To Circumcise or Not To Circumcise?

Once a proverbial given in this and a number of other countries, circumcision has become a hot button issue, intensely debated in both family and medical circles. For decades it was standard procedure for hospital births, but the numbers are quickly declining. Today, 56% of newborn boys are circumcised, although the rate varies considerably by geographic region in the U.S. In 1999, the American Pediatric Association revised their statement on circumcision to acknowledge the “potential medical benefits” of the procedure but concluded “these data are not sufficient to recommend routine neonatal circumcision.” Most of Canada has “de-listed” circumcision as a necessary (i.e. paid for) procedure.

In truth, the decision to circumcise isn’t purely medical even as it becomes increasingly controversial. Intangible aspects play as much or more of a role in parents’ choice as scientific research. For some families, circumcision is an age-old rite celebrating religious covenant. For others, it’s a venerated custom that manifests cultural identity. Families who aren’t influenced by religious or cultural values might choose circumcision for social or aesthetic reasons in an effort to allow junior to look like the other boys at school or like the father. However, other families and experts argue that the practice is a painful, unnecessary procedure that violates the physical dignity and even legal rights of the child.

The history of circumcision is imprecise, but the practice is thought to have its roots in the Middle East. Experts suggest a number of potential reasons behind the initial practice of circumcision, including figurative sacrifice, virility ritual, and cultural hygienic custom. In many tribal societies, circumcision was observed as a cultural rite of passage into manhood. Although circumcision predates religious directive, it eventually became a sacred practice in the early Jewish faith and for the followers of Islam. At various times in history, circumcision was also used to designate social status as well as religious identity. On an odder note, Western societies, particularly in the 19th and early 20th centuries, practiced circumcision to discourage masturbation. In these same centuries, the issue also became medicalized around tenets of basic hygiene. In the late 19th and 20th centuries, the rate of newborn circumcision increased as hospital births rose and the public accepted the medical argument for standard circumcision.

For our part, let’s delve into the medical side.

These days, one of the most commonly cited health reasons for routine circumcision is decreased STD risk. Numerous studies based in Africa show that circumcision reduces the risk of heterosexual HIV contraction by 50-60%. In response the assembled research, the World Health Organization/United Nations Joint Programme on HIV/AIDS issued their official recommendation of circumcision as one method to prevent the spread of HIV. Critics caution that the “context” of the African epidemic, which is as high as 25% of the population in some areas, is so different from the disease rate (as well as cultural and hygienic practices ) in the West that the protective factor of circumcision isn’t nearly as high in Western countries. Some experts estimate a 10% risk reduction in Western societies (PDF). Other Western-based research demonstrates reduced risk for other sexually transmitted disease like genital herpes and HPV as well as a decrease in bacterial vaginosis risk for female partners of circumcised men. Research exploring the impact of circumcision on infection reduction in homosexual men has been more limited but so far shows a mixed picture of protective influence. A review published this month indicates that circumcision appears to reduce risk in primarily “insertive” rather than receptive partners.

The physiological logic behind circumcision’s reduced infection risk involves the bacterial ecology of the inner foreskin itself, which harbors anaerobic bacteria that appears to fuel inflammation and infection. The inner foreskin is home to the highest concentration of so-called Langerhans’ cells, which facilitate HIV transmission and replication.

A less dangerous but more common problem for uncircumcised males, particularly boys, is recurrent urinary tract infection. Circumcision is considered a standard treatment option for those with recurring UTI or serious complications from an initial case of UTI. Some experts have questioned the usefulness and cost efficiency of routine circumcisions to prevent infections in a relatively small number of boys. According to a British study, 111 routine circumcisions must be performed to prevent a single UTI. However, other experts suggest that there’s more at stake than simple urinary infection risk. Another study found that 18% of young boys in the study who had UTI showed signs of kidney scarring. Follow-up circumcision in these boys substantially reduced subsequent UTI occurrence. As a research commentator noted (PDF) in light of this picture, “[I]f the circumcision had been done in the newborn period would the kidneys have been protected from damage in the first instance?”

In response to these infection-related findings, critics of the procedure counter that diligent safe sex and hygienic measures more reliably protect both the man and his partner from infection. Opponents say that circumcision (or at least the public message about its lower infection risk) can give men an inflated sense of protection against life-threatening diseases and discourage use of condoms, testing and other safe sex methods. Nonetheless, many physicians and public health experts maintain that circumcision is a practical strategy for reducing disease in males and their respective partners.

As for the other physical conditions circumcision is meant to prevent, many experts say that the evidence just doesn’t support the need for routine circumcision in every boy. The nonretractable foreskin in childhood is often a misdiagnosis, since separation of the glans happens over time (a protective feature) and may not even be noticeable until puberty. Common infections can be treated with a plethora of modern medications like antibiotics and steroid creams. As for penile cancer, the risk is so low (approximately 9-10 per million men) that circumcision choice shouldn’t be based on this concern.

Then there are the medical complications. They can be everywhere from aesthetic-based to functionally impairing. Infection rates hover close to five percent. Significant narrowing of the urethra occurs in anywhere from 5-10% of circumcisions and must be addressed with follow up treatment. Injury to the urethra can occur. The least common but most dramatic complications include partial to full penile amputation or even the rare death from serious infection.

On a considerably lighter note, critics also suggest that circumcision compromises sexual pleasure. They argue that the foreskin, as host to a dense network of nerves, is a functional erogenous zone in itself.

Although it’s likely impossible to reach any definitive conclusions regarding the issue, self-report research on men who are circumcised in adulthood show mixed results. In one such study, the majority of men did not experience a decrease in libido or pleasure. Eighty-two percent reported the same (44%) or enhanced (38%) penile sensitivity. A smaller study (PDF), however, recorded patients’ written comments about the impact of the procedure on their sex life and calculated that nearly half of respondents experienced less penile sensitivity after circumcision.

Now that we’ve laid out some of the arguments and medical research, we want to hear what you have to say. What is your thinking on the subject, and what factors have or would influence your choice to circumcise or not circumcise? Thanks for reading and contributing.



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