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.