studies, leading to criticisms. As a result there is still no overwhelming agreement. In 1947 a study of 1300 consecutive patients in a Canadian Army unit showed that being uncircumcised was associated with a 9-fold higher risk of syphilis and 3-times more gonorrhea ^[55] . At the University of Western Australia a 1983 study showed twice as much herpes and gonorrhea, 5-times more candidiasis and 5-fold greater incidence of syphilis ^[39] . In South Australia a study in 1992 showed that uncircumcised men had more chlamidia (odds ratio 1.3) and gonoccocal infections (odds ratio 2.1). Similarly in 1988 a study in Seattle of 2,800 heterosexual men reported higher syphilis and gonnorrhea in uncircumcised men, but no difference in herpes, chlamidia and non-specific urethritis (NSU). Like this report, a study in 1994 in the USA, found higher gonnorhea and syphilis, but no difference in other common STDs ^[12] . In the same year Dr Basil Donovan and associates reported the results of a study of 300 consecutive heterosexual male patients attending Sydney STD Centre at Sydney Hospital ^[16] . They found no difference in genital herpes, seropositivity for HSV-2, genital warts and NSU. As mentioned above, 62% were circumcised and the two groups had a similar age, number of partners and education. Gonorrhea, syphilis and hepatitis B were too uncommon in this Sydney study for them to conclude anything about these. Thus on the bulk of evidence it would seem that at least some STDs may be more common in the uncircumcised, but this conclusion is by no means absolute and the incidence may be influenced by factors such as the degree of genital hygiene, availability of running water and socioeconomic group being studied. 

Cancer of the penis 

The incidence of penile cancer in the USA is 1 per 100,000 men per year (i.e., 750-1000 cases annually) and mortality rate is 25-33% ^{[27, 31]} . It represents approximately 1% of all malignancies in men in the USA. This data has to be viewed, moreover, in the context of the high proportion of circumcised men in the USA, especially in older age groups, and the age group affected, where older men represent only a portion of the total male population. In a study in Melbourne published in Australasian Radiology in 1990, although 60% of affected men were over 60 years of age, 40% were under 60 ^[45] . In 5 major series in the USA since 1932, not one man with penile cancer had been circumcised neonatally ^[31] , i.e., this disease only occurs in uncircumcised men and, less commonly, in those circumcised after the newborn period. The proportion of penile malignancies as a fraction of total cancers in uncircumcised men would thus be considerable. The predicted life-time risk has been estimated as 1 in 600 in the USA and 1 in 900 in Denmark ^[27] . In under-developed countries the incidence is higher: approx. 3-6 cases per 100,000 per year ^[27] . 

The so-called ?high-risk? papillomavirus types 16 and 18 (HPV 16/18) are found in a large proportion of cases and there is good reason to suspect that they are involved in the causation of this cancer, as is true for most cases of cervical cancer (see below). HPV 16 and 18 are, moreover, more common in uncircumcised males ^[35] . These types of HPV produce flat warts that are normally only visible by application of dilute acetic acid (vinegar) to the penis and the data on high-risk HPVs should not be confused with the incidence figures for genital warts, which although large and readily visible, are caused by the relatively benign HPV types 6 and 11. Other factors, such as poor hygiene and other STDs have been suspected as contributing to penile cancer as well ^{[8, 31]} . 

In Australia between 1960 and 1966 there were 78 deaths from cancer of the penis and 2 from circumcision. (Circumcision fatalities these days are virtually unknown.) At the Peter McCallum Cancer Institute 102 cases of penile cancer were seen between 1954 and 1984, with twice as many in the latter decade compared with the first. Moreover, several authors have linked the rising incidence of penile cancer to a decrease in the number of neonatal circumcisions ^{[13, 45]} . It would thus seem that ?prevention by circumcision in infancy is the best policy?. 

Cervical cancer in female partners of uncircumcised men 

A number of studies have documented higher rates of cervical cancer in women who have had one or more male sexual partners who were uncircumcised. These studies have to be looked at critically, however, to see to what extent cultural and other influences might be contributing in groups with different circumcision practices. In a study of 5000 cervical and 300 penile cancer cases in Madras between 1982 and 1990 the incidence was low amongst Muslim women, when compared with Hindu and Christian, and was not seen at all in Muslim men ^[22] . In a case-control study of 1107 Indian women with cervical cancer, sex with uncircumcised men or those circumcised after the age of 1 year was reported in 1993 to be associated with a 4-fold higher risk of cervical cancer, after controlling for factors such as age, age of first intercourse and education ^[1] . Another study published in 1993 concerning various types of cancer in the Valley of Kashmir concluded that universal male circumcision in the majority community was responsible for the low rate of cervical cancer compared with the rest of India ^[14] . In Israel, a 1994 report of 4 groups of women aged 17-60 found that gynaecologically healthy Moshav residents had no HPV 16/18, whereas healthy Kibbutz residents had a 1.8% incidence ^[24] . Amongst those with gynaecological complaints HPV 16/18 was found in 9% of Jewish and 12% of non-Jewish women. HPV types 16 and 18 cause penile intraepithelial neoplasia (PIN) and a study published in the New England Journal of Medicine in 1987 found that women with cervical cancer were more likely to have partners with PIN, the male equivalent of cervical intraepithelial neoplasia (CIN) ^[6] . Thus the epidemic of cervical cancer in Australia, and indeed most countries in the world, would appear to be due at least in part to the uncircumcised male and would therefore be expected to get even worse as the large proportion that were born in the past 10-20 years and not circumcised reach sexual maturity. 

AIDS virus 

In the USA the estimated risk of HIV per heterosexual exposure is 1 in 10,000 to 1 in 100,000. If one partner is HIV positive and otherwise healthy then a single act of unprotected vaginal sex carries a 1 in 300 risk for a woman and as low as a 1 in 1000 risk for a man ^[9] . (The rates are very much higher for unprotected anal sex and intravenous injection). In Africa, however, the rate of HIV infection is up to 10% in some cities. (A possible reason for this big difference will be discussed later.) In Nairobi it was first noticed that among 340 men being treated for STDs they were 3-times as likely to be HIV positive if they had genital ulcers or were uncircumcised (11% of these men had HIV) ^[50] . Subsequently another report showed that amongst 409 African ethnic groups spread over 37 countries the geographical distribution of circumcision practices indicated a correlation of lack of circumcision and high incidence of AIDS ^[7] . In 1990 Moses in International Journal of Epidemiology reported that amongst 700 African societies involving 140 locations and 41 countries there was a considerably lower incidence of HIV in those localities where circumcision was practiced ^{[33, 34]} . Truck drivers, who generally exhibit more frequent prostitute contact, have shown a higher rate of HIV if uncircumcised. Interestingly, in a West African setting, men who were circumcised but had residual foreskin were more likely to be HIV-2 positive than those in whom circumcision was complete ^[40] . 

Of 26 cross-sectional studies, 18 have reported statistically significant association [e.g., 15, 23, 25, 54], by univariate and multivariate analysis, between the presence of the foreskin and HIV infection, and 4 reported a trend. The findings have, moreover, led various workers such as Moses and Caldwell to propose that circumcision be used as an important intervention strategy in order to reduce AIDS [9, 19, 23, 26, 32-34]. 

Perhaps the most interesting study of the risk of HIV infection imposed by having a foreskin is that by Cameron, Plummer and associates published as a large article in Lancet in 1989 ^[10] . This had the advantage of being prospective. It was conducted in Nairobi. These workers followed HIV negative men until they became infected. The men were visiting prostitutes, numbering approx. 1000, amongst whom there had been an explosive increase in the incidence of HIV from 4% in 1981 to 85% in 1986. These men were thus at high risk of exposure to HIV, as well as other STDs. From March to December 1987, 422 men were enrolled into the study. Of these, 51% had presented with genital ulcer disease (89% chancroid, 4% syphilis, 5% herpes) and the other 49% with urethritis (68% being gonorrhea). 12% were initially positive for HIV-1. Amongst the whole group, 27% were not circumcised. They were followed up each 2 weeks for 3 months and then monthly until March 1988. During this time 8% of 293 men seroconverted (i.e., 24 men), the mean time being 8 weeks. These displayed greater prostitute contact per month (risk ratio = 3), more presented with genital ulcers (risk ratio = 8; P <0.001) and more were uncircumcised (risk ratio = 10; P <0.001). Logistic regression analysis indicated that the risk of seroconversion was independently associated with being uncircumcised (risk ratio = 8.2; P <0.0001), genital ulcers (risk ratio = 4.7; P = 0.02) and regular prostitute contact (risk ratio = 3.2; P = 0.02). The cumulative frequency of seroconversion was 18% and was only 2% for men with no risk factors, compared to 53% for men with both risk factors. Only one circumcised man with no ulcer seroconverted. Thus 98% of seroconversion was associated with either or both cofactors. In 65% there appeared to be additive synergy, the reason being that ulcers increase infectivity for HIV. This involves increased viral shedding in the female genital tract of women with ulcers, where HIV-1 has been isolated from surface ulcers in the genital tract of HIV-1 infected women. 

It has been suggested that the foreskin could physically trap HIV-infected vaginal secretions and provide a more hospitable environment for the infectious innoculum. Also, the increased surface area, traumatic physical disruption during intercourse and inflammation of the glans penis (balanitis) could aid in recruitment of target cells for HIV-1. The port of entry could potentially be the glans, subprepuce and/or urethra. In a circumcised penis the dry, cornified skin may prevent entry and account for the findings. 

In this African study the rate of transmission of HIV following a single exposure was 13% (i.e., very much higher than in the USA). It was suggested that concomitant STDs, particularly chancroid ^[9] , may be a big risk factor, but there could be other explanations as well. Studies in the USA have not been as conclusive. Some studies have shown a higher incidence in uncircumcised men. Others do not. In New York City, for example, no correlation was found, but the patients were mainly intravenous drug users and homosexuals, so that any existing effect may have been obscured. A study in Miami, however, of heterosexual couples did find a higher incidence in men who were uncircumcised, and, in Seattle homosexual men were twice as likely to be HIV positive if they were uncircumcised ^[28] . 

The reason for the big difference in apparent rate of transmission of HIV in Africa and Asia, where heterosexual exposure has led to a rapid spread through these populations and is the main method of transmission, compared with the very slow rate of penetration into the heterosexual community in the USA and Australia, now appears to be related at least in part to a difference in the type of HIV-1 itself ^[29] . In 1995 an article in Nature Medicine discussed findings concerning marked differences in the properties of different HIV-1 subtypes in different geographical locations ^[37] . A class of HIV-1 termed ?clade E? is prevalent in Asia and differs from the ?clade B? found in developed countries in being highly capable of infecting Langerhans cells found in the foreskin, so accounting for its ready transmission across mucosal membranes. The Langerhans cells are part of the immune system and in turn carry the HIV to the T-cells, whose numbers are severely depleted as a key feature of AIDS. The arrival of the Asian strain in Australia was reported in Nov 1995 and has the potential to utilise the uncircumcised male as a vehicle for rapid spread through the heterosexual community of this country in a similar manner as it has done in Asia. It could thus be a time-bomb about to go off and should be a major concern for health officials. 

To summarize: 

Lack of circumcision: 

• Is the biggest risk factor for heterosexually-acquired AIDS virus infection in men (8-times higher risk by itself, and even higher when lesions from STDs are added in). 
• Is responsible for a 12-fold higher risk of urinary tract infections. 
• Carries a higher risk of death in the first year of life (from complications of urinary tract infections: kidney failure, meningitis and infection of bone marrow). 
• One in ~600-900 uncircumcised men will die from cancer of the penis or require at least partial penile amputation as a result. (In contrast, penile cancer never occurs in men circumcised at birth). (Data from studies in the USA, Denmark and Australia, which are not to be confused with the often quoted, but misleading, annual incidence figures of 1 in 100,000). 
• Often leads to balanitis (inflammation of the glans), phimosis (inability to retract the foreskin) and paraphimosis (constriction of the penis by a tight foreskin). Up to 18% of uncircumcised boys will develop one of these by 8 years of age, whereas all are unknown in the circumcised. 
• Means problems that may result in a need for circumcision late in life: complication risk = 1 in 100 (compared with 1 in 1000 in the newborn). 
• Is associated with higher incidence of cervical cancer in the female partners of uncircumcised men. 

• 18% of uncircumcised males underwent circumcision later in life anyway. 
• 21% of uncircumcised men who didn't, nevertheless wished they were circumcised. (There were also almost as many men who wished they hadn?t been circumcised and it could be that at least some men of either category may have been seeking a scapegoat for their sexual or other problems. In addition, this would no doubt be yet another thing parents could be blamed for by their children, whatever their decision was when the child was born.) 
• No difference in sexual performance (consistent with Masters & Johnson). 
• Slightly higher sexual activity in circumcised men. 
• No difference in frequency of sexual intercourse for older uncircumcised vs. circumcised men. 
• Men circumcised as adults were very pleased with the result. The local pain when they awoke from the anaesthetic was quickly relieved by pain killers (needed only for one day), and all had returned to normal sexual relations within 2 weeks, with no decrease in sensitivity of the penis and claims of 'better sex'. (Badger?s findings are, moreover, consistent with every discussion I have ever had with men circumcised as adults. The only case to the contrary was a testimonial in a letter I received in the mail from a member of UNCIRC.) 
• Women with circumcised lovers were more likely to reach a simultaneous climax. 
• Women with uncircumcised lovers were 3 times as likely to fail to reach orgasm. (These data could, however, possibly reflect behaviours of uncircumcised males that might belong to lower socio-economic classes and/or ethnic groups whose attitudes may differ from groups in which circumcision is more common.) 
• Circumcision was favoured by women for appearance and hygiene. (Furthermore, some women were nauseated by the smell of the uncircumcised penis, where, as mentioned above bacteria and other micro-organisms proliferate under the foreskin.) 
• The uncircumcised penis was found by women to be easier to elicit orgasm by hand. 
• The circumcised penis was favoured by women for oral sex. 

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