Controversy: Circumcision- The Cruellest Cut of All?

"You wouldn't..would you?"

“You wouldn’t..would you?”

Part One – Infections and Disease

To circumcise or not to circumcise? Some parents of baby boys don’t think twice about the routineness of circumcision, others are hell-bent against it, and still others agonize over the decision, a decision made harder by the contradictory information out there.  As with most of our controversies, there are multiple angles to the circumcision debate, a debate that is tied into moral arguments and religious freedom as well as hard data regarding health benefits and risks. Our goal will be to summarize all the arguments we can find, and to collate the medical information into plain language.  As there is a lot out there on circumcision, we’ll be breaking this research up into different parts.

Infection rates:

A 2009 meta analysis of studies on sexually active men in Africa found that circumcision reduces the infection rate of HIV among HIV among heterosexual men by 38-66% over a period of 24 months.  In addition, studies have concluded it is cost-effective against HIV in sub-saharan Africa.

A systematic review of interventions worldwide to prevent sexually transmitted infections, to include but not limited to circumcision, found that male circumcision protected against viral STIs and possibly trichomoniasis.  Specifically, male circumcision reduced the incidence of herpes HSV-2 infections by 28%.

Circumcision is also associated with reduced HPV prevalence. This means that a randomly selected circumcised man tested for HPV is less likely to be found to be infected with the virus than an uncircumcised man.  As a corollary to that, male circumcision also was associated with a reduced rate of transmission of HPV to the steady female partners of a circumcised man, leading also to lower cervical cancer rates.  Similar studies are found here, here, and here.

However, this study of course only shows correlation, not necessarily causation. Therefore, there may be other factors at play that lead to a reduced HPV prevalence that only appear to be related to circumcision.  In addition, no strong evidence (as explained in the studies above as well as the American Academy of Pediatrics’s task force on circumcision) indicates that circumcision reduces the rate of new infection.

Studies of its protective effects against other sexually transmitted infections have been inconclusive.

UTIs

Circumcision may also lead to a decreased risk of UTIs in male infants under 2 years old. However, most available data regarding the inverse relationship between UTIs and circumcision is from before 1995. There are two meta-analyses and one cohort study done after 1995 showing the inverse relationship, but data from randomized clinical trials are very limited.  In addition, there is only about a 1% risk of UTIs in boys under two years of age  (compared to a much higher number for girls) , and the majority of incidents occur in the first year of life.  Therefore, even a 10 fold reduction of risk is dealing with a very small number, and circumcision is most likely to benefit boys who have a high risk of UTIs due to anatomical defects.  Finally, a 1999 AAP article clearly states the studies on circumcision and male UTI do not look at potential confounder (such as prematurity, breastfeeding, and method of urine collection).  Some studies, for example, include premature infants, as they are less likely to be circumcised. However, their status as a premature infant itself may be a risk factor for UTIs.  I have also seen allegations on biased (anti-circ) sites that indicate many of the studies included pulling back the uncircumcised child’s foreskin to obtain samples – a method that may itself introduce infection.

Penile Cancer

There is indeed a correlation between decreased penile cancer rates and male circumcision.   However, penile cancer is rare, especially in the developed world (1 new case per 100,000/yr) and it appears to be declining among populations of both circumcised and uncircumcised males.  In addition, although there  appears is a slightly elevated risk in some cases of circumcised males and penile cancer,  in many instances the risk is not statistically significant. Finally, as two of the risk factors of penile cancer are 1.) cancerous HPV cells (which we have discussed at length above), and phimosis, which one would need a foreskin to even have, it is oversimplifying to state that circumcision prevents penile cancer.

Official Recommendations:

So what do the health organizations recommend?Anti-circumcision advocates often state that no health organization in the world recommends it.   This is partially true. The World Health Organization (WHO) does recommend circumcision in areas of high HIV prevalence to combat the rate of infection, although this is not applicable for American infants.  However, the CDC released a study in 2010 indicating that routine circumcision in American infants can be a cost-saving measure against HIV.  In addition, the American Academy of Pediatrics, while continuing to be ambivalent in its view of circumcision, has changed its language from a ambivalent slightly negative stance:

“At this time, there is insufficient data to recommend routine neonatal circumcision. Although there are potential benefits and risks, the procedure is usually not essential to the child’s well being.”

to an ambivalent, slightly positive stance:

“evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it.”

However, this is most commonly seen as a method to allow for circumcision to be covered by insurance carriers.  

As a summary? I wouldn’t circumcise based on a desire to protect from disease alone. However, there are other factors such as culture, religion, hygiene, and the desire to do it while young to prevent a possible need later, that parents need to weigh. We will discuss those issues (and counterarguments of infant pain and the morality of choice) in later articles.

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4 thoughts on “Controversy: Circumcision- The Cruellest Cut of All?

  1. I was 16 when I first learned about circumcision.

    I was in a child development class and as soon as I had a semi-clear understanding of what circumcision was, I immediately became disgusted at the fact that there were people who would do such things to children. Of course, it only took a couple seconds for it to hit me — the realization that this was done to me. I didn’t want to believe it. I couldn’t imagine that my parents would ever do something so obviously cruel to me, and right after I entered this world, but there was no denying it.

    After that painfully obvious realization my disgust was dwarfed by the most intense anger I have ever felt. I felt violated. As though I had just learned that I was sexually assaulted as a baby. Which literally is what it is, as far as I’m concerned. I’ve never seen circumcision as anything different. I still don’t understand how anyone can.

    As I felt all these feelings, I looked around the classroom. Too my horror no one else seemed to be bothered by this new information and the teacher was casually explaining the topic as though it were any other lesson. It was like something I would see in The Twilight Zone. I have never been so disappointed in people. How could everyone be so blind, I thought? This is how felt before I learned about the functions of the foreskin…

    For two years I thought I might actually be the only one in the world who felt this way. When I was 18 years old I decide to Google ‘circumcision.’ I knew there had to be others who felt this way. The first thing I saw was a video on YouTube of a girl expressing her feelings on the subject. It was relieving.

    And then I saw many other videos like it. Each one I watched made me feel better. After two long years I was finally able to get it off my mind and I was able to find my faith in human kind again. It took me years more before I could even talk about it with a friend. And longer still before I could confront my parents. No one should ever have to go through what men like myself have. And I will continue to fight until this cruel tradition meets its end.

  2. Why is it only in the USA that there seems to be claims of benefit to circumcision. No other non Jewish or non Muslim country routinely circumcises their children. Health statistics of non-circumcised men of Europe and Japan, for example, are better than those of the USA. Your information is dangerous and illogical.
    Amputating healthy erogenous tissue from an infant is as ridiculous and unethical as removing any other part.
    Circumcision began in the US to prevent masturbation, let’s not forget that. There is no reason to continue this human right’s abuse.

  3. I take issue with this because: Condoms prevent diseases, proper care and hygiene prevents infections and religion is often why those “lower” rates are found. Because those who circumcise are most often religious and so they keep to their ONE partner for life meaning that HIV doesn’t spread.
    Japan has a circumcision rate of less than 1% Australia less than 13% and both have better penile cancer rates. The great circumcision task forces efforts to prevent the spread of AIDS both on US soil and in Africa have failed miserably while Europe and Australia and Japan (all non-circumcising nations) have NOT seen significant increase and the Cancer council of Australia has publicly come out and stated that circumcision is NOT a cancer preventative measure and their are vaccinations available to prevent HPV. to top it off the Australian and Danish health boards recommend against circumcision as unnecessary but ultimately leave the decision to the parents. As for the hygiene argument- my husband and sons are not circumcised neither was either grandparent and we’ve not seen one UTI, Had no infections and NO it DOESN’T smell horrible either. sorry your willy is only clean if you wash it. To anyone NOT from the US or Israel Circumcision is a cruel and unusual way to welcome your new baby into the world. brought about by fear

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