Cervical cancer: Another reason for circumcision?

Prevention of cervical cancer in women is one of the oldest of the traditional medical motivations for circumcision of boys. The idea emerged in the early twentieth century, when circumcision was being widely hailed as the magic bullet against just about every disease and problem affecting the genital areas. The evidence was much the same as the evidence that circumcised men did not get syphilis: observations showed that Jewish women (whose husbands were of course circumcised) had a much lower incidence of cervical cancer than others. Circumcision promoters immediately hailed this observation as all the proof that was needed for the enforcement of widespread circumcision of male infants and boys. In relation to syphilis, sceptics pointed out that a much more likely explanation for the differing incidence of disease was simply that Jewish men and women were far less promiscuous than others and thus less likely to get infected. This argument was not then available in the case of cervical cancer, because it was not until very recently that it was recognised that this disease is also infectious, caused by a virus, and thus that it is nearly always caught through sexual contact. It is now appreciated that behaviour, not anatomy, is therefore the most important factor in susceptibility.

This fact has not prevented today's circumcision promoters from demanding circumcision of male infants and boys so as to prevent cervical cancer in their future sexual partners. Since 2001, cervical cancer has been second only to AIDS as the fearsome bogey intended to drive parents to circumcise their baby boys. The idea was to target women, exploiting the fact that mothers were more protective of their children and thus less likely to favour circumcision than fathers. There was, however, always something distinctly creepy about the idea that a baby boy should be circumcised in order to reduce the risk of a disease in hypothetical adult women. The American legal scholar Sarah Waldeck has gone so far as to argue that even if the claims about male foreskins causing cervical cancer in women were true, it would be ethically and legally impermissible to circumcise minors on this account because the person bearing the loss and risk was not the person reaping the benefit.

The suggestion was also highly sexist: imagine the outrage if it was suggested that women should have part of their genitals excised in order to reduce the risk of disease in men!

In truth, however, once it was realised that cervical cancer was spread by certain strains of a very common virus, the case against the foreskin collapsed. What is more, the development of a safe and effective vaccine, Gardasil, developed by the Australian scientist Ian Fraser, has made the whole controversy irrelevant.

The aim of this page is to bring you accurate information on cervical cancer and the Gardasil vaccine from official websites, and then to look back at the use that circumcision promoters made of the cervical cancer scare in advocating their favourite fix. It may be of no more than academic interest now, but it provides chilling insights into their scientific method and ethical (un)awareness.

Facts on cervical cancer

What is cervical cancer

Cervical cancer is cancer of the cervix. The cervix is the lower part of the uterus, or womb, and is situated at the top of the vagina. Cervical cancer develops when abnormal cells in the lining of the cervix begin to multiply out of control and form pre-cancerous lesions. If undetected, these lesions can develop into tumours and spread into the surrounding tissue.

Cause of cervical cancer

Cervical cancer is caused by infection with certain types of a common virus, called human papillomavirus, or HPV. While other factors such as the oral contraceptive pill, smoking, a woman's immune system and the presence of other infections also seem to play a part, a woman has to have been infected with certain 'high-risk' HPV types before cervical cancer can develop. High risk types 16 & 18 are responsible for ~70% of all cervical cancers. Abnormal cervical cells are also caused by HPV infection, and these may be detected when a woman has a routine Pap smear.

Human Papillomavirus (HPV)

Human papillomavirus, or HPV, is a common virus that affects both females and males. There are more than 100 types of the virus. In fact, certain types of HPV cause common warts on the hands and feet. Most types of HPV are harmless, do not cause any symptoms, and go away on their own. About 40 types of HPV are known as genital HPV as they affect the genital area. More than 50% of people (males and females) will be infected with at least one type of genital HPV at some time.

Genital HPV types may be "high-risk" types (such as HPV Types 16 and 18) that can cause cervical pre-cancer and cancer, or "low-risk" types (such as HPV Types 6 and 11) that can cause genital warts and usually benign (abnormal but non-cancerous) changes in the cervix. Both the "high-risk" and "low-risk" types of HPV can cause abnormal Pap smears.

Anyone who has any kind of sexual activity involving genital contact could get genital HPV. That means it's possible to get the virus without having intercourse. And, because many people who have HPV may not show any signs or symptoms, they can transmit the virus without even knowing it. A person can be infected with more than one type of HPV. HPV is highly contagious. It is estimated that many people get their first type of HPV infection within their first few years of becoming sexually active.

Genital HPV infection is not something to feel embarrassed or ashamed about. It is very common and most often goes away without any ill effects. It could almost be considered a normal part of being a healthy sexually active woman.

For full information about cervical cancer, see www.cervicalcancer.com.au

Facts from Australian Department of Health

What is human papillomavirus (HPV) and how is it linked to cervical cancer?

HPV is a sexually transmitted infection, mostly affecting women 20 to 24 years of age. Almost all abnormal Pap smear results are caused by HPV. In 98 per cent of cases, HPV clears by itself. In rare cases, if the virus persists and if left undetected, it can lead to cervical cancer. This usually takes about 10 years.

What can be done to prevent cervical cancer?

Early detection is the best protection from cervical cancer. Australia has one of the best national cervical screening programs in the world. Every year the Australian Government and the state and territory governments invest more than $90 million in the National Cervical Screening Program. This investment has cut deaths from cervical cancer by around 60 per cent since 1985 and has halved the number of cases of cervical cancer. Australia currently has the second-lowest incidence of cervical cancer and the lowest mortality rate from cervical cancer in the world.

Are there vaccines available to protect people from HPV?

There are many strains of HPV, only some of which can cause cancer. HPV strains 16 and 18 cause around 70 per cent of all cervical cancers. There is one vaccine (GARDASIL) which has been approved for use in Australia. This vaccine prevents infection from HPV strains 16 and 18 if individuals are vaccinated before they are infected with them.

How does GARDASIL work?

GARDASIL is administered as a series of three injections over a period of seven months. To ensure that some girls do not miss out, an immunisation program needs to run over a whole school year.

All medicines and vaccines considered for funding by the Australian Government must first be approved by the Therapeutic Goods Administration (TGA) for use in Australia. This guarantees they are safe and clinically effective, but it does not assess their cost-effectiveness. The TGA approved GARDASIL on 16 June 2006 for females aged 9 to 26 years and males aged 9 to 15 years.

Commonwealth Department of Health Fact Sheet

Gardasil: A safe and effective vaccine

The Therapeutic Goods Administration reports that Australia was one of the first countries to roll out a national cervical cancer immunisation campaign using Gardasil. To date more than 5.8 million doses of Gardasil have been distributed in Australia. The overall number of suspected adverse events reported following Gardasil administration is very low, and consistent with other new vaccines and adverse event rates reported in other countries. Worldwide, over 45 million doses have been distributed, with equally minimal side effects.

For a full analysis of the safety of Gardasil, see TGA website.

News reports on human papilloma virus and cancer

Circumcision insignificant protection against cancer virus: Vaccination recommended

An American study of of 4000 men in Brazil, Mexico and Florida (USA) has found that around half the population carries strains of the human papilloma virus (HPV) implicated in the generation of cervical and prostate cancer, but that the main risk factor for developing cancer is having a large number of sexual partners. Circumcision was found to have little protective effect against infection with the virus. Instead, the researchers recommend that vaccination with one of the new HPV vaccines that are already being given to women also be made available to men. The report follows

Half of adult males carry HPV: Human papillomavirus lingers for months in men, study shows
by Nathan Seppa
Science News, Web edition, February 28th, 2011

The virus notorious for causing cervical cancer in women also turns up frequently in men and can hang on unnoticed for months or even years, researchers report online March 1 in Lancet. The study solidifies earlier research indicating that human papillomavirus is highly prevalent in men and strengthens the case for vaccinating men and boys against it, the report’s authors say.

There are dozens of types of HPV, including more than 40 that can be transmitted sexually. Some can cause cancer. Two vaccines, Merck’s Gardasil and GlaxoSmithKline’s Cervarix protect against two types of cancer-causing HPV. Both vaccines are approved and recommended for girls and young women. Gardasil is also recommended for boys up to age 18 since its protection extends to two additional types of HPV that cause genital warts in males and females.

It’s widely assumed that limiting the virus in men or women would diminish its spread in the whole population. But while HPV has been extensively studied in women, its prevalence is less well understood in men, says Joseph Monsonego of the Institute of the Cervix in Paris, writing in the same Lancet issue. For that reason, he says, the new study results “are of substantial interest.”

Starting in 2005, epidemiologist Anna Giuliano of the H. Lee Moffitt Cancer Center & Research Institute in Tampa, Fla., and an international team of researchers recruited more than 4,000 men living in Brazil, Mexico and Florida into a study of HPV. The new study reports on the first 1,159 of these volunteers. Their average age was 32 and none had been vaccinated against HPV. Swabs of the penis and genital area of each man revealed that 50 percent were infected with at least one HPV type upon enrollment. The researchers repeated these exams every six months, and the men completed personal-history questionnaires. Over a median of 28 months, the group acquired 1,572 new HPV infections.

The human immune system can clear HPV out of the body, and the men wiped out most of their new infections during the study period. But it took a median 7.5 months. Median clearance times didn’t vary substantially among the countries, but did vary between HPV types. Some cases lingered as long as 24 months in the men.

HPV 16 is the type responsible for the most cervical cancers in women and is covered by both vaccines. It took a median of 12 months to clear. “It’s hanging around longer, and it’s completely asymptomatic,” Giuliano says. “You don’t even know you have it.” This silent infection means a person can transmit this HPV type for longer periods and “might help explain why HPV 16 is one of the most common types in both men and women,” she says.

The data also reveal that men who reported having 10 or more sexual partners in their lifetimes had roughly twice as many HPV infections as did men who had had one partner. Giuliano says many insurance programs cover HPV vaccination in boys up to age 18.

Male circumcision and the use of condoms have shown little protection against HPV infection, Monsonego says. “HPV vaccination in men will protect not only them but will also have implications for their sexual partners,” he says.

Science News, Web edition, February 28th, 2011

Additional source: A.R. Giuliano et al. Efficacy of quadrivalent HPV vaccination against HPV infection and disease in males. New England Journal of Medicine, Vol. 364, Feb. 3, 2011, p. 401. Abstract here.

Circumcised men at equal risk of HPV infection

A large-scale study at the University of Washington has found no difference in the incidence of HPV infection between circumcised and uncircumcised male college students. HPV (Human Papilloma Virus) is a large group of viruses that may cause genital warts, and are implicated in the genesis of genital cancers. HPV is very common among the sexually active population. but most people never show any symptoms. The risk factors for the development of cancer have been shown to be numerous different sexual partners and smoking. The new study confirmed previous research which showed that the location of the virus differed between circumcised and uncircumcised men: circumcised men tend to carry the virus on the shaft skin of the penis, while intact men are more likely to carry it on the glans. The study also also found that circumcised men have more sexual partners. In a previous study the researchers found found that for college females the circumcision status of their partner was NOT a risk factor for HPV infection in women. The authors comment that the African Random Clinical Trials, which seemed to show that uncircumcised men were more likely to carry the HPV virus, were seriously flawed because they took samples only from the glans (not from the shaft skin, where the virus is concentrated in the circumcised).

ABSTRACT

Background: The role of circumcision in male HPV acquisition is not clear.

Methods: Male university students (aged 18–20 years) were recruited from 2003 to 2009 and followed up triannually. Shaft/scrotum, glans, and urine samples were tested for 37  human papillomavirus (HPV) genotypes. Cox proportional hazards methods were used to evaluate the association between circumcision and HPV acquisition. Logistic regression was used to assess whether the number of genital sites infected at incident HPV detection or site of incident detection varied by circumcision status.

Results: In 477 men, rates of acquiring clinically relevant HPV types (high-risk types plus types 6 and 11) did not differ significantly by circumcision status (hazard ratio for uncircumcised relative to circumcised subjects: 0.9 [95% confidence interval{CI}: 0.7–1.2]). However, compared with circumcised men, uncircumcised men were 10.1 (95% CI: 2.9 –35.6) times more likely to have the same HPV type detected in all 3 genital specimens than in a single genital specimen and were 2.7 (95% CI: 1.6–4.5) times more likely to have an HPV-positive urine or glans specimen at first detection.

Conclusion: We found no differences by circumcision status in overall HPV acquisition or in number of HPV types acquired. Findings held for all clinically relevant HPV types, as well as for the subgroups of high-risk types, high-risk -9 types, and HPV-16. This observation is consistent with findings from other longitudinal studies.

Bottom line: Circumcision does not lower the risk of infection with Human Papilloma Virus. People who claim that uncircumcised men are more likely to develop or communicate genital cancers are ignoring the facts and spreading misleading information.

Source:  Kelley Van Buskirk et al, Circumcision and Acquisition of Human Papillomavirus Infection in Young Men, Sexually Transmitted Diseases 38 (12), December 2011.

Journal homepage:  http://journals.lww.com/stdjournal/pages/default.aspx

Abstract available at journal - Published ahead of print:  http://journals.lww.com/stdjournal/toc/publishahead

Study finds no association between HPV risk and lack of circumcision

A large-scale study has found no association between circumcision status and susceptibility to infections with human papilloma virus (HPV), a group of wart viruses responsible for genital herpes and implicated in the generation of cervical and other genital cancers. The study involved 3463 heterosexual men from 71 sites in 18 countries in Africa, Asia-Pacific, Europe, Latin America, and North America. Although there have been claims that circumcision may reduce the risk of infection with HPV, this study was unable to confirm such findings.

ABSTRACT

Background. We examined the baseline prevalence of penile, scrotal, and perineal/perianal human papillomavirus (HPV) in heterosexual men (HM). We also evaluated baseline characteristics of HM to assess factors associated with prevalent HPV detection.

Methods. We tested serum samples from 3463 HM aged 16–24 years with 1–5 lifetime female sexual partners for antibodies to HPV 6, 11, 16, and 18. We collected baseline swab specimens for the detection of DNA of HPV 6, 11, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59 from 3 areas: penile, scrotal, and perineal/perianal. Risk factors for prevalent HPV DNA detection were evaluated.

Results. The prevalence of any tested HPV type was 18.7% at the penis, 13.1% at the scrotum, 7.9% at the perineal/perianal region, and 21.0% at any site. Having >3 lifetime female sexual partners had the greatest impact on HPV prevalence: odds ratio (OR) 3.2 (95% confidence interval (CI) 2.1–4.9) for HPV 6, 11, 16, and 18; and OR 4.5 (95% CI 3.3–6.1) for all HPV types tested. HPV DNA detection was highest in Africa. Neither condom usage nor circumcision was associated with HPV DNA prevalence.

Conclusion. Genital-HPV DNA detection is common in young, sexually active HM. We found HPV to be most prevalent in African men and least prevalent in men from the Asia-Pacific region. Increased numbers of sexual partners was an important risk factor for HPV DNA prevalence.

Source:  Eftyhia Vardas et al. External Genital Human Papillomavirus Prevalence and Associated Factors Among Heterosexual Men on 5 Continents. Journal of Infectious Diseases 2011:203 (January 2011) 58-65.

Boys HPV vaccination program a success

A program to vaccinate adolescent boys against human papilloma virus (HPV) has been hailed as a great success, with very few adverse side effects reported. Referring to an article in the 3 June issue of the Medical Journal of Australia, the director of the National HPV Vaccination Program Register, Dr Julia Brotherton, told MJA Insight that “The second round of the first year of human papillomavirus vaccinations for adolescent boys has been completed with no reports of serious adverse outcomes”. HPV is a large group of viruses, some of which can cause various types of cancer in both males and females (especially cervical cancer), as well as anal and genital warts. Some years ago Australian researchers developed an effective vaccine, and health authorities launched a program to vaccinate girls. As a result of this effort, the incidence of genital warts among young women has fallen by about 80%. The vaccine also provides protection for males, as well as ensuring that they will not be carriers of the virus and at risk of infecting female sexual partners; Australia is the first county in the world to endorse a program to vaccinate adolescent boys.

Cate Swannell, Boys’ HPV vax going well. MJA Insight, 3 June 2013

Hazel J Clothier et al, Human papillomavirus vaccine in boys: background rates of potential adverse events. Medical Journal of Australia 198 (10), 3 June 2013, 554-558.

The HPV vaccine protects against the two main types of cancer-causing HPV (HPV16 and 18), as well as two types that cause genital warts. Clinicians have already seen a dramatic decrease in genital warts in young women since the vaccination program was introduced in mid-2007; the prevalence of genital warts plummeted from 9.6% in 2004, to less than 2% in 2010-11. It is likely that a similar decline in throat cancers will result from vaccination, especially as boys are included in the immunisation program in Australia.

Dyani Lewis, Michael Douglas, oral sex and cancer – the facts about HPV. The Conversation, 3 June 2013.

This is an effective reply to circumcision advocates (such as those in the so-called Circumcision Foundation of Australia) who try to use fear of cervical and other cancers caused by HPV to promote forcible circumcision of baby boys. Unlike circumcision, vaccination is an effective, modern, scientific way to reduce the risk of infection with cancers and other serious diseases without harm or damage to the body. Vaccination is modern medicine; circumcision is nineteenth century quackery.

Circumcision and vaccination

Circumcision is not a surgical vaccine

So much for the facts; now for the the mythology.

2002: The new cervical cancer scare

The following essay was written in 2002, in response to the publication of Castellsague's article in the New England Journal of Medicine, and the subsequent media hoo-ha, the intellectual quality of which may be judged by the screaming headline in (where else?) the Sydney Morning Herald, which never misses an opportunity to defame the foreskin: "Men can double women's risk of cancer". It is not likely that Castellsague's research has done anything to reduce the incidence of cervical cancer, but you can be sure that it has succeeded in its other objective of accelerating the destruction of infant foreskins. That Castellsague's principal aim was the promotion of circumcision is indicated by his co-authorship of subsequent papers attacking the policy of the Royal Australasian College of Physicians and demanding routine circumcision throughout the western world as a "public health requirement". (See note below.)

THE NEW CERVICAL CANCER SCARE

In 2002 the latest scare about the possible "association" between the normal male genitals and an increased risk of cervical cancer seems to have had 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.

What is cervical cancer?

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 colleagues, and they have been eagerly parroted ever since by circumcision crusaders such as Brian Morris. The article was accompanied by fire-breathing editorials, the thrust of which was much the same as Cato's policy on Carthage back in the days of Republican Rome: Delenda est praeputium! (The foreskin must be destroyed!)

Lessons of history

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 decade) 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.

In the medical journals and among responsible health specialists, 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.

NOTE: Brian Morris, Stefan Bailis, Xavier Castellsague, Thomas Wiswell, Daniel Halperin, "RACP's policy statement on male circumcision is ill-conceived", Australian and New Zealand Journal of Public Health, Vol. 30 (1), 2006. The article concluded by demanding that the RACP revise its policy so as to emphasise "the prophylactic health benefits" of circumcision and "the low rate of mostly minor complications associated with this simple procedure, which for maximum benefits and minimal risk should ideally be performed in the neonatal period".

The editors of the journal were so edgy about such partisan advocacy that the article was followed by a commentary by an Australian public health specialist that more or less rebutted every one of the authors' many claims. Incidentally, quite apart from the fact that the alleged "advantages" of prophylactic circumcision are a matter of controversy and doubt, there is no evidence at all that it must be done in infancy for maximum benefits, and plenty of evidence that neonatal circumcision is significantly more risky and harmful than if done later. The real reason circumcision promoters want it done soon after birth is that babies can't object.

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.

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:

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.

Country Human development index Incidence of circumcision in adults (%) Male life expectancy Prevalence of HIV in adults (cases per 100,000) Cervical cancer incidence (cases per 100,000)
USA 6 70 73.9 61 8
Australia 2 55 76 15 7
Canada 3 50 75.9 19 8
Britain 14 20 75 11 9
Sweden 4 <5 77 8 9
Norway 1 <5 75.4 7 13
Finland 10 <5 73.7 5 4
Japan 9 <5 77.3 2 11

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.

Virus lives in male and female genital tissue

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.

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."

Did you catch that: "sexual promiscuity is the most important risk factor for penile HPV infections."

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

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:

  Venereal cases Gonorrhoea Syphilis
Non-Jews 272 107 165
Jews 58 47 11

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

Social class/occupation Death rate per million Death rate rank
Upper and middle 302 3
Intermediate 280 4
Skilled labourer 264 5
Intermediate 304 2
Unskilled labour 429 1
Textile workers 186 6
Miners 177 7
Agricultural labourers 108 8

Source:  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 (agricultural) 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 about an association between normal male anatomy and risk of disease

Even 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.

Medical research theorists must learn to accept the human body as nature made it, not devise tunnel-visioned strategies that require doctors to 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.

Genetic mutation protects Jewish women

For many years it was assumed that the low incidence of cervical cancer among Jewish women was related to the fact that most of their husbands were circumcised (though a few researchers tried to find an association withnot eating pork products). In 2003 new evidence came 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

A concluding comment from  Andrew Sullivan

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?

The Daily Dish, 12 April 2002

 

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