Endorsed by Dr. Alex Rotta, Critical Care Pediatrician, Durham, NC and Dr. Gregory Boyle, Honorary Professorial Fellow at the University of Melbourne, Dr. Cammy Benton, Dr. Ryan McAllister, and Marilyn Fayre Milos, RN.
“What are the pros of circumcision?”
This is a question many American parents type into search engines when they find out a new addition is on the way. Featured prominently among the returned results is an article from Mayo Clinic entitled “Why it’s done.” Here, the article’s authors provide a variety of reasons why the procedure is performed, including a supposed decreased risk of urinary tract infections, sexually transmitted infections, and penile cancer. Well-meaning parents may take these claims at face value and base their decision to circumcise a child on the small amount of information presented, but does this list of alleged benefits tell the whole story?
First on the list of purported benefits is the following:
“Easier Hygiene. Circumcision makes it simpler to wash the penis. Washing beneath the foreskin of an uncircumcised penis is generally easy, however.”
This statement ignores the fact that the care of an infant or child’s penis differs from that of an adult; in fact, circumcision makes it more difficult to wash the penis of an infant, as the immediate days following the procedure require that parents be cautious of the circumcision wound. Beyond this initial healing time, "The circumcised penis requires more care than the intact penis during the first 3 years of life. Parents should be instructed to retract and clean any skin covering the glans in circumcised boys, to prevent adhesions forming and debris from accumulating.” Specifically, parents should continue to retract any remaining foreskin and apply a barrier cream for a minimum of six months to reduce the chance of meatal stenosis, although many doctors neglect to mention this necessary step or tell parents they only need to use a barrier cream for a short time.
By contrast, the intact penis of an infant or child can simply be rinsed with water. Because the prepuce is initially fused to the head of the penis, there is no space between the foreskin and glans that requires cleaning; in fact, attempting to retract the foreskin of an intact infant or child to clean or for any other reason is actually harmful. On a circumcised infant, however, any remaining foreskin can gather debris underneath and may need to be pulled back to clean. Claiming that circumcision makes it “simpler to wash the penis” is incorrect with regard to infant care, thus making the entire statement misleading.
As for adolescents or adults, having a natural penis does not make hygiene difficult, which the authors of the Mayo Clinic article acknowledge. Generally, by the time puberty is completed, the foreskin will have become retractable. Several studies (Oster [1968], Kayaba et al. [1996], Ishikawa & Kawakita [2004], and Thorvaldsen & Meyhoff [2005]) indicate an average age of around ten, although there is a wide variance of normal. This change only necessitates that the owner of the penis simply retract their own foreskin, rinse with water, and replace to its forward position.
Interestingly, in countries where circumcision is not the norm, the medical community does not promote the misguided idea that circumcision makes it “simpler to wash the penis”; in fact, the U.K.’s National Health Service even points out that “Circumcised men have to be just as careful about washing their penis” as intact (uncircumcised) adults, and that both should rinse daily with water. The only additional step for intact adults is retracting the foreskin to rinse, which takes mere seconds. Just as parents can trust that their daughters will be capable of cleaning their natural genitals properly, they should be able to trust that their sons can handle this task, as well.
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Next the Mayo Clinic claims:
“Decreased risk of urinary tract infections. The overall risk of urinary tract infections in males is low, but these infections are more common in uncircumcised males. Severe infections early in life can lead to kidney problems later on.”
Urinary tract infections are caused by bacteria entering the urethra. The foreskin in childhood is a one-way protective system that allows urine to escape while keeping contaminants from entering and causing infection. However, it is true that intact babies who are incorrectly cared for are susceptible to infection: pulling back the foreskin before it has naturally separated introduces bacteria to the urethra and glans.
While some studies have shown a higher risk of UTIs for intact infant males during the first year of life, researchers failed to ensure that the intact control groups did not have their foreskins retracted or manipulated. Thus, any UTIs experienced by intact baby boys very well could have been iatrogenic in nature. Until a study is conducted that ensures parents and medical professionals caring for the intact control group do not retract or otherwise manipulate the foreskin, we cannot rely on the claim that circumcision reduces the likelihood of UTIs. Considering circumcised boys have a permanently exposed urinary meatus — allowing bacteria free reign to enter the urethra and cause infection — it would not be surprising if intact boys who are properly cared for actually experience fewer UTIs than their circumcised peers.
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One of the most common justifications comes next:
“Decreased risk of sexually transmitted infections. Circumcised men might have a lower risk of certain sexually transmitted infections, including HIV. Still, safe sexual practices remain essential.”
The mucosa of foreskin contains a relatively high concentration of Langerhans cells, which provide a line of defense against infection. Some research suggests that “Langerin is a natural barrier to HIV-1 infection, and strategies to combat infection must enhance, preserve or, at the very least, not interfere with Langerin expression and function.” Thus, removing the prepuce as a “preventative” measure contradicts the evidence that shows these cells serve a critical immunological response.
But what about the studies that show circumcision reduces HIV transmission? The oft-cited “60% reduction” claim is based on the relative rate of risk reduction rather than the absolute risk reduction, which was a statistically insignificant 1.31%. And even that figure is questionable, as the three randomized control trials that produced these numbers not only saw a significant amount of participants lost to followup, but also all were terminated early, a practice that can “systematically overestimate treatment effects." (Please see this 2011 paper by Gregory Boyle and George Hill, published in the Journal of Law, Medicine & Ethics, for further detail.) Furthermore, at least one report indicates that HIV has increased in Malawi, where a VMMC program has been initiated. Perhaps most convincing is the fact that the United States, with its relatively high rate of circumcision among adult men, conversely has a higher rate of HIV infection than many other developed nations; one would expect the opposite to be true if foreskin removal was actually an effective means of prevention of HIV transmission.
As for other STIs, recent research shows that circumcised men may be more likely to transmit HPV to their partners, which contradicts previous claims. Other research also indicates that “the female partners of both circumcised and uncircumcised men are exposed to similar rates of yeast infection despite the absence of symptoms in circumcised men”; in other words, circumcised men might be unaware they are experiencing yeast overgrowth and pass along the infection to their partners.
Perhaps the most important point is that infants are not at risk for contracting HIV or other STIs through sexual contact. If an adult male wants to have his healthy foreskin removed because he believes this claim, he can do so. Even still, regardless of circumcision status, condom use is critical for protection against STIs and “Safe sex practices remain essential,” as the Mayo Clinic acknowledges.
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“Prevention of penile problems. Occasionally, the foreskin on an uncircumcised penis can be difficult or impossible to retract (phimosis). This can lead to inflammation of the foreskin or head of the penis.”
Infants and children are often misdiagnosed with phimosis by doctors who do not understand the difference between pathologic phimosis and physiologic phimosis; the latter is simply a superfluous medical term describing the naturally fused state of the foreskin in infancy and childhood. Moreover, circumcised infants can develop pathologic phimosis, as well, so the claim that circumcision “prevents” this risk is misleading. In fact, one study determined that the rate of pathologic phimosis (which can typically be treated with topical steroid treatment rather than an invasive circumcision) among intact boys was less than 1% (a mere .6%), whereas the aforementioned study on circumcised infants found a rate of 2.9% among circumcised boys. That’s right — intact boys had a lower rate of pathologic phimosis than circumcised infants, which is not surprising considering the adhesions experienced following circumcision are unnatural and more likely to be problematic than the normally fused state of the foreskin at birth. Until our doctors have a better grasp of the natural preputial development and stop misdiagnosing healthy intact children with phimosis — while also brushing off adhesions experienced by circumcised children as a normal part of recovery — we cannot adequately analyze this risk reduction.
As for penile health issues beyond phimosis:
Circumcised boys may be more likely to develop balanitis than intact boys.
The American Urological Association (AUA) cites circumcision as a cause of meatal stenosis, a condition marked by the narrowing of the urethral opening. Current research indicates that it may affect 5-20% of circumcised males. According to the AUA, the best way to treat meatal stenosis is surgery.
Even if we accepted the Mayo Clinic’s argument that circumcision “prevents” penile problems, then we should accept the reverse, as well: keeping a child intact prevents complications from circumcision. Please see Stanford University’s lengthy list of possible issues arising from infant circumcision for more details.
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Lastly on the Mayo Clinic’s list:
“Decreased risk of penile cancer. Although cancer of the penis is rare, it's less common in circumcised men. In addition, cervical cancer is less common in the female sexual partners of circumcised men.”
Penile cancer is extremely uncommon, with an annual diagnostic rate in the U.S. of 1/100,000 men, making it one of the rarest cancers. By contrast, vulvar cancer has an annual diagnostic rate of around 2.5/100,000; while still a very rare cancer, it is more than twice as common as penile cancer, yet we would never use this as an excuse to remove external genital tissue from infant females. The American Cancer Society does not recommend routine infant circumcision for the prevention of penile cancer; in fact, their website states that “the risk of penile cancer is low even among uncircumcised men” and that “Men who wish to lower their risk of penile cancer can do so in other ways.” Countries that do not practice routine infant circumcision (such as Denmark, Finland, Norway, and Japan) have lower rates of penile cancer than the U.S. where most adult males are circumcised.
Even if all of the Mayo Clinic’s claims were undeniably true — which is clearly not the case — the fact remains that we do not routinely and prophylactically remove any other healthy tissue from individuals who cannot consent in the name of preventing medical issues. Why should the foreskin of newborn males be an exception?
Last updated 6.29.19.