Circumcision, Science, and Religion: Part 2

By Tracy G. Cassels

Picking up where we left off…

The Science around Circumcision, continued

Penile Cancer

This is considered one of the major bonuses by some religious sites[1] who reported that in one study, none of the individuals with penile cancer had been circumcised in childhood.  A review of all the research does find many studies showing that infant or early childhood (not adult) circumcision seems to act as a preventative measure against penile cancer[2][3][4].  In fact, as of the 1980, there had only been two confirmed cases of penile cancer in Jewish men circumcised neonatally[5].  Interestingly, though, the relationship is limited to invasive penile cancer.  Stage 0 of penile cancer, known as carcinoma in situ, in which abnormal growths start to appear on the surface of the skin of the penis is equally likely to be found in circumcised and non-circumcised men[3][4].  This raises the question of how circumcision prevents the spread of the disease, particularly as it has to be childhood circumcision – adult circumcision has no effect.

While a full understanding of how penile cancer spreads is unknown, the fact that later circumcision has no effect on the outcome raises questions about the assumption that it is circumcision per se that reduces the likelihood of penile cancer.  In this regard, several researchers have focused their attention on a condition called phimosis which has been found to be present in a large majority of penile cancer cases.  Phimosis is a condition in which the foreskin cannot be fully retracted over the head of the penis (or glans penis) and is common in infancy and into adolescence, but after adolescence is considered a health concern.  Phimosis has been found to be a strong risk factor for penile cancer[6][7][8], but interestingly, when both individuals who do not have a history of phimosis are excluded from analyses, circumcision ceases to have a significant protective effect[7].  That is, the benefits of circumcision are mediated by phimosis such that the protection conferred by infant circumcision seems to only be there for those who have phimosis, presumably because phimosis cannot occur when one has been circumcised.  Some researchers have argued that it is the retention of smegma (a secretion from the genitals that occurs in men and women) that is brought on by phimosis or poor hygene of the penis (another risk factor, see [8]) that causes invasive penile cancer[6], but the jury is still out.

What does this mean?  It means that while infant circumcision does offer protection from penile cancer, it does so only for those who would develop phimosis (which can be diagnosed relatively young, as about 90% of children have retractable foreskin by age 3, 99% by age 17) or who do not practice proper hygienic care of the penis.  It is currently unknown if other practices could be as helpful in preventing penile cancer (as the increase in hygienic care proved to be) or if people feel the risks or problems associated with circumcision outweigh the potential benefits with respect to penile cancer (which affects 0.5-1.5 per 100,000 in Western countries, or 0.0005% of the population).  As it stands, it is fair to say that infant or early childhood circumcision reduces the risk of penile cancer by reducing the risk or occurrence of phimosis and any negative hygienic practices.  However, whether that risk is worth it given the low incidence of penile cancer and the higher rate of complications from circumcision, remains up to the individual.

Urinary Tract Infections

In the 1980s there was a fair amount of research that found urinary tract infections were more common in children who had not been circumcised (e.g., [9]).  More recently, research has suggested that routine infant circumcision could save the health care system a lot of money with respect to the costs of treating UTIs in infant males[10] (though notably the rate of UTIs is nearly double for female newborns).  Meta-analyses and reviews continue to find that UTIs are more likely to be found in non-circumcised infants[11][12].  While this may seem to suggest that routine infant circumcision is the way to go, one of these studies highlighted something the others clearly ignored.  While Dr. Singh-Grewal and colleagues did find that there was a significant reduction of risk of UTI in circumcised males, the overall risk of a UTI currently stands at 1%, though it jumps to 10-30% for boys with a history of recurrent UTIs.  Complications from circumcision stand at 2% and most commonly include haemorrhage and infection, which means that if we assume the costs are equal, there is no reason to suggest circumcision as a means to prevent against UTIs[12].

What does this mean?  Yes, circumcision does seem to prevent UTIs and later circumcision seems to help boys who have had recurrent UTIs, so there is something about the circumcision process that confers protection.  However, as Dr. Singh-Grewal pointed out, the overall risk of a UTI is lower than the risk of complications from circumcision, suggesting that the net benefit lie in not circumcising low-risk boys if UTIs are the only outcome considered.

Pain

Pain is the number one concern for those who are against circumcision.  For many years, the vast majority of circumcisions were done without any anesthetic at all, and apparently a sizeable number of Jewish circumcisions are still done without anesthetic.  For those that use anesthetic, there are many different types of anesthetic available for those who do choose to use it, all with differing utility in reducing or blocking pain to the newborn.  Let us start by examining what we do know about the pain response to circumcision done without any anesthetic.  Probably the most notable study on the matter was done in the late 1990s by a group of researchers at the University of Alberta[13].  In this study, the goal was to compare various forms of anesthetic with no anesthesia used as the baseline (as it was current practice at the time) in a randomized controlled trial.  They measured pain using heart rate, crying response, and levels of methemoglobin (a type of hemoglobin which occurs in higher amounts with greater pain levels).  Notably, children in the control group demonstrated far more behavioural markers of pain than any other group and in fact was so bad that the researchers had to stop the study part way through out of ethical considerations.  The heart rate of infants in the placebo group was dramatically larger than all other groups at all stages after cleansing and remained high for the entire follow-up period.  Similarly, the proportion of time spent crying was significantly higher, reaching a peak of 98% of the time during separation, and remained far higher during the follow-up period (between 62 and 67% of the time).  Finally, two out of 11 infants in the placebo group experienced extreme side effects including prolonged period of apnea, projectile vomiting, and choking.  The conclusion of this team of doctors and researchers was that “newborns in this study who did not receive an anesthetic suffered great distress during and following circumcision, and they were exposed to unnecessary risk” (p. 2161).  Other research on cortisol levels has found circumcision raised cortisol levels three to four-fold[14].  In short, the myth that infants do not feel the pain is completely and totally wrong.

With respect to other forms of anesthetic, multiple researchers have found that the ring block provides the greatest relief from pain, though it is not 100%[13][15].  The dorsal penile block has also been found to be effective[15], though not as much as the ring block[13].  Topical anesthetic (the most common form is EMLA), which is one of the common forms of pain relief, is not nearly as effective as one might think, with heart rate elevation and crying periods reaching the levels seen in those without anesthetic[13], however it has been found to reduce the pain response relative to no anesthetic at all[16].  Finally, the use of an oral sucrose mix for infants to suck on has been suggested as a non-pharmacological means of dealing with pain for infant procedures[17]; however it may work for other procedures, it has been found to have zero effect on pain management for circumcision[15][18].

What does this mean?  Unfortunately many people believe that in today’s society, anesthetic during circumcision is not only a given, but that it works quite well.  What the research shows is that this is, in fact, not the case.  In one study on training practices surrounding circumcision, 26% of programs did not teach techniques for anesthetic for circumcision[19].  The topic of anesthesia becomes even more difficult with respect to Jewish ceremonial circumcisions because they are done in the home and thus without a skilled anesthetist, which is most likely why a topical anesthetic is of high value despite the fact that it is the least efficient in reducing pain.  Regardless of any other ‘benefit’ that circumcision may confer, the notion of putting an infant through sever pain (which is what it has been assessed to be) without consent is wrong.  When anesthesia is used, the pain during the procedure is diminished (though I do not know about the pain thereafter and how long the pain lasts), but not completely removed; however, it may be akin to the pain associated with vaccines, but more research is needed to make such a comparison.  In short, circumcision hurts.  A lot.  And this pain is only reduced in a small way with topical anesthetic, yet there seem to be few options beyond that for a home-based circumcision, or bris.

To Be Continued… Click  here for Part 3

For Part 1, click here.



[1] http://www.aish.com/jl/l/48959461.html

[2] Maden C, Sherman KJ, Beckmann AM, et al.  History of circumcision, medical conditions, and sexual activity and risk of penile cancer.  Journal of the National Cancer Institute 1993; 85: 19-24.

[3] Daling JR, Madeleine MM, Johnson LG, et al. Penile cancer: Importance of circumcision, human papillomavirus and smoking in in situ and invasive disease.  International Journal of Cancer 2005; 116: 606-616.

[4] Schoen EJ, Oehrli M, Colby CJ, Machin G. The highly protective effect of newborn circumcision against invasive penile cancer.  Pediatrics 2000; 105: e36.

[5] Boczko S, Freed S. Penile carcinoma in circumcised males.  NY State J Med 1979; 39: 1903-04.

[6] Hellberg D, Valentin J, Eklund T, Nilsson S. Penile cancer: Is there an epidemiological role for smoking and sexual behaviour? British Medical Journal 1987; 295: 1306-08.

[7] Tseng H-F, Morgenstern H, Mack T, Peters RK. Risk factors for penile cancer: Results of a population-based case-control study in Los Angeles County (United States). Cancer Causes and Control 2001; 12: 267-277.

[8] Brinton LA, Jun-Yao L, Shou-De R, et al. Risk factors for penile cancer: Results from a case-control study in China. International Journal of Cancer 1991; 47: 504-509.

[9] Wiswell TE, Smith FR, Bass JW. Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1985; 75: 901-903.

[10] Schoen EJ, Colby CJ, Ray GT. Newborn circumcision decreases incidence and costs of urinary tract infections during the first year of life. Pediatrics 2000; 105: 789-793.

[11] Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of urinary tract infections in childhood: A meta-analysis. Pediatric Infectious Diseases 2008; 27: 302-308.

[12] Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: A systematic review of randomized trials and observational studies. Archives of Disease in Childhood 2005; 90: 853-858.

[13] Lander J, Brady-Fryer B, Metcalfe JB, Nazarali S, Muttitt S. Comparison of a ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision. JAMA 1997; 278: 2157-2162.

[14] Gunnar MR, Malone S, Vance G, Fisch RO. Coping with aversive stimulation in the neonatal period: quiet sleep and plasma cortisol levels during recovery from circumcision. Child Development 1985; 56: 824-34.

[15] Razmus IS, Dalton ME, Wilson D. Pain management for newborn circumcision. Pediatric Nursing 2004; 30: 414-7.

[16] Benini F, Johnson C, Faucher D, Aranda JV. Topical anesthesia during circumcision in newborn infants. JAMA 1993; 270: 850-853.

[17] Tsao JCI, Evans S, Meldrum M, Altman T, Zelzer LK. A review of CAM for procedural pain in infancy: Part I. Sucrose and non-nutritive sucking. eCAM 2008; 5: 371-81.

[18] Donahue KM. The effect of oral sucrose on neonatal pain during circumcision when combined with topical anesthesia. Presentation made at the 2007 biennial Sigma Theta Tau International Conference.

[19] Howard CR, Howard FM, Garfunkel LC, de Blieck EA, Weitzman M. Neonatal circumcision and pain relief: Current training practices. Pediatrics 1998; 101: 423-8.

Comments

  1. Jespren says

    Question with the topical, because we used a topical pain relief for a procedure on our son once (blood draw that we knew was going to be multiple sticks) and the doctor said it takes 30 minutes to take affect. But when reading hospital accounts of circumcision it’s inevitably along the lines of ‘nurse applies cream, doctor immediately preforms circumcision’. (At least in the accounts I’ve read of U.S. hospitals). So in the study, did they follow ‘standard practice’ when using topical analgesics (little or no wait time after application) or was sufficient time given to actually allow the absorbtion and thus effect of the topical? Also, in many states at least although I don’t think all, lidocaine can be used legally by non-doctors. Lay midwives are allowed to use it for stitches for instance or other non-md health care providers for trigger point injections or as prep for a procedure later preformed by a doctor or may despense it as long as the prescription came from a doctor. So I don’t see it unrealistic that a bris could be attended by someone capable of injecting lidocaine, which has to be better than a topical cream.
    Randomly, too, I know some traditional Jews use a few drops of wine to help calm/relieve the baby. Don’t know how effective alcohol is in general, but it has been used as a primary pain reliever for all age groups for several hundred years. Seems relevent.

    • says

      All studies had the wait time for the topical cream to be effective so these were findings with the appropriate care given to wait time.

      I didn’t find a study with lidocaine used as an anesthesia for circumcision, but that’s not to say there isn’t any out there (I can only search so far and wide). I agree that there should be a way to have someone at a bris be able to administer some *effective* form of pain relief.

      I did read about the alcohol, but no one (to my knowledge) has studied its effect on pain in circumcision. If there wasn’t a study that I found, I didn’t include it because it seemed like conjecture which may or may not be helpful :)

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