The kindest cut?

ResearchBlogging.orgThe best way to prevent sexually transmitted infections is the proper use of condoms. That being said, it's not the only way to prevent STI's. Abstinence is one way, but it involves an amputation of sorts---the removal of a critical human behavior. Another amputation (of sorts) that prevents STIs is circumcision. Male circumcision has been found in several good studies to reduce the rate of HIV transmission, and now a study out of Uganda shows a significant decrease in rates of genital herpes infections (HSV-2), human papilloma virus (HPV) infection (the strains that cause penile, cervical, and anal cancer), but no decrease in syphilis infection.

This study complements the our knowledge on the benefits of circumcision to prevent disease. The authors emphasize that circumcision alone is not sufficient, but may be a useful adjunct to prevent serious STIs. In fact, STI's tend to travel together, and ulcerative diseases such as herpes increase transmission of HIV.

Now people get a little touchy about male circumcision. Despite the lack of data to show negative effects, there is a reasonable question to be asked as to whether the removal of the foreskin, whatever benefit may accrue, is worth any loss of sexual pleasure that may result. This is a tough outcome to study. Most males are circumcised as infants and know no different. However, a small study was published in the Journal of Urology a few years back that asked an interesting question: if you circumcise an adult male, what differences will he report? In the study published, they found that men reported decreased erectile function, decreased penile sensitivity, but increased satisfaction.

The study has its limitations of course, but what it did not find was a group of terribly unhappy men.

The science is quite clear; circumcision effectively prevents the transmission of a number of important diseases, and used in congress with condoms has a great potential to reduce the plagues killing millions of people yearly. What has yet to be answered is whether the human cost of circumcision, whatever that may be, justifies its use.


Aaron A.R. Tobian, M.D., Ph.D., David Serwadda, M.Med., M.P.H., Thomas C. Quinn, M.D., M.Sc., Godfrey Kigozi, M.B., Ch.B., M.P.H., Patti E. Gravitt, Ph.D., Oliver Laeyendecker, M.S., M.B.A., Blake Charvat, M.Sc., Victor Ssempijja, B.Stat., Melissa Riedese (2009). Male Circumcision for the Prevention of HSV-2 and HPV Infections and Syphilis The New England Journal of Medicine, 360 (13), 1298-1309

FINK, K., CARSON, C., & DEVELLIS, R. (2002). Adult Circumcision Outcomes Study: Effect on Erectile Function, Penile Sensitivity, Sexual Activity and Satisfaction The Journal of Urology, 167 (5), 2113-2116 DOI: 10.1016/S0022-5347(05)65098-7


More like this

In my earlier post about HIV therapy (a post I strongly recommend), I wrote, "After entering a cell (never mind how for now), HIV needs to find a way to makes copies of itself, which requires DNA." Because of some recently released data, it's time to look at how HIV enters the cell, and to expand…
This article is going to be about sex. I promise. But first, some reflections. Well, Pepsipocalypse continues. The Management pulled the ill-conceived PepsiCo nutrition blog, which is a Good Thing. This doesn't change my misgivings about what has happened. As many other bloggers have already…
Male circumcision is a difficult topic to discuss rationally. At the core, it's a medical procedure, but it's one tinged with centuries of cultural influences, and emotions tend to run high on both the pro- or anti-circumcision side of the discussion. One of the reasons that's been given in favor…
One of the frequent complaints I hear about real medicine is that it is dangerous. Of course, it's true---so is riding in a train, but it sure beats walking. And that's the danger of this particular fallacy---yes, medicine is a sharp tool, but it's also an effective tool, so we must use it…

My view of this is that circumcision should be postponed until the man/boy is old enough to make up his own mind. You can always get snipped, you can't get unsnipped (well not really)

As for that study in JofU, I'm going to hazard a guess and suggest that those men wanted to get snipped so of course they would be more happy with the results. I'm sure if you found a similar cohort of circumcised men who wanted to go back and you found a way to reverse the procedure then they would have similar satisfaction. People tend to approve of the things that they chose. I heard about a study on the radio (no I can't remember enough of the details to google it) that compared the ranks that people gave to a series of things (appliances in this case). If they were given a choice of two appliances they would later rank the one that they choose as being better within a larger pool of possible appliances than they would have otherwise (I also can't recall how the control was set up). So there you have a vaguely recollected study to support my claims.

I don't rememeber the specific study either Mattk, but cognitive dissonance and selection bias absolutely affect that study.
Don't get me wrong, I'm all for prevention of STI's, but noone's snipping me in the forseeable future!

By Whitecoat Tales (not verified) on 26 Mar 2009 #permalink

An article about an advantage with circumcision? VERY RISKY - all the crazies will respond! Didn't you see the fallout on the thread that Harriet posted a while back over at SBM?


I have no idea what you're talking about (looking away innocently)

What is missing in these studies is the original and continuing motivation for infant circimcision

It's also salient to note that the cost-effectiveness of such an intervention is dependent on the natural background rate of infection.

So circumcision may be a cost-effective STD prevention adjunct in an AIDS-ravaged African country or in particular at-risk subgroups in America. But that does not mean that it will be worth the trouble for the entire male population of Sweden, for instance.

As for the Journal of Urology study. It's good to see a lack of adverse effects. But patient satisfaction can be meaningless in an open label study. These men chose to be circumcised as adults- they must have had a very good reason. Religious conversion and/or an overly tight foreskin for instance. But Matt and WhitecoatTales have already ably made that point.

By antipodean (not verified) on 26 Mar 2009 #permalink

What is missing in these studies is the original and continuing motivation for infant circimcision

Well, it sure beats castration or infanticide...

MattK: I tend to agree with you to an extent. While I at a later stage in my life chose to undergo circumcision, I am unconvinced infant circumcision should be mandated precisely because of the consent issue. On the other hand, since it is a relatively benign procedure (much more painful later on in life though, take my word for it) and, if it shows even marginal benefit, then it should be within realm of parents to decide. Perhaps some men involved in the movement to abolish/reverse circumcision is due to resentment on not being provided with any choice early on in their lives, rather than any type of actual discomfort. As to my personal before/after comparison, it is similar to the one PAL cited above. I would not say I'm happier now than before, I'm complacent. Overall, I do not regret my choice, but other than that loss of sensitivity without any significant loss of pleasure is a fairly objective description. Happiness is subjective; some are never happy.

Possibly the cells in the foreskin (Squamous?) had a role in detecting STDs. ie freely allow possible pathogens in, present to the immune system as in FDC?.
HIV then takes advantage of this system to infect the immune system itself.
If HPV and HSV do not do this, if they are just 'typical' pathogens, then my argument collapses.
Either way, circumcision could save 10s of millions.

While I understand and can appreciate the hard facts (no pun intended!), to me it seems just plain wrong to be amputating something long before it's even going to cause any discernible risk just because it's more convenient to do it at birth.

It kind of reminds me of docking sheep - it help prevents fly-strike, but if we had tails, would you want it docked without your consent. I guess the analogy is a of a stretch, since we don't first gain the ability to poop at puberty, but even so. :-)

That said, I guess we aren't really capable of informed consent about chopping off our foreskin until well after puberty, for that matter....


decreased erectile function, decreased penile sensitivity, but increased satisfaction.

One benefit of decreased sensitivity is a prolonged period of arousal prior to orgasm, which generally results in more satisfaction all around. I would imagine that anyone in the study who had previously had issues with premature ejaculation could well have reported increased satisfaction post-cut.

My son (eight) is uncircumcised, because I couldn't justify the procedure medically, and neither could any of the MDs I spoke with. It seems to be an entirely culturally driven practice in the US, and it frankly horrified me to contemplate letting anyone near my baby's penis with a sharp implement just to conform to some tribal norm. He may well chose to have the procedure later in life, but at least he will have that choice.

About circumcision, It is a procedure that is devised with premise that the foreskin is an unnecessary part of the body( a vestigial organ if you may) , something we could do without. At this rate, a kidney is one too. Afterall , we can do without a pair. coming back to the point in question,
For some reason, I fail to accept the theory of vestigial organs altogether. You see, I don't think that centuries and thousands of years of evolution would allow for vestigial organs to remain in our bodies at all. It just is that we as scientists haven't yet figured out the biological function of say The appendix or the foreskin to make sure we don't discount them as dispensible organs.
Like you said, the best way to prevent STD's is a condom (male and female) and also perhaps abstinence and single sexual partners. With regards to all those other problems associated with an intact skin like phimosis, I think, a good genital hygeine and prevention of accumulation of stuff between the foreskin and shaft is so important. I always tell my patients to retract and clean while in the shower just so that things don't first accumulate there and then lead to infections and then finally we end up doing emergency circumcisions in adults.
I am sure the body needs the foreskin .

How on earth would you control for cognitive dissonance on the part of the men who were circumcised? Too busy to read paper just now but seems that would be a MASSIVE confound with self-reported satisfaction

Probably the same way you control for cognitive dissonance in any plastic surgical procedure looking for satisfaction among its recipients. The simple fact is that all data obtained on satisfaction is subjective, whereas statements as to sensitivity, subsequent health issues or lack thereof has some objectivity to it.

"For some reason, I fail to accept the theory of vestigial organs altogether. You see, I don't think that centuries and thousands of years of evolution would allow for vestigial organs to remain in our bodies at all."

That's not how evolution works. There are many things about our bodies that are not optimally designed or don't serve a clear purpose, but since they don't confer any particular disadvantage at this time they are here to stay. However, one might argue that the second law of thermodynamics would necessitate removal of those organs serving no purpose yet requiring an expenditure of energy to grow. Either way, I'm not an expert on the topic nor do I know anything about foreskin being a vestigial organ.

Whether the male foreskin is vestigial or not is irrelevant (and please read some evolutionary bio so that you can understand what "vestigial" really means); the real question is, given that male circumcision has some clear benefits, and that we have not yet shown any clear harm (which is different from there being no harm), is it acceptable to remove male foreskins for the amount of benefit that may accrue.

I think that the consent thing is a red herring. Parents appropriately give consent for children, so parents must be given the appropriate info to make the decision.

"For some reason, I fail to accept the theory of vestigial organs altogether. You see, I don't think that centuries and thousands of years of evolution would allow for vestigial organs to remain in our bodies at all."

I'm afraid that this argument doesn't make a lot of sense. If something is still made but useless, but is not a significant waste of energy and is not harmful, then where is the selective pressure to get rid of it? I don't think there's a lot of pressure to get rid of vestigial organs over time unless very specific circumstances arise. I am however, like Igor, not an expert on the topic.

There may not yet be discovered a function of the appendix, but as most people tolerate its removal with no ill effects, it may very well be vestigial at this point. The same would go, I should think, for male nipples, eyebrows, and possibly also the foreskin. Though I think a function of the foreskin may be found, right now its removal doesn't seem to result in excessive harm.

I think that the consent thing is a red herring. Parents appropriately give consent for children, so parents must be given the appropriate info to make the decision.

The thing is, it's not at all clear what the 'appropriate info' actually is. I mean, based on the NEJM data, could/should a pediatrician today recommend circumcision with the same conviction that he/she would use in recommending the Gardasil vaccine for girls? In general, do the parameters of parental consent for treatment impacting sexuality or reproduction vary in any substantial way from consent required or given for more run of the mill health issues? There certainly are some different standards with respect to consent for teenage girls seeking reproductive health services, e.g.

Danio, I agree...i think it isn't clear, and i also think there may be significant geographic variations in benefit. Also, it may be that as the risks of many of these diseases decrease for other reasons, the question may become less important.

The issue of consent is not a red-herring if you are the parent (or someone with a penis for whom the decision has been made). If you're a physician then of course you have to rely on the parent's role in giving consent but this does not inform the parent's decision. They know that they have the ability to consent for their child but what issues should they consider? Specifically, what is the benefit of performing circumcision during infancy rather than, say at adolescence as in many other cultures? Even if you accept that there is a net benefit, since it does not begin to accrue until the onset of sexual activity, why the rush? If you can't bring yourself to get your 14yo snipped maybe you shouldn't do it to a baby either.

The difference between Gardasil and circumcision (besides the timing as mentioned above) is the way that the risks are compared. The risks of Gardasil and similar vaccines are death or morbidity via Guilliene Barre syndrome (which is very rare) and the benefits are avoidance of death or morbidity via cervical cancer. There is an additional benefit of reduced risk of warts but the point is that the choice for most people boils down to simple math. However, it is very difficult to quantify what is lost after circumcision, especially on someone else' behalf. Therefor the equation can't really be solved. It is a subjective judgment that should be made by the individual concerned.

One benefit of decreased sensitivity is a prolonged period of arousal prior to orgasm, which generally results in more satisfaction all around. I would imagine that anyone in the study who had previously had issues with premature ejaculation could well have reported increased satisfaction post-cut.

Of course there are other sexual dysfunctions that arise from the difficulty that some men have achieving orgasm.

I don't have strong opinions on circumcision one way or another, but do want to point out a major limitation of the study of the results of circumcision in adults: The majority of the adult cases were patients who were having problems related to their foreskin in some way (infection, excess, etc). So their rsults may not be typical of the general population. I agree that the basic conclusion that circumcision doesn't make men totally miserable is a reasonable one, but I'm not sure if one can conclude that it is really harmless as far as sexual functioning goes based on the available evidence.

It's my 8-day old nephew's bris today.

You know what else *dramatically* reduces STDs? Washing genitals with soap and water after sex. Good way to avoid the ethical issues involved in circumcision.

I expect that most men, if given the choice, would not get circumcised. Partly out of squeamishness but mostly through appathy.
If one were to encourage circumcision as an anti-STD measure it ought ideally to be done before the male becomes sexually active, so possibly before the age of majority. I suspect that it's young men in particular who are most at risk so it'd be a bit pointless to leave it 'til they were all grown up and sensible.

I have a sneaking suspicion that a lot of the most rabid objections to circumcision is due to envy: those damn females get to complain when they're circumcised so it's only fair that we do, too.

I applaud your bravery in tackling this topic, especially after the crazy incessant SBM thread a while back! :D

In a stunning reversal of stereotype, I was far too squeamish to say yes to circumcision for our boy, but my husband wanted it done. I must report that beginning at age ONE our boy showed, er, an extremely healthy interest in his penis... so if his sensitivity was diminished by the circumcision, I can only think it's for the greater good of society at large. ;)