Circumcision for all: the pro side

The 8 best reasons for routine newborn male circumcision

• 8. Circumcision decreases the risk of urinary tract infection.

• 7. Circumcision reduces the risk of heterosexually acquired HIV infection in men.

• 6. Circumcision lowers the risk of STDs.

• 5. Circumcision protects against penile cancer.

• 4. Circumcision reduces the risk of penile HPV infection and the risk of cervical cancer in female partners.

• 3. Circumcision prevents chlamydia infections and subsequent pelvic inflammatory disease, ectopic pregnancy and infertility.

• 2. Circumcision decreases the risk of balanoposthitis and phimosis and the later need for postneonatal circumcision.

• 1. Circumcision improves sexual function and creativity.

8. Circumcision decreases the risk of urinary tract infection

Since the first report by Wiswell and colleagues, a significant number of studies have confirmed the lower incidence of urinary tract infection (UTI) in circumcised, compared with uncircumcised, boys.¹,²,³,⁴ The only matter of debate in this area is the magnitude of the circumcision protective effect. Depending on which author one reads, it could range from a 10-fold decreased risk to 3.7. One will argue that for circumcision to be cost effective the rate of UTI among infant boys would have to be equal to or above 29%,⁵ which is far from the accepted rate of about 1%.⁶ But one has to expand one's thinking further to be able to better analyze the impact of a UTI early in life. Indeed, it has been reported that as many as 10% of infants with UTI will have simultaneous bacteremia and 3%–5% of children will develop concurrent meningitis.⁷ Other severe acute complications of UTI during infancy have been reported, including renal failure and death.⁸ Thus, for a small lifetime net cost estimated at US$17, a circumcised male infant can expect an average 10-fold decrease in relative risk of UTI, including a 15-fold reduction in relative risk of serious UTI requiring hospitalization, not to mention the decreased risk of severe concomitant complications.⁴ It is not so inconsequential after all to be able to reduce 10-fold the risk of UTI early in life and its associated cost, even in the face of its low incidence!

7. Circumcision reduces the risk of heterosexually acquired HIV infection in men

Recently 3 independent trials have demonstrated that male circumcision reduces the risk of heterosexually acquired HIV infection in men by about 60%.⁹,¹⁰,¹¹ This has prompted the WHO to recommend that male circumcision be part of a comprehensive HIV prevention package including the provision of HIV testing and counselling services, treatment of sexually transmitted diseases (STDs), promotion of safer sex habits, and the promotion of correct and consistent condom use. It seems evident that this would be effective in regions where the transmission is predominantly heterosexual, but what about regions where transmission is predominantly by mother to child, blood and blood products transfusions, use of contaminated syringes and needles, and homosexual contact? It may not be as obvious, but male circumcision may still play an indirect role in reducing HIV transmission. Indeed, if male circumcision results in an overall decrease in HIV infections, then women will ultimately benefit as it will consequently prevent male–female sexual transmission of the infection from men infected by other sources.¹² Several mechanisms have been postulated to explain how the foreskin could increase the risk of HIV infection. These include poor foreskin hygiene, the propensity of the foreskin to ulcerative lesions or abrasions, and the presence of high concentrations of HIV target cells on the inner or mucosal surface of the foreskin, which is not protected by keratin, making it vulnerable to HIV infection.¹²

6. Circumcision lowers the risk of STDs

In 2006, a systematic review and meta-analysis confirmed that male circumcision provides a direct benefit in reducing the risk of STD as well as indirect protection against HIV by lowering STD prevalence.¹³ Thus, if male circumcision is promoted as an HIV prevention measure, an added benefit would be protection against ulcerative STD, both of which carry a significant public health burden. Considering that circumcision reduces the incidence of genital ulcer diseases and enhances penile hygiene and thereby protects both against HIV transmission and cutaneously acquired STD, it should be advocated as a public health measure along with the continued promotion of condom use.

5. Circumcision protects against penile cancer

The most important etiologic factor of penile cancer is thought to be the presence of an intact foreskin.¹⁴ Recently, in a study of a large population-based sample of men, Schoen and colleagues demonstrated the highly protective effect of newborn circumcision on invasive penile cancer.¹⁵ These results in turn confirmed the original findings of Wolbarst's study in 1932 and of 5 other major series since then, which showed in the 592 cases of penile cancer in the United States, that none of those afflicted were circumcised in infancy despite a high prevalence of newborn circumcision.¹⁶

4. Circumcision reduces the risk of penile HPV infection and the risk of cervical cancer in female partners

It has been shown that male circumcision is associated with a reduced risk of penile human papillomavirus (HPV) infection and, in cases of men with history of multiple sexual partners, a reduced risk of cervical cancer in their current female partners.¹⁷ The incidence of cervical cancer has been reported to be twice as high if the uncircumcised men are at low risk, but it increased to 5 times higher in men with 6 or more sexual partners.¹⁷ Even in a population in which circumcision is rare, being uncircumcised is one of the strongest risk factors for oncogenic and nononcogenic HPV infection.¹⁸ Even if one considers the use of surgery as an unusual public health intervention for prevention, one has to recognize its permanency, which is far from proven for the popular HPV vaccine.^19,20 In fact, the benefits, particularly in terms of cervical cancer reduction, are thought to be highly dependent on the duration of vaccine protection for which evidence is currently limited.^20,21 Moreover, the cost effectiveness of prophylactic HPV vaccines in Canada remains to be clearly demonstrated.²²

3. Circumcision prevents chlamydia infections and subsequent pelvic inflammatory disease, ectopic pregnancy and infertility

Chlamydia is a major cause of pelvic inflammatory disease, ectopic pregnancy and infertility. It is the second most common STD, behind HPV infection. Chlamydia is recognized as a cofactor for the transmission of HIV and HPV owing to the local inflammatory state it induces. By preventing chlamydia infection, circumcision reduces the added cost of treating infertility by in vitro fertilization and the extra cost of dealing with ectopic pregnancy²³ in addition to the protective effects against STD, HIV and penile cancer.

2. Circumcision decreases the risk of balanoposthitis and phimosis and the later need for postneonatal circumcision

On the basis of published studies, it is estimated that balanoposthitis and phimosis will develop in 3.5% of uncircumcised males.²⁴ In addition, in Finland, where the rate of circumcision has been cited as low, it has been reported that about 7.1% of uncircumcised male infants will require circumcision later in life (M. Gissler, National Research and Development Center for Welfare and Health, written communication, February 2000). It is also generally accepted that postneonatal circumcision is not only more costly than newborn circumcision,²⁵ but also that it carries an added risk attendant to the usually required general anesthesia and additional morbidity in the form of time lost from school or work.⁶

1. Circumcision improves sexual function and creativity

Laumann and colleagues, in 1997, demontrated that not only were uncircumcised men more prone to have sexual difficulties, compared with circumcised men, but also that circumcised men enjoyed a more elaborate sexual lifestyle and that their female partners were more pleased with the esthetics of the circumcised penis.²⁶ In addition, Masters and Johnson have long established that there were no differences in glandular tactile stimulation between circumcised and uncircumcised men.²⁷

Evidence is accumulating and a consensus is forming that neonatal circumcision offers non- negligible lifetime health benefits by protecting against infant UTI and its associated, possibly severe, complications, HIV, ulcerative STD, and penile and cervical cancers. Complications to the procedure are rare and almost always minor.^8,28 Even from a cost analysis perspective, neonatal circumcision, once totally unthinkable, is gaining more attention and respect.⁴ Consequently, parents should always be given the most current and sound medical information regarding the benefits and risks of the procedure. One should remember, however, that one's decision is more greatly influenced by the circumcision status of the father, ethnic background and religion.²⁹ Cost and health factors should then be removed from the decision and personal factors should be considered of primary importance when the procedure is discussed.