Health beyond the headlines
200248835-001

Making the Cut: Is It Time To Put the Circumcision Debate To Rest?

Should we advocate for the procedure to improve global health?

By Larkin Callaghan

Published December 11, 2012

Circumcision is not a new practice by any means. It is well known as a religious practice in many communities. But its implementation for public health purposes has been controversial. Raising ethical concerns and questions of tractable population health impact, the procedure has gained increasing attention in the past couple of years as it treads on unprecedented ground—surgery for the prevention of infectious disease.

Research in support of circumcision as a protective measure against the spread of HIV and other sexually transmitted diseases is mounting, countering concerns of its potential risks. Most recently, the American Academy of Pediatrics officially articulated that the health benefits outweigh the risks.

The circumcision debate turns largely on biological, behavioral, and relational factors.

Biologically speaking, the foreskin is the ideal environment for bacterial and viral infections to flourish. Heat and lack of oxygen facilitate the growth of pathogens. When the inner foreskin is retracted during heterosexual intercourse, for example, it is exposed to the vaginal secretions of a female partner, which if carrying HIV and other sexually transmitted infections easily fosters transmission. A 2009 study indicated that the greater the size—and therefore surface of—the foreskin, the higher the incidence of HIV in an infected male, underscoring how it can be a breeding ground for the virus.

A recent study conducted by Dr. Ronald Gray of Johns Hopkins University, in which researchers followed Ugandan adult study participants after a circumcision intervention, showed that the subsequent risk of acquiring HIV was reduced for the 40-month follow-up period. In addition, circumcision decreased the viral load of high-risk human papillomavirus—the strains that can cause penile, cervical and anal cancers—in men.

Other studies have shown significant reductions in bacteria after circumcision, which also benefits the female partners of the men. Adverse events or complications appear to be rare in both HIV-positive and HIV-negative men who undergo the procedure, with one study documenting moderate-to-severe complications occurring between 3-4 percent of men regardless of HIV-status.

Behavior change also features prominently in the circumcision debate. Opponents of circumcision express concerns that the procedure may contribute to a perception of immunity against HIV and result in the reduction of condom use. Additionally, there is a question of whether or not it may increase the number of sex partners one has, for the same reason of rationalizing post-surgery invincibility.

Many circumcision intervention studies are not so cut and dry, so to speak. A number contain significant education components, which makes the procedure’s contribution to HIV risk reduction less clear.

One study examined the length of time men who had undergone circumcision waited before engaging in sexual activity. If a man HIV-positive, the risk of infecting a partner is notably higher if he engages in sexual activity before the wound heals, highlighting the importance of the quality of the surgery to minimize healing complications and the importance of concurrent education to delay sexual activity. Since a 2008 study showed that after 30 days, 73% of HIV-positive men had healed wounds, compared to 83% of HIV-negative men (the discrepancy owing to greater time HIV-positive individuals may take for any kind of wound healing), this is of particular importance.

It seems that being married, not single, might diminish concerns about the length of time it takes wounds to heal. There was no statistically significant difference in time waited to engage in sex post-surgery between HIV-positive and HIV-negative men who were married; nearly 28 percent and 29 percent, respectively, engaged before the wound healed, which is the single greatest cause of post-procedure complications. However, among single men, roughly 13 percent of HIV-positive men resumed sex before their wound was fully healed, compared to about 6 percent of HIV-negative men.

The significant difference between the single HIV-positive men and the single HIV-negative men underscores the potential for altered beliefs about post-circumcision HIV transmission. However, HIV-positive men reported more sexual partners and less consistent condom use than the HIV-negative men throughout the study—itself underscoring the difficulty of risky behavior change. Encouragingly, condom use among HIV-positive men increased over the course of the study.

The relational impacts of circumcision have also been examined. Researchers have assessed the perceptions and opinions of the women in relationships with those who have undergone the surgery. A 2009 study indicated that women whose male partners were circumcised were either more sexually satisfied than they had been previously, or felt no difference. Thirty-nine percent of women indicated more satisfaction, 57 percent noted no change, and less than 3 percent said they were less satisfied than they had been when their partners were uncircumcised. The greater satisfaction, according to the women, was primarily attributed to better hygiene.

These results are important, as one of biggest issues around circumcision is “the sell.” The best way to make that sell, researchers argue, is to have the female partners articulate their preference for and encouragement of circumcision to their male partners. It appears that there may also be a generational difference in the acceptance and uptake of the procedure. Dr. Gray and his colleagues have found that adolescent males disproportionately access circumcision procedures. Even some fathers who encouraged circumcision in their sons refused the procedure themselves.

Precautions are of course essential. Research has shown that it takes practitioners approximately 100 circumcision procedures before they can be considered adept at performing the surgery.

And not all the research being done has produced promising results, specifically for women. While some studies suggest that HIV-discordant couples—HIV-negative woman and HIV-positive man—benefit from circumcision and the procedure prevents infection of the woman, other studies have produced conflicting results.

Biologically, the circumcision seems to benefit primarily men in preventing the contraction of HIV from an HIV-positive female partner. The same is not necessarily true for HIV-negative women whose male partners are HIV-positive. This biologically higher risk of infection for women is well known among public health researchers. Of course, decreasing the prevalence of HIV-positive men will ultimately, in the long run, help to lower the HIV incidence in women.

Indeed, population health benefits are already emerging. Dr. Gray and colleagues showed earlier this year that in Uganda, 37 percent of the reduction in HIV incidence could be attributed to circumcision, since there was no change in risk behaviors. The impact was not observed in women.

Circumcision seems to make economic sense. The male circumcision procedure costs $30-$60 in adults, and $5-$10 in infants. For each HIV infection avoided due to five to 15 male circumcisions performed, the savings reach well into the billions of dollars with the assumptions of a $150-$900 cost per infection (depending on HIV incidence in a specific region) over the next ten years.

Critics of course remain, and most vocally claim that other strategies, like education and behavior change, are viable solutions that should be championed. Regarding the sustained HIV epidemic and the hopeful strategies of condom use, testing, and treatment, Dr. Gray himself remarked, “I don’t know how to change behavior, I wish I did.”

So while behavior change strategies are perhaps the most important intervention to counter the HIV epidemic, they are not the only effective HIV interventions. The evidence seems to indicate that voluntary circumcision also makes the cut as a contender in the global fight against HIV.

 

Edited by Dana March. Additional research by Josh Brooks.

13 Responses to “Making the Cut: Is It Time To Put the Circumcision Debate To Rest?”

  1. October 28, 2014 at 5:51 pm, Charlie said:

    It’s hard for many men to admit that something they were born with is best dispensed with soon after birth. The reason Congress criminalized female circumcision here and the legislation does not apply to male circumcision is that the male version is a medical procedure whereas the other is mutilation. Someday it will be possible to genetically engineer circumcision during gestation. Until then, circumcision instruments are well available to remove the offensive tissue. And it rankles some men to know that many males are being circumcised by female physicians. I happen to be dating one of them and she sees foreskins the way an exterminator sees rats. I am comfortable with her viewpoint.

    Reply

  2. October 16, 2013 at 8:56 pm, cameron said:

    I was cut at 16 and although i did have complications ( corrected after the initial surgery) i maintain it was the best choice I could have made i had condition which made it uncomfortable when haveing intercourse so it was a medical issue even with the complication which was upsetting at the time being cut certainly made my life personally better my belief is to let people do what THEY want it should be choice of a individual i know first hand that things go wrong trust me i know first hand but to call it mutilation when.it is need is to say that any operation to improve the patients life is also mutilation make your own minds as to make it for someone else could be seen as ignorance (just saying) as i find that both sidea can be as ignorant as the other. and as someone who has been uncut and cut it is so infuriating to see that people cannot see the other sides reasoning or even just agree to dissagree and follow there own veiws without having to blast the other side of the arguement as bigotted.

    Reply

  3. October 15, 2013 at 11:57 am, Craig Adams said:

    I was neonatally “circumcised” by the doctor who delivered me at a New Jersey hospital and it completely injured me — traumatic corrective meatotomy surgery at age 5 for meatal stenosis, not enough skin for a comfortable erection, and other complications. I have seen a male infant circumcision surgery on the Internet, and it is horrifying. I have not had a good night’s sleep for the past 3 months since I saw and heard the babys’ screams. I am a circumcised father of an intact son. In looking at my perfect 6 month old son I can see just how much healthy, protective tissue was removed from me. I am angered and distressed that my right to bodily integrity was violated. Some cultures that practice female circumcision (forced genital cutting) defend it on the grounds that it provides better hygiene as well. Infants and children deserve the greater protection from invasive, traumatic, and injurious surgery. Leave all children as nature made them. When they are adults, they can decide for themselves on the health measures they wish to take, the behaviors they wish engage in, and the body modifications, if any, they wish to make.

    Reply

    • July 16, 2014 at 8:22 am, Jackson said:

      What a load of crap. I didn’t have enough skin either and the remedy for this was simple and painless. Do you whine that much when you get splinters too?

      Reply

  4. July 01, 2013 at 6:49 am, Yada said:

    What if your son approaches you and says “mom, dad, i want to be circumsized?” Will you stop him?

    Where I live, babies are not usually circumsized. People wait for them to grow up and decide for themselves. And usually by the age of 10, these boys tell their parents THEMSELVES that they want the cut.

    Reply

  5. June 15, 2013 at 1:43 am, Unc Urb said:

    misery loves company. leave the babies how nature made them, not how some cult decided they ought to be!
    babies are born complete, no ‘procedure’ necessary!

    Reply

  6. May 18, 2013 at 2:33 pm, Ronald Goldman, Ph.D. said:

    Here is what they do not tell you. Studies show that circumcision causes significant pain and trauma, behavioral and neurological changes in infants, potential parental stress from persistent crying (colic) of infants, disrupted bonding between parent and child, and risk of surgical complications. Other consequences of circumcision include loss of a natural, healthy, functioning body part, reduced sexual pleasure, potential psychological problems, and unknown negative effects that have not been studied.

    Some circumcised men resent that they are circumcised. Sexual anxieties, reduced emotional expression, low self-esteem, avoidance of intimacy, and depression are also reported. Some doctors refuse to perform circumcisions because of ethical reasons. Relying on presumed authorities (e.g., American Academy of Pediatrics or doctors who echo AAP views) is not sufficient because of personal, religious, financial, and political conflicts of interest. For more information see http://www.circumcision.org.

    Reply

  7. January 21, 2013 at 1:37 pm, Sriram said:

    A poorly written article with a very biased POV….promoting genital mutilation based on archaic and medieval ideologies, what a shame……

    Reply

  8. January 15, 2013 at 9:04 pm, John Vasquez said:

    circumcision to prevent aids? Bacteria under the skin? What about teaching our boys and son responsibility and personal hygeine? Instead of cutting off a useful and sensitive part of the penis to prevent aids, why not educate our boys to respect women and themselves, this means not having multiple partners and engaging in sexual activity responsibly(condoms). Whether circumcised or not I don’t want my sons having sex with women who have HIV. What about all the men who are intact? I circumcision is good why aren’t they all lining up and why aren’t their wives complaining? As far as bacteria under the skin why not teach our sons how to bathe properly. I mean come on most of the world is uncut.

    Reply

  9. December 31, 2012 at 4:15 pm, William O'Shea said:

    HIV prevention? Please. Look at the sample group and the study a bit more closely. In the stampede to eradicate aids why is it that men have to get a portion of their penis cut off? Your article seems to be extremely female centric addressing what WOMEN want, the more please women get from sex with a circumcised man. Did you ever think about what it is like for men, have you asked them?

    The modern day push to cut male penis’s is about power.

    Reply

  10. December 28, 2012 at 7:58 am, angel said:

    What rubbish to promote medical fraud. American doctors have claimed benefits for years now, anything from curing blindness, epilepsy etc. Every decade they fund new research to keep the industry going and to replace the “benefits” that have been disproven.

    Now they are opening franchises in Africa because sales are down in the US?

    HIV prevention has become suddenly also become very profitable since circumcision was added to the mix. The studies were done with a desired outcome already in mind, that is why those specific areas were chosen where a link was suspected. Research from other parts of the word showed no correlation or indeed the opposite, but these studies are simply ignored. When “evidence strongly suggests” something only it is not fact and does not have real world applications. Go read the actual studies… all of them and then read the scientific arguments against them. The “evidence” is rather poor.

    Pro circumcision doctors and those who profit have been trying to prove links to whatever dread disease of the time for years now to further their agendas. This is not evidence, it is “jumping to conclusions”. In marketing we call this “dazzle them with science” to sell circumcision kits to misinformed people that exploit men in Africa.

    In Zimbabwe the HIV rate is higher for circumcized men yet they are still rolling out this policy… does that make any sense? But it makes it obvious that there are agendas other than HIV prevention driving this exploitation. Condom use is promoted as part of the consultation for men getting circumcised, but no individual consultations are provided for uncircumcised men, so if HIV rates drop it will be condoms that made a difference not circumcision. What a clever strategy to make some easy money.

    Some of the Isreali doctors on the original task force happen to be the inventors of new circumcision devices. One doctor on the WHO task force happens to be the inventor of another such device. Conflict of interest perhaps?

    Men in Kenya are now being paid in vouchers to get circumcised. The marketing materials used in Africa states that women should put pressure on men to go, downplays the risks and misleads men and parents. Can it be considered voluntary when this happens?

    The only reasons those involved in HIV adopts these ideas is to get their hands on donor money. If the experiment fails it will simply be blamed on poor condom use.

    This is unethical, we dont remove healthy body parts for fears of future disease or infection in any other scenario. The male genitals seems to be a curious exception to the rule “first do no harm” when more conservate prevention and treatment options are available.

    It is a multi-million dollar industry in the US and the aftersale value of foreskins used to make foreskin fibroblasts support a multi-billion dollar cosmetic and biotech industries. These are used to extract insulin, elastin, collagen etc and grown into tissue cultures for research. Google it!

    Reply

    • June 22, 2013 at 1:26 pm, That One Guy said:

      Couldnt have said it better myself

      Reply

    • July 16, 2014 at 8:28 am, Str8erNarrow said:

      What I find odd is that, apparently, lots of men once in adulthood also see the benefits, not just the “medical fraud” doctors. If there were truly no reason, why do so many grown men choose to do this (me included)? And in America, a country where there is no pressure to get cut (actually, maybe the opposite nowadays). After working for a few hours every day, I got pretty tired of my own stink. You’re not always in a position to stop and wash it. Try having intercourse on a hot camping trip. It’s an embarassment. They can do as they please with the snipped skin for all I care, I never have to see that look of disgust on her face when she pulls it back to find something unpleasant underneath.

      Reply

Elevate the conversation

 
The views and opinions expressed on this website are solely those of the authors and do not represent those of the Department of Epidemiology, the Mailman School of Public Health, or Columbia University.