Danish Researcher explains the function of the foreskin and harms of circumcision

HEARING ON CIRCUMCISION in Danish Parliament on October 22, 2014

Arranged by the Danish Parliament's Cross-Party Network for Sexual and Reproductive Health and Rights

Presentation by Morten Frisch, MD, PhD, DSc (Med), Adjunct professor of sexual health epidemiology

Thank you for the invitation. I have placed my ”starters’ kit” on circumcision on every chair and freely accessible on Facebook and Twitter today, such that everyone can get information about the basic health-related and ethical issues related to the circumcision problem. The widespread taboo surrounding the human genitals imply that few people really know what circumcision is all about. Please listen carefully.

During fetal development the male and female genitalia develop from the exact same embryonic structure. Here you see the external genitals of the male (left) and female (right) fetus at around 12 weeks of gestation. At this point in development it is not possible to distinguish between the two sexes. At birth, however, everybody can see the difference.

Please note that all male structures have equivalent female structures. The foreskin covers the penile glans in most boys and men. The foreskin protects the glans. Consequently, the glans of intact men is sensitive, smooth and moist, while the glans of circumcised men is relatively insensitive, uneven and dry. The size of the scar that all circumcised men have depends on the amount of penile skin removed.

The penile glans is exposed during erection, and sexual stimulation occurs when the foreskin moves back and forth over the glans. Only few people know that women also have foreskins known as the clitoral hood. The clitoral hood has the same protective and stimulating functions as the male foreskin. During female sexual arousal the size of the clitoris increases, and the clitoral glans is exposed.

Most women can easily imagine how unpleasant direct stimulation of the clitoral glans will feel in the absence of the clitoral hood. This is the situation for many women after sunna circumcision, and this is the situation for circumcised men. Over time, circumcised men gradually develop a keratinized layer, which results in reduced sensitivity of the glans. The missing foreskin, and the reduced sensitivity of the glans, explain the long-known circumcision-related sexual difficulties, which have been confirmed in recent studies.

The foreskin is not a small, superfluous piece of skin. The foreskin is a complex, double-layered structure rich in sensory nerves. The area of the foreskin is typically between 50 and 90 square centimeters (8-14 square inches), the better part of a dollar note. The foreskin has skin on the external side and an equally large mucous membrane on the interior.

During erection the glans grows in size and pulls with it the mucosal part of the foreskin on its way out. In the picture to the right, you can see that this man’s penile shaft is covered by foreskin from the root of the penis and all the way to the glans. Recalling the slide showing the relatively insensitive, uneven and dry glans, it becomes clear that circumcised men have reduced sensitivity from the root of the penis to the very tip of the glans. This is the future scenario awaiting every circumcised boy.

The Danish National Board of Health’s ”Note on the circumcision of boys” from 2013 is full of errors, inaccuracies, trivializations and serious omissions. From a health professional’s perspective, this “Note” is an embarrassing presentation of the topic, leaving ample room for religious views.

In March 2014, I wrote a harsh commentary in the newspaper Politiken about the National Board of Health’s handling of the circumcision problem. The Board has never proved me wrong in any of the criticisms I have raised. Regrettably, however, the “Note” is often used by ministers and politicians who are too busy to evaluate the matter themselves. From a health professional’s perspective the “Note” is medically substandard and, moreover, entirely unacceptable from a medical ethics perspective.

The “Note” is the central Danish health authority’s recognition that foreskin amputation is acceptable, if the boy is given a little sugar while his body and sexuality is altered for life. European doctors agree that there are no relevant health benefits associated with circumcision of boys. Not one medical association in the whole world recommends circumcision of healthy boys. In contrast, several advocate against circumcision.

Last year, I took the lead in this article together with 37 other professors and consultants in 17 European countries and Canada. We reject the poorly substantiated myths about health benefits gained by circumcision that American pediatricians earn good dollars persuading baby boys’ parents to believe.

Seven minutes do not permit detailed scrutiny of all the complications that may occur. A 2013 study from Rigshospitalet, showed that when the most experienced pediatric surgeons in Denmark perform non-therapeutic circumcision in boys, one in 20 boys will experience a non-trivial complication.

In countries where boys undergo routine circumcision, vast finances are spent on circumcisions and on subsequent operations repairing the consequential damages. In a university hospital in Boston, pediatric surgeons spend 5-7 percent of their operating hours doing circumcision repair operations.
Between 10 and 20 percent of boys circumcised shortly after birth develop narrowing of the urethral opening (meatal stenosis) that requires intervention. Intact boys almost never develop this condition.

All boys experience some level of procedural and postoperative pain. Moreover, they lose sensitivity and are subjected to unnecessary risks. Hemorrhage, infection and meatal stenosis are common, and unpleasant, serious and outright life-threatening conditions may occur – however, fortunately only rarely. Problems can arise with the youngest and older boys – and with adult men and their partners. New studies document that many women can relate to this as well.

According to the Hippocratic oath, doctors are obliged not to cause pain or damage to fellow human beings. This is a good principle that should be extended to everyone, particularly when handling our most vulnerable fellow human beings, our children. However, when it comes to circumcision - whether in boys or girls - this is exactly what the circumciser does. He causes pain and inflicts irreversible, physical damage to the child’s body. An open, painful wound with lifelong consequences that are sometimes serious. This summer, a newborn boy was in a coma in Hvidovre Hospital after a botched circumcision performed by a surgeon in Copenhagen.

Circumcision is not mainly a health issue. Circumcision is first and foremost a human rights issue, a gender equality issue and, lastly, a judicial issue. It is my sincere hope that you politicians will take your responsibility seriously and ensure that future boys will enjoy the same rights to physical, psychological and sexual integrity as those conveyed to Danish girls back in 2003.

Thank you for listening.

AAP technical paper on circumcision called "epidemiologically incompetent and an embarrassment to the AAP."

• • 
    
• • Letter from a Fellow of the Royal Australasian College of Physicians (RACP) on the AAP technical report on circumcision.
  • 
    
  Christopher R Lawson, Deputy Head

Sunshine Coast Clinical School, University of Queensland

Among many basic errors of epidemiology, the authors do not even understand how to calculate Number Needed to Treat. (From p. e767: "Given that the risk of UTI among this population is approximately 1%, the number needed to circumcise to prevent UTI is approximately 100.")

Two of the referenced papers from which this figure was derived, written by investigators who do understand how to calculate NNT, found respectively that 111 and 195 circumcisions were needed to prevent one UTI. These data were reported in the abstracts.

Finally, for the authors to say "Most available data were published before 1995 and consistently show an association between the lack of circumcision and increased risk of UTI" and then <i>arbitrarily exclude all data prior to 1995</i> is an unforgiveable design flaw.

This paper is epidemiologically incompetent and an embarrassment to the AAP.

Conflict of Interest:

None declared

.

Freedom of Information requests finds dozens of life threatening injuries from circumcision from one hospital

" In 2011 alone, nearly a dozen infant boys had to be treated for “life threatening haemorrhage, shock or sepsis” as a result of their non-therapeutic circumcisions at a single children’s hospital in Birmingham.[96] This information was made public due to a specific freedom of information request, and so would not otherwise have been reported. It is clear, then, that we are seeing only the tip of the iceberg in terms of risks and complications " = Ref : [96] Checketts, R. (2012). Response to freedom of information request, FOI/0742. Birmingham Children’s Hospital, NHS Foundation Trust. Available at http://www.secularism.org.uk/uploads/foi-bch-response-received-260612.pdf.


The above quote was taken from the Skeptic Magazine article found here: http://www.skeptic.org.uk/magazine/onlinearticles/articlelist/711-infant-circumcision

Circumcision & Risk Compensation

Risk compensation is a theory that developed from observing that human beings changed their behaviour according to their assessment of risk level.  It basically states that human beings will do more of something if they feel they have a low risk of harm, or do less of something if there is a high risk of harm.   When applied to circumcision it suggests that if circumcised men feel they are at less of a risk of acquiring an STI/HIV infection, then they are less likely to practice safe sex and more likely to practice risky sexual behaviour, leading to the unwanted outcome of placing circumcised men and their partners at greater risk of infection.  We are already now seeing HIV infections rising in Africa following circumcision campaigns = http://mondofown.blogspot.com.au/2014/05/media-reports-showing-rise-in-hiv.html

When you look at epidemiological health outcome data, you find that the USA with the highest adult circumcision rate in the western world also has the highest rates of HIV & STI infections in the western world.  In Africa 10 of 18 nations, the circumcised populations have higher HIV.  In one longitudinal study in NZ which followed males from birth they found no statistical difference in STI infections and circumcision status. In a recent study from Puero Rico they found circumcised men had higher STI infections: https://www.ncbi.nih.gov/m/pubmed/22897699/  What all this data suggests is one of 2 things, firstly that circumcision status does not prevent HIV/STI infections, or secondly that if circumcision does provide some protection against HIV STI infections, then high risk behaviour or risk compensation behaviour cancels it out.

The latest research shows risk compensation taking hold in South Africa

A study of a rural community in South Africa has found that circumcised men generally are more likely to be infected with HIV, and that males circumcised in hospitals are 20 per cent more likely to be HIV positive than those left intact. Where 24 per cent of uncut men were found to be HIV positive, the incidence of HIV among males circumcised in hospitals was 31 per cent. These findings have come as a shock to the South African Medical authorities who have been following the orders of US and WHO health officials and “rolling out” the provision of mass circumcision as a response to the nation’s AIDS crisis. As the authors of the report comment ruefully, it seems that when it comes to the spread of HIV, anatomy is less important than behaviour - exactly what critics of the circumcision programs have been arguing for years. In fact, many other studies have found that in the real world there are many regions in Africa where there is little or no difference in the incidence of HIV infection between cut and uncut men, and that in quite a few places cut men are more likely to be HIV positive.

The conclusion of the report reads as follows: “Medically circumcised older men in a rural South African community had higher HIV prevalence than uncircumcised men, suggesting that the effect of selection into circumcision may be stronger than the biological efficacy of circumcision in preventing HIV acquisition. The impression given from circumcision policy and dissemination of prior trial findings that those who are circumcised are safer sex partners may be incorrect in this age group and needs to be countered by interventions, such as educational campaigns.”

Molly S. Rosenberg et al. Are circumcised men safer sex partners? Findings from the HAALSI cohort in rural South Africa. Plos One, 1 August 2018.

Report in Business Day with critical commentary

Robert Darby. Syphilis 1855, HIV-AIDS 2007: Historical reflections on the tendency to blame human anatomy for the action of micro-organisms. Global Public Health 10 (5-6), 2015.

In realty, Circumcision is not a medical solution to HIV/STI prevention, circumcision is just a deeply embedded cultural practice which forever seeks to justify itself because its victims need for validation. In this current age, circumcision cultures try to defend the practice by pointing to medical benefits, which epidemiological outcome studies have repeatedly shown dont exist at population levels.  Europe & Japan with the lowest circumcision rates have the lowest HIV/STI's rates in the world, and its people live the longest with lowest levels of disease.  Proof circumcision not required for good health.

If one is truly interested in reducing the risk of HIV/STI infections then Education, Behaviour Change, Condoms, HPV Vaccination & Retro-Viral medication are much more effective without all of the problems associated with circumcision.

The human tendency to risk compensate means circumcision is at the very least useless or at its worst, a risk to public health by endangering both men and women to infections, disease and ultimately death in some situations. (Death has been documented from circumcision itself, and many circumcised men have died from HIV/AIDS around the world, just look at America)

Media Reports showing rise in HIV following Circumcision campaigns

Media reports here:

Latest from Mozambique : http://allafrica.com/stories/201705100560.html?aa_source=nwsltr-health-en

http://www.standardmedia.co.ke/?articleID=2000093293#?1#?1#WebrootPlugIn#?1#?1#PhreshPhish#?1#?1#agtpwd


http://www.netnewspublisher.com/hiv-infections-rising-amongst-circumcised-men-in-botswana/

http://www.gabzfm.com/circumcised-men-still-run-risk-hiv-infection