Keep your fiscal powder dry. Barry Eichengreen

Because The Doctor Says So

The best arguments for circumcision aren’t religious or cultural, but medical.

There is currently an enormous body of high quality medical research evidence in support of infant male circumcision. Some of the best research has been carried out by scientists and doctors in Europe, especially in France and Spain.

Why is it then that there seems to be very little knowledge in European countries about the many benefits? One possibility is that some people confuse male circumcision with female genital mutilation. These are in fact completely different. While ritual female cutting stands condemned because it has no benefits, but only harms, removal of the foreskin at birth should be encouraged because it is almost always harmless and provides major benefits to health and sex.

Most of what has appeared in the news media lately stems from a court decision in Cologne to ban the circumcision of boys. Now that the German government seems poised to overturn this ban it really is time for Europe to consider the medical evidence.

An evidence-based policy statement on infant male circumcision was published recently in the peer-reviewed Open Journal of Preventive Medicine. Although this pointed out that there were risks from having a medical circumcision, these occur in less than 1% of infants, and are virtually all minor and immediately and completely treatable. A risk-benefit assessment in this article found that the benefits were considerable and exceeded risks by well over 100 to 1. The benefits are even greater than this when one considers the ability of circumcision to prevent suffering and deaths from various cancers and from HIV/AIDS.

In effect, provision of circumcision in hospitals and clinics is comparable to the provision of childhood vaccination. Each present minor risks, possibly more so for vaccination than circumcision. But the benefits of each to public health and individual well-being are massive. So much so that these days infant male circumcision is referred to as a “surgical vaccine.”

It has been argued that circumcision should be delayed until the boy or young man can decide for himself. This issue too has been addressed recently in an article that was published in “BMC Pediatrics”, and entitled “A ‘snip’ in time: what is the best age to circumcise.” This article shows why infancy is the best time to circumcise. Performing circumcision of boys in the neonatal period using local anesthesia maximizes benefits, safety, convenience, cost savings, and cosmetic outcome. At later ages the barriers are considerable, meaning that it will probably never happen, even if the teenager or man wants to be circumcised.

So what are the benefits? These begin soon after birth, so supporting circumcision soon after birth. Importantly, circumcision protects the baby boy against urinary tract infections. These are common, affecting 2-4% of boys in the first few months of life, and very painful. They are often the cause of severe fevers that warrant hospital admission. In half of boys urinary tract infections cause permanent kidney damage.

Circumcision also protects against yeast infections (thrush) under the foreskin, as well as inferior penile hygiene. In 10% of boys and men a tight foreskin (phimosis) interferes with their ability to pass urine, adversely affects sexual function, and is a major risk factor for cancer of the penis. Another condition seen in uncircumcised males is an inability to return the foreskin after it is retracted (paraphimosis), which is regarded as a medical emergency should it occur, owing to the fact that the lack of blood flow to the penis can result in gangrene.

Circumcision also protects against many common, as well as not so common, sexually transmitted infections. There is currently a worldwide epidemic of cancer-causing types of human papillomavirus (HPV) and genital herpes. Despite the availability of a HPV vaccine this only targets 2 of the over 15 types of this virus that cause cervical cancer. Penile cancer is less common, affecting 1 in 1,000 uncircumcised men but virtually no men who were circumcised in infancy. Since HPV is found in only half of cases of penile cancer vaccination of boys will have only a small effect.

These days most people know that circumcision protects men against being infected by HIV during heterosexual intercourse. But in Europe, as in other developed countries, the biggest source of HIV infections are from receptive anal intercourse in men who have sex with men, and the sharing of infected needles by drug-users. But over time heterosexual exposure could increase, just as happened in Africa.

There is also some evidence that circumcision reduced the risk of prostate cancer.

In women if her male partner is circumcised she is protected to a varying degree not just against cervical cancer, but also against cancer-causing human papillomavirus infection, genital herpes, and bacterial vaginosis (Gardneralla).

So, what about sex? Extensive research, including randomized controlled trials, shows no adverse effect on sexual function, sensation, or satisfaction. If anything sex is better after circumcision. The receptors for sexual sensation are not present in the foreskin, so myths perpetrated by opponents about loss of sensory receptors should be ignored.

When all adverse foreskin-medicated medical conditions are considered together it has been found that over their lifetime an uncircumcised male has about a 50% chance of getting at least one of these.

There is no medical reason why Europe should not embrace infant medical male circumcision, just as as it embraces childhood vaccination. Health bodies, governments, doctors, and the general public should be made aware of the considerable benefits and cost-savings that promotion of this simple safe procedure entails. Medical male circumcision should be legislated and encouraged.

Read more in this debate: André Schulz, Gert van Dijk, Aiman Mazyek.

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