Spencer Beasley

It is as hazardous to write about circumcision as it is to venture into the equally controversial areas of abortion, stem cell research, and euthanasia. Few subjects generate as much passion and conflicting opinion. Those who hold views at each end of the spectrum promote them with fanatical fervour. Often they are highly selective in the information they use, and tend to cite ‘evidence’ that supports their argument while ignoring material (that may be more scientifically sound) that negates it.

In the case of circumcision, extremes of view range from a website that ‘blacklists’ surgeons believed to perform circumcisions (not referenced here to avoid giving it undeserved credibility or publicity) to authors who claim that it is negligent not to circumcise all boys. Even in peer-reviewed scientific journals, discussion of circumcision frequently contains emotive language and extravagant claims, not necessarily supported by the evidence presented. For these reasons, journals tend to be hesitant about publishing opinion on circumcision.

In this issue, despite the risks, the Journal has taken the bold step of publishing an opinion by Robert Darby on the origins of circumcision, and the part that balanitis or infection under the foreskin may (or may not) have had in leading to cultural circumcision, or to the increase in the incidence of the operation in Australasia after the two World Wars.1

Although Darby was unable to find any reference to recurrent balanitis in the British History of the Second World War, the problems created by dust storms in troops who had limited access to facilities for washing were well known to the returning servicemen of the various medical corps. For example, both the eminent Australian surgeon, Russell Howard FRACS and physician Dr Andrew Hutson, of Melbourne, described the significant problems experienced by uncircumcised men in North Africa during the Second World War (personal communication, John Hutson, 2005).

Their colleagues and trainees remember their descriptions of troops suffering from irritation from sand beneath the foreskin—trivial and unspectacular, perhaps, compared with the other illnesses and wounds treated, but not pleasant for the afflicted, nevertheless. The omission of balanitis from tomes primarily focused on the major battles that weaved their destructive courses across continents is not surprising, but does not mean that balanitis was not a cause of significant morbidity for the hapless soldier on the ground. Nor does irritation of the foreskin after a dust storm equate with circumcision on the front line.

It is unlikely many circumcisions would have been performed during the desert campaign itself (and this has not been claimed by those quoted in the accompanying article), but it does seem that the experience of war contributed to surgeons (on their return to Australia and New Zealand) being willing to support routine circumcision of boys in the neonatal period, presumably to reduce the likelihood of balanitis later in life.

The incorrect suggestion by Darby in his Abstract that ‘mass circumcision was necessary’ (or occurred) during the Second World War may have resulted from his misinterpretation of the implications of balanitis, and failure to recognise that it was almost always managed non-operatively.

What Darby has shown us is that the origin of cultural circumcision remains far from clear. Many of the theories promoted to account for ritual circumcisions2 may seem fanciful to us, but so too do some of the medical indications for circumcision that have been promulgated by some Western physicians in recent centuries. While they may not have received general acceptance, they are widely quoted and have included epilepsy and for the prevention of masturbation—for the latter, as temporary relief only, we would imagine.

As to whether considerations of hygiene or the discomfort produced by foreign material causing irritation beneath the foreskin played any part in the requirement for circumcision in a variety of religions remains uncertain—and may never be known for sure. There is a lot of conjecture, but not much evidence. While the accompanying article may not shed much light on these aspects, it will prove interesting for those readers not familiar with the controversies surrounding the practise of circumcision in males.

Finally a word of caution: so-called ‘circumcision’ in females is a somewhat misleading term that covers a variety of procedures, some of which are extremely mutilative and extend well beyond the phallus. None of them are performed in this country. These procedures are alluded to in the article, but have little bearing on discussion of male circumcision.

Author information: Spencer Beasley, Paediatric Surgeon/Paediatric Urologist, Christchurch Hospital, Christchurch

Correspondence: Professor Spencer Beasley, Department of Paediatric Surgery, Christchurch Hospital, Private Bag 4710, Christchurch. Fax: (03) 364 1584; email: spencer.beasley@cdhb.govt.nz