[This is an entry to the 2019 Adversarial Collaboration Contest by Joel P and Missingno]

“They practise circumcision for cleanliness’ sake; for they would rather be clean than more becoming.” – Herodotus, The Histories – 2.37

The debate over circumcision in the Western world today is surprisingly similar to the conflict that Greeks and Egyptians faced 2500 years ago. Supporters tend to emphasize its hygiene and health benefits; opponents tend to call it cruel or to emphasize its deviation from the natural human form. In this adversarial collaboration we address medical aspects, sensitivity and pleasure, and ethical aspects of infant circumcision.

Effect on penile cancer

Circumcision greatly reduces the relative rate of penile cancer, a relatively uncommon malignancy in developed nations which kills a little over 400 American men each year. Denmark, while it has one of the lowest rates of penile cancer for a non-circumcising country, nevertheless has 10x the rate of penile cancer as Israel – where almost all men are circumcised. Likewise, a Kaiser Permanente study of patients with penile cancer found that 16% of patients with carcinoma in situ had been circumcised; only 2% of patients with invasive penile cancer had been circumcised. Since the circumcision rate of Kaiser patients of the appropriate age was ~50%, this is in line with the 90% reduction.

While these are observational rather than prospective trials, the magnitude of the reduction is quite high. It is unlikely to be simply due to class or race given that it exists when comparing countries and when comparing individuals within the same health care system. Additionally, there is some association of penile cancer with HPV and a very strong association with phimosis, and circumcision reduces the rate of both of these. This provides a highly plausible theoretical explanation of how circumcision might lead to this risk reduction in penile cancer. However, this does raise the question of whether more aggressive future treatment of phimosis combined with HPV vaccination might reduce the rate of penile cancer in uncircumcised men in the future somewhat. Of course, more aggressive treatment of phimosis would require more childhood circumcisions, which carry higher risk than infant circumcision.

Effect on transmission of HIV and STDs

HIV: Three large randomized control trials have been performed in South Africa, Uganda, and Kenya, together comprising over 11,000 men. These men were randomized to be circumcised or not at the start of the studies for primary HIV prevention. The reduction in female to male HIV transmission seen in these studies is about 50%. This is consistent with observational studies and is the highest quality evidence: three independent, large-scale randomized control trials with similar results scrutinized by the Cochrane Collaboration. The studies were terminated early due to positive results, which is appropriate ethical practice, but which can tend to overestimate positive effects. However, the data is consistent with observational data so this is less likely a concern. Some have expressed the concern that the two groups did not receive identical HIV counseling.

It is true that the circumcision group felt much more comfortable having sex without condoms, and additional counseling was given to the circumcision group to tell them this was not adequate protection. Condom use was, despite the counseling, lower in the circumcision group than in the control. In one sense this means that the protective benefits of circumcision vs HIV may be understated. In another sense, this creates a large concern with advertising circumcision for the stated purpose of HIV prevention. Any such efforts must be careful not to oversell the benefits and thereby reduce condom usage. Additionally, the results are only applicable to heterosexual HIV transmission. Homosexual transmission has not been shown to be decreased by circumcision, presumably because of the extremely high risk of receptive anal sex. IV drug related transmission is almost certainly unaffected except via “herd immunity”.

The data for other STIs is far less compelling than for HIV. Secondary endpoints of the African HIV studies were other STIs, and rates of HPV and HSV were reduced by circumcision. This was only a secondary outcome, however, and other studies have had mixed results. The data for lower rates of bacterial vaginosis and trichomonas in female partners of circumcised men is somewhat stronger. However, none of these benefits are nearly as strongly supported or as high impact as the HIV reduction. Additionally, when considering the benefits and harms of an intervention such as circumcision, there are strong reasons not to consider the benefits that accrue to the patient’s future partners, but instead to focus only on the individual in question.

It is ironic that the evidence for reduction in other STIs is fairly weak, because as historian David Gollaher shows in Circumcision: A History of the World’s Most Controversial Surgery, this is the primary reason the US adopted widespread circumcision in the early 20th century. There had been very small-scale interest in circumcision due to religious ideas about masturbation and ideas about balanitis and phimosis causing systemic illness, but these ideas do not appear to have motivated a large number of circumcisions. Mainstream circumcision of healthy males caught on as a way to reduce STI rates – particularly syphilis. Physicians both in the US and UK saw the far lower rates of STIs Jews experienced than gentiles and attributed these primarily to circumcision. In the US, the time was just right for such STI reduction efforts – worries about infection were widespread and an increasing number of people were adopting hospital births where there was ready access to a physician able to perform a circumcision.

Meanwhile, during WWI and WWII the military offered circumcision to many conscripts to protect vs STIs (the wealthier officer class already having a much higher circumcision rate than the enlisted men as more of their parents could afford hospital births). The UK’s experience of WWI and WWII was quite different from the US’s. For one thing, STIs ranked far lower on the set of risks to soldiers. And rather than seeing a boom in hospital births, the UK’s medical resources were strained during WWI and WWII. Circumcision was seen as something of a waste compared to the UK’s more pressing needs. Presumably, arguments that positively presented Jews as having low STI rates did not catch on in early 20th century mainland Europe to nearly the extent that was seen in the US and UK.

Effect on UTIs

In the first year of life, the rate of UTIs is approximately 1% per year among uncircumcised boys and 0.1%-0.2% among circumcised boys. Particularly in the first year of life, UTIs can be severe, causing fever and hospitalization, as well as permanent kidney damage. Circumcision is presumably protective against UTI primarily by reducing the bacterial load around the urethra. Some sources have suggested that the difference is primarily one of contamination during sampling. However, studies looking only at clean catch urine samples or suprapubic tap samples give similar reductions (90%). Unlike many of the other benefits listed above, UTI avoidance is specifically a benefit of infant circumcision.

Effect on Penile Problems

Many penile problems such as balanitis (inflammation of the glans), pathologic phimosis (inability to retract the foreskin), and paraphimosis (foreskin entrapment, which requires emergency treatment to preserve the penis) are prevented by circumcision. Others, including meatal stenosis, scarring, bleeding are caused by circumcision. A New Zealand cohort study directly comparing the incidence of penile problems requiring intervention found a rate of 1.1% in circumcised children and 1.8% in uncircumcised children when followed to age 8.

Risks of surgery

The risks of surgery include pain, bleeding, bruising, inadequate foreskin removal, excess skin removal, swelling, meatal stenosis, scarring, infection, and anesthetic complications. These are different based on age group; neonatal circumcision is associated with a much lower risk of complications than other age groups. However, studies show a wide range of rates of complications dependent on practitioner training level. Overall, the rate of minor complications (bleeding, bruising) is ~1.5% worldwide and the rate of major complications (scar, severe infection, meatal stenosis, or need for additional surgery) is <0.2%. In comparison, the risk of complications in children past infancy and adults is approximately 6% with trained practitioners – significantly higher than for infant circumcision. Indeed, the majority of cases of the most severe complication (penectomy) related to circumcision appear to occur in people who were not circumcised as infants. This would include both adults with penile cancer as well as children undergoing phimosis surgery (as in the infamous case of David Reimer).

Sensitivity and Sexual satisfaction

There is a highly plausible mechanism by which circumcision could reduce sexual sensitivity: the foreskin is highly innervated (20,000 nerve endings is often repeated, but this appears to be a case of citogenesis and is likely far too high), produces lubrication for the penis, and is sensitive to light touch. Several studies demonstrate that the foreskin is more sensitive to certain forms of nonsexual stimulation than other parts of the penis. The glans itself does not change in sensitivity from circumcision.

Sexual satisfaction, particularly in sexually active heterosexual men, seems to be unchanged with adult circumcision. During studies of adult circumcision for HIV prevention, in which large numbers of men were randomized to receive circumcision at the time of the study or after, sexual satisfaction of did not significantly differ between the two groups. On the other hand, a South Korean study of men circumcised as adults (as has become traditional there) found decreased pleasure from masturbation after circumcision. It is certainly possible that both these things are true – that masturbation is impaired by adult circumcision while intercourse is not. It is also possible that the Korean study (retrospective, smaller than the African studies, and with much higher rates of scarring than are observed in the US) was unrepresentative. There are two European studies which are frequently cited: cohort studies look at circumcised and uncircumcised men in Denmark and Belgium. However, circumcision is quite rare in these countries, and the majority of the circumcisions in the study groups were performed to correct problems such as phimosis. They are thus comparing men who had penile problems requiring surgical correction to men who did not; it is therefore unclear why they are frequently cited in discussions of elective circumcision.

No available studies actually measure sensitivity to sexual stimulation, which is of course an important topic – but one requiring consummate professionalism on the part of the researcher. We are left waiting for such a study, but in the meantime may reasonably fear that there is some decrease in at least masturbatory pleasure due to circumcision even though the evidence for this is weak. The evidence does not support any change in sexual pleasure otherwise.

Infant circumcision may be different than adult circumcision, in addition. If circumcision eliminates important nerves, due to brain plasticity infants are likely better able than adults to reassign the portions of the brain processing the foreskin to other areas of the penis. A large survey of circumcised and uncircumcised men in the US (where infant circumcision is the most common) found similar sensation in circumcised and uncircumcised men. The uncircumcised men appear to have had slightly higher incidences of sexual dysfunction. Also of interest, circumcised men appear to have an easier time obtaining oral sex, which may relate to subtle aspects of class or may have to do with the perceived cleanliness of circumcised penis.

Ethics

The ethics of infant circumcision is a complex topic, and the answers likely depend on one’s ethical system. The benefits of infant circumcision appear to outweigh the risks and harms. Additionally, it is safer to be circumcised as an infant than as an adult, and a significant portion of the benefits of circumcision accrue to infants and children. From a strictly utilitarian perspective, infant circumcision should therefore be encouraged – whether we consider society as a whole or only the boy in question. However, autonomy is an important value, and while a man can become circumcised (missing only some of the benefits of having been circumcised as an infant), it is impossible to effectively restore the foreskin and become “de-circumcised”. An ethical system that heavily values personal choice over cost-benefit analysis may reasonably reject circumcision – especially one that rejects currently-widespread societal assumptions about parents making medical decisions for their children. Furthermore, many of the benefits of circumcision accrue only to men who have sex with women. For men who exclusively have sex with men and for men who do not have sex, the benefits and risks are close to equipose. There is a moral concern with performing a procedure that can thus tend to reinforce heteronormativity and sex-normativity.