The following originally appeared on The Upshot (copyright 2016, The New York Times Company).
In 2012, the American Academy of Pediatrics declared that the benefits of circumcising boys outweighed the risks of the procedure. They cited health benefits that, while not great enough to warrant a recommendation for all males to undergo the procedure, were significant enough that it should be available to all, and that it should be covered by insurance. Not long after, the CDC concurred.
Let’s look at the evidence. For years, pediatricians have cited studies that show that being uncircumcised is a risk factor for developing a urinary tract infection. They point to research that shows that circumcised penises have lower levels of yeast and bacteria. Even more compelling, cohort studies showed that there was a tenfold increase in the rate of urinary tract infection in boys who were uncircumcised versus those who were.
The actual rates of urinary tract infection were 1.1 percent versus 0.1 percent, for an absolute rate difference of 1 percent. This means that 100 boys would need to be circumcised to prevent one urinary tract infection.Other studies say the number might be higher.
It’s really hard to argue that this decrease is worth a permanent, surgical procedure. It’s especially hard to argue given that we don’t really have data from randomized controlled trials. It’s possible that there’s something else different between boys who were circumcised and those who were not, especially since the vast majority (more than 80 percent) of boys in these studies were circumcised. Regardless, this amount of benefit seems to pass the threshold for coverage by insurance (which is low), so the procedure is available.
Another benefit sometimes mentioned is a reduced risk of penile cancer. Case control studies have reported that uncircumcised men have a three times greater chance of developing penile cancer. Again, this is relative: Penile cancer is very rare in the United States, so the actual risk reduction from circumcision is very, very small. It’s estimated that more than 300,000 infants might need to be circumcised to prevent one case of penile cancer.
Some argue that circumcision can reduce the chance of contracting a sexually transmitted infection later in life. A systematic review of 26 studies found that circumcised men are at a lower risk of syphilis or chancroid. There might be some protection against herpes, but it’s less significant.
The strongest case for circumcision can be made as a benefit against the transmission of H.I.V. In Africa, where H.I.V. is much more prevalent,randomized controlled trials of circumcision have been performed. The results were quite convincing. Absolute rate reductions of 1-2 percent over one to two years were seen. Some estimate that for 10 to 20 males circumcised, one fewer man might contract H.I.V. over a lifetime. One study likened circumcision to a vaccine of high efficacy.
Again, though, these results apply to countries with a much higher prevalence of H.I.V. than we see in the United States. The protection afforded, therefore, is much less significant here.
Opponents of circumcision point to its potential downsides. Surgical complications, while rare, are greater than zero. Pain is a concern as well; evidence exists both to support and rebut the notion that infants recover quickly.
More prominent concerns focus on sexual function and satisfaction. Opponents argue that the foreskin, like much of the penis, contains many nerve endings. It also protects the head of the penis; without it, the penis might become less sensitive over time.
But does this actually happen? A recent study in the Journal of Urology, discussed in The New York Times, measured penile sensitivity in circumcised and uncircumcised men and found no real difference. It wasn’t the first, or the best, study to look at this.
A randomized controlled trial of more than 2,700 men in Kenya found that after circumcision they experienced increased sensitivity, and that they had an easier time reaching orgasm. A systematic review and meta-analysisfound that circumcision was unrelated to premature ejaculation, erectile dysfunction or difficulty achieving orgasm.
Over all, the evidence arguing for and against circumcision fails to make a compelling case in either direction. The benefits, while arguably real, are small; likewise the harms. In such cases, we usually leave the decision to the patient.
There is, of course, an ethical problem here, since the choice is almost always made by parents, not by the boys themselves. Circumcision is irreversible, and many argue, quite stridently, that this is “genital mutilation” inflicted on children for no reason.
All cards on the table: I’m Jewish, and I’m circumcised, as are both my sons. The procedure has a spiritual weight in my community. When confronted by people who use terms like mutilation, I generally recoil. Circumcising my boys was a personal decision for my wife and me, and I understand the various arguments for and against. People angry about this choice seem to imagine that we haven’t thoroughly considered it.
I also live with the knowledge that it’s possible that my children might have chosen differently. But we also have to recognize that parents make many, many decisions for their children with a greater and more meaningful impact on them than circumcision. That’s what parents do. Assuming that this is the most consequential one we might have made about our boys’ lives, and focusing so much attention on it — when evidence makes the value of either choice unclear — seems out of proportion.
That doesn’t mean opponents don’t have a point. Circumcision is much rarer in most other industrialized countries. Health organizations in those countries don’t advocate the procedure as we do in the United States. An argument can also be made for waiting until boys are old enough to make a decision for themselves. A number of factors make that difficult, though. It’s a more complicated procedure then, with greater risks and higher costs.
Given that religion and culture are tied up in this, it’s clear that this issue won’t be decided soon. It’s also clear that evidence won’t make anyone’s choice easier. In the end, the decision as to whether parents opt to have their babies circumcised will remain a personal one.
