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Male circumcision has become a somewhat controversial issue in the U.S. with some people having such an hostility towards circumcision such that they are unwilling to look at the research. This hostile attitude is even more prevalent in Europe. Some campaigners against male circumcision seriously distort the scientific evidence which clearly favors circumcision. The evidence appears clear that circumcision is saving the lives of at least 2,000 American women each year from lower rates of cervical cancer, the lives of 200 American men each year from lower rates of penile cancer, and an unknown number of American men and women each year from lower AIDS rates. Circumcision of infant males in the U.S. has been shown to decrease the incidence of childhood urinary tract infections, sexually transmitted diseases, phimosis, paraphimosis, balanitis, and other genital dermatoses, invasive penile cancer, and the sexually transmitted diseases human papilloma virus and HIV, the causes of cervical cancer and AIDS. It also decreases epididymitis in boys and bacterial urinary tract infections in men, although neither of these diseases is common. Although 17% of uncircumcised men in one study harbored gram negative bacteria under their foreskins, and although gram negative bacteria are the most common cause of urinary tract and kidney infections in women, I have been unable to find even one study looking at whether infected uncircumcised males can spread their infections to their female partners causing disease. Of course, it's hard to believe that they don't. Urinary tract and kidney infections are a major cause of illness in women. Also, many cases of pelvic inflammatory disease and infertility in women are also caused by gram negative bacteria. Why it appears that no one has ever looked at this issue is beyond me. Circumcision has gone out of fashion in Europe, in part due to socialized medicine and their governments not wishing to pay for the procedure. While there is a small expense involved and a very low rate of usually minor side-effects, the benefits appear to outweigh the costs. Research on AIDS suggests that the use of circumcision is already savings the lives of millions in Africa and Asia and could save many more if it become more widespread. Even in wealthy countries, AIDS continues to spread, condemning hundreds of thousands to a life-time of very expensive medications and a fair number of deaths. Circumcision Markedly Reduces Risk of AIDS: In a 21-month random assignment study of 3000 men ages 18-24 in South Africa, all the men in the trial received intensive counselling on avoiding infection with HIV during heterosexual sex at the beginning of the trial and at 3-month, 12-month, and 21-month follow-ups. They were given free condoms. Men in the circumcised group reported slightly more sexual contacts than the uncircumcised men (7.6 contacts in the first 9 months of the trial compared to 6 contacts in the uncircumcised group) but had fewer cases of HIV infection. Eighteen men in the circumcised group and 51 in the uncircumcised group became infected. The trial was stopped early and circumcision offered to all participants. Bertran Auvert, et al. University of Versailles.(Science 2005;309:860). Sexually Transmitted Diseases Much Lower: In a 25-year follow-up study of 510 newborn New Zealand boys, 30% of whom had been circumcized, STD's were 219% higher for men who were uncircumcised after adjusting for family background, number of partners, and self-reported unprotected sex. Fergusson DM, et al. New York Times 11/28/06. Less Cervical Cancer in Wives of Circumcised European Males: In a study of 1,913 couples from six different European countries, circumcised males with a history of 6 or more partners were much less likely to be positive for HPV (19.6% vs. 5.5%). Monogamous women with circumcised husbands with history 6 or more partners had a much lower risk of cervical cancer, OR 0.41. N Engl J Med. 2002 Apr 11;346(15):1105-12. Scandinavian Uncircumcised Males More Likely to Carry HPV: In a recent Danish study of 216 men in an STD clinic, the most important predictors of any HPV infection were the lifetime number of sex partners (OR = 4.3; for 25-39 vs. 1-9 partners), young age, and being uncircumcised. Sex Transm Infect. 2002 Jun;78(3):215-8 Ed: Cervical cancer is still kills over 4,000 American women each year and a major cause of death in third world countries. Circumcision is still a good idea for infant boys. Penile Cancer Considerably Less in Circumcised: A case-control study of 100 males with penile cancer found that neonatal circumcision was inversely associated with invasive carcinoma (OR = 0.41). Cancer Causes Control. 2001 Apr;12(3):267-77. In a Kaiser-Permanente California study, of 89 men with invasive penile cancer, 2 (2.3%) had been circumcised as newborns, and 87 were not. Circumcision was highly protective against invasive penile cancer. Pediatrics. 2000 Mar;105(3):E36. A California report on over 130,000 circumcisions, a complication can be expected in 1 out every 476 circumcisions. Six urinary tract infections can be prevented for every complication endured and fewer than 2 complications can be expected for every case of penile cancer prevented. Complications usually involved bleeding and serious complications were very rare. Pediatrics. 2000 Jan;105(1 Pt 3):246-9; While penile cancer is considered "rare," well over 1,000 American men develop it each year with over 200 deaths. The numbers would be several times higher if there were no circumcision. In one report of 50,000 cases, only 10 had been circumcised in infancy. One out of every 600 uncircumcised males develops penile cancer. There is some evidence that most American women prefer circumcised male partners for both aesthetic and hygienic reasons. While it is theoretically easy to keep the foreskin clean, in fact, even in middle class European families, hygiene is often a problem. Arch Dis Child. 1997 Sep;77(3):258-60 Less HIV and AIDS in Circumcised Males: 34 observational studies have been done on the issue and all have found at least a trend towards more infections in uncircumcised males. The average findings suggest that uncircumcised males suffer an HIV infection rate at least twice as high as circumcised males. Skeptics point out that the studies are not as well as controlled as would be desired. Three prospective randomized studies have been started. Male circumcision for prevention of heterosexual acquisition of HIV in men. Siegfried N, Muller M, Volmink J, Deeks J, Egger M, Low N, Weiss H, Walker S, Williamson P. Cochrane Database Syst Rev. 2003;(3):CD003362. The studies find the strongest protective effect among males with otherwise high risk factors. AIDS. 2000 Oct 20;14(15):2361-70. Ed: Even in the U.S., every year another 40,000 people, primarily young adults, become infected with HIV. The HIV medical treatment costs of just those people will be at least $30 billion over their lifetimes unless some new, inexpensive treatment is discovered. Of course, many of them will also die prematurely. The average age for circumcision in many areas of Africa is 20 years of age, but infant circumcision has fewer complications and is better at reducing disease transmission. Big Factor in AIDS Rates in Four African Areas Studied: A study of 1000 interviews of adults in two sub-Saharan areas of high AIDS (23%) and two of low AIDs (4%) found that male circumcision was almost universal (99%) in the low-prevalence areas, whereas only 10-30% of men in high-prevalence sites were circumcised. Circumcised men in one of the high cities had 3 times the HIV rates as uncircumcised men. The other city had too few uncircumcised men to make a reliable comparison. AIDS Anal Afr. 2000 Jan;10(4):9-10; AIDS. 2001 Aug;15 Suppl 4:S31-40; However, in the US, data from the 1992 National Health and Social Life Survey, a nationally representative sample of 1511 men and 1921 women aged 18-59 found no evidence of a prophylactic role for circumcision with regard to sexually transmitted diseases (STDs). Network. 1998 Spring;18(3):9. Ed: Since HIV is not primarily spread heterosexually in the U.S., and since such a high percentage of Americans are circumcised, this factor may not have shown up in such a small study. Less than 20 of the men in the study would have been HIV positive, assuming a random sample. Circumcision is becoming more popular in Africa (Sex Transm Dis. 2001 Apr;28(4):214-8.) where it is widely viewed as a means of avoiding AIDS. Unfortunately, one study found that men thought circumcision prevented contracting HIV and they became more sexually promiscuous. In any case, circumcision rates are still quite low in most areas due to a lack of funds for medical circumcision. Circumcised Less Likely to Both Contract and Spread HIV: A Kenyan study by Johns Hopkins found that none of 50 uncircumcised men with HIV infected partners contracted HIV during the one year study but that 17% of the uncircumcised men became infected. Among infected men with viral loads below 50,000 copies/ml, circumcised males were considerably less like to spread the disease to their female partners than were uncircumcised males. AIDS. 2000 Oct 20;14(15):2371-81. Ed: Research suggests that widespread circumcision in a population develops a degree of "herd immunity." By that I mean, an circumcised male is much less likely to contract HIV infection in a nation of circumcised males than in a nation of uncircumcised males. That is the main reason AIDS is so much lower in Moslem countries including very poor countries like Pakistan and Bangladesh. Bizarre: Sweden Outlaws Jewish and Moslem Religious Circumcision of Male Infants: Many Swedes have an hostility against circumcision despite research showing Scandinavian husbands who are circumcised are less likely to infect their wives with HPV virus, the main cause of cervical cancer. In 2000, a Muslim boy in Sweden died due to circumcision. This led the Swedish Parliament to pass a law requiring circumcision be done by a physician under anesthesia. Ironically, that is what had happened to the boy and the anesthesia had killed him. However, most Jewish and Muslim circumcision has been done by religious leaders. Jewish and Muslim leaders are concerned the high cost and hostility of many Swedish physicians to circumcision will make it hard for them to fulfill their religious obligations. BBC News Monday, 1 October, 2001. In the U.S., circumcision is rarely if even done under anesthesia. The penis skin may be briefly anesthetized to minimize pain, but never the general anesthesia that killed the boy in Sweden. Circumcision in Europe: Despite a claim which I have received that circumcision has never been practiced in Europe, a reported 10-15% of European males are currently circumcised despite governments refusing to pay for the procedure and intense hostility against circumcision by some campaigners. Circumcision was more prevalent in England (30%) until the government refused to allow it in their national health program in order to save money. I suspect that the same is true in a number of other European countries and the information has simply gone unreported. In the Catholic community I was part of in Annecy, France, in 1962-3, many of the European boys I went to school with were circumcised. Many websites by Europeans attack Americans for circumcising the large majority of our boys as if we were committing some horrible crime. In fact, its saving over 2,000 female lives every year is the U.S. alone and hundreds of thousands in Africa. Thousands of European women die of cervical cancer every year and HPV infections in Europe, the leading cause of cervical cancer, are clearly increased by the lack of circumcision. Circumcision Strongly Lowers AIDS Risk in India: Laboratory findings suggest that the foreskin is enriched with HIV-1 target cells. In a prospective study of 2298 HIV-uninfected men attending sexually transmitted infection clinics in India, circumcision was strongly protective against HIV-1 infection (adjusted relative risk 0.15; p=0.0089). There was no protective effect against herpes simplex virus type 2, syphilis, or gonorrhea, which suggests a biological rather than behavioral explanation for the protective effect of male circumcision against HIV-1. Male circumcision and risk of HIV-1 and other sexually transmitted infections in India. Reynolds SJ, Shepherd ME, et al. Johns Hopkins. Lancet. 2004 Mar 27;363(9414):1039-40 Foreskin Often Unretractable in Uncircumcised Japanese Infant Boys Leading to an Increase in Infections and Fevers: Almost all newborns have phimosis, which is known as one of the risk factors for urinary infection. In a study of 64 boys and 36 girls with febrile urinary infection, foreskins were classified by their retractability in the male patients and in 714 healthy boys. Ninety-four percent of first febrile urinary infections occurred before 7 months of age in boys, whereas only 37% of the girls had first infections by that age. The foreskin covered the external urethral meatus in 96% of the healthy boys aged 3 years or less. A gentle retraction maneuver could not uncover the urethral meatus in approximately 40% of the boys aged 0-6 months. The frequency started to decline spontaneously after that age. Male patients aged 0-6 months significantly more often had tightly covered meatus than did healthy neonates (85%vs 42%, P < 0.0001). Meatus tightly covered by the prepuce is associated with urinary infection. Hiraoka M, Tsukahara H, Ohshima Y, Mayumi M. Fukui Medical University, Pediatr Int. 2002 Dec;44(6):658-62 Japan. Uncircumcised Infants 1100% More Urinary Tract Infections; Found in 5% of Male Infants Admitted to ICU: In a retrospective chart review of all male infants admitted to the neonatal intensive care unit at the Medical College of Georgia--a large academic medical center with a tertiary Level III unit--to investigate the frequency and potential prevention of recurrent UTI in hospitalized infants, there were 38 infants with 53 UTIs among 744 male infants admitted during the study period (5.1% of all admissions). None of the premature infants in the study had a recurrent UTI once a circumcision was performed. Premature uncircumcised males had an increased risk for UTI (Odds Ratio=11.1, p<0.001). Can circumcision prevent recurrent urinary tract infections in hospitalized infants? Cason DL, Carter BS, Bhatia J. Medical College of Georgia, Augusta. Clin Pediatr (Phila). 2000 Dec;39(12):699-703. Ed: While UTIs are not common in male infants, they are definitely not rare and result in infections and fevers. The cost of these hospitalizations would have paid for a lot of routine newborn circumcisions. 2% of Uncircumcised Male Infants Develop Clinical UTIs: Of 28,812 infants delivered during 1996 at Kaiser Permanente Medical Care Program of Northern California (KPNC) hospitals, 64.9% of males were circumcised. The infants had 446 UTIs (292 in females; 154 in males); 132 (86%) of the UTIs in males occurred in uncircumcised boys. The mean total cost of managing UTI was twice as high in males ($1111) as in females ($542) because of the higher rate of hospital admission in uncircumcised males with UTIs (27.3%) compared with females (7.5%); The total cost of managing UTI in uncircumcised males ($155,628) was 10 times higher than for circumcised males ($15,466) despite the fact that uncircumcised males made up only 35.1% of the male patient base in 1996, reflecting the more frequent occurrence of UTI in uncircumcised males (132 episodes) than in circumcised males (22 episodes), and the larger number of hospital admissions in uncircumcised males (38) than in circumcised males (4). The incidence of UTI in the first year of life was 1:47 (2.15%) in uncircumcised males, 1:455 (.22%) in circumcised males, and 1:49 (2.05%) in females. Newborn circumcision decreases incidence and costs of urinary tract infections during the first year of life. Schoen EJ, Colby CJ, Ray GT. Kaiser Permanente. Pediatrics. 2000 Apr;105(4 Pt 1):789-93 Complications Rare and Almost Always Minor; Five Lives Saved for Each Complication Endured: Using the Comprehensive Hospital Abstract Reporting System for Washington State, researchers examined routine newborn circumcisions performed over 9 years (1987-1996). Of 354,297 male infants born, 130,475 (37%) were circumcised during their newborn stay. Overall 287 (0.2%) of circumcised children and 33 (.01%) of uncircumcised children had complications potentially associated with circumcision coded as a discharge diagnosis. A complication can be expected in 1 out every 476 circumcisions. Six urinary tract infections can be prevented for every complication endured and almost 2 complications can be expected for every case of penile cancer prevented. A trade-off analysis of routine newborn circumcision. Christakis DA, Harvey E, et al. University of Washington, Seattle. Pediatrics. 2000 Jan;105(1 Pt 3):246-9. Ed: Complications are almost always very minor. Assuming proportionality reported elsewhere, five cervical cancer deaths are prevented by circumcision for each complication suffered by circumcised male infants. 25% of Males Around the World Circumcised: Globally approximately 25% of men are circumcised for religious, cultural, medical, or parental choice reasons. The authors says that circumcision is common in the U.S., Canada, Muslims countries and parts of sub-Saharan Africa. There is substantial evidence that circumcision protects males from HIV infection, penile carcinoma, urinary tract infections, and ulcerative sexually transmitted diseases. They could find little scientific evidence of adverse effects on sexual, psychological, or emotional health. Male circumcision: assessment of health benefits and risks. Moses S, Bailey RC, Ronald AR. University of Manitoba, Winnipeg, Canada. Sex Transm Infect. 1998 Oct;74(5):368-73 Epididymitis in Boys Increased by Lack of Circumcision: In a study comparing the rates of circumcision in 79 boys hospitalized with epididymitis in two studies to the rates of circumcision in the general population in two studies, researchers found only 25% of epididymitis victims had been circumcised vs. 65-70% of the general population. The statistical difference in circumcision status among the 4 groups was significant (p >0.0004). Epididymitis in children: the circumcision factor? Bennett RT, Gill B, Kogan SJ. Duke University. J Urol. 1998 Nov;160(5):1842-4 Uncircumcised English Boys Frequently Harbor Pathogenic Bacteria: A prospective study of 25 boys who underwent circumcision for medical reason took specimens of periurethral bacterial flora before operation as well as 3 weeks after surgery. Before circumcision, 13 (52%) harbored uropathogenic organisms (Escherichia coli and other coliforms, Enterococcus spp, Proteus spp, Pseudomonas spp, and Klebsiella spp); after circumcision, none of the boys did; the only organisms cultured from the periurethral region being skin commensals. Circumcision converts a 'cul-de-sac' that is a reservoir of organisms capable of causing ascending urinary tract infection into a surface colonised by natural skin organisms. Does circumcision alter the periurethral bacterial flora? Wijesinha SS, Atkins BL, et al. John Radcliffe Hospital, Oxford, UK. Pediatr Surg Int. 1998 Mar;13(2-3):146-8. Ed: Surprisingly, even though the lack of circumcision in males causes many cases of female cervical cancer and even though adults female urinary tract infections are a very common disease caused by the very organisms listed above, I have been unable to find a single study looking at the rates of urinary tract infections in the female partners of circumcised vs. uncircumcised males. Uncircumcised Male Adults Harbor Pathogenic Bacteria Much More Often: The periurethral area of 125 uncircumcised and 46 circumcised healthy males (average age 27) was swabbed and cultured. Facultative Gram positive cocci predominated in both groups (62% and 80%, respectively). Pure culture of facultative Gram negative rods was more common in uncircumcised males (17% v 4% in circumcised males, p = 0.01). Streptococci, strict anaerobes and genital mycoplasmas were found almost exclusively in uncircumcised males. Comparative periurethral bacteriology of uncircumcised and circumcised males. Serour F, Samra Z, et al. Holon, Israel. Genitourin Med. 1997 Aug;73(4):288-90 37% of Japanese 11-15-Years-Olds Still Cannot Completely Retract Foreskin: In a study of 603 Japanese boys ages 0 to 15, the incidence of a completely retractable foreskin gradually increased from 0% at age 6 months to 63% by 11 to 15 years, while that of a tight ring decreased with age from 84% to 9%. Analysis of shape and retractability of the prepuce in 603 Japanese boys. Kayaba H, Tamura H, et al. Fujiwara Memorial Hospital, Akita, Japan. J Urol. 1996 Nov;156(5):1813-5 Bacterial UTIs 300% More Common in Uncircumcised Adult Men: Twenty-six men (median age, 30 years) with symptomatic UTIs (cases) with positive cultures were compared with 52 men (median age, 32 years) who had urinary symptoms but negative urine cultures (controls). Eight (31%) of the 26 bacteriuric men were uncircumcised compared with 6 (12%) of the 52 nonbacteriuric men (P = .037; odds ratio, 3.4). Among 19 patients infected with gram-negative bacilli, 42% were uncircumcised vs. 12% of 52 nonbacteriuric men (P = .004; odds ratio, 5.6). Escherichia coli was the most common urinary isolate (15 of 26 isolates), and the majority of E coli strains possessed urovirulence determinants. Lack of circumcision increases the risk of urinary tract infection in young men. Spach DH, Stapleton AE, Stamm WE. University of Washington Medical Center, Seattle. JAMA. 1992 Feb 5;267(5):679-81. Ed: Of course, UTIs are very uncommon in men. The real issue is that a fair percentage of uncircumcised men harbor these pathogenic bacteria. It is hard to believe that female partners are not getting many more UTIs, since females in general are much more susceptible to UTIs than men, HIV Infections Rising: While the number of deaths due to AIDS in Western Europe dropped to only 3,500 in 2003, the number of infected doubled in the United Kingdom between 1998 and 2002 (UNAIDS, 2003). Of 18,000 new cases in 2003, 58% were contracted through heterosexual intercourse (www.Avert.org). In 16 countries for which data is available, the number of newly diagnosed HIV infections rose slowly between 1998 and 2001, before increasing substantially by 26% between 2001 and 2002. This rise continued with a 9% increase in 2003 with a 39% increase in the U.K.! Portugal, the U.K., Switzerland, Belgium, the Netherlands, and Ireland have been particularly hard hit. Central Europe has so far been largely spared, but Russia and the Ukraine are even worse than Western Europe. The most recent report from CBS on Feb. 23, 2004 is that there have been a record 35,000 new cases in Western Europe. In Russia and the Ukraine an incredible 1% of the population is thought to be infected vs. 0.3% in Western Europe. In 1998, there were very few infections in Eastern Europe. The U.S. rate is about 0.3% although it rose much earlier than in Europe and has not been accelerating like Western Europe. Only 15% of U.S. infections are from heterosexual sex. Many of the European heterosexual infections involve sub-Saharan African immigrants transmitting the disease. |