The neutrality of this article is disputed

Circumcision, which was a religious requirement for Muslims and Jews, or a cultural requirement of certain other communities, was taken up by members of the medical profession in the late 19th century in several English-speaking countries. It never gained popularity in continental Europe, but became more or less accepted in the United States, much of English-speaking Canada, Australia and New Zealand.

Then the tide turned. First in England and then in other Commonwealth countries, circumcision fell out of favor. As this happened, voices of concern were raised in the United States about routine infant circumcision. The procedure is now highly controversial among American medical professionals. All major medical groups in the United States now no longer recommend, and some even discourage, routine infant circumcision, because the risks are either perceived greater than the benefits (if any), or the benefits are not believed to have been sufficiently substantiated, or to be too small to justify recommending routine genital surgery.

In other English-speaking countries, circumcision is viewed critically or actively discouraged by medical bodies.[3]class="external">[2class="external">[1

Numerous medical studies have tried to assess the effects of circumcision. These studies are discussed below.

Table of contents
1 Phimosis
2 Paraphimosis
3 Balanitis
4 Skin diseases
5 Circumcision and cancer
6 Circumcision and Urinary tract infection (UTI)
7 Circumcision and HIV/AIDS
8 Medical complications of circumcision
9 Long term effects of circumcision
10 Effects on masturbation and sex
11 Statements by American health groups
12 External links

Phimosis

Phimosis is the inability to retract the prepuce over the glans penis. It is natural for the foreskin to be unretractable when a baby is born. This is accepted by all. There are differences of opinion about how long this should continue, and how the foreskin should be treated if it remains too tight for too long. According to some researchers, a lack of understanding of the natural development of the penis has led to many misdiagnoses of phimosis. Rickwood et al. write in their 2000 paper "Towards evidence based circumcision of English boys" in the British Medical Journal [1]:

Too many English boys, especially those under 5 years of age, are still being circumcised because of misdiagnosis of phimosis. What is phimosis? At birth, the foreskin is almost invariably non-retractable, but this state is transient and resolves in nearly all boys as they mature through puberty. Such normality, with an unscarred and pliant preputial orifice, is clearly distinguishable from pathological phimosis, a condition unambiguously characterised by secondary cicatrisation of the orifice, usually due to balanitis xerotica obliterans. This problem, the only absolute indication for circumcision, affects some 0.6% of boys, peaks in incidence at 11 years of age, and is rarely encountered before the age of 5. (...) Strictly, only some 0.6% of boys with pathological phimosis need to be circumcised, although more relaxed criteria would allow for a similar proportion affected by recurrent balanoposthitis.

A 1968 Danish study of 9,545 boys, which distinguished between phimosis and preputial adhesion (a weaker condition which can lead to phimosis), found that both conditions steadly declined as the boys became older: While the incidence of phimosis was at 8% among 6-7 year olds, it was only at 1% among 16-17 year olds; similarly, the incidence of preputial adhesion was at 63% among 6-7 year olds, and at only 3% among 16-17 year olds. The author, Jakob ěster, concluded that, "Phimosis is seen to be uncommon in schoolboys, and the indications for operation even rarer if the normal development of the prepuce is patiently awaited. When this policy is pursued, in the majority of cases of phimosis, it is seen to be a physiological condition which gradually disappears as the tissues develop." [1]

Paraphimosis

The American Academy of Family Physicians says this about paraphimosis:

"Paraphimosis is a urologic emergency, occurring in uncircumcised males, in which the foreskin becomes trapped behind the corona and forms a tight band of constricting tissue. Often iatrogenically induced, paraphimosis can be prevented by returning the prepuce to cover the glans following penile manipulation. Treatment often begins with reduction of edema, followed by a variety of options, including mechanical compression, pharmacologic therapy, puncture technique and dorsal slit. Prevention and early intervention are key elements in the management of paraphimosis. (Am Fam Physician 2000;62:2623-6,2628.)"[1]

The article goes on to say that the cause is most often iatrogenic, i.e., caused by doctors. It further stated:

"Rare causes of paraphimosis include self-inflicted injury to the penis (such as piercing a penile ring into the glans and paraphimosis secondary to penile erections."

This is quite different from people's fear that an overtight foreskin will cause problems if it becomes trapped behind the glans of the penis and restrict blood flow (paraphimosis) and that this typically arises in teenagers experimenting with sex. The medical advice is that it rarely happens that way.

Several different techniques are mentioned of dealing with this condition, and these are listed by the article in the American Family Physician, and also in CIRP. [1] One procedure is minor surgery to make a small slit in the foreskin without removing any tissue.[1] Another method of treating paraphimosis is called the "Dundee technique." [1]

Balanitis

Balanitis is inflammation of the glans penis and may occur both in circumcised and in intact males. It can lead to adhesion of the prepuce to the inflamed glans. It is generally believed to be more frequent in uncircumcised boys, even though a 1997 study by R.S. Van Howe concluded that "circumcised boys are more likely to develop balanitis" [1]. Many studies of balanitis do not examine the subjects' genital washing habits; a 1993 study by Birley et al. did so and found that excessive genital washing with soap may be a strong contributing factor to balanitis. Escala and Rickwood, in a 1989 examination of 100 cases of balanitis, concluded: "[T]he risk in any individual, uncircumcised boy appears to be no greater than 4% ... A policy of routine neonatal circumcision to avoid these preputial complains of childhood would be difficult to justify. We found no evidence that balanitis causes phimosis." [1]

Skin diseases

Researchers from the Imperial College School of Medicine, Chelsea & Westminster Hospital, London, England reported the results of their study of 357 patients referred for genital skin disease:

The most common diagnoses were psoriasis (n=94), penile infections (n=58), lichen sclerosus (n=52), lichen planus (n=39), seborrheic dermatitis (n=29), and Zoon balanitis (n=27). Less common diagnoses included squamous cell carcinoma (n=4), bowenoid papulosis (n=3), and Bowen disease (n=3). The age-adjusted odds ratio for all penile skin diseases associated with presence of the foreskin was 3.24 (95% confidence interval, 2.26-4.64). [1]

It should be noted that this was a retrospective study, so the differences between the circumcised and uncircumcised patients may be be related to other factors. Circumcision is more common in the wealthier sections of British society, and it is well known that health and wealth are positively correlated. This would be a confounding variable.

Some American military doctors have recommended prophylactic circumcision because of the difficult conditions during wartime. For example, a United States Army report regarding World War II noted that in case of penile lesions, the foreskin may "invite secondary infection". The sexually transmitted disease chancroid, now very uncommon, was also associated with phimosis, which could hardly occur in circumcised males, and "soldiers in combat were seldom able to practice personal hygiene". (Source: JF Patton, Medical Department, United States Army, Surgery in World War II, Urology , p. 64)

Circumcision and cancer

Early studies by circumcision advocates have found a reduced risk of penile cancer in circumcised males, or that their mates had a lower risk of cervical cancer; these conclusions are, however, no longer fully accepted. The idea that circumcision prevents penile cancer was first stated by Dr. Abraham Wolbarst in The Lancet (1932;1:150-3). Wolbarst was an ardent circumcision advocate for many years. In 1914 he first stated his belief that he would uphold in later publications that circumcision was also useful to prevent masturbation and epilepsy:

"It is generally accepted that irritation derived from a tight prepuce may be followed by nervous phenomena, among these being convulsions and epilepsy. It is therefore not at all improbable that in many infants who die in convulsions the real cause of death is a long or tight prepuce. The foreskin is a frequent factor in the causation of masturbation ... Circumcision offers a diminished tendency to masturbation, nocturnal pollutions, convulsions and other nervous results of local irritation. It is the moral duty of every physician to encourage circumcision in the young." Abraham L. Wolbarst, Universal Circumcision, Journal of the American Medical Association, vol. 62 (1914): pp. 92-97.

Wolbarst implicated smegma as a causative agent, however, as of 1963, it was conclusively proven that smegma is not carcinogenic (by injecting it into animal wounds). Wolbarst used hospital data of the time to support his hypothesis and claimed that of 1,103 men with penile cancer in his sample, not a single one was circumcised. His study on penile cancer has been criticized on methodological grounds; for example, it has been stated that the hospital data went back to men born in 1830, when hardly any circumcisions took place in the United States. He made no attempt to verify circumcision status, and used no control group. From his research, the conclusion was drawn that circumcised men could not get penile cancer, which is now universally recognized as false as several case reports have entered the scientific literature. In fact, according to a case study by Cold et al., "the commonly believed notion that circumcised men cannot develop penile cancer can result in delays in diagnosis." [1]

Some writers still rely on Wolbarst's work, even though his research has been superseded by well designed, controlled studies. This tendency has been criticized by medical professionals who oppose the practice. For example, circumcision opponents Paul M. Fleiss and Frederick Hodges wrote in a 1996 letter to the British Medical Journal in response to a recent paper on circumcision that relied on Wolbarst [1]:

Epidemiological studies disproved Wolbarst's myth long ago. In North America the rate of penile cancer has been estimated to be 1 in 100000 (...). Maden et al. reported penile cancer among a fifth of elderly patients from rural areas who had been circumcised neonatally and had been born at a time when the rate of neonatal circumcision was about 20% in rural populations. Their study also shows that the rate of penile cancer among men circumcised neonatally has risen in the United States relative to the rise in the rate of neonatal circumcision.

The American Cancer Society noted in a 1998 statement [1]:

"[T]he penile cancer risk is low in some uncircumcised populations, and the practice of circumcision is strongly associated with socio-ethnic factors, which in turn are associated with lessened risk. The consensus among studies that have taken these other factors into account is circumcision is not of value in preventing cancer of the penis.

"Proven penile cancer risk factors include having unprotected sexual relations with multiple partners (increasing the likelihood of human papillomavirus infection), and cigarette smoking."

It has also been noted that in spite of the fact that circumcision is only practiced on about 1.6% of boys in Denmark, the penile cancer rate is only 0.82 per 100,000, lower than the up to 2.2 per 100,000 estimated for the United States. According to circumcision opponent Robert S. Van Howe, M.D., Japan and Norway, countries in which fewer than 2 percent of men are circumcised, also have lower rates of penile cancer than the United States.

Some medical professionals continue to promote routine infant circumcision on the basis that it prevents penile cancer. Circumcision advocate Edgar Schoen has tried to quantify this association:

In the US, incidence of penile cancer in circumcised men is essentially zero (about one reported case every five years), but it is 2.2 per 100 000 in uncircumcised men (about 1000 cases are reported annually). On the basis of life table analysis, Kochen and McCurdy estimated that an uncircumcised man in the US has a lifetime risk of penile cancer of one in 600.

During the last 50 years in the US, six major series of cancer of the penis encompassing more than 1600 cases have been reported; none of these cancer patients was circumcised in infancy. Human papilloma virus and smegma have been implicated in the aetiology of penile cancer. Of the approximately 50,000 cases of cancer of the penis that have occurred in the US since the 1930s (and which resulted in about 10,000 deaths), only 10 were reported in circumcised men.

(Source: Edgar J Schoen, Benefits of newborn circumcision: is Europe ignoring medical evidence?, Arch Dis Child 1997;77:258-260 ( September ); footnotes deleted.) [1]

Rowena Hitchcock of the Department of Paediatric Surgery, John Radcliffe Hospital, Oxford, published a commentary in the same issue in response to Schoen's analysis:

Circumcision as an alternative to hygiene in prevention of penile carcinoma is an oft voiced argument. The author has quoted figures based on the 1971 national cancer survey (US) and extrapolated from the unsupported assumption that all penile carcinomas occurred in uncircumcised males. More recent data calculate the relative risk in the US to be 3.2 times greater in the intact male. Using the author's own source, the quoted incidence of penile carcinoma in the US was one per 100,000 (1969-71). This is a comparable incidence with that in Finland at the same time, where the circumcision rate is less than 1%, of 0.5 per 100,000 (1970) with a 78% relative 20-year survival rate. Thus, I find Marshall's argument at a meeting of the Society for Paediatric Urology, that one would have to perform 140 circumcisions a week, for 25 years, to prevent one case of carcinoma of the penis, enough to prevent me from setting out on such a course.

Circumcision itself is, of course, not a riskless procedure, so its risks have to be compared to those of penile cancer. According to Sydney Gellis, MD, in 1978 there were more annual fatalities from circumcision complications than from penile cancer [1], and this simple comparison does not take into account that there remains at least some (if not the entire) risk of penile cancer after the procedure.

Cervical cancer and HPV

The claim that circumcision reduces cervical cancer in female partners remains controversial. It was first put forward by Wynder et al. in 1954, with smegma as the hypothesized causative agent, but later relativated because female subjects gave incorrect information about the circumcision status of their partners (even a substantial number of males in the US fail to properly identify their circumcision status). Stern and Neely disproved the hypothesis that smegma causes cervical cancer in female partners in 1962 [1]. In 1996, the American Cancer Society stated: "Research suggesting a pattern in the circumcision status of partners of women with cervical cancer is methodologically flawed, outdated and has not been taken seriously in the medical community for decades."

Cervical cancer has been related to the presence of human papillomavirus infection. On this basis, an alternative hypothesis for the reduction of cervical cancer through circumcision has been proposed; namely, that there is a higher HPV infection rate among uncircumcised men. An international group of researchers conducted a study published in the New England Journal of Medicine that concluded:

Male circumcision is associated with a reduced risk of penile HPV infection and, in the case of men with a history of multiple sexual partners, a reduced risk of cervical cancer in their current female partners. [1]

The study has elicited a strong response from anti-circumcision advocates. A detailed analysis from the Internet group "Circumstitions" [1], for example, criticized especially the pooling of data from countries with very different circumcision rates. The only country with a high circumcision rate in the sample were the Philippines, so that the comparison of circumcision rate and HPV rate is also a comparison of HPV rate in the Philippines and HPV rate in other countries. According to critics, this makes it crucial to examine other social, economic, demographic and environmental factors on the Philippines that might explain the

There was no statistically significant risk of cervical cancer for partners of uncircumcised men; there was a 0.23 to 0.79 risk (CI 95%) for partners of uncircumcised men with a history of multiple partners (the population of women was previously limited to those with few partners). Critics see this type of limiting of populations to find the one that matches a given hypothesis as problematic and note that again, cultural and reporting differences may explain the difference given that about 80% of circumcised men were from the Philippine sample (it should be pointed out that the Philippines are a highly religious country, so women may be less likely to report having had multiple partners, which again would distort the results, as women who reported having multiple partners were not included in the cervical cancer analysis). Media commentator Dr. Dean Edell summarized the study like this: "If you are an intact male, have had lots of unprotected sex with lots of different women and marry a virgin, your wife may have a real but statistically insignificant increased chance of getting HPV."

Circumcision and Urinary tract infection (UTI)

Infections of the urinary tract (kidneys, ureters, bladder and urethra) can lead to kidney damage if undetected, but can generally be treated effectively with antibiotics. Recent studies find a three to seven times increased risk of uncircumcised UTIs in male infants within the first year of life. A 1998 Canadian population based cohort study by To et al. [1], for example, reported a relative risk of 3.7. The overall incidence of UTIs in infants was low, 1.88 and 7.02 per 1000 respectively. According to the American Medical Association, "There is little doubt that the uncircumcised infant is at higher risk for urinary tract infection (UTI)."

These studies have nevertheless been extensively criticized for their methodology. The American Academy of Pediatrics noted in its 1999 circumcision policy statement:

Few of the studies that have evaluated the association between UTI in male infants and circumcision status have looked at potential confounders (such as prematurity, breastfeeding, and method of urine collection) in a rigorous way. For example, because premature infants appear to be at increased risk for UTI, the inclusion of hospitalized premature infants in a study population may act as a confounder by suggesting an increased risk of UTI in uncircumcised infants. Premature infants usually are not circumcised because of their fragile health status. In another example, breastfeeding was shown to have a threefold protective effect on the incidence of UTI in a sample of uncircumcised infants. However, breastfeeding status has not been evaluated systematically in studies assessing UTI and circumcision status. [1]

The research by T.E. Wiswell on the subject, who has found an up to 20 times higher incidence of UTIs among uncircumcised infants and alleged that the rate of UTIs was up to 4% high, has generated particularly strong controversy and been criticized on methodological grounds, especially for its lack of control for confounding variables.[1] It is now generally considered flawed and superseded by modern, well designed studies. Some studies which found that most patients admitted with UTI were uncircumcised (e.g. Ginsberg CM, and McCracken GH: Urinary tract infections in young infants. Pediatrics 69:409, 1982 [1]) lacked even a control group that would have allowed a comparison with the general hospital population.

UTI is usually detected through urine tests. Depending on the method of urine collection, there is a varying risk of false positives through contamination. The bacteria detected may in fact come from the foreskin itself, not the urinary tract. In spite of this, an increased risk of UTI in uncircumcised males is generally considered plausible, a higher likelihood of bacterial colonization being the proposed mechanism.

However, studies of UTI and circumcision do not classify groups of circumcised males according to their mothers' handling of the foreskin, making it impossible to infer any link with specific hygienic practices. It is generally recommended not to retract the foreskin of an infant during hygiene [1]. Hodges and Fleiss claim that "it has been proven that retraction and washing of the infant foreskin can cause urinary tract infections by irritating the mucous membranes and destroying the naturally occurring beneficial flora which protects against pathogens."

If circumcision does indeed reduce the incidence of UTIs, To et al. estimate that 195 circumcisions would be needed to prevent one hospital admission for UTI in the first year of life.

Circumcision and HIV/AIDS

In 1986 Aaron J. Fink, a circumcision advocate, first proposed that circumcision might prevent the distribution of AIDS. He hypothesized that the keratinization of the circumcised penis might prevent HIV infection. Other researchers soon investigated the question whether there is a link between circumcision and HIV infection rates.

After more than 40 studies, the evidence has remained largely inconclusive. The American Medical Association states:

"The data on circumcision status and susceptibility to HIV infection and other sexually transmissible diseases have been recently reviewed. Five of 7 prospective studies involving heterosexual transmission of HIV-1 found a statistically significant association between lack of circumcision and elevated risk for acquisition of HIV." (Report 10 of the Council on Scientific Affairs on Neonatal Circumcision, [1])

Several studies of African populations found a significantly reduced risk of HIV transmission in circumcised males. For example, in a 1988 study published in the New England Journal of Medicine, researchers studied patients appearing at a Nairobi, Kenya, STD clinic. They found "[m]en who were uncircumcised were more likely to have HIV infection (odds ratio, 2.7; P = 0.003)" [1].

At least 16 studies found no statistically significant link between circumcision and HIV transmission, and four studies found an increased risk in circumcised males. [1] Studies have mostly focused on the female-to-male heterosexual transmission. It is axiomatic that possession (or not) of a foreskin does not influence transmission rates associated with the non-insertional partner's acquisition of HIV/AIDS through anal, vaginal, or oral sex, or any partner through pregnancy, nursing, blood transfusions, needle sticks or sharing needles.

the following para is disputed

Tying AIDS/HIV rates to circumcision status in the abstract has been eschewed by careful scientists and statisticians. One must correct base data that may tend to favor societies that practice other behavior regardless of circumcision or whose behavior in transmission of HIV has less to do with heterosexual sex, wherein the vulnerability of men with foreskins to female-to-male transmission may be demonstrated to anal or oral homosexual sex wherein the mode of transmission of tears in the colon or gums are the primary vectors of spread of the virus.

The ongoing research has been extensively methodologically criticized. The main criticism is that past studies have ignored substantial confounding variables. Perhaps most notably, most studies have not controlled for different socio-sexual behaviors. In their meta-analysis of related studies [1], Vincenzi and Mertens note that "circumcision is not performed randomly". Circumcision in central Africa is primarily a Muslim practice, and Islam requires ritual washing, marital fidelity and periodic abstinence from sex. Similar relationships have been found in other cultures that practice male circumcision [1]. In addition, in many studies, the circumcision status of subjects has not been directly verified. The authors of the meta-analysis conclude that there is not sufficient evidence for a link between circumcision and HIV transmission. Similarly, Van Howe in another 1999 meta-analysis concludes that "the recommendation to routinely circumcise boys in Africa is unfounded and even dangerous." [1]

Studies have also failed to control for the specific practice of "dry sex" (vaginal lubrication is dried out by various means, presumably to heighten the male's sexual pleasure), which is common among uncircumcised males in sub-Saharan Africa. Dry sex increases HIV infection risk dramatically. Other confounding factors that have been cited as possibly relevant are regionally prevalent diseases and "female circumcision", the effects of which on HIV transmission have not been investigated. It has also been claimed that circumcision changes sexual behavior directly, either leading to more or less risky sexual behavior. Because of these criticisms and the inconclusive results, no medical body has so far accepted circumcision as a means to reduce HIV transmission.

Among industrialized nations, AIDS rates are highest in the three countries which still practice routine infant circumcision at substantial levels (table 2). Circumcision critics point to this data not as evidence that circumcision is in any relationship to HIV infections, but that use of safe sex practices far outweighs any beneficial effect circumcision may or may not have. Critics also warn that advertising circumcision as a way to prevent AIDS (e.g. "could potentially save millions of men and their partners", as a unversity press release claims) might be used to promote and justify the belief that safe sex practices are unnecessary.

the following para is disputed

The position of the circumcision critics has been criticized by circumcision proponents because the predominant modes of HIV/AIDS transmission in industrial societies is not heterosexual intercourse, but through homosexual sex, blood transfusions, needle sticks or sharing needles, which are not addressed in the HIV/AIDS rates. Contrary to the data on the industrial world (table 1), the studies linking circumcision with lower HIV/AIDS incidence in the developing world have mostly focused on the female-to-male heterosexual transmission (tables 2-5). It is axiomatic that possession (or not) of a foreskin does not influence transmission rates associated with the non-insertional partner's acquisition of HIV/AIDS through anal, vaginal, or oral sex, or any partner through pregnancy, nursing, blood transfusions, needle sticks or sharing needles.

Table 2
World Health Organization data of AIDS rates for 1995
Nation AIDS cases per 100,000 pop.
USA16.0
Australia4.5
Canada3.8
France3.5
Netherlands3.1
United Kingdom2.4
Germany2.2
Sweden2.0
Norway1.6
New Zealand1.2
Finland0.9
Japan0.2

Some specific studies

this section is disputed

In a study published in Lancet in 1989, researchers studied possible risk factors in female-to-male HIV transmission. The researchers found that uncircumcised men (29.0%) were ten times more likely to acquire HIV from a single sexual encounter than circumcised men (2.5%). Uncircumcised men with genital ulcers (52.6%) were four times more likely to become infected than circumcised men with genital ulcers (13.4%).

(Source: Cameron DW, Simonsen JN, D’Costa LJ, Ronald AR, Maitha GM, Gakinya MN, et al. Female to Male Transmission of Human Immunodeficiency Virus Type 1: Risk Factors for Seroconversion in Men. Lancet 1989; 2:403-27.) [1]

Another set of researchers concluded that “In the AIDS belt, lack of male circumcision in combination with risky behavior, such as having multiple sex partners, engaging in sex with prostitutes and leaving chanchroid untreated has led to rampant HIV transmission.”
(Source: "The African AIDS Epidemic," by J. C. Caldwell and Pat Caldwell,
Scientific American, March 1996, p. 62)

Researchers from the University of Manitoba also studied heterosexual HIV transmission in Africa. The researchers concluded that: “There is substantial evidence that circumcision protects males from HIV infection, penile carcinoma, urinary tract infections, and ulcerative sexually transmitted diseases. We could find little scientific evidence of adverse effects on sexual, psychological, or emotional health.”

(Source: S Moses, RC Bailey and AR Ronald, Male circumcision: assessment of health benefits and risks, Sexually Transmitted Infections, Vol. 74, Issue 5, p. 368-373) [1]

Another publication in the New England Journal of Medicine found that “Male circumcision consistently shows a protective effect against HIV infection” and noted that HIV prevalence was 1.7 to 8.2 times higher among uncircumcised heterosexual men than among circumcised heterosexual men. The study faulted the Langerhans cells in the foreskin and a “receptive HIV environment between foreskin and glans” for the increased risk.

(Source: Rachel A. Royce, Ph.D., M.P.H., Arlene Se˝a, M.D., Willard Cates, M.D., M.P.H., and Myron S. Cohen, M.D, Sexual Transmission of HIV, The New England Journal of Medicine, Volume 336:1072-1078, April 10, 1997)

A group of researchers from the University of Washington studied truckers in Kenya who used the services of prostitutes. They found that a trucker’s uncircumcised status was associated with a four-fold increased risk of contracting HIV even after eliminating behavior, religion, or other factors.

(Source: Lavreys L; Rakwar JP; Thompson ML; Jackson DJ; Mandaliya K; Chohan BH; Bwayo JJ; Ndinya-Achola JO; Kreiss JK; Effect of circumcision on incidence of human immunodeficiency virus type 1 and other sexually transmitted diseases: a prospective cohort study of trucking company employees in Kenya, J Infect Dis. 1999 Aug;180(2):330-6) [1]

In the Lancet, researchers at the University of California, San Francisco (“UCSF”) and the University of Illinois, Chicago, published the results of their review of over 30 studies on the association between circumcision and HIV. The researchers concluded that circumcision “could potentially save millions of men and their partners” and were sufficiently motivated to cause UCSF to issue a press release announcing the discovery. [1] The report contains tables showing the significantly higher HIV infection rate among countries with non-circumcised majorities.

(Source: Daniel T Halperin, Robert C Bailey, Viewpoint: Male Circumcision and HIV Infection: 10 Years and Counting, The Lancet, 354 (9192): pp. 1813-15.) [1]

Further tables

this section is disputed

Table 2
World Health Organization data of HIV infection rates for 1998
Nation HIV infections per 100,000 pop. in African countries with under 20% circumcision rate
Zimbabwe25,840
Botswana25,100
Namibia19,940
Zambia19,070
Swaziland18,500
Malawi14,920
Mozambique14,170
Rwanda12,750

Table 3
World Health Organization data of HIV infection rates for 1998
Nation HIV infections per 100,000 pop. in Asian countries with under 20% circumcision rate
Cambodia2,400
Thailand 2,230
Myanmar1,790
India820
Nepal240

Table 4
World Health Organization data of HIV infection rates for 1998
Nation HIV infections per 100,000 pop. in African countries with over 80% circumcision rate
Kenya11,640
Congo (Brazzaville)7,640
Cameroon4,890
Nigeria4,120
Gabon4,250
Liberia3,650
Sierra Leone3,170
Ghana2,380
Gambia2,240
Guinea2,090
Benin2,060

Table 5
World Health Organization data of HIV infection rates for 1998
Nation HIV infections per 100,000 pop. in Asian countries with over 80% circumcision rate
Pakistan90
Philippines 60
Indonesia50
Bangladesh30

[1]

The Cochrane Library exhaustive systematic review of the medical literature (May 2003) "found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men." [1] The Cochrane Library reported that the studies are unable to control the numerous confouding factors so the evidence from those studies is very poor.

Recent research, correcting for confounding factors found an 8-fold risk associated with possession of a foreskin in males. The joint Indian-American study involved males in Pune, India over a seven year period, and corrected for confounding factors such as sexual behavior and risk-based behavior.[1] The results were sufficiently compelling that the study's authors concluded that "circumcised men are at reduced risk of HIV infection due to a specific biologic effect resulting from the removal of the foreskin." This conclusion was picked up by international media. [1]

Medical complications of circumcision

While all benefits associated with circumcision are controversial, the procedure has risks. Complications of circumcision are relatively rare. They range from bleeding, infections, disfigurement, scarring and sexual dysfunction through severe mutilation of the penis, to (in few cases) death.

the following quote is disputed
In general, neonatal circumcision is safe, although there is a complication rate of 0.2% to 3% (Ross, 1995). Dorsal penile nerve block with either lidocaine or bupivacaine significantly reduces the pain associated with the procedure (Ryan et al, 1994)
(Source: Walsh, Campbell's Urology, 7th ed. 1998)

Williams and Kapila observe:

Some authors have reported a complication rate as low as 0.06 per cent while at the other extreme rates of up to 55 per cent have been quoted. This reflects the differing and varying diagnostic criteria employed; a realistic figure is 2-10 per cent. Although haemorrhage and sepsis are the main causes of morbidity, the variety of complications is enormous. The literature abounds with reports of morbidity and even death as a result of circumcision.

It has been claimed that deaths that are the indirect result of a circumcision (e.g. infections of the circumcision wound) are often not registered as a complication. The overall number of deaths from circumcision per year is unknown, but it has been estimated by circumcision-critical health professionals to be over 200 per year in the United States
class="external">[1. Circumcision advocates dispute these numbers and claim that if they were true, a large outcry would already have resulted.

In countries with lower medical standards, complication rates are higher, and historically, circumcision has been a risky procedure. The Talmud grants an exemption from circumcision if the first three sons died from it [1].

Several extreme cases of circumcision complications have been documented in the scientific literature. Perhaps best known is the case of "Bruce/Brenda/David", an infant whose genitalia were amputated after a botched circumcision and who was then raised as a girl, with severe traumatic consequences. The case has been documented by John Colapinto in the book As Nature Made Him.

Long term effects of circumcision

Meatal stenosis is a condition that is "exceedingly rare" in intact males, yet occurs in 9-10% of males who are circumcised at birth. It is caused by exposure of the meatus to urine or by rubbing against the diaper. The disorder "is characterized by an upward deflected, difficult-to-aim urinary stream and, occasionally, dysuria and urgent, frequent, and prolonged urination. Surgical meatotomy is curative." [1] Meatal stenosis usually occurs too late to be registered as a circumcision complication. Meatitis (inflammation of the meatus) is also more common in circumcised boys.

The process of keratinization after circumcision is thought by some to occur. As one study notes[1]:

There is controversy about whether the epithelium of the glans in uncircumcised men is keratinised; some authors claim that it is not,15 but we have examined the glans of seven circumcised and six uncircumcised men, and found the epithelia to be equally keratinised.

Keratinization is thought to negatively affect the sexual sensitivity of the glans to stimulation. A recent study found that there was no difference in the sensitivity of the glans[1], confirming an earlier study by Masters and Johnson. Nevertheless, this controversial effect of the procedure is thought by many to occur, and is sometimes presented as an advantage (prolonging the sexual act) or as a disadvantage (decrease in sensation). In a study of adult males who decided to become circumcised (in 84% cases due to medical conditions), 38% reported negative outcomes such as decreased sensitivity and erectile dysfunction [1]. Of course, circumcisions to correct severe phimosis and paraphimosis tend to enable sexual functioning that was previously painful or impossible.

Because the foreskin acts as a natural lubricant, uncircumcised men and boys can usually masturbate without any external aids by simply sliding the foreskin back and forth over the glans. Circumcised men frequently have to resort to using a lubricant and other techniques. [1] With total foreskin amputation, which is no longer common, erection can become painful or even impossible as the remaining skin is stretched to its limits. This effect on masturbation and sexual behavior was alluded to in early circumcision advocacy (see below).

O'Hara and O'Hara have conducted a survey among women who had sex with both circumcised and uncircumcised males, and found that 85.5% preferred intact partners. Women reported having had more single and multiple orgasms with uncircumcised men, and less vaginal discomfort. Specifically regarding the loss of vaginal secretion in partners of circumcised men, the authors write [1]:

When the anatomically complete penis thrusts in the vagina, it does not slide, but rather glides on its own 'bedding' of movable skin, in much the same way that a turtle's neck glides in and out of the folder layers of skin surrounding it. The underlying corpus cavernosa and corpus spongiosum slide within the penile skin, while the skin juxtaposed against the vaginal wall moves very little. This sheath-within-a-sheath alignment allows penile movement, and vaginal and penile stimulation, with minimal friction or loss of secretions.

Circumcision without anaesthesia is believed by many child psychologists and neurologists to have severe long term traumatic effects. [1] However, circumcision is usually practiced today with local anaesthesia.

Effects on masturbation and sex

this section is disputed

Various benefits and harms in sexual feeling have been ascribed to circumcision.

The process of keratinization after circumcision is well known. It negatively affects the sexual sensitivity of the glans to stimulation. This effect of the procedure is sometimes presented as an advantage (prolonging the sexual act) or as a disadvantage (decrease in sensation). In a study of adult males who decided to become circumcised (in 84% cases due to medical conditions), 38% reported negative outcomes such as decreased sensitivity and erectile dysfunction [1]. Of course, circumcisions to correct severe phimosis and paraphimosis tend to enable sexual functioning that was previously painful or impossible.

Because the foreskin acts as a natural lubricant, uncircumcised men and boys can usually masturbate without any external aids by simply rolling/sliding the foreskin back and forth over the glans. Circumcised men frequently have to resort to using a lubricant and other techniques. [1] With total foreskin amputation, which is no longer common, erection can become painful or even impossible as the remaining skin is stretched to its limits. This effect on masturbation and sexual behavior was alluded to in early circumcision advocacy (see below). Notwithstanding these effects, studies show that circumcised men do not masturbate less than uncircumcised ones. Indeed, one study published in the Journal of the American Medical Association found a higher incidence of masturbation in circumcised men.[Laumann, E. et al., Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice, JAMA 277 (1997): 1052–57]

The primary source for the argument that women prefer uncircumcised partners is O'Hara and O'Hara, who conducted a survey among 138 women who had sex with both circumcised and uncircumcised males, and found that 85.5% preferred uncircumcised partners. Women reported having had more single and multiple orgasms with uncircumcised men, and less vaginal discomfort. Specifically regarding the loss of vaginal secretion in partners of circumcised men, the authors write [1]:

When the anatomically complete penis thrusts in the vagina, it does not slide, but rather glides on its own 'bedding' of movable skin, in much the same way that a turtle's neck glides in and out of the folder layers of skin surrounding it. The underlying corpus cavernosa and corpus spongiosum slide within the penile skin, while the skin juxtaposed against the vaginal wall moves very little. This sheath-within-a-sheath alignment allows penile movement, and vaginal and penile stimulation, with minimal friction or loss of secretions.

This study has been criticized for several reasons. The authors are not doctors and have no formal medical training, and the study was limited to only 138 participants. They also, prior to the study, had indicated a strong anti-circumcision bias, writing a book entitled “Sex as Nature Intended It” which they and anti-circumcision advocates promote as the “most important book on sexuality ever written,”[1] and the journal in which the article was written is not peer reviewed, and, oddly, because the article itself notes that circumcision removes 33% to 50% of penile skin—a matter that is not subject to reasonable dispute.

Another study – published in a peer reviewed journal – came to a contrary conclusion.

Williamson and Williamson also studied 145 American women and found that 71% of them preferred circumcised partners for sexual intercourse while only 6% preferred uncircumcised partners; the remainder had no preference. The disproportion increased when the women were questioned about fellatio to an 83% to 2% preference for circumcised. The absence of smegma in the circumcised penis was noted as a major reason behind the preference. (Source: Williamson, Marvel L., Ph.D., R.N. and Williamson, Paul S., M.D., Women's Preference for Penile Circumcision in Sexual Partners, Journal of Sex Education and Therapy, Vol. 14, No. 2 (Fall/Winter 1988): pp. 8-12.)

Williamson and Williamson were careful to state that their study applied to the American context, where infant circumcision was widespread. 77 per cent of their subject said that the circumcised penis seemed "more natural' . Most of the women in the study had no sexual experience with a natural penis.

In response to the question "With which penis types have you had sexual experience?", 16.5% revealed that they had had sexual contract with both circumcised and uncircumcised men. Only 5.5% had sexual experience exclusively with uncircumcised sexual partners, and the remainder of the sample was sexually experienced only with circumcised men.

Williamson & Williamson made the following statement about the circumcised penis:

While the foreskin of an uncircumcised penis can be retracted, the circumcised penis exists in exposed beauty whether flaccid or erect. [1]

This is not the language of a neutral point of view. It demonstrates the strong bias of the researchers towards circumcision and suggests that their preference had a strong emotional component.

Laumann et al. studied 1410 men and found that circumcised men were more likely to engage in a variety of sexual practices and less likely to suffer from erectile disfunction. At the same time they found that circumcised men in their sample suffered from more sexually transmitted infections, though this was not a statistically significant difference. However, their study also found that circumcision in the United States was positively correlated with education and race. As educated white men enjoy better health, on average, in the United States, this would be a confounding variable. This could also explain the difference in sexual practices between the groups. (Source: Laumann, E. et al., Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice, JAMA 277 (1997): 1052–57.)[1]

Circumcision without anaesthesia is believed by many child psychologists and neurologists to have severe long term traumatic effects. [1] Circumcision nowadays is usually practiced today with local anaesthesia.

Statements by American health groups

The American Academy of Pediatrics created a Task Force on Circumcision, which issued an official policy statement. The abstract of their statement reads:

"Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be provided."

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists issued a statement in 1997 that "newborn circumcision is an elective procedure to be performed at the request of the parents on baby boys who are physiologically and clinical stable."

The American Academy of Family Physicians Reference Manual states: "Current medical literature regarding neonatal circumcision is controversial and conflicting. The decision to perform neonatal circumcision should be based on the informed consent of the parents, and requires objective, factual counseling of parents by the family physician."

In recent years the American Cancer Society has come out against routine circumcision. "We would like to discourage the American Academy of Pediatrics from promoting routine circumcision as a preventive measure for penile or cervical cancer...Perpetuating the mistaken belief that circumcision prevents cancer is inappropriate." [1] The American Academy of Pediatrics no longer promotes routine circumcision.

The American Medical Association states:

There is little doubt that the uncircumcised infant is at higher risk for urinary tract infection (UTI), although the magnitude of this risk is debatable... Despite the increased relative risk in uncircumcised infants, the absolute incidence of UTI is small in this population... One model of decision analysis concluded that the incidence of UTI would have to be substantially higher in uncircumcised males to justify circumcision as a preventive measure against this condition.

The data on circumcision status and susceptibility to HIV infection and other sexually transmissible diseases have been recently reviewed. Five of 7 prospective studies involving heterosexual transmission of HIV-1 found a statistically significant association between lack of circumcision and elevated risk for acquisition of HIV... At least 16 studies have examined the relationship between circumcision and sexually transmissible diseases other than HIV. In general, circumcised individuals appear to have somewhat lower susceptibility to acquiring chancroid and syphilis, possibly genital herpes, and gonorrhea compared to individuals in whom the foreskin is intact... Regardless of these findings, behavioral factors are far more important risk factors for acquisition of HIV and other sexually transmissible diseases than circumcision status.

The Council on Scientific Affairs of the American Medical Association classifies neonatal circumcision as a non-therapeutic surgical procedure.[1]

External links