Circumcision Decision: Weighing the Risks and Benefits

Male circumcision reduces HIV, cervical cancer, syphilis, and chlamydia. Is it time to reconsider its merits?

From the WebMD Archives

If there was a cheap, safe, one-dose vaccine that gave your newborn boy significant lifelong protection against AIDS and other sexually transmitted diseases, as well as protection against cancer and various annoying infections, would you get it for him? Well, there is one. It’s called neonatal circumcision.

In studies published in the past decade, the removal of the foreskin provided a 50% reduction in HIV transmission, a threefold reduction in human papillomavirus (HPV) infections in female partners of circumcised men (HPV can cause cervical cancer), and lower rates of syphilis and chlamydia, which causes sterility and is the main sexually transmitted disease among teenagers. Circumcised infants were also roughly 10 times less likely to suffer urinary tract infections and the high fevers associated with them. And circumcision virtually eliminates serious penile cancers, which invade about 1 in 100,000 uncircumcised men.

The evidence from Africa of circumcision’s potential role in AIDS prevention led the New York City Health Department in April to begin considering outreach programs to promote circumcision among gay adult men and drug addicts.

My unscientific justifications for circumcision

I didn’t know about any of this in 1996 when my son, Ike, was born, but I sure as hell wasn’t going to have any son of mine sporting a flesh hood over his ding-dong. Since I’m half of a mixed-faith marriage, the decision to circumcise wasn’t without controversy.

My wife’s golden California family, God bless them, aren’t remotely in favor of character-building suffering, whether Biblical or the not. My sister-in-law, a family practitioner whose wisdom in things medical (and other things) is deep, felt the cut wasn’t necessary. My wife, Margaret, was uncomfortable with the idea of inflicting pain on her newborn firstborn.

I, however, was as inflexible as a nose ring. Ike was going under the knife. For a cultural, non-practicing Jew such as myself, circumcision was one of the only ways I had of proclaiming the tribal allegiance of me and mine. Sound primitive? Well, yeah.

When the time came, Margaret tearfully abandoned the operating theater. Dr. Blank, our obstetrician-cum-mohel, stretched the foreskin with a pair of clamps and deftly snipped with the aplomb of a man about to enjoy a fine Cuban cigar. Ike screamed and flailed his arms for five seconds, then fell soundly asleep. That was it.

Continued

The ancient Egyptians were the first to circumcise because sand under the foreskin was itchy and caused infections. The Jews and Muslims incorporated the practice as a ritual mainstay, and it spread through the United States a century ago because, along with other reasons, reformers thought it would prevent masturbation.

Over the past couple of decades, circumcision has come under growing scrutiny in the U.S. because it’s obviously painful and is perceived by some as a form of mutilation. Since the dawn of the Dr. Spock age, when people began to agree that it’s a good thing to diminish kids’ pain, circumcision has come to be portrayed as a pointless bloodletting ritual, like something commemorated on the wall of a Mayan temple. A plethora of passionately anti-circumcision web sites proclaim things such as, “Bring your boy home whole!”

Oddly, the opposition to circumcision on grounds of preventing suffering has been growing in tandem with scientific evidence of how much lasting suffering the procedure can prevent.

If my son lost anything in the procedure other than a few grams of flap (one 1997 study did link circumcision with later fear of vaccinations), I don’t know what it would be. As I recall, Dr. Blank didn’t even use an anesthetic, which has since become the norm. Applying a numbing agent makes the operation completely painless.

“Before they screamed for a little while,” says Edgar Schoen, MD, a leading proponent of circumcision who was chief of pediatrics at Kaiser-Permanente Healthcare for 24 years. “Now they sleep through it.”

Does circumcision affect sexual pleasure?

Some foes of circumcision claim that it diminishes sexual pleasure. That’s impossible to disprove, since a clipped boy will never know what it would have felt like to have a foreskin. But it seems bogus. Are two-thirds of us missing the joy of sex? I think not. Surveys of men circumcised as adults found no difference in their sex lives.

And yet, it appears that fewer U.S. parents are having their boys circumcised. In 16 states, Medicaid won’t pay for circumcision, and the most recent federal data show that the number of boys circumcised at birth fell from 65 to 55 percent between 1993 and 2003. Schoen believes these data, based on incomplete hospital records, undercount circumcisions.

The Medicaid coverage and other challenges to circumcision can be attributed at least in part to the American Academy of Pediatrics’ (AAP) stance in a 1999 position paper that says despite “potential medical benefits” the data were “not sufficient to recommend routine neonatal circumcision.”

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Circumcision and HIV

Schoen and others, such as Harvard medical anthropologist Daniel Halperin, PhD, say the evidence that circumcision prevents HIV transmission has been solid since the late 1980s. But the medical community has been skeptical until recently, and the most convincing studies emerged after the AAP statement.

Early this year, three trials in which Kenyan and Ugandan men were randomly selected to receive circumcision were halted when it became clear that circumcision helped prevent transmission of HIV. Men who got it were about half as likely to get infected. “A 50% reduction is about the same as some vaccines,” says Schoen. Final vindication came in March of this year when the United Nations World Health Organization announced that male circumcision should be added to the list of interventions that can help prevent the disease.

It appears that circumcision helps fight AIDS because the foreskin is particularly susceptible to attack by HIV. It often develops cracks or tears that can be infected by viruses. And diseases such as syphilis and chancroid, a bacterial infection more common in uncircumcised men, can provide a gateway for HIV.

The AAP is now finalizing a new statement on circumcision and expects to release it in 2008 or 2009.

Is circumcision dangerous? Not very

To be sure, there are some risks to circumcision. About 1 in 100 infants suffer brief bleeding or infections, but these are easy to fix. Serious mistakes, like cutting the shaft of the penis, occur rarely; death occurs about once in 500,000 circumcisions, making it the safest of surgeries.

Still, circumcision opponents are easy to find on innocuous sounding web sites like circumcision.org. Their arguments, which carried more weight before the benefits of circumcision came into focus, “range from psychological to religious to emotional,” says Schoen. He’s been threatened with death by anti-circumcision groups and his talks on the subject are often picketed.

About 7% of males who aren’t circumcised as newborns end up needing to have the procedure done later because of infections or painful adhesions of the foreskin to the head of the penis.

The choice, as they say, is yours.

WebMD Feature Reviewed by Sheldon Marks, MD on April 01, 2007

Sources

SOURCES: Edgard Schoen, MD, Kaiser Permanente. Daniel Halperin, PhD, Harvard Unviersity School of Public Health. Gollaher, D. Circumcision: A History of the World’s Most Controversial Surgery, Basic Books, 2005. Schoen, E. Ed Schoen, MD on Circumcision, RDR Books, 2005. American Academy of Pediatrics Task Force on Circumcision, Pediatrics, March 1999; vol 103(30): pp 683-689. New York Times: “New York City Considers Push to Circumcision.”

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