Circumcision may be the kindest cut of all

Circumcision (the surgical removal of the foreskin) has been practiced for millennia, often as part of religious rituals. Recent research confirms that from a health standpoint circumcision is a good idea.

There may have been other reasons for circumcision, as well. It is a mark that could distinguish male tribesmen who were circumcised from other tribes whose members decided to not circumcise. It may have been used to help promote an increased degree of hygiene, when water to bathe was in limited supply. It may have been used to mark slaves, or, in other groups, to denote social superiority. Or it may have been done because of some other cultural ritual.

More recently, in the last hundred years or so, circumcision came into vogue for other than religious reasons. It became popular, then briefly fell into disfavor, then began a slow rebound. Today, in the US many men are circumcised, though percentages vary depending on ethnic group. More white males are circumcised, followed by blacks and Hispanics.

Some of the reasons for circumcision other than religion

One key reason for circumcision is to decrease the spread of sexually transmitted infections (STIs, formerly STDs).

Research has shown that circumcised men have a decreased likelihood of becoming infected with a number of STIs. HIV is one. Circumcised heterosexual men have a lower rate of acquiring HIV, based on a few different studies. There also may be a lower risk for men who have sex with men (MSMs) to get HIV, as well. But the evidence is much more equivocal in this case. Additionally, circumcised males get herpes (HSV) and human papilloma virus (HPV) less frequently.

Additionally, circumcision seems to benefit the female partners of these men. Data shows that the female partners had a lower incidence of bacterial vaginosis, human papilloma virus infection and trichomoniasis. In MSMs (men who have sex with men), there is a somewhat decreased risk of HIV transmission when the circumcised male is the partner who penetrates the other partner in couples who have unprotected sex. There doesn’t seem to be a benefit for the receptive partner.

Why is the risk of acquiring HIV decreased in circumcised men?

A possible explanation is that circumcision changes the bacterial types present on the penis. Circumcision causes a decrease in anaerobes (bacteria that grow best in the absence of oxygen). The foreskin also contains denditric cells (in this case Langerhans cells) that can be infected by HIV. And, the increased numbers of bacteria on the penis in the uncircumcised male may lead to recruitment of additional immune cells that could also be infected with HIV.

 An anti-circumcision protester stands in front of the White House in Washington DC on March 30, 2013. Rena Schild / Shutterstock.com

An anti-circumcision protester stands in front of the White House in Washington DC on March 30, 2013. Rena Schild / Shutterstock.com

Another feature is that circumcised men tend to develop fewer genitourinary diseases. Circumcised infants have a lower risk of urinary tract infections. Their risk for meatitis (inflammation of the urinary opening) and balanitis (inflammation of the head of the penis) are both greatly decreased, and phimosis (inability to draw the foreskin back over the head of the penis) is eliminated. The number of cases of cancer of the penis is decreased in circumcised males. As are cases of ulcerations of the penis, which may be caused by viral infections. Similarly, female partners of circumcised men have a lower risk of getting HPV which can cause cancer in women.

Because of the above reasons, and others, the American Academy of Pediatrics (AAP) says that the health benefits of circumcision outweigh the risks:

[A]fter a comprehensive review of the scientific evidence, the American Academy of Pediatrics found the health benefits of newborn male circumcision outweigh the risks, but the benefits are not great enough to recommend universal newborn circumcision. The AAP policy statement published Monday, August 27, says the final decision should still be left to parents to make in the context of their religious, ethical and cultural beliefs.

The AAP lists their reasoning here.

An argument has been made that male circumcision reduces the sensitivity of the head of the penis, since the head is now permanently uncovered. The Journal of the American Medical Association weighs in:

Some who oppose male circumcision cite anecdotal reports that male circumcision can cause sexual dysfunction. The male circumcision trials evaluated sexual satisfaction in adult men and their female partners before and after the procedure and compared men randomized to male circumcision with uncircumcised controls. There were no significant differences in male sexual satisfaction or dysfunction among trial participants, and in one trial, circumcised men reported increased penile sensitivity and enhanced ease of reaching orgasm. In addition, 97% of female partners reported either no change or improved sexual satisfaction after their male partner was circumcised.

Why not wait and let the child decide when he gets older?

Other people feel that the parents should not opt to circumcise. They say that the infant can make that choice when he reaches his late teens. The problems with that are that waiting would increase the child’s risk for urinary tract infection as a baby, and leave him at increased risk for phimosis, balanitis, meatitis and other genitourinary diseases.

Also, many young males may have become sexually active before choosing to have a circumcision done. They could have already acquired herpes, HPV and/or HIV by the time the decision to circumcise is made. Also, circumcision as a neonate is usually an uncomplicated procedure that has very little risk for the infant. In someone older, there is pain, bleeding and risk of infection. The patient may need to take time off from school or work to recover. Therefore, a delay in circumcision could have negative consequences for the male, both as a child and as an adult.

In spite of this data and the recommendation of the American Academy of Pediatrics, there has been a decrease in male circumcisions in the US. The lower incidence of circumcision is more pronounced in states in the western US. This corresponds to an increase in Hispanic populations there, which traditionally tend to not circumcise their male children. Additionally, in some states, Medicaid will not pay for circumcisions. So these uncircumcised infants, later men, and their future sexual partners are at higher risk for a number of conditions and diseases. These conditions could not only affect the quality of their lives but also, in some cases, the very lengths of their lives. Secondarily, the medical conditions that these men, and their partners, may develop can cost billions in health care dollars.

From the Mayo Clinic Proceedings:

A cost-effectiveness study that considered only infant urinary tract infections and sexually transmitted infections (STIs) found that if male circumcision rates were to decrease to the levels of 10% typically seen in Europe, the additional direct medical costs in infancy and later for treatment of these among 10 annual birth cohorts would exceed $4.4 billion, even after accounting for the cost of the procedure (average, $291; range, $146-$437) and treatment of complications (average cost, $185 each [range, $130-$235]; prevalence, 0.4% [range, 0.2%-0.6%]).Each forgone infant circumcision procedure was estimated to lead to an average of $407 in increased direct medical expenses per male and $43 per female. This analysis did not consider other conditions, and neither did it consider the indirect costs. It seems logical then that this analysis might have greatly underestimated the true cost.

The study adds to one by the CDC that found that neonatal male circumcision was cost-saving for HIV prevention, at least in black and Hispanic males, in whom HIV prevalence is highest.

An Australian analysis of genital cancer prevention found that neonatal circumcision provides at least partial cost savings for these.

A study of a Medicaid birth cohort of 29,316 found that for every year of decreased circumcision due to Medicaid defunding there would be more than 100 additional HIV cases and $30 million in net medical costs as a result of these. The cost to circumcise males in this birth cohort was $4,856,000. Modeling has found that cost savings initially generated by noncoverage of elective circumcisions by Medicaid in Louisiana and Florida was mitigated by increases in the rate and expense of medically indicated circumcisions. The Louisiana study considered only the costs of these for boys aged 0 to 5 years. Lifetime costs would represent a much greater financial impact on health care systems. The Florida study involved males aged 1 to 17 years undergoing circumcision between 2003 and 2008 and found that Medicaid defunding was followed by a 6-fold rise in publicly funded circumcisions (cost = $111.8 million).

In light of the fact that there are clear benefits to circumcision, and negative consequences when this procedure is not performed, we may want to address two targets. The first would be to educate the parents (as addressed in the link to the AAP paper on circumcision, above) to the risks and benefits of circumcision. Also, to educate uncircumcised males as to the health benefits of circumcision. Another, would be to apply pressure to state governments to cause them to have their Medicaid programs fund circumcisions.


Mark Thoma, MD, is a physician who did his residency in internal medicine. Mark has a long history of social activism, and was an early technogeek, and science junkie, after evolving through his nerd phase. Favorite quote: “The most exciting phrase to hear in science... is not 'Eureka!' (I found it!) but 'That's funny.'” - Isaac Asimov

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