by Patricia Salber

Uncircumcised penis photo by David G Weismiller, MD (from Up-to-Date)

Eighteen states, including Colorado and South Carolina have eliminated Medicaid coverage for male circumcision.  Furthermore,  ballot initiatives, including one attempted in my hometown San Francisco, are being discussed that would ban the procedure altogether.  I always worry when politics and political agendas start to mess with public health.

How about inserting some facts into the decision-making process?  Well, the American Academy of Pediatrics 1999 policy on circumcision, reaffirmed in 2005 and soon to be updated again, states that, although there could be medical benefits to male circumcision (including reduction of transmission of sexually transmitted diseases), “the procedure is not essential to the child’s currentwell-being, parents should determine what is in the best interestof the child. To make an informed choice, parents of all maleinfants should be given accurate and unbiased information andbe provided the opportunity to discuss this decision.” Ok, that is sensible…informed choice should be an essential ingredient for all health decisions.

So here is some more useful information that the public and policy makers should consider.  Aaron Tobian, MD, PhD and Ronald Gray, MD, MSc, of John Hopkins School of Medicine and Bloomberg School of Public, respectively, reviewed recent medical evidence about the risks and benefits of Male Circumcision in their commentary, “The Medical Benefits of Male Circumcision” featured in the November 23, 2011 issue of JAMA.

Here is a summary of their key findings:

  • Studies in Africa have demonstrated that adult male circumcision decreases human immunodeficiency virus (HIV) acquisition in men by 51% to 60%.  They go on to say that “there is substantial evidence that removal of the foreskin reduces the risk of male heterosexual HIV acquisition, however, the effect of male circumcision on reducing HIV acquisition among men who have sex with men is unclear.”
  • Male circumcision reduces the risk of acquiring and transmitting certain heterosexually acquired sexually transmitted diseases (STDs), such as genital herpes, bacterial vaginosis, and trichomoniasis.
  • The risk of acquiring high risk human papillomavirus (a cause of penile and cervical cancers) is reduced by about a third.
  • Although these studies were conducted in Africa, STDs, including heterosexually transmitted HIV are common in the US.
  • Neonatal male circumcision provides other potential benefits during childhood such as prevention of infant urinary tract infections, meatitis, balanitis, and phimosis
  • The Joint United Nations Programme on HIV/AIDS (UNAIDS) and the WHO have adopted a policy advocating male circumcision in countries with heterosexual HIV epidemics and the US Centers for Disease Control and Prevention (CDC) found economic benefits to the procedure based on reducing HIV infections alone.

Digital StillCameraOpponents of male circumcision consider the procedure to be a form of genital mutilation sometimes comparing it to female circumcision which involves removing some or all of the clitoris, a procedure that is associated with a lot of morbidity and even mortality.   Newborn male circumcision, usually performed in the hospital a few days after birth, is a relatively simple procedure that involves snipping of the foreskin.  I have a attended couple of brit’s, the Jewish ceremonial circumcision that takes place when the boy baby is 8 days old.  Neither the hospital- performed nor the religious circumcision seem to cause much distress to the infant.  They cry for a bit, but are easily soothed by the parents (or by a drop of wine in the case of a brit) – it doesn’t seem any worse than the first sprained ankle or skinned knee.  That being said, I personally don’t know any circumcised men who are obsessed by the trauma of their early childhood penile operation or their sprained ankle/skinned knees, do you?

Some who oppose male circumcision say that male circumcision can cause sexual dysfunction.  However, Tobian and Gray state that “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.”

As is true with all health care interventions, the consumer and policy makers needs to weigh the pros and cons – but they need solid information upon which to base their decision.  It would be a shame if, like the hysteria over vaccinations related to faked research, the politics surrounding male circumcision lead to public health policies that are not sound..and safe.

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