The debate over male circumcision was revived last month with the publication of two controversial journal articles. First, the Archives of Pediatrics & Adolescent Medicine published an article concluding that if male circumcision rates continue to fall in the U.S. over the next decade, we will end up spending $4.4 billion more on health care due to a projected increase in sexually transmitted infections.1 The article estimates that fewer circumcisions would result in double digit percentage increases in men infected with HIV, herpes, and the human papillomavirus, as well as corresponding increases in such infections for their (assumed) female partners. Second, the journal Pediatrics published a policy statement on male circumcision in which they concluded that the benefits of the procedure far outweigh the risks.2 What I would like to do in this post is share my thoughts on circumcision based on my own reading of the science in this area.
I have previously written about different perspectives on male circumcision and have reviewed the relevant research here. Thus, if you do not have much background on this topic, I would suggest reading that first. Below are my conclusions after taking into account everything I have read on this topic.
1. The primary benefits of circumcision could be achieved even more effectively through better sex education. The main argument in favor of routine circumcision is that it would reduce men's risk of contracting and spreading various sexually transmitted infections (STIs). However, while circumcision may reduce this risk to some degree, it by no means eliminates it—circumcised men can and do still contract STIs in large numbers.3 Thus, we still need to be teaching men about safe-sex practices and giving them the tools they need to protect themselves and their partners. If we really want to get serious about reducing rates of STIs and their associated healthcare costs, we need to spend our resources on improving sex education programs because that has the potential to save a lot more money and lives than any kind of genital surgery.
2. The benefits of circumcision can still be obtained if the procedure is performed in adulthood. Studies of adult male circumcision in Africa have found that it is still possible to reduce men’s STI risk even if they wait until much later in life to undergo the surgery.4 One of the main arguments against circumcision is that infants cannot consent to the procedure and the effects are irreversible—once the foreskin is gone, there’s no bringing it back. Thus, if most of the potential benefits of circumcision can still be achieved by postponing the surgery until the individual is old enough to consent and can evaluate the pros and cons for himself, then why rush into it and take the ability to make that decision away from the patient?
3. The argument that circumcision should be more widely performed because it is cost effective takes us down a dangerous path. Is it appropriate to encourage people to undergo a medical procedure that removes a part of their body because there are potential, but not guaranteed, cost savings for others? If I may take the “cost effectiveness” argument to an extreme, why stop at removing the foreskin? Couldn’t we save even more money by removing the whole penis? Just think of how many STIs and unplanned pregnancies we could avoid that way! The point of this ridiculous argument is simply that while circumcision may indeed save some money in the long run, advocating a surgical procedure because it could save us some money does not necessarily make it the right thing to do for everyone. Each person has their own set of risk factors based on their genes and behavior, which means that the best course of action for one person may not be appropriate for another. Not only that, but we have rights when it comes to deciding what happens to our bodies, and those rights should not always be given away because there are potential cost savings.
In short, my view on the issue of male circumcision is that the evidence does not support making this a routine practice during infancy, especially given that the benefits can still be achieved by holding off on the surgery until the patient can make their own informed decision. Societal efforts to reduce the spread of STIs should take the form of enhanced sexual education and greater access to condoms, which will prevent far more infections than routine circumcision ever could.
1Kacker, S., Frick, K. D., Gaydos, C. A., & Tobian, A. A. R. (in press). Costs and effectiveness of neonatal male circumcision. Archives of Pediatrics & Adolescent Medicine.
2American Academy of Pediatrics. (2012). Circumcision policy statement. Pediatrics, 130, 585-586.
3Tobian, A. A. R., Serwadda, D., Quinn, T. C., Kigozi, G., Gravitt, P. E., Laeyendecker, O., … Gray, R. H. (2009). Male circumcision for the prevention of HSV-2 and HPV infections and syphilis. The New England Journal of Medicine, 360, 1298-1309.
4Roehr, B. (2007). Dramatic drop in HIV infections halts circumcision trials. British Medical Journal, 334, 11.
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