Robert S. Van Howe

Nat Clin Pract Urol. 2009;6(2):74-75. ©2009 Nature Publishing Group
Posted 03/26/2009

Clinical benefit is only one facet of clinical decision making; medical risks and financial costs also need to be considered. For example, many of the benefits espoused by advocates of circumcision would be more effectively achieved by penectomy, which has the additional benefit of preventing unwanted pregnancies. Of course, penectomy is too invasive, and is not a practical solution. Many of the “clinical benefits” lauded by advocates of circumcision include reduced risk of phimosis, balanitis, urinary tract infections (UTIs), genital cancer and sexually transmitted infections (STIs); however, evidence for these benefits are weak or nonexistent, and several alternatives to circumcision are available that are more effective, less invasive, and less expensive.

Phimosis is as common in circumcised newborns as it is in boys who are not circumcised. Topical steroids are effective in approximately 85% of patients,[1] and could eliminate the need for newborn circumcision to avoid phimosis. Balanitis is more common in circumcised than uncircumcised boys under age 3 years, but may be more common in uncircumcised older boys. The only published adult study of balanitis showed that a referral bias occurred among circumcised men: the control group had a 47.8% circumcision rate,[2] but the participants were from the UK, where the circumcision rate is around 21%. Balanitis can typically be treated with topical antimicrobials.

Newborn boys are more likely to have urinary tract abnormalities compared with girls, particularly in the first 6 months of life; however, many boys later outgrow these abnormalities. Observational studies have found that uncircumcised boys are at increased risk of UTIs during the first 6 months, but this finding might be a result of differential rates of prematurity, urine collection, false-positive urine specimens, and the frequency at which health care is sought.[3] In the absence of anatomic defects, UTIs do not require surgery and can be treated with oral antibiotics. The risk of UTI resulting in chronic renal disease is remote.

Of the 16 studies that assessed whether an association exists between circumcision status and the risk of cervical cancer in female partners, only 1 study found a significant association: a positive association in 1 study out of 16 studies is what would be expected by chance alone. Furthermore, a newly available vaccine against human papillomavirus (HPV) could prevent most cases of cervical cancer. With regard to a reduced prostate cancer risk after circumcision, the medical evidence that supports this association is weak.[4] The incidence of penile cancer is rare (0.8 cases per 100,000); two case–control studies in the US found that, when adjusted for phimosis, newborn circumcision was not associated with penile cancer.[5,6] The association between phimosis and penile cancer might explain why only half of patients with penile cancers are positive for HPV DNA, whereas nearly all patients with cervical cancer have HPV DNA. The other half of patients with penile cancer are probably associated with balanitis xerotica obliterans, the leading cause of true phimosis. Countries with very low circumcision rates, such as Japan, Norway, Finland and Denmark, have a lower age-adjusted incidence of penile cancer than the US. Low-risk sexual practices combined with screening and treatment of HPV infection and phimosis may be more effective and less invasive than universal circumcision.

The effect of circumcision on STIs is varied. Circumcision status has no consistent association with herpes simplex virus 2, HPV, gonorrhea, or chlamydia.[7-9] Men who are not circumcised, particularly in Africa, are at a slightly greater risk of syphilis and genital ulcerative disease, but have a lower risk of genital discharge syndrome compared with circumcised men.[7-9] As genital discharge syndrome is more common than genital ulcers, the overall rate of STIs is greater in circumcised men. STIs can be prevented and/or treated more effectively, less invasively, and less expensively with condoms and antibiotics than with circumcision.

Randomized controlled trials in Africa have shown some efficacy for circumcision in preventing HIV infection; however, these trials have bias for both participants and researchers (e.g. selection, lead time, expectation, attrition, intervention and length), improper randomization and early study termination, which amplified the lead-time bias. Each type of bias contributed towards overestimating the treatment effect. Advocates for circumcision believe that data from these randomized controlled trials, which recruited motivated, self-selected, well-compensated, high-risk adults, can be extrapolated to the general population in Africa and to infants; however, no studies have shown an association between HIV and neonatal circumcision. On the contrary, in a study of 52,143 heterosexual men attending a sexual health clinic, circumcised men had a greater risk of HIV infection than uncircumcised men.[10] Among developed nations, the US has the highest rates of heterosexually transmitted HIV and newborn circumcision. Condoms, when used consistently, provide 99% protection. HIV infections can also be prevented by choosing sexual partners responsibly and by treating STIs. For the cost of every circumcision performed in Africa, 3,500 condoms can be purchased. As condoms can provide nearly complete protection from HIV infection, circumcision adds little value.

Circumcision removes a complex, pentilaminar, specialized, junctional structure that contains nearly all the penis’ fine-touch neuroreceptors. Not surprisingly, the foreskin is the most sensitive portion of the penis. Circumcision can reduce the sensitivity of the glans to fine-touch and vibration.[11,12] No wonder adults who undergo circumcision report less-satisfying sex, reduced sensitivity and erectile function, difficulty with intromission, and increased premature ejaculation.[13] Other commonly reported complications of circumcision include infection (1–3%), excessive bleeding (1–9%), meatitis (20%), meatal stenosis (5–8%), subcutaneous granuloma (5%), balanitis (16%), coronal adhesions (30%), skin bridges (2%), and phimosis (1–2%). Parents also request a repeat circumcision for cosmetic reasons in 2% of cases. Furthermore, circumcised newborn boys are 12 times more likely to acquire community-associated methicillin-resistant Staphylococcus aureus infections than uncircumcised newborns.[14] Other less-common complications of circumcision include septicemia, meningitis, Fournier gangrene, staphylococcal scalded skin syndrome, osteomyelitis, septic arthritis, tetanus, herpes simplex infection, empyema, pubic hair strangulation, denudation of the penis, glans amputation, urethral fistula, penile edema, pyogenic granulomas, acute urinary retention with acute renal failure, ruptured bladder, UTI or urine advancing in subcutaneous fascial plains, penile ischemia, pneumothorax, pseudoparaphimosis, pulmonary embolism, unilateral leg cyanosis, gastric rupture, myocardial injury and erythema multiforme.

Circumcision has no medical indication during the newborn period, and it is not the first-line preventive for any illness. Very few adult men choose to be circumcised, full disclosure is a rarity, and parental proxy consent for newborn circumcision is not valid.[15] No reason exists that can justify why circumcision cannot wait until the infant is old enough to choose for himself. As a public health measure, newborn circumcision in the US has failed to show a benefit in protecting against cervical cancer, penile cancer, STIs, and HIV.

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References
Ashfield JE et al. (2003) Treatment of phimosis with topical steroids in 194 children. J Urol 169: 1106–1108
Mallon E et al. (2000) Circumcision and genital dermatoses. Arch Dermatol 136: 350–354
Van Howe RS (2005) Effect of confounding in the association between circumcision status and urinary tract infection. J Infect 51: 59–68
Van Howe RS (2007) Case number and the financial impact of circumcision in reducing prostate cancer. BJU Int 100: 1193–1194
Daling JR et al. (2005) Penile cancer: importance of circumcision, human papillomavirus and smoking in in situ and invasive disease. Int J Cancer 116: 606–616
Tseng HF et al. (2001) Risk factors for penile cancer: results of a population-based case–control study in Los Angeles County (United States). Cancer Causes Control 12: 267–277
Weiss HA et al. (2006) Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect 82: 101–109
Van Howe RS (2007) Genital ulcerative disease and sexually transmitted urethritis and circumcision: a meta-analysis. Int J STD AIDS 18: 799–809
Van Howe RS (2007) Human papillomavirus and circumcision: a meta-analysis. J Infect 54: 490–496
Mor Z et al. (2007) Declining rates in male circumcision amidst increasing evidence of its public health benefit. PLoS ONE 2: e861
Sorrells ML et al. (2007) Fine-touch pressure thresholds in the adult penis. BJU Int 99: 864–869
Yang DM et al. (2008) Circumcision affects glans penis vibration perception threshold [Chinese]. Zhonghua Nan Ke Xue 14: 328–330
Fink KS et al. (2002) Adult circumcision outcomes study: effect on erectile function, penile sensitivity, sexual activity and satisfaction. J Urol 167: 2113–2116
Nguyen DM et al. (2007) Risk factors for neonatal methicillin-resistant Staphylococcus aureus infection in a well-infant nursery. Infect Control Hosp Epidemiol 28: 406–411
Svoboda JS et al. (2000) Informed consent for neonatal circumcision: an ethical and legal conundrum. J Contemp Health Law Policy 17: 61–133

Reprint Address

Department of Pediatrics and Human Development Michigan State University College of Human Medicine, 1414 West Fair Avenue Suite 226, Marquette, MI 49855, USA; E-mail: rsvanhowe@mgh.org

Robert S. Van Howe, Clinical Professor in the Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, Marquette, MI, USA.

Disclosure: The author declared no competing interests.

From a female perspective, the science is pretty clear that a circumcised partner offers considerable health advantages to the woman, to say nothing of the man. All of which argues for mandatory male circumcision as a public health measure.

It has always seemed obvious to me that cutting the genitals of a healthy child, whether male or female, is unjustified and cruel. Male circumcision among white non-Jews began as a way to stop Victorian boys from masturbating. It was also perfectly ineffective. (Did any age masturbate more than the Victorian?)

In time, the British abandoned circumcision, but we did not. Instead, as Americans often do, we came up with cheap, incoherent rationalizations to keep right on doing exactly what we’d “always” been doing.

Today we generally don’t see masturbation as evil. If anything, masturbation is a healthy outlet for the male sexual appetite. This appetite clearly wasn’t designed for today’s world, and it participates only sporadically in what we think of as civilized life. Masturbation tames men, and perhaps women too, and thank goodness for it.

So instead of stopping men from masturbating, today we hear that circumcision makes women more willing to perform oral sex. Today circumcision isn’t anti-sex; it’s pro-sex. A striking turnabout; it would be wicked fun to take back to the Victorians. “More willing to what?” they’d ask. “Well, no son of mine is going to be circumcised!”

Perhaps empirically speaking, being cut does mean getting more oral sex. But this will last only as long as women keep up what amounts to chauvinism against the male body: Women’s genitals are perfect the way Nature made them. Men’s, however, are filthy, at least until they are mutilated, after which they’re just fine.

Uh. Yeah. But getting head from women isn’t, from what I understand, a serious problem for European men, virtually none of whom are circumcised. Men don’t demand a similar procedure of women — only that they wash, which seems reasonable enough for both. Washing seems, suspiciously, to work everywhere but in America.

We further hear that if a child isn’t circumcised, he will wonder if something is wrong with his anatomy, because all of his friends and even his father will have been cut. This however is decreasingly true. As I understand it, only about 50% of American boys are cut these days, and the number continues to decline.

Must we worry, now, about all of our boys, cut and uncut, because every single child is going to grow up in a world of discordant penis types? Will every single boy now be subject to this soul-crushing and nigh-insurmountable psychological trauma? Please. The fear that your child may see a child who looks different simply isn’t a rational fear. Nor, if it were, could we possibly guard against it. Everyone’s different these days.

Look closely: This is what a taboo looks like. It’s a familiar, domesticated taboo, not some alien Polynesian thing about how women aren’t allowed to eat bananas. It makes sense, apparently, until that moment at which it stops making any sense whatsoever: Here we see how a very unreasonable thing is defended by a colossally unreasonable thing, and then the debate is over. Taboo.

And of course there’s the recent claim that circumcision helps reduce the spread of HIV — perhaps as much as 60% (but perhaps not). The experiments have been tried in Africa, where circumcision is now being aggressively promoted, not only on adults, but on children down to age four. (This, one would think, would be a bit bigger trauma than seeing a child whose penis looks different.)

It is always interesting to watch this claim get trotted out, particularly by American conservatives — the very people who might otherwise insist on the fact that condoms sometimes fail, and that, for this reason, we shouldn’t be pro-condom. Condoms, if used consistently, are far better than circumcision at preventing the spread of HIV.

So, for that matter, is abstinence, if you are one of the rare people who can do it. Or try limiting yourself to fewer sex partners — say, one — or just do low-risk sexual activities. Any of these choices would do vastly more to prevent AIDS. Recommending circumcision makes no sense at all here, particularly when we consider the likelihood that, in African nations’ rudimentary health systems, it will cause both infections and a false sense of security.

If a man wants to be circumcised, let him get it done as an adult. Yes, this absolutely means that fewer men will be circumcised. But we beg the whole question if we assume that we should circumcise infant boys because it will be more painful to do it later. If he’s not going to want it later, then it shouldn’t be done at any time, sooner or later.

In all, there is a very strong libertarian case against circumcision, even when done for religious reasons. It’s an attack on bodily integrity; it’s usually done without consent; it can’t be adequately reversed. We don’t typically let religions do these kinds of things, do we? And if it were any other optional bodily modification, we’d immediately bring out some very cogent arguments: Ear piercings? Save that for adults, who can decide for themselves! But that logic is rarely applied to circumcision.

So… Now you know what camp I’m in. If you’ve read very much by me, you know that these longer posts often take a hairpin turn. Here it comes.

I have to tell you that I think protesting circumcision in front of the White House is just plain stupid. It betrays a really warped sense of how, for want of a better word, to care for a culture. The president isn’t going to save us on this one, nor should he. Nor would I welcome it if he could. We ought to resist becoming that kind of society.

This isn’t an issue that can be won or lost with legislation. It goes deeper than that. It’s about attitudes and values. It could just be the ultimate issue in the great debate between rationalism and tradition. And tradition still runs strong. Legislation is probably doomed to fail, no matter where the reasoning leads us. That’s how politics works. Or rather, how it often doesn’t. Prohibiting something that 50% of American parents are already doing is a non-starter. Change minds first. Yes, it will be difficult. But reducing the amount of cruelty in the world always is.

The HIV research found that the cut men were MORE likely to infect their partners.

HPV has a vaccine now. What other maladies cited to justify an infant’s mutilation will be non-issues by the time he’s old enough to make HIS OWN rational choice.

There’s no emergency here. Infants don’t have sex. The studies are far from conclusive, hence the rebuttal in the British Journal of Urology.

Trust YOUR SON to weigh the evidence available when it’s relevant to him, rather than forcing risky irreversible pleasure-reducing cosmetic penile reduction on him now. 95% of the non-Muslm world does not circumcise. No national medical association on earth (not even Israel’s) endorses routine circumcision. Foreskin feels REALLY good. HIS body HIS decision.

2) These latest studies are from Africa. A 29 year study of males in New Zealand showed a slightly *higher* rate of STI’s among circumcised men:
http://www.jpeds.com/article/S0022-3476(07)00707-X/abstract

3) If we found out that cutting off part of a girl’s genitals reduced her risk of contracting an STI, would that make it acceptable?
This study shows exactly that: http://www.ias-2005.org/planner/Abstracts.aspx?AID=3138

If female circumcision had caught on in the USA (it was promoted in medical papers till at least 1959, and practised till the early 70’s), and western researchers were now looking for benefits of female circumcision as enthusiastically as they are looking for benefits of male circumcision, we’d now be getting news articles about how female circumcision help prevent STI’s. It wouldn’t mean that there aren’t better ways to prevent STI’s, and it wouldn’t make it right.

News just in last week: A jury in Atlanta has awarded $1.8 million to a boy whose penis was severed in a botched circumcision five years ago. The Fulton County jury also awarded the boy’s mother another $500,000.