My wife and I are currently expecting our first child at the end of October, a boy, and have recently started discussing whether or not we should be circumcised. For those who don’t know, circumcision is the surgical removal of the foreskin that covers the tip of the penis. I entered the discussion in favor, but with no strong feelings either way. However, after researching the scientific literature and expert opinion, I was strongly in favor of the procedure and, frankly, somewhat frustrated by the recent trend against it.
It’s not hip to tiptoe
Circumcision has become an increasingly complex issue in recent decades, as new American parents have become uncomfortable with the idea of cutting off a piece of their child’s body, even a minor one. This is understandable from an ethical perspective: a baby cannot consent to such an unalterable act. Anti-circumcision advocates argue that it is better to forego the procedure during childhood and allow the child to make his own decision later. As a result of this intuitive reasoning, circumcision rates have fallen from about 85% in 1965 to about 58% in 2010, the latest year for which robust data are available.
Parents, however, also have a responsibility to do what is best for their child, even if that decision causes them personal discomfort. And the evidence for the health benefits of circumcision, accumulated over decades of research, is overwhelming.
Strong evidence in favor of circumcision
“Our risk-benefit analysis showed that the benefits outweighed the procedural risks, which are predominantly minor, by as much as 200 to 1,” an international team of researchers reported in a 2017 systematic review of 140 studies conducted during the previous decade
The multiple benefits include:
- A major reduction in urinary tract infections, which affect 1 in 12 circumcised men in their lifetime compared to 1 in 3 uncircumcised men.
- A large reduction in blebs, a painful, itchy and potentially disfiguring swelling of the head of the penis, usually caused by a fungal infection. The lifetime rate is 12% for uncircumcised men compared to 2% for circumcised men.
- 15% to 50% less risk of prostate cancer. Prostate cancer is the second leading cause of cancer death in men in the United States, killing 34,500 each year.
- 70% less of contracting HIV.
- 50% less risk of contracting the genital human papilloma virus.
- A very reduced risk of penile cancer (although it is rare). The lifetime risk is about 1 in 1,000 for an uncircumcised man versus 1 in 50,000 to 1 in 12,000,000 for a circumcised man.
- A reduced risk of giving sexual partners bacterial vaginal infections and sexually transmitted infections.
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The warm, moist environment under the foreskin is a breeding ground for fungi and bacteria. Proper penile hygiene can be a challenge for uncircumcised men.
In 2012, public health researchers at Johns Hopkins University calculated the national costs of declining circumcision rates in the United States.
“If rates of male circumcision in the United States among men born in the same year fell to European rates (~10%), one would expect a 12% increase in HIV-infected men (or 4,843); a 29 per hundred more men infected with the human papilloma virus (57,124); a 19 percent increase in men infected with the herpes simplex virus (124,767); and a 211 percent increase in the number of ‘childhood male urinary tract infections (26,876). Among their female sexual partners, there would be 50% more cases of bacterial vaginosis (538,865) and trichomoniasis (64,585). The number of new infections with the high-risk form of the human papillomavirus, which is closely related to cervical cancer in women, would increase by 18 percent (33,148 more infections).
Critics claim that male circumcision reduces sexual pleasure later in life, causes regret, causes harm and often results in adverse outcomes, and can easily be performed later in life at the child’s choice. The accumulated evidence counters all these objections.
High-quality studies show no difference in sexual function and a potential increase in penile sensitivity after circumcision. A survey of circumcised and uncircumcised men published earlier this year found no differences between the groups in feelings of regret about their circumcision status or sexual satisfaction. Adverse events occur in approximately 0.4% of infant circumcision procedures, almost all of which are mild and without long-term complications. Surgical providers in the US now routinely use analgesia to numb any pain during the procedure.
Finally, as Australian scientists wrote in 2019, compared to circumcision later in life, infant circumcision is “simpler, faster, less expensive, with a lower risk of complications, healing is faster and the scar can be almost invisible.” They added: “There are substantial barriers to post-circumcision. These barriers include the decision-making process, peer pressure, affordability, slower healing, pain during nighttime erections, the need to abstain from sexual activity for about 6 weeks and a visible scar afterwards.” The simple fact is that the vast majority of uncircumcised men do not choose to be circumcised later, even if it is to their advantage, because the procedure is much more onerous, risky and expensive.
As Missouri urologists Elizabeth A. Piontek, MD and Justin M. Albani, MD wrote in 2019, “Parents make countless decisions on behalf of their children every day to keep them healthy and safe, and that includes routine procedures . Clearly, circumcision and its medical benefits fall into that same realm.”
Of course, parents are free to make their own decisions regarding their young children. The American Academy of Pediatrics said so in its latest position statement on circumcision, noting that the benefits outweigh the risks, but ultimately parents should make the decision. However, the simple fact is that if parents choose not to circumcise, they are denying their children clear medical benefits that improve their health and the health of their future partners.