men’s health

Circumcision

The debate of medical necessity

By Duong Tu, MD

• Newborn circumcision using a nondisposable clamp such as the Mogen, Gomco or Plastibell under local anesthesia.
• Circumcision in older infants, children and adults, which is performed under local or general anesthesia and usually is done as a surgical procedure.

Religious and social factors

Circumcision originated in different parts of the world and dates back to ancient Egypt, 2400 BCE and biblical times. Circumcision throughout the ages may have been perpetuated in various cultures as a religious mark, status symbol or rite of initiation, as well as scorned as a social stigma, depending on the group or particular time in history. This deep connection to global spiritual history and cultural identity is one of the reasons why assessing its legitimacy in the modern world is not a straightforward proposition. One can see there is not just a medical side to this discourse, but also an emotional and spiritual one.

Although the covenant of circumcision described in Genesis has been paramount to Jewish and Muslim identity, it is not a tenet of most Christian beliefs, with exceptions such as the Coptics. It is clear that circumcision was maintained in many Christian societies for puritanical reasons rather than religious beliefs. The “medicalization” of circumcision began in Victorian England, where infant circumcision was established due to inaccurate associations with sexual activity, especially masturbation, and venereal disease, as well as blindness, tuberculosis and psychiatric illness. Victorians erroneously believed the removal of the sensitive foreskin would serve as a deterrent to masturbation and promiscuity. However, the availability of circumcision remained limited, and it was reserved for the upper class. Similar parallels were made in the United States when circumcision miraculously cured a young boy’s paralysis in 1870. After that, routine circumcision spread like wildfire as surgical prophylaxis against all sorts of seemingly unrelated diseases. It became so prevalent in the United States that it morphed from a health measure to a symbol of American citizenship.  

According to a journal article from “Urology”:

• “It became a mark of distinction, separating those who were born in the United States from those who were not, those who were clean and well bred from those who were poor, foreign, and unhygienic.”  
• Ironically, perhaps due to the wide scale availability of newborn circumcision in the US, even the poor and foreign now have access to the procedure.

This prevalence withstood the test of time even when the historical rationales for circumcision were either forgotten or refuted. The issues of circumcision and its relationship to health promote ongoing debate regarding the role of circumcision, especially as societies and cultures evolve, leading toward re-evaluation and skepticism. This is healthy; when you close off the discussion, you stifle progress.

Assessing its legitimacy in the modern world is not a straightforward proposition.

Economics

From a financial perspective, newborn circumcision is roughly ten times less expensive than the cost of adolescent or adult circumcision, mainly due to the added cost of general anesthesia in the latter group. If that group opted for local anesthesia, the cost discrepancy would be greatly minimized. For example, a clinic in California that offers circumcision under local anesthesia over the full range of ages charges an estimated cost difference of $700 for clients age one and older. These clinics provide the service to a population not typically covered by health insurance programs (ages greater than 1), albeit sometimes at a premium, and demonstrate the actual feasibility of circumcision under local anesthesia past the newborn phase.

Medical benefits

In the discourse of the medical benefits of circumcision, three primary arguments are decreasing: 1) risk of urinary tract infection (UTI), 2) risk of penile cancer and 3) risk of transmission of sexually transmitted infection (STI), especially HIV.

Preventing UTI

The risk of UTI for boys is the highest in the first year of life. This risk is significantly higher in uncircumcised boys, but this trend begins normalizing after six months to a similar risk after one year. The risk is attributed to the natural history of colonization of the foreskin and progressive resolution of physiologic phimosis, i.e., the very normal inability to fully retract the foreskin in early life.

Studies have demonstrated this increased risk, but most of these studies are observational studies. Moreover, a significant number of them poorly define their method of urine collection and include bagged urine specimens, notorious for their inaccuracy in diagnosing UTI. The high false-positive rate is attributed to foreskin colonization inevitably sampled by a bagged specimen, thus skewing the risk of uncircumcised boys. However, that increased risk is likely genuine even if the magnitude of the increase is in question. The risk is even higher for boys with another risk factor, such as an underlying urologic abnormality, i.e., vesicoureteral reflux (VUR) or a history of recurrent UTI. UTI risk stems from phimosis. Recent studies reveal that treating phimosis with steroid cream significantly decreases UTI risk to that of circumcised boys. Therefore, treat the phimosis; decrease the risk.

Preventing penile cancer

A case-controlled study from Washington State revealed a higher risk of invasive penile cancer (odds ratio of 2.3) in individuals who were not circumcised as newborns, and the highest risk among those with a history of phimosis  (odds risk of 11.4). Two findings from this study: 1) “late” circumcision did not decrease the risk, and 2) there was no increased risk when phimosis, or more precisely penile tear resulting from phimosis, was not present. A systematic review and meta-analysis confirmed these results.

Why is only newborn circumcision protective? Given the prevalence of newborn circumcision in the US, there are many more circumcisions performed later in life for various medical indications usually related to infection, inflammation, scarring or pathological phimosis–risk factors for penile cancer themselves. Performing the circumcision after those risk factors have already occurred will not remove the risk. The mechanism is underlying and already underway. 

As an alternative to routine circumcision, perhaps a more cost-effective way to mitigate risk would be education towards recognition of these risk factors and the natural history of foreskin retraction. It is not simply the presence of the foreskin that conveys risk; it is what can happen when the foreskin is unretractable. In addition, penile cancer is rare in the U.S. as well as inNorthern Europe, where most men are uncircumcised. There is nothing magical about newborn circumcision and penile cancer; the circumcision is another way to treat phimosis. Therefore, treat the phimosis; decrease the risk.

Preventing STI and HIV

Three randomized controlled trials were performed in Sub-Saharan Africa to validate the global HIV/AIDS crisis response, and the results are indisputable. In an area of a generalized epidemic (high HIV prevalence in the general population) and low circumcision prevalence, adolescent and adult circumcision cuts the risk of HIV acquisition in half. This sounds very specific, and that specificity has relevance.

Aside from the discourse regarding whether the studies performed in Africa were ethical from a research perspective, many have questioned the applicability of this finding for areas without a generalized epidemic, e.g., North America, Europe, Australia, etc., and whether you can relate that benefit to newborn circumcisions in these respective environments. In fact, studies have surfaced illustrating a significant attenuation if not the absence of the risk reduction in these Western populations. The posited reasons for these results are numerous and essentially relate to differences in transmission patterns of HIV and the availability of antiretroviral therapy (ART).

The World Health Organization (WHO) acknowledges the utility of male circumcision in preventing transmission of HIV only in the context of high HIV incidence and existing low circumcision rates, such as in the African countries where the three major randomized trials took place.     In Africa, circumcision as HIV prevention was directed toward the at-risk population, in this case the general population. That same strategy can be recommended to at-risk people in other locations. The newborn in a place like the US is not among them. 

When you close off the discussion, you stifle progress.

What about the other sexually transmitted infections? Circumcision reduces the risk for chancroid (haemophilus ducreyi) infection. There is conflicting evidence regarding herpes simplex virus 2 (HSV-2). Circumcision decreases the risk of syphilis, but this finding was also drawn from the data collected in Africa. This correlation seems to exist in populations at-risk for acquiring STIs in general. A systematic review and meta-analysis of the literature revealed no significant impact of circumcision on non-ulcerative STIs such as gonorrhea, chlamydia, trichomonas and human papilloma virus (HPV).  

The risk of STI is grounded in behaviors (multiple sexual partners, inconsistent condom use, transactional sex) occurring after sexual debut. They are conscious–and hopefully informed–decisions made when the person can exercise some level of autonomy. For example, if an adult male wants a circumcision to prevent HIV, he can choose to do so after being informed that it is never a substitute for safe sex practices. Therefore, with regard to STI, it can wait.

Mutilation

With regard to circumcision, there exists a double standard. For a boy, the procedure is rooted in tradition, religion and history. For many, now and likely for a long time, it is acceptable to perform circumcisions routinely.

One can argue that male circumcision has health benefits, whereas female genital mutilation does not. However, as discussed, the health benefits of male circumcision are conflicting, particular to a population, can be delayed or can be replaced with viable and less invasive alternatives. To force adults to undergo circumcision for potential benefit would be a coercive public health strategy, but for the newborn boy, it is legitimized.

Malpractice claims

A recent review of a legal database from the University of California - San Francisco revealed only 77 cases from 1939 to 2021. The most common reason for litigation was negligent surgical performance, and the top three cases reported regarding complications were dissatisfaction with appearance, pain and impaired sexual function. Most verdicts favored the physician, especially when negligent informed consent was alleged.

The physician’s role

Parents rely on us for our expertise and knowledge. Therefore, we should do our best to deliver the best evidence-based care possible and maintain as much objectivity as possible; we should lay out the facts and share in the decision. We should construct an environment for non-judgmental discussion and recognize personal biases. An addition to that discussion would be allowing their children to decide for themselves when they can understand the stakes. For some, this can take the burden off them and at the same time empower their children.

The American Academy of Pediatrics’ Committee on Bioethics suggests that 14 years is a good age for an individual to meaningfully provide input for informed consent. It is far easier to perform a circumcision later in life when informed consent can be obtained than to reverse a circumcision performed as a newborn.

A deeper dive into the ethics of circumcision is beyond the scope of this discussion, and notably missing is a discussion of the complications that play into the risk/benefit ratio of the procedure. Many providers reading this will already know the likely complications, but some will not see the morbidity and mortality associated with such a routine procedure. Its complications can be as catastrophic as penile loss or amputation, along with sepsis from infection and death. Therefore, the procedure cannot and should not ever be taken lightly.

In Conclusion

Today, our task was to shed light on only some controversies surrounding circumcision. It will likely be a long time before we come to a consensus. It is an immense task to ask for sweeping change, but people are working on it. These people include bioethicists, those involved in the medical humanities and providers striving to produce evidence to deliver optimal care. In the meantime, we should meet in the middle and focus on harm reduction rather than prohibition. Circumcision is often performed on a small person, but the impact can be far-reaching and broad. Providers performing circumcisions need to be appropriately trained in the technique and their results audited. Informed consent should not be restricted to only potential physical trauma. One can expect that inclusion of potential mental trauma in the effort of full disclosure would make anyone take pause. Complications should come back to the provider in full accountability; only then can the process improve.

Duong Tu, MD, is a pediatric urologist at the University of Minnesota Medical School.