Cervical cancer: The real causes and the real cure

Cervical cancer is caused by a virus, or group of viruses, known as Human Papilloma Virus (HPV). They are similar to the viruses which cause warts and herpes, though obviously far more dangerous. Like herpes, they can be spread by sexual contact, but only a few of those who harbour the virus actually develop cancer. Two of the major factors which cause the virus to become active seem to be smoking and poor nutrition. Although regular screening can greatly reduce the risk of cervical cancer in women - thanks to screening, the incidence of the disease in Australia has declined steadily for the past 20 years - the disease is a serious cause of death in Third World countries, where standards of hygiene are poor, malnutrition is common, and societies lack the resources for preventive programs.

This last point has led some tunnel-visioned researchers to suggest that, since HPV can be transmitted sexually, the best way to control it is by altering the anatomy of the genitals - that is, by cutting parts of them off. These claims received massive publicity in 2002 following the publication of a polemical article in the New England Journal of Medicine by Xavier Castellsague, and they have been eagerly parroted ever since by circumcision crusaders such as Brian Morris. In the medical journals, however, there has been no confirmation of Castellsague's opinions, and the focus of public health policy remains on prevention. On this page we reply to Castellsague's bizarre Victorian notions.

• The new cervical cancer scare
  
• Vaccine for cervical cancer soon available
  
• Jewish women protected by genetic mutation
  
• Editorial: Claims for link between the foreskin and cervical cancer: not new; not medically valid; not ethical
  
• Australian Medical Association Policy
  
• Earlier Castellsague study shows Third World location more important than circumcision
  

The new cervical cancer scare

The latest scare about the possible "association" between the normal male genitals and an increased risk of cervical cancer seems to have a lot of usually rational people running scared. This is an old claim, going back to the 1930s, when the causative agent was imagined to be smegma; now they have found a virus, but the scent of quackery (trying to scare people into needless, ineffective or nasty operations) is still strong. You can imagine the outcry if it were suggested that part of the external female genitalia should be amputated to protect men from disease, or even to protect women themselves.

Back in the 1860s the London doctor Isaac Baker Brown started performing clitoridectomies on women because the orthodox theory of nervous disease then in force held that epilepsy, hysteria and even insanity could be caused by "irritation" of the pudic nerve, brought on by masturbation, and cured by excision of the clitoris. (Amputation of the foreskin of boys had already been introduced with the same justification in mind.) Brown's technique was indignantly rejected by the British medical profession: even if the treatment worked, it was unethical and illegitimate to mutilate women's bodies in this way. One of his critics said: "this particular form of quackery is an operation which is in itself a mutilation. I will not call it an operation: it is a mutilation", which could not be sanctioned by a profession governed by the ethics of Hippocrates - "First, do no harm". (British Medical Journal, 6 April 1867).

The frightening implication drawn from the cervical cancer study in the highly coloured editorial in the New England Journal of Medicine, and its even more extravagant press releases, is that that every male baby in the world should now be automatically circumcised. Such an extreme response should be rejected by the modern medical profession many reasons, but not least because such a mutilation of the male body is equally unethical. The NEJM (which has been waging a vendetta against the foreskin for decades) will apparently seize on almost anything in its efforts to keep routine male circumcision alive in the USA. At least a virus is a real cause, but if doctors are going to fight disease by amputating all the parts of the body where its infectious agents are thought to hide, there will not be much left for them to keep healthy.

For a useful summary of the rise and fall of this medical delusion, see
www.cirp.org/library/disease/cancer/

Vaccine for cervical cancer soon available

According to a recent report on the Lancet, it will not be long before an effective vaccine against cervical cancer is available. If it works against the virus (Human Papilloma Virus) which causes cervical cancer in women, it seems likely that it will also be possible to develop a vaccine which will protect men from cancer of the penis.

Diane M Harper, Eduardo L Franco, Cosette Wheeler et al Efficacy of a bivalent L1 virus-like particle vaccine in prevention of infection with human papillomavirus types 16 and 18 in young women: a randomised controlled trial Lancet, Volume 364 No. 9447,13 November 2004, pp. 1757-65

Prevention of HPV in women: "Vaccination against such infections could substantially reduce incidence of cervical cancer"

Vaccination against the most common oncogenic human papillomavirus (HPV) types could prevent development of up to 70% of cervical cancers. In a randomised controlled trial, Diane Harper and colleagues assessed the efficacy, safety, and immunogenicity of a bivalent HPV-16/18 L1 virus-like particle vaccine in 1113 young women. In according-to-protocol analyses, vaccine efficacy was 91·6% against incident infection and 100% against persistent infection. In a Comment paper, Matti Lehtinen and Jorma Paavonen suggest that an HPV vaccine will probably be the first licensed immunisation against a sexually transmitted infection.

Matti Lehtinen, Jorma Paavonen* "Vaccination against human papillomaviruses shows great promise"

It took almost 10 years from the discovery of an association between human papillomavirus (HPV) and cervical cancer [1] to the finding of HPV type 16 in cervical cancer tissue. [2] It took another 10 years to show that past infection with HPV [16] increases the risk for subsequent development of invasive cervical cancer, [3] and yet another decade to show that the seven most prevalent HPV types cause 87% of all cervical cancers. [4] By comparison, the creation of HPV virus-like-particle (VLP) vaccines has been a rapid breakthrough. VLPs mimic the true structure of the virion and induce a striking antibody response after vaccination. [5] Two years ago, Koutsky et al [6] showed that vaccination with HPV16 VLPs protected 768 vaccinated women from persistent HPV16 infection.

In today's Lancet, Diane Harper and colleagues now expand this rapid development in a phase 2 trial in just over 1100 participants, a study that lasted 2·5 years. VLPs of the two most important oncogenic HPV types, HPV16 and HPV18, were combined in a preventive vaccine. According-to- protocol and intention-to-treat analyses showed high efficacy for this bivalent vaccine against both the incident and persistent HPV16 and HPV18 infections. This efficacy turned out to be excellent even though the most sensitive method, vaginal self-sampling, was used to define the endpoints.

The efficacy of the bivalent vaccine against HPV18 infection is particularly important. HPV18 is more closely associated with cervical adenocarcinoma, which is more difficult to detect by Pap-smear screening. The target cells of this HPV type (and others such as HPV45) might be endocervical cells. This s uggestion is seen in the disease associations - ie, HPV16 is more closely associated with cervical squamous-cell carcinoma, and HPV18 is more closely associated with cervical adenocarcinoma. From the public-health point of view, an intervention effective against cervical adenocarcinoma is indeed needed.

It is also important to emphasise that these oncogenic HPV types are associated with chronic infections, chronic diseases, and neoplasms in many other sites, such as the vulva, vagina, anus, penis, and oropharynx. [7,8] The effectiveness of preventive vaccination against the oncogenic HPV types against the non-cervical HPV-associated neoplasms may be as good as against cervical neoplasia.

The cytological endpoints used by Harper and colleagues represent the clinical manifestations of infections with the oncogenic HPVs. It is encouraging that the bivalent vaccine protects against these cytological abnormalities and cervical intraepithelial neoplasia. However, long-term passive follow-up of cohorts of vaccinees and non-vaccinees by population-based cancer registries is needed to prove that HPV vaccination ultimately protects against invasive cervical cancer. [9]

Licensure of the HPV vaccine is not far away. It will probably be the first licensed vaccine against a common sexually transmitted infection. However, the implementation should be accomplished in a controlled way with community randomised trials. Several questions on the effectiveness and the public-health impact of vaccine implementation remain unanswered. [9-11] How to implement HPV vaccination in national vaccination programmes to guarantee high coverage in adolescents before they become sexually active? Should both girls and boys be vaccinated? How many oncogenic HPV types should the vaccine contain? Is resurgence of oncogenic HPV types not included in the vaccine a real threat? When is booster vaccination required? Harper and colleagues show, for instance, that the vaccine induces a robust B- cell response, but it is not known whether it induces a significant T-cell response.

While we trust that the remaining questions can be answered, a straightforward message of Harper and colleagues' work is that preventive vaccination against the oncogenic HPV types will soon be available.

* National Public Health Institute, Department of Infectious Disease Epidemiology, 00300 Helsinki, Finland (ML); and Department of Obstetrics and Gynaecology, University of Helsinki, Helsinki, Finland (JP) Matti.Lehtinen@uta.fi

1. zur Hausen H. Human papillomaviruses and cancer. Bibl Haemotol 1975; 43: 569-71.

2. Durst M, Gissmann, L, Ikenberg H, zur Hausen H. A papillomavirus DNA from a cervical carcinoma and its prevalence in cancer biopsy samples from different geographic regions. Proc Natl Acad Sci USA 1983; 80: 3812-15.

3. Lehtinen M, Dillner J, Knekt P, et al. Serological diagnosis of human papillomavirus type 16 infection and the risk for subsequent development of cervical carcinoma. BMJ 1996; 312: 537-39.

4. Munoz N, Bosch X, de Sanjose S, et al. Epidemiological classification of human papillomavirus types associated with cervical cancer. N Engl J Med 2003; 348: 518-27.

5. Harro CD, Susana Pang Y-Y, Roden R, et al. Safety and immunogenicity trial in adult volunteers of a human papillomavirus 16 L1 virus-like-particle vaccine. J Natl Cancer Inst 2001; 93: 284-92.

6. Koutsky LA, Ault KA, Wheeler CM, for the Proof of Principle Study Investigators. A controlled trial of a human papillomavirus type 16 vaccine. N Engl J Med 2002; 347: 1645-51.

7. Bjorge T, Engeland A, Luostarinen T, et al. A prospective study implicates human papillomavirus infection as a risk factor for anal and perianal cancer. Br J Cancer 2002; 187: 61-64.

8. Mork J, Lie A-K, Glattre E, et al. A prospective study on human papillomavirus as a risk factor for head and neck cancer cancer. N Engl J Med 2001; 344: 1125-31.

9. Lehtinen M, Paavonen J. Effectiveness of preventive human papillomavirus vaccination. Int J STD AIDS 2003; 14: 787-92.

10. Garnett G, Waddel H. Public health paradoxes and the epidemiology of human papillomavirus vaccination. J Clin Virol 2000; 19: 101-12.

11. Pinto L, Edwards J, Castle P, et al. Cellular immune responses to HPV16 L1 in healthy volunteers immunized with recombinant HPV16 L1 virus-like particles. J Infect Dis 2003; 188: 327-38.

Genetic mutation protects Jewish women

New evidence has recently come to light that the proverbially low incidence of cervical cancer among Jewish women has nothing to do with the condition of their husbands' penises, but is the effect of a genetic mutation. In an article published in the Israeli Medical Association Journal, Dr Joseph Menczer, of the Gynecologic Oncology Unit, Department of Obstetrics and Gynecology, Wolfson Medical Center, Israel, found that there was little or no evidence of any "protective effect" from male circumcision, but that a genetic mutation common among Jewish women offered resistance to the virus which caused the cancer. Relevant paragraphs from Dr Menczer's article are as follows:

Although the dispute over the association of circumcision and cervical cancer in various populations is still ongoing [23,24], there seems to be no hard evidence that circumcision prevents its occurrence in Jewish women, and it is no longer considered to play a protective role.

These findings support the possibility that the low prevalence of the homozygous arginine polymorphism may play a role in determining the low incidence of cervical cancer in Jewish women and may also explain the differences between the ethnic groups. If these observations are confirmed, then the low incidence of cervical cancer in Jewish women is genetically determined, and an explanation for the ethnic incidence pattern of cervical cancer in Jewish women has also finally been found.

Conclusions

For many years it was predicted, on the basis of observations in selected cohorts or individual institutions, that the incidence of invasive cervical carcinoma in Israeli Jewish women will increase [37-39]. While ritual circumcision is still practiced widely, today only a minority of Jewish women observes the laws of Niddah. Sexual habits have also changed considerably, becoming far less stringent. In spite of these trends of the last four to five decades, the population-based incidence of cervical cancer in Israeli Jewish women has not increased and remains very low [22,40].

Braithwaite [6], who first noted the low incidence in Jewish women in 1901, suggested two explanations for this immunity. The first was the difference of race, and the second the difference in diet, namely "the absence of bacon and ham in the diet of Jews". He then added: "The latter is far more probable than the former, although there may be something in race". Now, a century after Braithwaite's original observation, it seems that there may indeed be something in "race".

Menczer J. "The Low Incidence of Cervical Cancer in Jewish Women: Has the Puzzle Finally Been Solved?" Israeli Medical Association Journal, Vol. 5, 2003, pp. 120-3

http://www.cirp.org/library/disease/cancer/menczer1/

PDF also available here.

http://www.ima.org.il/imaj/ar03feb-11.pdf

Claims for link between the foreskin and cervical cancer:
not new; not medically valid; not ethical

Despite the enormous publicity received by the recent article by Dr Xavier Castellsague et al in the New England Journal of Medicine, and more especially by the alarmist editorial in the same issue by Drs Dimitri Trichopoulos and Hans-Olov Adami. It should be noted that, despite the impressions given by the NEJM editorial and press coverage, the original study was based on and was intended to apply only to the Third World, not to developed countries.

A reply to the NEJM claims is available here:

http://www.nocirc.org/statements/cervical_cancer_stmt2002.php

The following comments are made by Circumcision Information Australia.

Circumcision and cervical cancer

There are many flaws in the NEJM study and subsequent suggestions that all boys should be compulsorily circumcised at birth to protect women from cervical cancer. These fall into the following categories:

• statistical evidence from developed countries contradicts claims;
  
• failures of logic;
  
• ignorance of medical history
  
• lack of knowledge about previous claims about an association between normal male anatomy and risk of disease;
  
• dubious ethics;
  
• a misguided and false concept of the role of medicine.
  

Evidence from the developed world contradicts claims

The incidence of cervical cancer in Australia has been declining as the rate of male circumcision has declined.

The effect of media reports based on the press release issued by the NEJM has been to give ammunition to advocates of routine circumcision in wealthy countries, enabling them to scare parents into having their newborn sons circumcised. This is despite the fact that cervical cancer rates in the developed world are low, and declining, and that male circumcision, if it has any impact at all, is a blunt and relatively ineffective means of intervention, with regrettably severe side effects. They suit doctors such as Australia's Dr Terry Russell who has boasted of getting "a lot of personal satisfaction" from performing up to 2,000 circumcisions a year, and has claimed that "there is no other single procedure that would give a person as much protection against as many diseases as does circumcision" (60 Minutes, 8 October, 2000).

Other advocates of circumcision make equally bizarre claims. According to Dr Edgar Schoen, perhaps the most aggressive champion of forcible and universal routine circumcision in the USA (though he is keen to see it everywhere else as well), "A one-week-old circumcised boy has a significant health advantage over his uncircumcised contemporary." If that were the case, one might expect males in the USA to enjoy better health than their counterparts in comparable developed countries, but this table, showing circumcision rate in comparison with life expectancy and rates of HIV infection and cervical cancer, does not appear to support that contention:

Sources:

Human Development Index and Life Expectancy:
United Nations Development Program, Human Development Report 2001
http://www.undp.org/hdr2001/

Circumcision Prevalence:
Own estimates

HIV Prevalence:
UNAIDS
http://www.unaids.org/epidemic_update/report/Table_E.htm

Cervical Cancer:
CANCERMondial
http://www-dep.iarc.fr/

Australia, Canada and Britain were selected because of their cultural similarities with the USA and because they have an intermediate level of circumcision prevalence. The Scandinavian countries and Japan were selected because they have very low rate of circumcision.

There is nothing in the table to suggest that circumcision confers any health advantage at all, let alone a significant one, to males in the USA compared with males in the other countries. There is a strong correlation between circumcision prevalence and HIV prevalence, and a negative correlation between circumcision and life expectancy. Although the primary purpose of the table is to test Dr Schoen's claim, it also provides an opportunity to observe that any association between male circumcision and cervical cancer is also very weak.

Human papillomavirus does not generate spontaneously. It did not originate in the foreskin of the man who is infected. He was most probably infected with it by one of his female partners. There is a continuous cycle of infection from male to female to male or, equivalently, from female to male to female. Headlines such as that in the Sydney Morning Herald, "Men can double women's risk of cancer" (in inch high letters across the top of page 3), with its none too subtle implication that men are to blame for the cycle, simply reflect a thoughtless culture of selective (and sexist) blame - a mood in which amputative surgery can be performed upon a male now, without his consent, on the pretext that it may reduce the probability of a hypothetical female partner a long time in the future developing a disease - a disease, moreover, that is largely preventable by other (non-injurious) means. Paradoxically, the double standard in current attitudes would make it a serious crime to perform any surgery upon females which was thought to benefit males.

The startling fact is that cervical cancer has been declining in Australia, along with decline in the rate of male circumcision.

In April 2002 the Cancer Council of New South Wales released its annual report on cancer in NSW, Cancer Incidence and Mortality in NSW 2000. The report showed that cervical cancer cases in NSW declined from an average of 363 new cases in the five years 1988-1992 to 267 in 2000. At the same time the Council issued a media release in which it stated: "Cervical cancer to halve by 2010". The statement continued: "Numbers of new cervical cancer cases are expected to continue to decline from 267 to 195 in the period 2001 to 2010. Rates are also expected to almost halve from 7.4 to 4.7 per 100,000 in 2001 to 2010."

By these calculations, if Dr Castellsague's figures for the relative risk of cervical cancer among women with circumcised partners compared with women with uncircumcised partners could be applied to NSW, and the risk to a female of developing cervical cancer was reduced by 25 per cent (in accordance with the overall Odds Ratio in his Table 4) if she had a circumcised male partner as opposed to an uncircumcised male partner (a premise which is not supported by the data and trends cited in the succeeding two paragraphs), more than one thousand circumcisions would be required to prevent one case of cervical cancer.

Would it not be cheaper, more effective, more productive of happiness and more ethical to encourage those women who do not have regular pap smears to do so?

The steep decline in the number of cervical cancer cases in the decade 1990 to 2000 took place at he same time as a significant decline in the percentage of sexually active men who had been circumcised. During the decade, Australia was in transition from a population with a predominantly circumcised male population to a predominantly uncircumcised one. Thus, across time there is actually an association between circumcision and cervical cancer.

Among the three most populous states in Australia, accounting for almost 80 percent of the Australian population, Queensland had the highest rate of cervical cancer, NSW the second highest, and Victoria the lowest. Queensland also has the highest proportion of circumcised males, NSW the second highest, and Victoria the lowest. Thus, across space there is also an association between circumcision and cervical cancer.

Failures of logic

Even if it were true that women had a higher risk of picking up HPV from uncircumcised men, why should it follow that all boys should be circumcised? It could be argued with equal logic that uncut men faced a greater risk of picking up HPV from infected women and thus that the focus of prevention should be on purifying them. Dr Castellsague and his team are not blaming women for infecting men with HPV, but where else do they get it from? If the foreskin provides a nest for the virus, so does the clitoral hood and the folds of the labia in females; perhaps routine circumcision of women would reduce the incidence of HPV infection and penile cancer in men. Because western doctors regard amputation of any part of the female genitals as mutilation, however, they have no interest in exploring this intriguing therapeutic possibility, and they do not try to find associations between normal female anatomy and risk of disease. It is a different story in the Islamic cultures which practise various forms of female circumcision, where both doctors and religious leaders do indeed make similar claims about its benefits for women's health, including its effect in reducing the incidence of cancer, herpes and AIDS.

Early detection: pap smears

While it seems remiss of the study not to have mentioned the possibility of a vaccine affecting the utility of circumcision, yet another search, for "smear", turns up empty too. One might have expected some comparison of the relative effectiveness of pap smears and male circumcision in preventing cervical cancer. No doubt there are immense obstacles to providing all women in poor countries with regular tests, but the same indigent circumstances would guarantee high rates of injury, morbidity and mortality arising from circumcision carried out in such primitive conditions. Deaths and injuries resulting from male circumcision have always been swept under the carpet; in many of the latter cases the victim may not even be aware that a functional problem or deformity is the result of a circumcision injury.

The Harvard School of Public Health is sponsoring another research program, led by Dr Sue Goldie and Jane Kim, on a cheap method of screening for and thus preventing cervical cancer in Third World countries. Their work suggests that Dr Trichopoulos (a professor at HSPH) may be not be regarded so highly by his colleagues there as the media has assumed. See:

New Approach to Cervical Cancer Screening Could Save Lives, Billions in Health Care Costs

Inconsistencies with Dr Castellsague's previous studies

Dr Castellsague's analysis showed inconsistencies with several of the detailed studies on which it was meant to be based. To take a striking example, in a study published in 1997 and cited in 2002, he found that Colombia has eight (8) times the incidence of cervical cancer as Spain. Given that the rate of male circumcision would be about the same in each country (i.e. very low), this alone would seem to exonerate the foreskin - or would do in a court of law where reasonable doubt was the rule. It shows that the real causes are not anatomy, but poverty, ignorance, lack of personal hygiene (whether from lack of running water or deficiency of knowledge or both) and promiscuity, particularly with prostitutes, without using condoms. The most important factor is simply poverty. Cervical cancer is a less serious problem in developed countries because they have the wealth and education to keep it at a low level through regular medical check-ups, and the medical resources to treat it effectively in the early stages. Such conditions do not apply in the developing world.

The really important points are in the opening and last three paragraphs:

1. Incidence of cervical cancer in Spain is 6/100,000; in Colombia 48/100,000; yet the rate of male circumcision in the two countries is about the same.

2. Comparisons of HPV DNA prevalence in healthy men are difficult to interpret across studies.

3. The correlation of HPV results of males with the results for their wives revealed little evidence of shared concordant infections (meaning they could not have infected each other).

4. HPV DNA prevalences were significantly related to the sexual behaviour characteristics of the couple.

5. Rates of HPV infection in the male population of Colombia are much higher than in Spain.

6. Dr Castellsague states: "In conclusion, the 5-fold difference in penile HPV DNA prevalences in the male populations of Colombia and Spain is consistent with the 8-fold difference in cervical cancer incidences between the two countries. Strong and statistically significant dose-response relationships were found between penile HPV DNA prevalence and all sexual behaviour-related variables of the couples in Spain but not in Colombia, where penile HPV prevalences were higher and of similar magnitude across all levels of the sexual behaviour variables. These data support the hypothesis that sexual promiscuity is the most important risk factor for penile HPV infections, which are in turn related to cervical carcinogenesis in their female sex partners."

On a more ironic note, Dr Castellsague reports proudly that "Informed consent was obtained from the women enrolled in the case-controlled studies ... and from their respective husbands" - a courtesy that Dr Trichopoulos and the NEJM do not propose to extend to the little boys they want to circumcise.

Citation details: Citation #23
Journal of Infectious Diseases 1997 Aug;176(2):353-61

Prevalence of penile human papillomavirus DNA in husbands of women with and without cervical neoplasia: a study in Spain and Colombia.
Castellsague X, Ghaffari A, Daniel RW, Bosch FX, Munoz N, Shah KV.

Ignorance of medical history

In a review of studies on a possible relationship between Trichloroethylene and kidney cancer for submission to the National Toxicology Program on which you and Dr Trichopoulos collaborated, you wrote: "It appears inconceivable to us that an investigator would ... rely on study principles and methodologies that were developed in the first half of the 20th century."

How much more strongly does this observation apply to citations from cranky nineteenth century physicians like (Sir) Jonathan Hutchinson, whom Castellsague quotes as having observed that circumcision provided a significant degree of protection against syphilis. Hutchinson's entire evidence for this remarkable and untenable claim consisted of the following data, based on a record of the incidence of venereal cases among Jewish and non-Jewish patients in his practice at the Metropolitan Free Hospital, London, during 1854:

Hutchinson (1828-1913) used these figures to claim that Jews were less likely to contract syphilis because they were circumcised and later asserted that circumcision conferred virtual immunity to syphilis. The figures could equally well have been claimed to prove that Jews were more likely to contract gonorrhoea because they were circumcised. Such figures proved nothing at all, but they were the data upon which routine circumcision in the English-speaking countries was built. Hutchinson's deeper motivation in urging universal circumcision of male infants was that it would discourage masturbation and promote continence; he abhorred condoms as immoral and physically harmful; and he asserted to his dying day that leprosy was a form of tuberculosis, caused by eating bad fish.

Dr Castellsague recited a list of diseases, beginning with Hutchinson's syphilis, the dread disease of his day, and ending with HIV, the dread disease of our time, yet omitted many of the other maladies for circumcision has been claimed as a preventive or cure in the intervening period, such as TB, polio, whooping cough, brass poisoning, epilepsy, and most of all, childhood masturbation. Dr Castellsague seems to take it as proven that circumcision does provide protection against various forms of venereal disease, especially syphilis, but that is simply not true. Innumerable studies have repeatedly failed to find firm evidence that uncircumcised men are more vulnerable to any forms of VD, and even so conservative an authority as the English Royal Commission on Venereal Diseases in 1916 found that syphilis was concentrated exactly where STDs, HPV and HIV are concentrated today: among poor and ignorant populations, living in dirty conditions and having frequent unprotected sex with multiple partners or prostitutes.

Social distribution of syphilis

Royal Commission on Venereal Diseases
Final report of the commissioners, p. 19
(British Parliamentary Papers, 1916, Vol. 16)

Circumcision at that time was most prevalent among the urban upper class, and rarest among rural workers and miners. Circumcision was also rare among unskilled labourers, but they were the group which lived in the worst urban squalor and practised the most sexual promiscuity.

Even so ardent a champion of universal male circumcision as Australia's Professor Brian Morris is unable to do better than reach the equivocal conclusions that (1) "based on the bulk of evidence it would seem that at least some STDs could be more common in uncircumcised males under some circumstances"; but that (2) "there may be little difference in most STDs between those with and those without a foreskin".(1) If the evidence was there he of all people would be trumpeting it. As anybody acquainted with the history of syphilis knows perfectly well, circumcision played no role at all in the conquest of that disease, which was tamed in the early twentieth century by increasing use of condoms and the application of Metchnikoff's ointment and Salvarsan, and defeated in the 1940s by penicillin.

1. Brian Morris, In favour of circumcision (Sydney 1999), pp. 38 and 39. See the scathing review by Basil Donovan in Venereology, Vol. 12 (1999), pp. 68-9. Professor Donovan describes Morris as "a man on a mission to rid the world of the male foreskin" and some of his claims as "so dangerous" that the publishers ought to withdraw the book.

Lack of knowledge about previous claims (and their refutation) about an association between the foreskin and cancer of the cervix

Eve more serious than Dr Castellsague's ignorance of the history of syphilis is his apparent unawareness of previous studies claiming an association between incidence of male circumcision and incidence of cervical cancer, and of their subsequent refutation. We have already been through all this. Apart from some quacks in the 1920s, the first serious study to implicate the foreskin as a cause of cervical cancer was by Sampson W. Handley in 1936 (Handley WS. The prevention of cancer. Lancet 1936 May 2;1(5879):987-91.) This had a very similar methodology to that of Dr Castellsague's study, taking mixed populations (Indians and native Fijians) in Fiji as its data. After that came Abraham Ravich who vehemently asserted the connection in:

Ravich A, Ravich RA. Prophylaxis of cancer of the prostate, penis, and
cervix by circumcision. New York State Journal of Medicine, Vol 12, June 1951.

Ravich believed that the foreskin caused not only cancer of the cervix and penis, but cancer of the prostate as well, as detailed in his crazy book, Preventing VD and cancer by circumcision (New York 1973).

Widespread acceptance of the more limited theory came with an article by E.L. Wynder in 1954 (Wynder EL, Cornfield J, Schrott PD, Doraiswami KR. A study of environmental factors in carcinoma of the cervix. Am J Obstet Gynecol 1954;68:1016-52) which pushed America's already high rate of RNC to near universal levels, though it was not long before the study was called seriously into question. Wynder et al had based their assumptions about the circumcision status of the male partners of women with cervical cancer on a questionnaire filled in by the women. In 1958 two other researchers reported a large error in self-reporting of circumcision status among men: while 35 per cent reported themselves circumcised, examination by physicians showed that the true number was 44 per cent (Lilienfeldt AM, Graham S, Validity of determining circumcision status by questionnaire as related to epidemiological studies of cancer of the cervix. J Nat Cancer Inst. 1958;21:713-20).

In 1960 Wynder revaluated and retracted his earlier study because he had realised that erroneous patient reporting had caused serious statistical errors. He found that 36 per cent of women did not know whether their husbands were circumcised or not, and that 24 per cent of his male patients were able to state correctly their own status (Wynder EL, Licklider SD. The question of circumcision. Cancer. 1960; 13:442-5). In another paper Wynder again conceded that his findings from 1954 were invalid: "The definitive determination of whether true association exists must await the conduct of an appropriate study within an ethnic group". This did not, however, prevent him from recommending the "more rapid spread of the practice of circumcision among newborn children" for other highly valid reasons. (Wynder, EL, Mantel N, Licklider SD. Statistical considerations on circumcision and cervical cancer. Am J Obstet Gynecol. 1960; 79:1026-30.)

In 1971, in relation to cancer of the prostate, he felt obliged to differ from Dr Ravich and concede: "Circumcision: There was no significant difference between the non-Jewish cancer and control groups in this regard" (Wynder EL Mabuchi K, Whitmore WF. Epidemiology of cancer of the prostate. Cancer. 1971; 28:344-60).

Although American doctors largely ignored Wynder's retractions and continued to cut as many boys as they could, researchers heeded his advice to carry out ethnic-specific studies, all of which found that there was no association between normal male anatomy and an increased risk of cervical cancer. A review of this literature is available at

http://www.nocirc.org/statements/cervical_cancer_stmt2002.php

Such studies throw serious doubt on the validity and even the usefulness of those by Dr Castellsague and his team. Male and female genitals are much the same in both the industrial and the developing world, so that any differences in their susceptibility to disease must be found in the social, cultural and behavioural factors, which do differ considerably from one country to another. It is there that both the problem and the solution will be found to lie, not in tampering with normal human anatomy.

Dubious ethics

It has long been established that scientists are subject to ethical constraints. They are not certainly not allowed to perform unethical research. An example of ethics in action occurred recently when a study on the efficacy of various kinds of anaesthesia used for circumcision of newborn boys was aborted because when the researchers saw how much pain the non-anaesthetised control group was suffering, they decided it would be unethical to continue. (For details see http://www.cnn.com/HEALTH/9712/23/circumcision.anesthetic ) Commendable though this was, it could hardly provide retrospective comfort to the 100 million or so American babies circumcised over the past hundred years with no form of pain control at all.

Equally, scientists ought not to be able to make unethical proposals. At the very least, in the case of Castellsague's study, this would require the authors to address the question of whether the circumcision of baby boys showing no genital abnormalities is ethical. Since the alteration of the female genitals is regarded as unethical - and is illegal in many jurisdictions - and since the surgical removal of any other part of a normal male newborn is both unethical and illegal, it is not self-evident that the question can be answered in the affirmative. A recent study on the legitimacy of prophylactic medical interventions in children unable to give legal consent concluded that it was ethical only in the case of highly contagious diseases which could not be avoided by reasonable behavioural modification. (See F.M. Hodges, J.S. Svoboda, R.S. van Howe, "Prophylactic interventions in children: Balancing human rights with public health", Journal of Medical Ethics, Vol. 28, 2002, pp. 10-16).

Yet a search for "ethics" and "ethical" in Dr Castellsague's study and the editorial turns up empty, except for the assurance that the study's protocols were approved by the local ethics committees. But what is at stake is not whether informed consent was obtained from the subjects of the study (for a harmless set of questions and non-injurious examination), but whether it is ethical to propose the removal of a normal, healthy body part from an individual without his agreement.

Following publication of Dr Castellsague's Dr Trichopoulos was reported as saying: "I would recommend circumcision of all male babies", adding with apparent regret, "but I don't think that will ever happen" (Los Angeles Times, 15 April 2002), and further that "on the strength of the study, if he had
a newborn son he would have him circumcised" (New York Times, 11 April 2002). Note the language: he would not seek circumcision for himself, even though he is (presumably) a sexually active adult; instead, he would circumcise a helpless baby who would probably not be sexually active with another person for at least sixteen years.

We would like to see the calculations Dr Trichopoulos used to reach his conclusion that he would have a newborn son circumcised. How many newborn boys must be circumcised in order to prevent one case of cervical cancer? What is the total financial cost of circumcising so many boys? What is the cost of all the short-term complications and long-term sequelae? What is cost of the deprivation of bodily wholeness and physical pleasure? And what is the cost of the violation of the right of all those boys to a normal body and a compete set of external genitals?

The principal putative beneficiary of the deed is an unknown person, most likely not yet born at the time of the deed. There is no guarantee that the deed will benefit anyone at all; in fact, it is highly unlikely that it will benefit anyone at all and thus probable that it will have been done in vain. If the son were to die before attaining the age of sexual activity, if the son were to be uninterested in women, or if, having reached heterosexual adulthood, displayed a low "sexual behaviour risk index", then the act of circumcising him as a newborn would have proved pointless. Dr Trichopoulos appears to be saying that he expects his son to have an intermediate or high "sexual behaviour risk index": that is the only circumstance in which Dr Castellsague's study found women with circumcised male partners less likely to develop cervical cancer. Evidently he also expects his son's female partners to neglect having regular pap smears: yet by this simple precaution the female partners could drastically reduce their likelihood of developing cervical cancer irrespective of whether he retains his foreskin or not.

A false concept of the role of medicine

Dr Castellsague seems to agree with Hamlet that "Diseases desperate grown, by desperate remedies are relieved" - that the seriousness of cervical cancer in Third World countries justifies desperate and heroic methods of treatment. But the severity of a problem does not necessarily demand severe or heroic methods at all: what it demands is effective methods. There is no evidence that the approaches used to control cervical cancer in the develop world will not work in the Third World; the suggestion that mass circumcision will be cheaper or easier to perform than educating women to have pap smears and men to practise safe sex is really an admission that people in Third World countries matter so little that they can be treated like animals. (See New Approach to Cervical Cancer Screening Could Save Lives, Billions in Health Care Costs)

It may at first look easier to force a baby to get circumcised than to persuade men to be less promiscuous or women to have regular check-ups, and to provide the necessary medical infrastructure for this, but it is not necessarily more effective as a disease control strategy, and it is certainly both immoral and likely to meet significant opposition.

Doctors must learn to protect the human body as nature made it, not cut off the bits that annoy them.

Medicine must learn to accept the human body as nature made it, imperfect though it may be, not try to turn it into the sort of streamlined machine it might have been if engineered by a committee of experts from the Harvard School of Public Health. Thanks to the workings of natural selection the foreskin is an integral part of the male genitals, and men have as much right to it as to their ear lobes, fingers, toes, kidneys, lungs and testicles. It may not be essential to survival, but nor are our limbs or the second unit of our duplicate organs; even non-essential items have their value and uses.

You can imagine the outcry if it were suggested that part of the external female genitalia should be amputated to protect men from disease, or even to protect women themselves. Back in the 1860s the London doctor Isaac Baker Brown started performing clitoridectomies on women because the orthodox theory of nervous disease then in force held that epilepsy, hysteria and even insanity could be caused by "irritation" of the pudic nerve, brought on by masturbation, and cured by excision of the clitoris. (Amputation of the foreskin of boys had already been introduced with the same justification in mind.) Brown's technique was indignantly rejected by the British medical profession: even if the treatment worked, it was unethical and illegitimate to mutilate women's bodies in this way. One of his critics said: "this particular form of quackery is an operation which is in itself a mutilation. I will not call it an operation: it is a mutilation", which could not be sanctioned by a profession governed by the ethics of Hippocrates - "First, do no harm". (British Medical Journal, 6 April 1867).

It is not the proper role of medicine pre-emptively to amputate parts of the body considered vulnerable to disease or implicated in disease transmission, but to protect all of it from harm; in the case of any part of the body except the foreskin, amputation is a last resort in cases of abnormality, injury or disease, not the starting point. Nobody has yet made the case that men are less entitled to a complete set of external genitals than women.

Other recent comments

Letter to The Medical Post (Canada), 14 May 2002.

Circumcision same as removing healthy breasts, fingers at birth

The finding that circumcision may reduce the risk of HPV infection needs to be put in perspective. The central issue is not whether circumcision might prevent disease, but whether removing normal, healthy tissue from infants
and children is ethical.

No part of the body comes with a lifetime guarantee against disease. Breasts become cancerous, fingers become arthritic, earlobes develop malignant melanomas. If disease prevention is insufficient justification for amputating fingers, breasts or earlobes, then it is insufficient justification for amputating foreskins.

The foreskin¹s location and structure indicate it is the most important sensory tissue of the penis. Just inside the tip of the foreskin is a prominent band of ridged mucosa (the "ridged band²) that expands and contracts like an accordion during erection and sexual intercourse, triggering sexual reflexes.

Because circumcision is a long-standing practice (and with religious significance for some), there has been reluctance to view this procedure with the same critical eye used to view other medical procedures. However, ethics are not ethics unless they are applied consistently. We believe circumcision practices in Canada should be carefully reviewed to ensure they conform to basic principles of ethics, law and human rights.

Dr. Arif Bhimji

Scientific American

Is there any conclusive medical evidence on the health benefits (if any) of circumcision? I've read of an increased incidence of vaginal cancer and venereal disease among the wives of non-circumcised men, but this information did not come from a reliable scientific source.

Ronald L. Poland, professor and chair of the Department of Pediatrics at the Pennsylvania State University College of Medicine, responds:

You have asked an interesting question, one that continues to puzzle the medical profession as well as the general public. It is a difficult question to answer, because one could not design a definitive yet ethical human study that would randomly select whether or not a group of enrolled neonatal subjects were circumcised. So the information that we do have is culled from studies of boys or men, circumcised or not, who differ from one another in non-random ways - that is, they differ in other characteristics that might have led to the original family decision about whether or not to circumcise. These potentially confounding characteristics include religion (which may modify behavior), ethnic group or tribal membership, and economic status, among others. Therefore, all studies of the medical effects of circumcision have inherent flaws that reduce their power to provide convincing evidence.

Researchers have published studies to show that vaginal or cervical cancer and penile cancer are more prevalent among couples in which the man is uncircumcised. But all of these cancers are strongly associated with, if not caused by, a virus (the human papillomavirus), which is transmitted through sexual contact. Even if circumcision does reduce the spread of this virus - or any virus for that matter - it could not be a reliable form of prevention. Many studies show that cervical and penile cancers are associated with sexual activity that starts at a young age and that involves many partners. The type of sexual activity may correlate with the social and cultural factors that control decisions about circumcision, producing a possible bias.

The same demographic limitations apply to the spread of human immunodeficiency virus (HIV). A study from a venereal disease clinic in Africa reported that circumcision was less common among HIV-infected males as compared with HIV- negative males who attended the same clinic. This clinic served two different tribes, each having who have different religions and mores. Again, the prevalence of circumcision was but one difference between the groups and so cannot be considered the only reason for the discrepancy in their infection levels - and circumcision certainly cannot be depended on for protection against a deadly virus.

There are several published studies that conclude that circumcision prevents urinary tract infection in infant boys. These studies focus on infants who were examined for fever, were hospitalized and were diagnosed as having discharge from a urinary tract infection. These studies may be biased in another way. For years, physicians have heard that uncircumcised boys may be more prone to urinary tract infections. Circumcised boys, therefore, are more likely to be checked for signs of infection than are their uncircumcised friends. Unfortunately, there have been no studies designed to test boys (circumcised and not) prospectively for urinary tract infection.

A 1996 statement of the Canadian Pediatric Society concluded that there are no medical reasons to perform a routine circumcision on a newborn infant. An earlier American Academy of Pediatrics Task Force on Neonatal Circumcision noted some potential risks and benefits associated with the procedure but did not see a compelling medical reason for recommending routine circumcision either. So the short answer to the question is no. There are no conclusive medical studies documenting the health benefits of circumcision, although there are suggestive studies on both sides of the issue.

http://www.sciam.com/askexpert/medicine/medicine2.html

Other comments

Comment from Andrew Sullivan, 12 April
(www.andrewsullivan.com)

The mutilation of children

I may be a broken record on this but the news today that circumcision may have a small effect in restraining transmission of the HPV virus strikes me as likely to be misused. The argument against the circumcision of infants is not that it might not conceivably have some future health-benefits. The argument against infant male genital mutilation is that it is the permanent, irreversible disfigurement of a person's body without his consent. Unless such a move is necessary to protect a child's life or essential health, it seems to me that it is a grotesque violation of a person's right to control his own body. It matters not a jot why it is done. It simply should not be done - until the boy or man is able to give his informed consent. And to perform such an operation to protect the health of others is an even more unthinkable violation. It's treating an individual entirely as a means rather than as an end. I'm at a loss why a culture such as ours that goes to great lengths to protect the dignity and safety of children (and rightly so) should look so blithely on this barbaric relic. Yes, I know there are religious justifications for it. But even so, religions should not be given ethical carte blanche over the bodies of children. Would we condone a religious ceremony that, say, permanently mutilated a child's ear? Or tongue? Or scarred their body irreversibly? Of course not. So why do we barely object when people mutilate a child's sexual organ?

Sydney Morning Herald

Michael Campion, a staff specialist in pre-invasive disease at the Royal Hospital for Women, said women should not rely on circumcision to protect their health. "An individual man could have had only one other partner, but the woman inherits the whole history [of the previous partner] ... it really doesn't matter whether men are circumcised or not - women need regular pap smears and that's the end of the story." Dr Campion said the majority of women contract HPV at some time in their lives but fight it off successfully through their own natural immune response before it can damage the cells of the cervix. Stress, smoking and poor diet all could make it harder to defeat the virus.

Sydney Morning Herald, 12 April 2002

Internet newsgroup comment

Over the last 150 years doctors have claimed that circumcision prevented or cured masturbation, epilepsy, convulsions, paralysis, elephantiasis, tuberculosis, eczema, bed-wetting, hip-joint disease, faecal incontinence, rectal prolapse, wet dreams, hernia, headaches, nervousness, hysteria, poor eyesight, idiocy, mental retardation, insanity, UTIs, penile cancer, cervical cancer (they tried that one already, a couple of times in fact) and AIDS. In fact, no procedure in the history of medicine has been claimed to cure and prevent more diseases than circumcision. If you have not figured it out by now there are many people of certain nations and cultures in the world that have tried, and will keep trying, to present circumcision as a medically justified procedure. So far all of this studies and researches have been proven wrong.

On this particular article, however, the whole thesis of this article is flawed, trying to lay responsibility on men while at the same time saying that all women have to do to avoid dying from cervical cancer is to get pap tests. Rather than encouraging parents to cut off the most sensitive part of baby boys' penises, doctors should be encouraging women to get pap tests - as stated in the article: "Doctors often say it is a disease that no woman should die of. It is easily cured if detected early by a pap test."

There were five study sites. In analysing the study sites separately, none produced statistically significant results associating circumcision status with penile HPV infection. It was only when the data were aggregated across study sites that there was a statistically significant result. This could merely be a numbers issue, but it could also have to do with unmeasured other factors. And the rate of penile HPV infection for circumcised men was higher in one study than the rate for uncircumcised men in another study - which may well be related to the fact that the circumcision status was so skewed in every study. (It wasn't even close to half and half, even though it looked that way with the aggregate numbers; in fact, the distribution was closer to 85/15 in each study).

This can create some statistical issues which distort results. Most of the circumcised participants (65 per cent) came from the Philippines (where most boys are forcibly circumcised in a public rough and tumble at around the age of 12), while the uncircumcised men were fairly evenly distributed throughout the remaining four study sites. That means that you're not comparing apples to apples here. Whatever is said about circumcised men is being said primarily about Filipino men, while whatever is being said about uncircumcised men is being said primarily about Brazilian, Colombian, Thai, or Spanish men. There are significant differences between the Philippines and the other four study sites. What if, say, religious and cultural issues in the Philippines made those men less likely to have penile HPV infections? This, in fact, is true according to this study: the Filipino men had lower rates of penile HPV infection for both circumcised and uncircumcised men, but the benefits accrued almost entirely to the circumcised camp because there were only 22 normal (uncut) Filipino men! In Thailand, where the vast majority of men are uncut, there was no relationship between circumcision status and penile HPV infection.

Looking at the entire study population, there was no statistically significant association between circumcision status and cervical cancer - not at any study location, not aggregated across all study locations. In fact, among women in one study location, circumcision was associated with a higher risk of cervical cancer in partners. (This was also true for women under 36 years of age.) Of course, one wouldn't take that too seriously since none of the analyses were statistically significant.)

They started to fish for significance, and got some when they limited the study only to (self-reported) women with only one lifetime sexual partner (75 per cent of the study participants). Are they kidding? So who are the 63 per cent of the men with more than six lifetime partners having sex with? And even within this limited group, circumcision status is not significant in predicting an increased risk of cervical cancer for most of the categories of stratification. It is significant only when you look at men with more than six sexual partners, men who have sex with prostitutes, and men with a high generally risk sexual behaviour index. In fact, the point estimate for the odds ratio shows circumcision increased the risk of cervical cancer in women whose partners had fewer than six lifetime sexual partners, did not have sex with prostitutes, or had a low sexual behaviour risk index. This makes me wonder whether promiscuity is a far more important factor than circumcision status.

Basically, if you accept that the women are self-reporting their number of partners accurately (which I doubt), that increases the likelihood that, if they have HPV infection (which this study doesn't report - it only reports if they have cervical cancer), they got it from their current partner. However, we find that if their partners engage in risky behaviour, the women are less likely to have cervical cancer if their partners are circumcised, but if their partners engage in low risk behaviour, the women are less likely to have cervical cancer if their partners are uncircumcised (even if the latter results don't achieve statistical significance).

Does this say something about circumcision status and cervical cancer, or does it say something about the partners of men who engage in risky behaviours? And what about the potential interaction between higher numbers of sexual partners and sex with prostitutes? If the women are accurately reporting, then if all these men are having multiple sexual partners, the likelihood is that more of these are prostitutes. (65 per cent of the men reported having sex with prostitutes.) Do these results say something more about the dynamics of widespread prostitution than about the value of circumcision?

Overall, I can't see that this study is particularly strong. They had to do a lot of fancy footwork to make these numbers come out saying what they wanted them to say. If they just did the straightforward analyses that one would expect, they get NO statistically significant results, which means that there's no assurance that any trends they found were more than random chance. I think the self-reporting of sexual partners is very flawed, especially given the social climates in the countries studied. It's also true that many men mis-report their circumcision status. They don 't report the numbers, but I'll bet that a number of the variables are significantly associated with each other and with study location.

It's certainly not enough to convince me to give up my foreskin, nor would my girlfriend want me to.

Dr. Dean Edell (US media commentator):

"If you are an intact male, have had lots of unprotected sex with lots of different women and marry a virgin, your wife may have a real but statistically insignificant increased chance of getting HPV."

Another comment from Internet discussion list

A number of observations can be made about the study, but surely none more important than this:

No statistically significant association

The study did not find a statistically significant link in the overall data between circumcision and (a reduction in) cervical cancer. To express it another way, the study found that the link between circumcision and (a reduction in) cervical cancer was not statistically significant.

That's worth repeating: the link between circumcision and (a reduction in) cervical cancer was found to be not statistically significant.

Notably, even when the data were narrowed down to consider only monogamous women (women who had only ever had one partner [in which the effect of the circumcision status of the current partner could not be attenuated by previous partners]), the link between circumcision and (a reduction in) cervical cancer was found to be not statistically significant.

In fact, the study's authors had to really slice, dice and heavily massage the data to find a subset of women which satisfied what they were trying, hoping and expecting to find, namely, a statistically significant link between circumcision and a reduction in cervical cancer. In doing so, they revealed other subsets in which there was a link between circumcision and an increase in cervical cancer, but these subsets, being inconvenient to the authors' objectives, were ignored.

HPV vaccines on the way

The second point I would make is that numerous firms are working on the development of HPV vaccines. Some of the vaccines are already in Phase III trials, There is every likelihood that a vaccine will be available before 2010, long before a baby boy born today will become sexually active. Given that, it would be not just a violation of medical ethics, but criminal to circumcise a baby boy today (or to recommend circumcision) on the grounds that it would lessen the risk of his acquiring HPV from a female 18 or more years hence and later passing on the infection to subsequent female partners. There's an unwritten slander in this search for "the elusive male factor" that the intact male is a filthy, disease-carrying creature; but, hey, guess what, every heterosexual male who acquired HPV caught it from some filthy, disease-carrying female. For strange some reason, in this chicken and egg situation, the buck always seems to stop with the male, and more precisely, with the intact male.

What about the female prepuce?

If the foreskin provides a refuge or nest for the HP virus, so must the clitoral hood and the folds of the labia in females, but western doctors have no agenda to find reasons for amputating those, so they do not try to find associations between anatomy and disease. (It is different in the Islamic cultures which practise various forms of female circumcision, where the doctors make the same claims about its beneficial effects on women's health.)

In circumcising cultures more women infected by circumcised men

The third point is that the ratio of circumcised sexually active males to intact sexually active males in the US is greater than the ratio of the proportion of HPV+ intact males to HPV+ circumcised males. It follows that the absolute number of circumcised HPV+ males in the US is greater than the absolute number of intact HPV+ males and, therefore, more females are being infected by circumcised males than by intact males. Looking at it from the point of view of an individual female selected at random from all females in the US who have acquired HPV in the past year, it is more likely that she acquired HPV from a circumcised male than from an uncut male.

Attack the virus, not male bodies

This serves to emphasise the fundamental point that the cancer-causing agent is HPV, not the normal male genitals. You could insert the intact penis of a HPV- male into the vagina of a HPV- female 1,000,000 times and the female would not acquire HPV. Alternatively, you could insert the intact penises of 1,000,000 different HPV- males into that vagina and the female would not acquire HPV. On the other hand, a single insertion of the circumcised penis of a HPV+ male could be sufficient to infect the female. The logical conclusion to this is that measures to reduce the prevalence of HPV (and thereby the incidence of cervical cancer) should focus on HPV itself, not on butchering the natural male anatomy.

It is also important to note that there are scores of strains of HPV, the vast majority of which are not implicated in cervical cancer.

Most males still have their foreskin

If one excludes Muslims, for whom prophylactic circumcision is not a consideration (boys of Muslim parents are forcibly circumcised at between 6 and 10 years of age) and who constitute 20% of the world population, at least 85% of all adult males worldwide have genitals as nature made them - that is, sport the foreskin with which they were born. If the world average rate of HPV infection of intact adult males is 20%, then 72% of all adult males are uncut and are and always will remain HPV-free. Half of the remaining 18% of the world's population who are intact but HPV+ have a strain of HPV which is not implicated in cervical cancer. Thus, more than 80% of all non-Muslim males remain intact and never acquire an infection which could potentially be passed on to a female sexual partner and result, in a small fraction of those cases, in cervical cancer. 80% of the world's non-Muslim male population numbers approximately 2 billion at present. The idea that two billion currently living intact males, who are never going to acquire a "dangerous" HPV infection, as well as 500 million who have or are going to (and one cannot predict who will and who won't) should be subjected to disfiguring genital surgery to effect a small reduction in the incidence of cervical cancer, serious disease though it may be, is immoral, depraved and not particularly effective as a disease control strategy

Australian Medical Association Policy

The Australian Medical Association adopted a policy on the prevention of cervical cancer in July 2001. It stresses the need for

• regular tests
  
• maintenance of a register
  
• special attention to women from the particular geographic, cultural andethnic backgrounds which make them more vulnerable
  
• development of a vaccine

Earlier Study shows Third World Status more important than circumcision

The media has not drawn much attention to some very significant data in one of the studies cited by Castellsague: that Colombia has eight (8) times the incidence of cervical cancer as Spain.

Given that the rate of male circumcision would be about the same in each country (i.e. very low), this alone would seem to exonerate the foreskin - or would do in a court of law where reasonable doubt was the rule. It shows
that the real causes are poverty, ignorance, lack of personal hygiene (whether from lack of running water or lack of knowledge or both) and promiscuity without condoms. The most important factor is poverty. Cervical cancer is not a serious problem in develop countries because they have the wealth and education to keep it at at a low level through regular medical check-ups, and the medical resources to treat it effectively in the early stages. Such conditions do not apply in the developing world.

Xavier Castellsague et al, "Prevalence of penile HPV DNA in husbands of women with and without cervical neoplasia: a study in Spain and Colombia", Journal of Infectious Diseases, Vol. 176, August 1997, pp. 353-61

Citation details:

Citation #23, J Infect Dis 1997 Aug;176(2):353-61
Prevalence of penile human papillomavirus DNA in husbands of women with and without cervical neoplasia: a study in Spain and Colombia.
Castellsague X, Ghaffari A, Daniel RW, Bosch FX, Munoz N, Shah KV.
Institut Catala d'Oncologia, Ciutat Sanitaria i Universitaria de Bellvitge, Hospitalet Llobregat, Barcelona, Spain.

Abstract from Pub Med

To investigate the role of men in cervical cancer, 816 husbands of women enrolled in four case-control studies of cervical neoplasia in populations at high (Colombia) and low (Spain) risk for cervical cancer were interviewed. Exfoliated cells from the penis were obtained and analyzed by polymerase chain reaction for the presence of human papillomavirus (HPV) DNA. Penile HPV DNA prevalences were higher in husbands of women with cervical neoplasia than in husbands of controls. Husbands of controls in Colombia had a 5-fold higher penile HPV DNA prevalence than the corresponding husbands in Spain. Strong dose-response relationships were found between penile HPV DNA prevalence and all sexual behavior-related variables in Spain but not in Colombia. Sexual promiscuity is the most
important risk factor for penile HPV infections. Differences in HPV DNA prevalence in the male populations of Spain and Colombia are consistent with their 8-fold difference in cervical cancer incidences.

PMID: 9237700 [PubMed - indexed for MEDLINE]