Letters

Evidence sketchy on circumcision and cervical cancer link

Dr Rivet1 has failed to review criticism of the article2 by Castellsagué et al in the New England Journal of Medicine. The article has been criticized for its poor methodology,3 because circumcision removes specific erogenous tissue4-6 and because male and female partners have different types of human papillomavirus (HPV).7

Castellsagué and colleagues admit to being “puzzled” by these findings. In addition, they emphasize that they did not recommend circumcision.8 These comments place Castellsagué and colleagues’ findings regarding circumcision’s protective effects against cervical cancer in the dubious category.

A vaccine for HPV has been tested and found to be effective.9 It is probable that, by the time infants born today reach maturity, a vaccine will be available to prevent cervical cancer.

In view of the above, neonatal circumcision cannot be recommended to prevent cervical cancer. Human papillomavirus causes cervical cancer; the foreskin does not. Safer sex, not circumcision, prevents the spread of HPV.

The recent cautionary statements by three provincial colleges of physicians and surgeons regarding non-therapeutic circumcision of male children should be of greater concern to family physicians.10-12

—George Hill
Executive Secretary, Doctors Opposing Circumcision
Seattle, Wash
by e-mail

References

1. Rivet C. Circumcision and cervical cancer. Is there a link? [Critical Appraisal]. Can Fam Physician 2003;49:1096-7.
2. Castellsagué X, Bosch X, Munoz N, Meijer C, Shah K, De Sanjosé S, et al. Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. N Engl J Med 2002;346:1105-12.
3. Travis JW. Male circumcision, penile human papillomavirus infection, and cervical cancer [letter]. N Engl J Med 2002;347(18):1452-3.
4. Bhimji A, Harrison D. Male circumcision, penile human papillomavirus infection, and cervical cancer [letter]. N Engl J Med 2002;347(18):1452-3.
5. Winkelmann RK. The erogenous zones: their nerve supply and its significance. Mayo Clin Proc 1959;34:39-47.
6. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-5.
7. Franceschi S, Castellsagué X, Dal Maso L, Smith JS, Plummer M, Ngelangel C, et al. Prevalence and determinants of human papillomavirus genital infection in men. Br J Cancer 2002;86:705-11.
8. Castellsagué X, Bosch FA, Muñoz M. Author’s reply. N Engl J Med 2002;347(18):1448.
9. Koutsky LA, Ault KA, Wheeler CM. A controlled trial of a human papillomavirus type 16 vaccine. N Engl J Med 2002;347:1645-51.
10. Kendel DA. Caution against routine circumcision of newborn male infants (Memorandum to physicians and surgeons of Saskatchewan). Saskatoon, Sask: College of Physicians and Surgeons of Saskatchewan; February 20, 2002.
11. College of Physicians and Surgeons of British Columbia. Infant male circumcision. College Q 2002;Fall:2.
12. College of Physicians and Surgeons of Manitoba. Caution regarding routine circumcision of newborn male infants. Newsletter 2002;38(Dec):4.

Dr Christine Rivet1 presents evidence suggesting that circumcision reduces risk of human papillomavirus (HPV) infection in men and cervical cancer in their female partners.

This evidence should be put in perspective. Other studies have found no significant correlation between circumcision and either HPV or cervical cancer.2,3 Moreover, a large and well controlled American study found that circumcised men were slightly more likely than uncircumcised men to have had both bacterial and viral sexually transmitted diseases.4 For chlamydia, one of the most common sexually transmitted diseases, the difference between circumcised men and uncircumcised men was quite large. While 26 of 1033 circumcised men had contracted chlamydia during their lives, none of the 353 intact men reported having had it.

Evidence linking the foreskin to sexually transmitted infections and cervical cancer is contradictory. But even if the evidence were conclusive, it would still not constitute a justification for circumcising baby boys. Because infants are not sexually active, they should not be required to bear the burden of preventing sexually transmitted infections. Sexually transmitted diseases will be prevented by practising safer sex, not by circumcising infants. If circumcision is touted as a prophylactic, it could confer a false sense of security and encourage high-risk sexual behaviour.

Some physicians believe that infant male circumcision should be a matter of parental choice, even though the procedure is not medically indicated. However, operating on an incapable patient who has no medical need for surgery is normally viewed as a violation of medical ethics. As the College of Physicians and Surgeons of Saskatchewan noted last year in a memo to its members, performing surgery of questionable value on an infant is generally considered “imprudent if not improper.”

—Arif Bhimji, MD
Richmond Hill, Ont
—Dennis Harrison, BSC
Vancouver, BC
Spokespersons, Association for Genital Integrity
by e-mail

References

1. Rivet C. Circumcision and cervical cancer. Is there a link? [Critical Appraisal]. Can Fam Physician 2003;49:1096-7.
2. Aynaud O, Piron D, Bijaoui G, Casanova JM. Developmental factors of urethral human papillomavirus lesions: correlation with circumcision. Br J Urol Int 1999;84(1):57-60.
3. Terris M, Wilson F, Nelson JH Jr. Relation of circumcision to cancer of the cervix. Am J Obstet Gynecol 1973;117(8):1056-66.
4. Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States. JAMA 1997;277(13):1052-7.

In assessing the link between male circumcision and cervical cancer in female partners, Dr Rivet1 ignores the fact that, morphologically, the prepuce is highly specialized tissue2 and might be worthy of preservation in itself.

The “ridged band” is a ring of uniquely corrugated mucosa just inside the tip of the prepuce: it is highly vascular, and its individual ridges are tipped with Meissner corpuscles known to be sensitive to movement, such as that incurred by sexual intercourse. Work in progress shows that stretching the prepuce and its ridged band triggers reflex contraction of muscles of the bulb of penis known to be associated with ejaculation and, not insignificantly, erogenous sensation. Further information on the ridged band can be found at http://research.cirp.org.

As if excision of the prepuce and its specialized tissue were not enough, my colleagues and I2 found that routine neonatal circumcision regularly removes a large portion of the true skin of the penile shaft. It follows that the usual parade of “cosmetic” side effects of routine neonatal circumcision woefully underestimates its true cost.

Sexual function is only rarely included in circumcision discussions and, without it, parents seeking advice for properly informed consent, as well as their baby boys, are poorly served.

Dr Rivet would be well advised to stick with her original and much sounder advice to parents. And, of course, to include an update on preputial structure and its relationship to adult sexual function.

—John R. Taylor, MB, FRCPC, MRCPEG
Winnipeg, Man
by e-mail

References

1. Rivet C. Circumcision and cervical cancer. Is there a link? [Critical Appraisal]. Can Fam Physician 2003;49:1096-7.
2. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-5.