THE QUESTION OF CERVICAL CANCER
Does the foreskin, or smegma, cause or contribute to cancer of the female uterine cervix? Cancer of the cervix (the lower, rounded part of the uterus which opens into the vagina) is second in frequency only to breast cancer among cancers that affect women.
According to Wynder and his associates:
“The uterine cervix is the second most frequent site of cancer in American women, accounting for approximately 10% of all newly diagnosed cases and for about the same percentage of total cancer deaths. In different American cities, its annual incidence varies from 30 to 60 per 100,000 females. The incidence rates are about the same in Western Europe. Scattered reports from Asia suggest that in these countries the uterine cervix is the most important site and may account for 40 or more percent of all newly diagnosed cases of cancer. Cancer of the cervix is infrequent among Jewish and Moslem women.”1
The presence or absence of the foreskin of a woman’s sexual partner has been one of many factors suggested as a variable in cancer of the cervix. The fact that the rates of this disease occur with approximately the same frequency in Europe (with a largely intact male population) as in the United States (with a largely circumcised male population) suggests that circumcision has little or no effect on the incidence of cervical cancer. However, because Jewish and Moslem women have relatively low rates of this disease, and because both of these peoples practice male circumcision, some authorities have concluded that the circumcision of Jewish and Moslem males is responsible for their women’s relative immunity to this disease.
Unfortunately, observations such as this often reach lay people in garbled bits and pieces. As a result, some women believe that “You can get cancer of the cervix if you have sex with a man who is not circumcised!” They have the idea that one could have sex once with an intact male and a few days later show up at a doctor’s office with an active case of cervical cancer in a manner similar to catching a sexually transmitted infection. I know of one man who had himself circumcised shortly before getting married out of fear that he would give cervical cancer to his wife.
Should all males sacrifice their foreskins to protect womankind from cancer of the cervix? Numerous studies must be analyzed carefully before an answer can be reached.
Factors Related to Cancer of the Cervix
A large number of variables have been mentioned in the literature as possible contributory factors to cervical cancer. Although in this review, each of these will be discussed separately, it can be seen that a cluster of interrelated variables tend to be associated with the disease. For example, cervical cancer has been purported to be related to non‑use of contraceptives. It has also been suggested that the disease is related to repeated childbearing. Obviously lack of contraceptive use and frequent childbearing are also interrelated. Similarly, cancer of the cervix appears more frequently in patients with a history of sexually transmitted infection. It also appears to be associated with frequent intercourse and numerous sexual partners. However, sexually transmitted infection and frequent intercourse with numerous sexual partners also tend to be interrelated.
While many factors appear with significantly greater frequency among cervical cancer patients than they do among other women with similar backgrounds, but without the disease, thus suggesting a causal relationship, it is interesting to note that there is no factor that is invariably present in all cases of cervical cancer. For example, although cervical cancer occurs more frequently among women who have had numerous sexual partners, it does occur in women who have had only one sexual partner and even in virgins.
In the United States, black women have a significantly higher incidence of cervical cancer than do white women. The incidence ranges from 28 to 59 cases per 100,000 among white women and 54 to 73 cases per 100,000 among black women, throughout various American cities.2
Heins et al report a study of 1,000 Pap smears of 98% black women, 3.1% of whom had cervical carcinoma, among clinical patients, compared to a rate of 0.9% cervical cancer cases among 1,000 Pap smears of primarily white private patients.3
Terris, Wilson, & Nelson studied 1,148 cases of cervical cancer in various stages. 454 of these women had invasive carcinoma of the cervix (spreading to other healthy tissue). 411 had carcinoma in situ (cancer confined to one area). 283 patients had cervical dysplasia (abnormal, precancerous changes in the tissue). 65% of the patients with invasive carcinoma, 72 % of those with carcinoma in situ, and 82 % of those with dysplasia were black. Puerto Ricans accounted for 15% of the patients with invasive carcinoma, 19% of those with carcinoma in situ, and 12% of those with dysplasia. 18 % of those with invasive carcinoma, 9 % of those with carcinoma in situ, and 12% of those with dysplasia were white.4 The authors do not state, however, the normal distribution of these three racial/ethnic groups in the population group from which these patients came.
The question arises as to whether a genetic factor among black people, Puerto Ricans, or other minority groups predisposes them to a greater frequency of the disease, or whether cultural factors such as early marriage, frequent childbearing, hygiene, or sexually transmitted infection are related.
Similarly, genetics may contribute to Jewish women’s relative immunity to this disease, or cultural factors may be involved irrespective of their husbands’ circumcision status.
“In England the incidence of cervical carcinoma among doctor’s wives, lawyer’s wives, and clergymen’s wives is barely one fifth that in the remainder of the population.”5
The significant variables are not the husband’s occupation or income level per se, but other factors which are interrelated with socioeconomic status.
Wynder et al mention studies which link low economic status with other factors such as:
“Poor obstetrical care and postpartum care, improper housing and poor nutrition … neglect of symptoms of the lacerated and ulcerated cervix … [which] account for the greater frequency of cervical cancer among the poorer classes.”6
Elsewhere in the article, the same authors suggest:
“The social‑class difference derives from the difficulty that men in unavoidably dirty occupations have in keeping clean, and from the different patterns of intercourse and marriage in the less favored classes.”6
Personal cleanliness, on the part of both men and women, appears to be a crucial factor in the development of cervical cancer.
Wynder, Mantel, and Licklider (who advocate neonatal circumcision as a supposed cancer preventative), claim that they have found a relationship between lack of circumcision and poor penile hygiene in connection with the development of cancer of the cervix. They concede that:
“…only one of three retrospective studies in the U.S. has obtained results suggestive of a positive association between cervical cancer and circumcision status…. it is clear that the [supposed] protective effect of circumcision would be less pronounced in the U.S than in many other countries. The higher level of personal hygiene would tend to provide many of the [supposed] protective benefits otherwise afforded by circumcision.”7
Heins et al mention poor vaginal hygiene among their previously mentioned clinic patients who had a significantly higher rate of cervical cancer than the private patients.3
Rates of cervical cancer have been observed among three different groups of people in Macedonia, Yugoslavia. These are Eastern Orthodox Christians (who do not practice circumcision), and two Moslem groups ‑- Shqyptars and Turks (both of which practice circumcision). While the Christian group had the highest rate of cervical cancer, the Turks had higher rates of the disease than the Shqyptars although both groups were circumcised. The author cites major differences in social life, sexual practices, and hygienic practices as accounting for the differences. The Shqyptars practiced a much stricter lifestyle, including shaving of the genital region and regular washing after intercourse.8
Age of First Coitus:
Many studies mention that early marriage, or more specifically intercourse before the age of 20 years, is associated with increased risk of cervical cancer.
In Terris and Oalmann’s study they found that 53% of the patients with cervical cancer and 26 % of the controls had experienced their first coitus before age 17. 39 % of those who were diagnosed after age 50 had their first coitus before age 17.9
Rotkin conducted an in‑depth study of adolescent coitus in relation to cervical cancer. He poses the following:
“Speculation suggests a male contribution that becomes established in adolescent girls because they are then most susceptive. This agent may be a substance, organism or particle not related to the ejaculate, perhaps borne on the unsanitary male organ or contraceptive, and remaining dormant during the mean latent period of 30 years before developing into carcinoma….”10
(In other words, a girl could have her first coitus at age 13 and ultimately get cervical cancer at age 43.)
Rotkin notes that adolescent coitus tends to be interrelated with other factors. He quotes Jones’ suggestion:
“…[The] importance of the socioeconomic complex of relative poverty (at least in early life) with rapid maturation sexually and a haste to begin early, and early to terminate, the reproductive phase of biologic destiny ‑ marriage, intercourse, first and last pregnancies, separation, divorce -‑ all of these events occur significantly earlier in the life of the woman destined to develop cervical carcinoma than the woman without this disease….”10
(Rotkin’s studies and observations were published in 1962. In the years since, social mores have changed and more middle class teenagers are having intercourse. Adolescent coitus today is certainly not confined to the lower socioeconomic groups. Some authorities have noted that the rates of cervical cancer in the United States are increasing, and will continue to increase, possibly because of this.)
Rotkin conducted a study involving interviews and questionnaires, with the following results: 9 patients and 8 controls experienced first coitus before age 15. 32 patients and 20 controls experienced first coitus between ages 15 and 17. 33 patients and 27 controls experienced first coitus between ages 18 and 20. 15 patients and 24 controls experienced first coitus between ages 21 and 23. 9 patients and 9 controls experienced first coitus between ages 24 and 26. 1 patient and 8 controls experienced first coitus after age 26. 1 patient and 4 controls had never experienced coitus.
Rotkin speculates that hormonal factors based on the rapid maturation, body changes, and emotional stresses of adolescence may somehow predispose the cervical tissue to eventual carcinoma if coitus is begun at this time.10
Cancer of the cervix is more prevalent in women who are or have been married than it is in women who have never married. However, factors other than simply being married are involved.
Stern and Neely investigated a number of possible variables associated with cervical cancer and found the number of “marital events”, i.e., marriages, divorces, widowhoods, and remarriages, to be the most significant factor in their study.11
Terris and Oalmann compared 122 patients with cervical carcinoma with 122 matched (by race and age) controls and found that 47% of the patients and 16% of the controls had been married more than once. 1 patient and 5 controls had never married. 34% of the patients and 14% of the controls were married before age 17.9
The woman’s age at the time of her first marriage has been mentioned as a factor in cervical carcinoma. This usually interrelates with her age at the time of first coitus.
Studies have revealed conflicting results over whether or not pregnancy or childbearing have any effect on eventual cervical cancer. It is not certain whether the disease is associated with early or repeated pregnancies, or method of delivery.
An article in the CMA Journal states that:
“…the risk of cervical cancer is twice as high in married infertile women as in single women….”12
Therefore, sexual intercourse, rather than childbearing alone appears more likely to be the important factor.
Wynder and his associates quote Hofbauer who speculates that:
“…excessive ovarian stimulation in multiparous women might be of etiologic significance.”13
Towne noted that cervical carcinoma is approximately eight times more frequent in parous (having given birth) women than in non‑parous women. She poses that pregnancy and labor with their attendant cervical trauma bear a causal relationship to cervical carcinoma. Towne reviewed the date collected between 1933 and 1953 and noted that among 574 patients with cervical cancer, 83.4% had borne children.14
The obvious discrepancy in her findings, however, is that she failed to account for age. Cervical cancer is most common in women past childbearing age. It occurs most frequently in women in their 40s and 50s. The older a woman is, the greater is the likelihood that she has ever been pregnant or borne a child. An age‑controlled study would yield more conclusive results.
It is plausible that damage to the cervix during birth, especially from forceps, other obstetrical interventions, or precipitous delivery, especially if the damage was never repaired, could contribute to cervical cancer. A more detailed study investigating types of birth complications involving cervical damage would shed further light on the subject. Would women who have given birth only by Caesarian delivery be less susceptible to cervical cancer than women who have given birth vaginally? Is there a relationship between cervical cancer and induced abortion which forces the cervix open prematurely?
Wynder, Cornfield, et al conducted an extensive, detailed study of cervical cancer. Their findings in regards to the correlation between pregnancies and cervical cancer revealed that among the white women in their study, 9% of the patients with cervical cancer and 12% of the controls had never been pregnant. Among black women, 11% of the patients and 17% of the controls had never been pregnant. However, they found that the event of pregnancy and early marriage were strongly associated.6
The age of a woman’s first pregnancy may be a factor in eventual cancer of the cervix. More likely, the significant factor is the age of first coitus, the pregnancy simply being the outcome of the coitus.
Use of Contraceptives:
Different authors have posed the possibility that cervical cancer may be related to non‑use of contraceptives. Some have speculated that use of obstructive type contraceptives such as condoms and diaphragms could decrease a woman’s susceptibility to the disease.
In Terris and Oalmann’s study of 122 cervical cancer patients and 122 matched controls the authors noted that:
“…few of the women had ever used contraceptives, but the proportion doing so was significantly lower in the patients than in controls.”9
In Aitken‑Swan and Baird’s study, they found that 13% of the patients and 43% of the controls had used a sheath (condom) or cap (diaphragm) type of contraceptive.
Wynder, Cornfield, and associates found no significant differences between their cervical cancer and control groups in regards to contraceptive practice.6
If smegma were an implicating factor in cervical carcinoma, use of obstructive contraceptives would presumably result in lower rates of cervical cancer since they would prevent smegma from reaching the cervix. However, the findings on contraceptive use fail to support this. Non‑use of contraceptives would also, for most women, be related to numerous pregnancies, thus tying this in with the possible correlation between repeated childbearing and cervical cancer. A study relating use of different types of contraceptives, investigating rates of cervical cancer among those using non‑obstructive contraceptives such as birth control pills, would shed further light on the subject.
Sandler mentions studies that have suggested that sperm may contribute to factors in the development of cervical carcinoma. He cites:
“Dr. Reid and colleagues correlate the protein chemistry of sperm with the socioeconomic status as an important etiological factor in carcinoma of the cervix uteri.”16
If sperm were indeed an implicating factor in cervical carcinoma, it would follow that use of obstructive contraceptives would protect the cervix from sperm contact therefore diminishing one’s susceptibility to this disease. Aitken‑Swan and Baird acknowledge this possibility in their study. They suggest:
“This method (obstructive contraceptives), like circumcision, would protect the cervix from contact with smegma. Unlike circumcision, it would also prevent contact with spermatozoa, if epithelial penetration by spermatozoa could initiate the process leading to cancer.”15
However, since other studies have found no differences between patients and controls in regards to contraceptive use, and since cervical cancer has been noted in women who regularly use obstructive contraceptives and even in women who have never experienced coitus, it is questionable whether either smegma contact or sperm contact are implicating factors. Since sperm contact unquestionably leads to pregnancy, it may be that repeated pregnancies are the significant factor in cervical cancer. However, data on the relationship between cervical cancer and childbearing are also inconclusive. It may simply be that non‑use of contraceptives is related to a number of other factors associated with lower socioeconomic status, poorer hygiene and general health.
Some authors have suggested that differences in diet may cause some women to be more predisposed to cervical cancer than others. It is plausible that nutritional deficiencies may contribute to the development of this disease.
Wynder and associates cite Khanolkar’s theory that:
“…women in the lower income groups with resulting inadequacy of diets might develop liver disfunction and subsequently might have a higher hormonal blood level because the damaged liver is unable to detoxify the estrogens.”
“Khanolkar feels that cancer of the cervix is most common in Hindu women who have a badly balanced and deficient diet, especially during the childbearing stage…. Horwitz considers ritual dietary laws among Orthodox Jewish women to be of possible etiological significance. Ayre proposes that deficiencies of thiamine and riboflavin might lead to a greater susceptibility of cervical tissues to cancer formation.”13
Clearly further investigation is needed in this area before a conclusion can be reached.
Coal Tar Douches:
It seems incredible that women would douche with coal‑tar based products such as Lysol. However, this has been a practice among some groups. Some authors have suggested that this practice may be a factor in cancer of the cervix. However, studies have failed to find a correlation.
Wynder and associates state:
“Lombard and Potter suggest that this may be of etiological significance. Smith notes no significant difference in the type of douches used by Italians and Jews in his study.”13
Terris and Oalmann found no differences between patients and controls in the duration and frequency of douching.9
Similarly, Wynder, Cornfield, et al found no differences between patients and controls in the type or frequency of douching.6
Nidah -‑ Jewish Ritual Abstinence Following Menstruation:
Traditionally Jewish women have observed a practice called “Nidah.” This involves ritual abstinence from intercourse during menstruation and for several days thereafter, followed by a ritual “Mikvah” bath. Some have suggested that this practice may be responsible for Jewish women’s lower rates of cervical cancer. However, Heins et al mention that the possibility is unlikely since today only about 5 % of Jewish women observe the laws of Nidah.3
Wynder and associates quote Kennaway who mentions the possible correlation between ritual abstinence and relative immunity to cervical cancer. They add that Parsis (a group in India) who have a relatively low frequency of cervical cancer also have a period of abstinence after menses. Weiner suggests that the apparent greater frequency of cervical cancer in Jewish women today, as compared to the beginning of this century, might possibly be explained by a greater laxity of Jewish women in following the law of abstinence.”17
Menstrual difficulties, as well as age of onset of menstruation have been suggested as possible factors in cervical cancer.
Wynder, Cornfield and associates found no differences between patients and controls in regards to the age of the onset of menses, the length of menstrual flow, or abstinence during or after menstruation.6
Other reports mention menstrual factors briefly, but apparently little has been studied about this.
Sexually Transmitted Disease:
Higher rates of sexually transmitted disease appear to be associated with cervical cancer. It is not clear whether STD is a direct cause of cervical cancer, or if the two simply tend to appear together and are interrelated to other causal factors such as frequency of intercourse and number of sexual partners.
In 1942 Levin, Kress, and Goldstein noted that:
“…it appears that in women with cancer of the uterine cervix, syphilis is found approximately three times as frequently as in women with cancer of the other sites…. Out of 930 patients with cervical cancer, 36, 3.9% had syphilis. Out of 3,680 female patients with other types of cancer, 41, 1.1% had syphilis. In a previous study, Belote, in 1931, found a percentage of 15.1 % syphilis out of 232 patients with cervical cancer, and 3.8% syphilis among 393 females with other types of cancer, yielding a ratio of 4 to 1.”18
In Terris and Oalmann’s study, comparing 122 cervical cancer patients with an equal number of controls, 13 patients and only 6 controls had positive tests for syphilis.10
In Wynder, Cornfield, and associates’ study, they found twice as many syphilitic patients among women with cervical cancer as in controls among the non‑Jewish white group. No difference was found, however, between the black patients and controls. They comment:
“Of interest, however, is the fact that those reporting a past history of syphilis also reported, as one might expect, earlier age at first coitus. These could operate together, or be related to more frequent coitus among this group.”6
In the same study the authors found no differences between patients and controls in regards to history of gonorrhea.6
One study suggests that Herpes Type 2 appears to be more prevalent in the history of women with cervical cancer. Taylor and Rodin state that antibodies to HSV Type 2 have been found more frequently in patients with cervical atypia and carcinoma than in controls.19
Use of obstructive contraceptives has been listed as a possible preventive factor in decreasing one’s susceptibility to cervical cancer. Obstructive contraceptives also help prevent sexually transmitted infections. Therefore, these two factors may interrelate.
Chronic Cervicitis and Lacerations to the Tissues:
Cervical cancer appears to be preceded, in most cases for many years, by irritation or damage to the tissues.
Rieser quotes Besseson who states:
“Cancer of the cervix is rarely seen without chronic endocervicitis, unhealed lacerations, erosions, scarring or chronic infections of types undetermined.”20
Wynder and associates mention Gagnon’s suggestion:
“The eradication of cervicitis equals the suppression of cancer of the cervix.”
They also add:
“Lombard and Potter found a rate of 26% of unrepaired lacerations (presumably from childbirth or abortion) among patients with cancer of the cervix and 13.2% among matched controls.”13
This obviously interrelates with other factors such as childbearing, obstetrical help, type of delivery, sexually transmitted infections, and personal hygiene.
Wynder and associates mention:
“Hausdorff suggests vaginal discharge as a causative factor in the production of cervical cancer.”13
More plausibly it would seem that the vaginal discharge is related to sexually transmitted infection or cervicitis, or may be a result of cervical cancer itself.
Some have speculated that hormonal factors may have an effect on whether or not women develop cervical cancer.
Wynder and associates quote Clemmesen’s suggestion of a “special hormonal status in these [Jewish] women,” that may be responsible for this group’s relative immunity to the disease.”17
Elsewhere the same authors mention:
“…Ayre believes estrogen to be a growth‑stimulating factor to cervical cancer. 90% of 50 patients with cervical cancer had evidence of excessive tissue estrogens on the basis of vaginal and cervical cornification…. Niebergs advances the contrasting idea that low estrogen levels might be of etiologic significance. Lombard and Potter propose that hormonal factors may account for earlier marriage and high divorce rates among patients with cervical cancer.” [!]13
Hormonal levels would in turn be interrelated with diet, pregnancy, and sexual stimulation.
Number of Sexual Partners:
A most significant factor in cervical cancer relates to lifestyle, number of marriages, and number of sexual partners. Women who have had many sexual partners throughout their lifetimes appear to be more likely to develop cervical cancer. This is not to say that every woman who develops cervical cancer has had a number of sexual partners. However, the likelihood of developing the disease is greater among women who have had numerous sexual partners.
Wynder and associates note that prostitutes are four times as numerous among women with cancer of the cervix as are other women of comparable socioeconomic groups. Conversely, there is a very low incidence of cervical cancer among nuns.17
Wynder, Cornfield, and associates found that:
“There is a consistently larger proportion of women who have been married two or more times in the cervical cancer group. 29% of the white, non‑Jewish patients, and 12 % of the controls had been married twice or more. Among blacks, 35 % of the cancer patients and 22 % of the controls had been married more than once.”6
The same authors found significantly low rates of cervical cancer among women who had had intercourse only with their husbands who also happened to be circumcised:
“Among the white, non‑Jewish groups, 3% of the patients and 9% of the controls had intercourse with only their circumcised husbands. For the blacks, the rates were 0 % and 9 % respectively.”
They note, however, that 10% of the white and 20% of the black subjects were unable to report on the circumcision status of their partners.6
Data about any woman’s number of sexual partners is understandably difficult to obtain. She may not wish to disclose this information, and there is no way of verifying what she reports. Therefore, studies about this facet of the cervical cancer question have been limited.
It may be, however, that marital fidelity is a crucial variable in the development of this disease. Certain peoples who have practiced male circumcision, such as the Jews, have also practiced a more conservative lifestyle in which marital fidelity is especially important.
Information about the cervical cancer rates among women who have had intercourse only with their intact husbands would help to answer the question. (Such data was not reported in Wynder, Cornfield, and associates’ study.)
Jeffrey R. Wood has posed the possibility that the absence of foreskin with resultant difficulty in sexual penetration and accompanying frustration leads to considerable sexual dissatisfaction. This would mean less satisfactory relationships. Consequently people would seek more sexual partners. If the above is indeed true, and if having numerous sexual partners does relate to cervical cancer, then theoretically circumcision could be a causative factor in cancer of the cervix.21
Circumcision Status of Sexual Partner:
Because Jewish and Moslem women have relatively low rates of cervical cancer, and Jewish and Moslem males are circumcised, it has been hypothesized that the presence of the foreskin is a factor which can contribute to cancer of the cervix.
Most of the studies that have investigated this possibility have found that when Jewish women are omitted from the group under investigation, circumcision is no longer a significant factor. Among American non‑Jewish women, there appear to be no differences in the rates of cervical cancer between those married to circumcised husbands and those married to intact husbands.22
During the years 1951‑1955, Dunn and Buell interviewed 429 patients with cervical cancer. The same number of controls were selected by matching age, race, ever married, and ever parous (having given birth). Five Jewish patients and 21 Jewish controls were omitted from the study.
Among the 334 cervix cases, 114 had circumcised husbands. Among the 364 controls, 126 had circumcised husbands. 220 patients and 238 controls had intact husbands.
Interestingly, instead of simply concluding that circumcision of the husband obviously has no effect upon cervical cancer, they attempt the hypothesis that intermittent exposure to other uncircumcised partners not accounted for in the study (which Jewish women supposedly would be less likely to encounter), or the remaining fragment of foreskin left by medical circumcision (which is sometimes less “complete” than Jewish circumcision) may be the culprits. (Some authors have even hypothesized that the higher rates of cervical cancer among American Jewish women, compared to those in Israel, are caused by extra‑marital affairs with intact American men.) The foreskin or smegma would have to be extremely carcinogenic to cause cervical cancer by brief extramarital contacts, or from a small fragment of foreskin!
In 1961 Stern and Dixon published a report comparing 403 women with atypical hyperplasia (excessive growth of normal cells) and pre‑ and invasive cancer of the cervix, with 4,738 controls. Age of first marriage, present marital status, number of marriages, divorces, widowhoods (termed “marital events”), religious affiliation, circumcision of husband, and contraception, were the variables studied. They found “marital events” and “Jewish” to be of primary importance. As in Dunn and Buell’s study, they found that omission of Jewish women from the study had an appreciable effect on the relationship of the other variables to the cancer status. In particular, the status of circumcision as a predictor of cancer remains of secondary importance.23
In Terris and Oalmann’s study of matched groups of cervical cancer patients and controls, the husbands of 44% of the patients were intact as were 25% of the controls. However, in one‑half of the patients and controls the circumcision status was unknown.9
In a study by Terris, Wilson, and Nelson, involving more subjects, no significant differences were found: Among the patients with invasive carcinoma and their matched controls (89 of each) 18.7% of the patients and 19.6% of the controls had intact husbands.
Among those with carcinoma in situ and their controls (133 of each) 18.0% of the patients and 22.4% of the controls had circumcised husbands, and 41.6% of the patients and 39.2 % of the controls had intact husbands.
Among those with dysplasia and their controls, (74 of each) 20.8% of the patients and 21.6 % of the controls had circumcised husbands, and 39.9 % of the patients and 35.5 % of the controls had intact husbands.4
Aitken‑Swan and Baird’s study suggests that perhaps use of an obstructive contraceptive combined with the husband being circumcised may be a factor in preventing cervical cancer. However, only a small number of subjects were involved. Most other studies have revealed no relationship between cervical cancer and either of these factors. Socioeconomic factors may simply be related to contraceptive use, circumcision, and cervical cancer.
Among the couples in which the husband was circumcised and a sheath or cap was used, there were no cancer patients and 7 controls. Among those in which the husband was circumcised and no sheath or cap used, there were 12 patients and 7 controls. Of those in which the husband was not circumcised, and a sheath or cap was used, there were 6 patients and 13 controls. Of those in which the husband was not circumcised and no sheath or cap was used, there were 26 patients and 15 controls.15
It appears from these findings that if either of these factors is valid, then use of an obstructive contraceptive seems to be a more important protective factor than lack of foreskin. Among the group in which the husband was intact and an obstructive contraceptive was used, there were more than twice as many controls as patients.
Interestingly, Aitken‑Swan and Baird cite the rates of 2.2 cases of cervical cancer per 100,000 among Jewish women in Israel; 17 per 100,000 among women in Sweden, and 44 per 100,000 among American women. The second and third statistics are especially worth noting for Sweden has a nearly exclusively intact male population and yet a lower rate of cervical cancer than does the United States which has a largely circumcised male population.15
Similarly, the World Health Organization reports statistics on the mortality rates from cancer of the cervix during the years 1958 to 1967. Among every 1,000,000 females, the percentage of deaths from cervical cancer was 7.3 to 9.8 in the United States; 6.2 to 6.9 in the Netherlands; 6.0 to 7.3 in Finland; and 6.5 to 8.3 in Sweden. Obviously the death rates from this disease are higher in our country with its largely circumcised male population, than they are in the Netherlands, Finland, or Sweden, all of which have a primarily intact male population.
The low rates of cervical cancer among Jewish women may be determined by lifestyle, sexual practices, personal hygiene, or genetic factors, instead of circumcision. The higher rates of cervical cancer among American Jewish women compared to Israeli Jewish women may be due to more intermarrying and conversion to Judaism of different types of peoples among the American Jewish population, thusly affecting their genetic makeup.
Controlled Experiments with Smegma
A number of experiments have been conducted with laboratory animals in an attempt to investigate the alleged carcinogenicity of smegma. Some of these have already been discussed in the chapter on penile cancer. Four other such studies, most of which have involved the direct application of smegma to the cervixes of mice, are discussed here.
Fishman, Shear, Friedman, and Stewart injected human smegma subcutaneously into 12 mice. There was abscess formation and ulceration at the sites of injections, but no tumors grew.
Smegma was applied intravaginally in 20 mice repeatedly over 15 to 17 months. A trauma control group of mice was regularly penetrated with a metal plunger with no substance applied. No tumors were found in either group.
20 other mice had smegma applied intravaginally with a plunger into the cervix, 203 times weekly for 12 months, receiving between 72 and 140 applications. Postmortem examinations revealed no tumors.
As a control, 10 mice had benzapyrene (a known carcinogen) applied to the cervix and vaginal canal, 2‑3 times weekly. By the end of 14 months all 10 mice had cancerous tumors.25
Pratt‑Thomas and associates injected whole human smegma into the vaginas of mice by various methods. Ovarian dermoid cyst contents were used as a control. Other mice were treated with methylcholanthrene in lard and in coconut oil, and insertion of speculum without substance applied.
Out of 12 of 15 mice that were given biweekly vaginal injections of smegma, 4 had overt invasive carcinomas, 1 had an early carcinoma, another had a “possible” carcinoma, and 6 had marked epithelial hyperplasia.
Of the mice receiving weekly vaginal injections of smegma, 11 out of 26 had marked hyperplasia, but none had definite invasive malignant tumors.
Of 21 mice that were injected with a vaginal ligation (smegma was injected and a suture was made to keep it in), 1 had a carcinoma, 1 had a questionable malignant papilloma, and 2 had sarcomas (cancer arising from underlying tissue).
Of 10 mice given estrogen injections with smegma (in an attempt to investigate a relationship between cervical cancer and hormones) 1 carcinoma developed.
Among the mice given estrogen injection, vaginal ligation and smegma, no neoplastic changes were found. Nor were any changes found among the mice given a simple vaginal ligation.
Among the mice injected with sterile smegma (autoclaved to kill bacteria) and vaginal ligation, no neoplastic changes or hyperplasia were found. (This suggests that the bacteria, not smegma itself, may be what stimulates tumors -‑ at least for this particular group of mice. If this is so, it follows that personal hygiene, not the mere presence or absence of one’s foreskin, would be the significant factor in preventing cervical cancer.)
Methylcholanthrene, a known carcinogen, was inserted in 26 mice. This produced marked to profound hyperplasia in 16 mice and moderate in 5. One had an active papilloma and one had a squamous cell carcinoma.
Insertion of dermoid cyst material with a vaginal ligation produced 2 squamous cell carcinomas, one papilloma, and one marked hyperplasia.26
All scientists who work with laboratory animals know that some genetic strains of animals are more prone to tumors than are others. Since a considerably larger number of tumors grew among Pratt‑Thomas and associates’ mice than did among the mice involved in Fishman and associates’ study, Pratt‑Thomas’ group may have had a selection of mice that were more tumor and cancer prone than others. It should also be remembered that lab animals are often given proportionately huge doses of whatever substance is involved in the test. An injection of smegma in a tiny mouse vagina is probably the equivalent of a cup full of smegma in a human vagina.
Heins and associates applied whole raw human smegma to the cervixes and upper vaginas of mice. Female genital tract bacteria and ovarian dermoid cyst contents were applied to control mice.
In one of their studies, 50 mice were repeatedly injected with smegma. 25 of these survived the study. Of these there was no change in 7, mild to marked hyperplasia in 17, and one cancer of the cervix. This tumor developed in a mouse that received 118 injections of smegma over 13.75 months.
In several other types of smegma application experiments conducted by the same authors, no tumors grew.27
Reddy and Baruah inserted fresh human smegma into the vaginas of 16 female mice. 19 male mice had human smegma applied to the penis beneath the prepuce. This was done to both groups 3 times a week for 16 months. At the end of this period 4 male mice and 6 female mice were still alive. Some had died from infection of the genital tract.
Of their small experiment, no macroscopic growths were observed. Some had hyperplasia and infections, but no abnormal or metastatic growth appeared.28
Laboratory experiments with animals are conducted under extremely abnormal conditions. It is highly doubtful that female mice living under normal conditions, having intercourse with uncircumcised male mice, with exposure to the smegma produced from a mouse penis, will develop cervical cancer.
Cancer of the cervix is associated with a number of related factors, none of which have been proven to be a cause of the disease. No one factor is universally present in all cases of cervical carcinoma. Many of these factors tend to be based on socioeconomic conditions relating to poverty, poor personal hygiene and general health, multiple sex partners, and beginning sexual relations at an early age.
When Jewish women are omitted from study groups, it is clear that there are no differences in the rates of cervical cancer between women married to circumcised husbands and those married to intact husbands.
Laboratory experiments with smegma applied to the cervixes of mice show questionable and inconclusive results in regards to the carcinogenicity of this substance.
Most studies involving the effect of obstructive contraceptives on cervical cancer rates show no differences in the rates of this disease among users and non‑users of the devices, yet these would protect the cervix from smegma contact.
If smegma were to be proven to be carcinogenic, certainly regular washing of the genitals would be effective in eliminating the problem. The same “washing versus surgery” argument that has been posed regarding other supposed “health benefits” of circumcision applies here.
For the present, the most effective means of controlling cervical cancer is widespread screening by detection with regular examinations and Pap smears for all women.
Most authorities agree that routine circumcision of males is not justified as a means of preventing cancer of the cervix in women. Neither the presence of the male foreskin nor smegma have been proven to be associated with the disease.
Dr. King of the Ad Hoc Task Force on Circumcision for the American Academy of Pediatrics concludes:
“… Neonatal circumcision is unproven as a means of reducing … carcinoma of the cervix in marital partners. The indication for neonatal circumcision most often invoked is seen as impractical. The greater question, relating to carcinoma, is the protective effect that circumcision may confer vis‑a‑vis carcinoma of the cervix in spouses. Here the data is less compelling [than for penile cancer] but good penile hygiene ‑ retracting and washing under the foreskin‑or genetic resistance to carcinoma of the cervix are equally plausible explanations for the relatively low incidence of carcinoma of the cervix found in Israeli or Scandinavian wives…. Compelling epidemiological data that would mandate circumcision as a means of preventing carcinoma of the cervix are presently lacking.”29
- Wynder, Ernest L., M.D.; Cornfield, Jerome, B.S.; Schroff, P.D., M.B., B.S., and Doraiswami, K.R., M.D. “A Study of Environmental Factors in Carcinoma of the Cervix” American Journal of Obstetrics and Gynecology, Vol. 68, No. 4, Oct. 1954, p. 1016.
- Ibid., p. 1017.
- Heins, Henry C., Jr., M.D.; Dennis, E.J., M.D.; & Pratt‑Thomas, H.R., M.D. “The Possible Role of Smegma in Carcinoma of the Cervix” American Journal of Obstetrics & Gynecology, Vol. 76, No. 4, p. 726‑727.
- Terris, Milton, M.D.; Wilson, Fitzpatrick, M.D.; & Nelson, James H., Jr., M.D. “Relation of Circumcision to Cancer of the Cervix” American Journal of Obstetrics and Gynecology, Vol. 117, No. 8, Dec. 15, 1973, p. 1056‑1066.
- Apt, Adolf “Circumcision and Prostatic Cancer” Acta Medica Scandinavica, Vol. 178, 1965, p. 496.
- Wynder, Cornfield, et al, p. 1024‑1052.
- Wynder, Ernest L., M.D.; Mantel, Nathan, M.A.; & Licklider, Samuel D., M.D. “Statistical Considerations on Circumcision and Cervical Cancer” American Journal of Obstetrics and Gynecology, Vol. 79, No. 5, May 1960, p. 1027-1029.
- Damjanovski, Ljubo; Marcekic, Violeta; and Miletic, Mirjana “Circumcision and Carcinoma Colli Uteri in Macedonia, Yugoslavia ‑ Results from a Field Study” British Journal of Cancer, Vol. 17, 1963, p. 406‑409.
- Terris, Milton, M.D.; & Oalmann, Margaret, R.N. “Carcinoma of the Cervix; An Epiderniologic Study” J.A.M.A., Vol. 174, No. 14, Dec. 3,1960, p. 1848‑1849.
- Rotkin, I.D., Ph.D. “Relation of Adolescent Coitus to Cervical Cancer Risk” J.A.M.A., Vol. 179, No. 7, Feb. 17,1962, p. 486‑489.
- Stern, Elizabeth, M.D., & Neely, Peter M., Ph.D. “Cancer of the Cervix in Reference to Circumcision and Marital History” Journal of the American Medical Women’s Association, Vol. 17, No. 9, p. 739‑740.
- “Cleanliness, Continence, Constancy, and Cervical Carcinoma” Canadian Medical Association Journal, Vol. 90, May 9, 1964, p. 1132.
- Wynder, Cornfield, et al, p. 1019‑1020.
- Towne, Janet E., M.D. “Carcinoma of the Cervix in Nulliparous and Celibate Women” American Journal of Obstetrics & Gynecology, Vol. 69, No. 3, March 1955, p. 606‑613.
- Aitken‑Swan, Jean, and Baird, D. “Circumcision and Cancer of the Cervix” British Journal of Cancer, Vol. 19, No. 2, June 1965, p. 217‑227.
- Sandler, Bernard “Sperm Basic Proteins in Cervical Carcinogenesis” The Lancet, July 22, 1978.
- Wynder, Cornfield, et al, p. 1018‑1019.
- Levin, Morton L., M.D.; Kress, Louis C., M.D.; & Goldstein, Hyman, Ph.D. “Syphilis and Cancer” New York State Journal of Medicine, Sept. 15, 1942, p. 42, 46.
- Taylor, P.K. & Rodin, P. “Herpes Genitalis and Circumcision” British Journal of Venereal Disease, Vol. 51, 1975, p. 274.
- Rieser, Charles, M.D. “Circumcision and Cancer” Southern Medical Journal, Vol. 54, Oct. 1961, p. 1133‑1134.
- Wood, Jeffrey R., (personal correspondence)
- Dunn, John E., Jr., & Buell, Philip “Association of Cervical Cancer with Circumcision of Sexual Partner” Journal of the National Cancer Institute, Vol. 22, No. 4, April 1959, p. 751‑752.
- Stern, Elizabeth, M.D.; & Dixon, W.J., Ph.D. “Cancer of the Cervix ‑ A Biometric Approach to Etiology” Cancer, Vol. 14, No. 1, Jan.‑Feb. 1961, p. 154, 158‑160.
- World Health Statistics Annual World Health Organization, Geneva.
- Fishman, M.; Shear, M.J.; Friedman, Harry F.; & Stewart, Harold L. “Studies in Carcinogenesis. XVII. Local Effect of Repeated Application of 3,4Benzpyrene and of Human Smegma to the Vagina and Cervix of Mice” Journal of the National Cancer Institute, p. 361‑366.
- Pratt‑Thomas, H.R., M.D.; Heins, Henry C., M.D.; Latham, Eugene, M.D.; Dennis, E.J., M.D.; and McIver, Forde A., M.D. “The Carcinogenic Effect of Human Smegma: An Experimental Study” Cancer, Vol. 9, No. 4, July‑August 1956, p. 671‑680.
- Heins, et al, p. 726‑732.
- Reddy, D. Govinda, M.D.; and Baruah, I.K.S.M.., M.B., B.S. “Carcinogenic Action of Human Smegma” Archives of Pathology, Vol. 75, April 1963, p. 414‑420.
- King, Lowell R., M.D. “The Pros and Cons of Neonatal Circumcision” (unpublished)