“If you are ever presented with a multifaceted social problem and the first solution that springs to your mind is “We’d better cut off part of everyone’s penis,” you might want to consider another line of work.”
Fatherhood For Geeks

circumcision bannerI received a comment today on my circumcision series questioning whether I had fully considered the role of circumcision in reducing STIs (Sexually Transmitted Infections).  Clearly this was from someone working in the field and who has a real interest in lowering STI rates in the US – a laudable effort, in my opinion – however, I immediately felt myself get annoyed because I find the issues surrounding STIs to be far more complex than just reducing it to circumcision.

First, let me say that the research has generally been mixed with some finding lower STI rates in circumcised men whereas others show no difference at all, though most importantly, most of this research has taken place in developing nations.  Notably, studies in “developed” nations like the United States[1], Britain[2], and Australia[3] have failed to find associations, suggesting the significant findings stem from other factors in developing nations that account for these differences (for a general meta-analysis, not by country and including developing nations, supporting the link between lower STIs and circumcision, see [4]).  There is one study, however, from New Zealand which suggests a strong association with circumcision and reduced STIs[5].  Using a birth cohort (meaning they followed these children from birth), they found that being circumcised (prior to age 1) reduced rates of STIs by 48.2%.  Huge, right?  On an epidemiological level, this would cause many to raise their eyebrows and want to know more.

And yet, I’m about to say it’s still crap.  Not crap in that the research was bad – not at all, in fact the research was very well done as the authors controlled for many confounding variables that should be related to STIs and still found significant results.  But crap in that the conclusions still ignore some very basic issues.

Let’s look…

  • The study included 510 men in total.
  • 42 individuals reports having an STI: 10.4% of the uncircumcised men and 4.6% of the circumcised men.
  • 10.4% of the uncircumcised group is equal to 37 individuals.
  • Routine infant circumcision would reduce the rate of STIs by 48%, or a reduction of 18 people in a sample of 356 (the number of uncircumcised men in the sample).
  • An average complication rate of 1.5%[6] means that of the 356 boys who would be circumcised, approximately 5 would have complications from circumcision.

Okay, so if we’re completely utilitarian about it, we see that RIC would keep 18 people in this sample from having an STI but 5 of these people would have had complications from the surgery.  The sheer numbers might suggest a benefit of RIC, but now we have to look at what we’re dealing with – sexually transmitted diseases for which other behaviour plays a large role.

  • Notably, in this sample of 510 men, 77% reported having unprotected sex (88.6% of the people who actually had an STI).
  • Furthermore, those with an STI reported an average of 20.6 sexual partners between the ages of 18 and 25 compared to 11.7 for those without an STI.

Call me weird, but shouldn’t THIS be the crux of the issue?  Why did no one this to say, ‘Hey! Look, we’ve got kids who are running around having LOTS of unprotected sex.  Maybe this will affect the STI rates?  Perhaps we should focus on this?’  I realize public health policy wants a quick fix that can be implemented easily.  Circumcision is that I suppose.  But it is NOT the answer to this.  If studies from other developed nations tell us anything, it’s that there may still be other factors at hand here.

Let me add this though: even if there was a benefit with respect to later sexual behaviour, it STILL doesn’t support circumcision for me.

Why?  Because you’re talking about inflicting pain (sometimes a lot depending on the pain relief used, but even the best pain relief isn’t 100%, or even close) on a newborn.  We know this increases the risk of problems breastfeeding[7] and that children who were circumcised show heightened pain responses to later pain like vaccinations[8], meaning that there are observable long-term effects that many have discounted.  If months later, the pain response is that heightened, we can say we have physiologically altered our children’s neurological response to pain (even when pain relief is used).  We know that no child can possibly consent to this procedure as they are too young, and that the argument that it is awful to have to have done as an adult (when done for medical reasons) should inherent mean we don’t want to do this to our newborns.  If it’s awful for an adult, why would we subject infants – who have no real comprehension of what is happening to them – to such a procedure?

If you want to reduce STIs, let’s look at getting real, honest, good sex ed in the classroom.  Let kids learn that sex can have very serious consequences and how they can reduce these risks but also how effective these methods are.  I’m continually dismayed when I hear of younger people shocked they got pregnant or got an STI because they used some form of birth control so ‘how could it happen?’.  Often people aren’t even using methods correctly which further reduces the effectiveness.  THIS is what our kids need.

What we don’t need is to round up all the males and cut off a part of their body.


Update:  Another study out of NZ contradicts the significant findings between circumcision status (early circumcision versus no circumcision) and STI status.  Again looking at birth cohorts, these authors found no differences between the two groups which remained non-significant when controlling for other pertinent variables, including sexual behaviour.  This adds to the literature from other countries that has found circumcision does not protect against STIs, despite some significant studies out of developing nations.  Source: Dickson NP, van Roode T, Herbison P, Paul C.  Circumcision and risk of sexually transmitted infections in a birth cohort.  Journal of Pediatrics 2008; 152: 383-7.

[1] Laumann EO, Masi CM, Zuckerman EW.  Circumcision in the United States.  Prevalence, prophylactic effects, and sexual practice.  JAMA 1997; 277: 1052-7.

[2] Dave SS, Johnson AM, Fenton KA, Mercer CH, Erens B, Wellings K.  Male circumcision in Britain: findings from a national probability sample survey.  Sex Transm Infect 2003; 79: 499-500.

[3] Richters J, Smith AMA, de Visser RO, Grulich AE, Rissel CE.  Circumcision in Australia: prevalence and effects on sexual health.  Int J STD AIDS 2006; 17: 547-54.

[4] Weiss HA, Thomas SL, Munabi SK, Hayes RJ.  Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis.  Sex Transm Infect 2006; 82: 101-10.

[5] Fergusson DM, Boden JM, Horwood J.  Circumcision status and risk of sexually transmitted infection in young adult males: an analysis of a longitudinal birth cohort.  Pediatrics 2006; 118: 1971-7.

[6] Weiss HA, Larke N, Halperin D, Schenker I. Complications of circumcision in male neonates, infants and children: A systematic review. BMC Urology 2010; 10: doi:10.1186/1471-2490-10-2.

[7] Hill G.  Breastfeeding must be given priority over circumcision.  J Human Lact 2003; 19: 21.

[8] Taddio A, Katz J, Ilersich AL, Koren G.  Effect of neonatal circumcision on pain response during subsequent routine vaccination.  The Lancet 1997; 349: 599-603.