The male circumcision debate continues

By Dr. Ananya Mandal, MDOct 5 2011

Much has been written on the controversies and debates on whether males – from infants to adults – have a human right to retain their foreskin. The protestors have helped persuade 18 states to stop paying for circumcisions under their Medicaid health insurance programs.

“If a vaccine were available that reduced HIV risk by 60%, genital herpes risk by 30%, and HR-HPV [high-risk human papillomavirus] by 35%, the medical community would rally behind the immunization and it would be promoted as a game-changing public health intervention,” Drs. Aaron Tobian and Ronald Gray write in Wednesday’s edition of the Journal of the American Medical Association. Those are just some of the proven benefits of circumcision, and if parents would like their sons to have them, “it would be ethically questionable to deprive them of this choice,” they write.

“The foreskin is there for a reason,” Lloyd Schofield, who spearheaded the San Francisco anti-circumcision bill, said.  Shofield called circumcision an “unnecessary surgery” with no “sound medical evidence” behind it.

In their commentary, Tobian and Gray recount the evidence in favor of male circumcision, much of it gathered in the last five years. They write that three randomized trials in Africa have shown that men who are circumcised reduce their risk of acquiring HIV by 51% to 60% compared with men who are not. Further two other trials have shown that the risk of acquiring genital herpes is 28% to 34% lower in men who are circumcised. Trials have found that male circumcision reduces the risk of genital ulceration by 47%. Men who are circumcised are 32% to 35% less likely to contract the HPV virus, which causes cancer.

The doctors add that women benefit when their partners are circumcised. Studies have found that the risk of HPV is 28% lower, the risk of bacterial vaginosis is 40% lower, and the risk of trichomoniasis is 48% lower for women whose sexual partners lack foreskin.

These are all good reasons for males to be circumcised – and the earlier they have the procedure, the better, Tobian and Gray write. They add that if circumcision could be performed only once boys became consenting adults at the age of 18, they would miss out on several years of protection against sexually transmitted diseases. (Tobian and Gray say that half of American high schoolers start having sex before they turn 18.)

In addition, the procedure is much safer for infants than for adults. Tobian and Gray write that the complication rate for newborns is in the range of 0.2% to 0.6%, but in clinical trials, the complication rate for men was in the 1.5%-to-3.8% range. “This is a simple surgery that’s been performed for over 6,000 years.  Clearly it’s safe to perform, and it has clear medical benefits,” says Tobian. Just 20 years ago as many as 67 percent of all male infants born in U.S. hospitals were circumcised. Today, that number hovers around 32 percent, in part due to decreased funding for the poor and a rise in controversy over the ethics of the practice.

Parents routinely make health decisions on behalf of their children and give consent for measures that will protect their health, the doctors write. They decide to have their children vaccinated, and if they become sick and need surgery they give the OK for that too. Circumcision, they say, should be no different.

“It’s like the anti-vaccine campaigns,” Tobian says. “The more vocal you are, the more press coverage, and people believe what people are yelling, despite what the medical evidence shows.” The historically neutral stance on circumcision taken by the Centers for Disease Control and the American Academy of Pediatrics only bolsters opponents’ questioning of circumcision, he notes. This is why Tobian and Gray are calling for medical associations to review the recent evidence and reconsider their stance on male circumcision.