Circumcision, Science, and Religion: Part 3

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By Tracy G. Cassels

Picking up where we left off…

The Science around Circumcision, continued

Sexual Functioning

While this is an area that hopefully is not an immediate source of concern for some parents (and may perhaps be seen as a benefit by some), there are those that claim that sexual satisfaction is reduced for both men who are circumcised and their female partners.  Part of the problem with this line of research as a whole is that is primarily focuses on males who have been circumcised as adults for one reason or another (e.g., [1][2][3][4]).  This has a couple implications for the research.  First, many men who are circumcised as adults do so for medical reasons meaning that the medical reason may influence sexual functioning prior to circumcision, and the results are thus not truly reflective of circumcision per se[3].  Second, it tells us nothing about the sexual satisfaction of men who are circumcised earlier in life.  While it may be seen as reasonable to believe that the outcomes would be the same, there is also no reason to believe it would be the same given that an individual who grows up circumcised may have completely different sexual experiences, particularly as they also may not have the medical conditions associated with adult circumcision.

With respect to male sexual satisfaction, results of studies are mixed.  On the one hand, there are studies suggesting that male sexual satisfaction is the same or even greater post-circumcision[1][4][5], and on the other we have studies finding worsened sexual satisfaction post-circumcision[2][3][6].  The same can be said for female satisfaction, with some research finding greater female satisfaction[7] and others not[8].  So what can we make of these contradictory findings?  One of the things that stands out is that the findings regarding increased sexual satisfaction were nearly all found in Africa whereas the findings about a loss of sexual satisfaction were all found in Western countries.  This applies for both men and women.  While this gives us something to look into, it’s unclear how it affects the results.  For example, the findings from Africa are true randomized controlled studies, so in one way they would be more applicable to many men in Western nations.  On the other hand, they were all conducted in places with rampant HIV, meaning sex prior to circumcision may also have been tainted with worry about very severe consequences which were potentially alleviated after circumcision.  After all, all the men knew they were being circumcised to help reduce the HIV transmission rate.  Similarly, the men in Western countries typically received circumcision for medical reasons, making their pre-circumcision ratings potentially irrelevant for men not suffering the same fate.  However, it’s unlikely that a medical condition increased sexual satisfaction, so if circumcision resulted in even less sexual satisfaction, that may be important for men and women to be aware of.

What does this mean?  Really this is a toss-up.  Far more research is needed before any firm conclusion one way or the other can be made.  This is especially true for men circumcised early in life for whom there is little research.  One survey study out of Denmark[6] did not specify adult circumcision and did find a decrease in sexual satisfaction for both men and their female partners, but one study does not a full conclusion make.  In my humble opinion, this is one area in which far less is known than people on both sides seem to believe.

Complications

There is no point denying that there are complications to circumcision.  The most common complications include blood loss and infection, but more serious complications include fusions, meatal stenosis (narrowing of the urethral opening), penile amputation, and death[9][10].  The question is really how frequently these complications occur and thus how to weigh the “benefits” versus the risks.  Results are mixed on how common various complications are, but larger a review of the research found an average complication rate of 1.5% (range of 0-16%) in neonates and 6% in children (range of 2-14%)[11].  Bleeding is the most common complication and in one study it alone was found to occur in 1% of cases[12].  One consideration is that these numbers typically involve complications that are apparent right after or shortly after the circumcision process and thus do not account for longer-term complications that may arise.  To this end, one study out of MassGeneral Hospital reported that 4.7% of child operations during a one-year period were done to correct previous complications from previous neonatal circumcision while 7.4% of cases in the outpatient clinic were seen because of less serious problems due to neonatal circumcision[13].

These are not numbers to ignore.  While 1.5% can seem small, when it comes to surgery, particularly non-life saving surgery performed on infants, one would hope for complication rates to be much lower.  Why do I say this?  Because the conditions for which circumcision has shown benefits have far lower risk percentages than 1.5% (with the exception of HIV in Africa, but that is adult circumcision and thus done on willing, informed adults and adolescents).  Interestingly, urinary tract infections have an occurrence rate of around 1%, similar to the rate of complications for circumcision, and while research has shown a potential to reduce the rates of UTIs via circumcision, UTIs are also listed as a common complication of circumcision in Israel[14].  This raises the question of how beneficial circumcision can be for UTIs when it also raises the risk.  Notably though, complication rates seem to be much lower in Israel (less than .01%)[15], where presumably there are far more skilled individuals performing the surgery, a factor that has been highlighted in reviews as being a huge factor influencing the rates of complications[9][11][13][16][17].

What does this mean?  It means complications are real and should not be discounted.  While there are clearly factors that can influence the rate of complications, like the skill of the individual performing the surgery, the fact remains that even with a skilled individual, there is a chance of both minor and major complications.  While death is rare (1 in 500,000 cases), it is not unheard of, and neither is a full penile amputation (1 in 1,000,000).  And while many of the complications can be handled quickly and effectively, some of the more serious or longer-term ones are not so simple.  When you consider discussions around making circumcision routine, we have to start thinking about how these numbers increase.  With approximately 2 million boys born each year in the United States, routine circumcision complications would affect approximately 20,000 boys and result in 4 deaths.  The question each parent has to ask, is it worth it?

Scientific Summary

There are clearly relationships in the research between circumcision and certain positive health outcomes.  The links to a reduction in sexually transmitted diseases (specifically HIV, though certain studies suggest HPV as well) is well-documented in Africa, if not as clearly in the West.  Penile cancer could be nearly eradicated with routine circumcision and urinary tract infections may also decrease.  However, and this is a big however, there are a few considerations that temper any “benefits” that may be seen.  First, the largest effects are for sexually transmitted diseases and the positive effects of circumcision are being found in adult circumcision.  No intactivist (that I know of) is against an adult making an informed decision about surgery that may reduce the risk of HIV or other STDs.  In fact, neonatal circumcision is not at all necessary in reducing these rates.  Second, when neonatal circumcision is suggested as being “necessary”, as is the case of penile cancer, research has also shown that it is not the circumcision per se that reduces the rates, but the effect on other factors, in this case, phimosis.  To me, this suggests that there may be other ways and other means to reduce the rates of penile cancer without resorting to routine newborn circumcision.  Third, all of these benefits must also be weighed against the pain and complications that are very real and present in circumcision.  At the very least, I believe these considerations would negate any push for routine circumcision, but must also be considered by any individual thinking of circumcision, for medical or religious reasons.

All of this research raises another question that must be answered… if adult circumcision is acceptable and can confer some of the benefits discussed herein, why is that not the answer?  Well, first there’s the religious aspect which seems to dictation earlier circumcision (neonatal for Jewish individuals and childhood for Muslim), but second there is the belief that the procedure is less “traumatic” in infancy.  We head there next.

To be continued… Click here for Part 4

For Part 1, click here.

For Part 2, click here.



[1] Kigozi G, Watya S, Polis CB, et al. The effect of male circumcision on sexual satisfaction and function, results from a randomized trial of male circumcision for human immunodeficiency virus protection, Rakai, Uganda. Sexual Medicine 2008; 101: 65-70.

[2] Masood S, Patel HRH, Himpson RC, Palmer JH, Mufti GR, Sheriff MKM. Penile sensitivity and sexual satisfaction after circumcision: Are we informing men correctly? Urologia Internationals 2005; 75: 62-65.

[3] Fink KS, Carson CC, DeVellis RF. Adult circumcision outcomes study: Effect on erectile function, penile sensitivity, sexual activity and satisfaction. Journal of Urology 2002; 167: 2113-6.

[4] Krieger JN, Mehta SD, Bailey RC, et al. Adult male circumcision: Effects on sexual function and sexual satisfaction in Kisumu, Kenya. J Sex Med 2008; 5: 2610-22.

[5] Senol MG, Sen B, Karademir K, Sen H, Saracoglu M. The effect of male circumcision on pudental evoked potentials and sexual satisfaction. Acta Neurol. Belg. 2008; 108: 90-93.

[6] Frisch M, Lindholm M, Gronbaek M. Male circumcision and sexual function in men and women: A survey-based, cross-sectional study in Denmark. International Journal of Epidemiology 2011; 40: 1367-81.

[7] Kigozi G, Lukabwe I, Kagaayi J, et al. Sexual satisfaction of women partners of circumcised men in a randomized trial of male circumcision in Rakai, Uganda. BJU International 2009; 104: 1698-1701.

[8] O’Hara K, O’Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU International 1999; 83: 79-84.

[9] Ceylan K, Burhan K, Yilmaz Y, Can S, Kus A, Mustafa G. Severe complications of circumcision: An analysis of 48 cases. Journal of Pediatric Urology 2007; 3: 32-35.

[10] Bocquet N, Chappuy H, Lortat-Jacob S, Cheron G. Bleeding complications after ritual circumcision: About six children. European Journal of Pediatrics 2009; 169: 359-362.

[11] 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.

[12] Gee WF, Ansell JS. Neonatal circumcision: a ten year overview: with comparison of the Gomco clamp and the Plastibell device. Pediatrics 1976; 58: 824–827.

[13] Pieretti RV, Goldstein AM, Pieretti-Vanmarcke R. Late complications of newborn circumcision: A common and avoidable problem. Pediatric Surgery International 2010; 26: 515-8.

[14] Prais D, Shoov-Furman R, Amir J. Is ritual circumcision a risk factor for neonatal urinary tract infections? Arch Dis Child 2009; 94: 191-194.

[15] Ben Chaim J, Livne PM, Binyamini J, Hardak B, Ben-Meir D, Mor Y. Complications of circumcision in Israel: A one year multicenter survey. IMAJ 2005; 7: 368-370.

[16] Krill AJ, Palmer LS, Palmer JS. Complications of circumcision. Scientific World Journal 2011; 11: 2458-68.

[17] Sahin C, Toraman AR, Kalkan M. Complications of circumcision: Our experiences over the last 15 years. Eur J Gen Med 2011; 8: 176-181.

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Comments

  1. Jespren says

    Another thing that I find very telling about the preceived benefits/risks is, with the exception of uti (and conflicting info if that even is a benefit) and penile cancer, the ‘benefits’ of circumcision are all related to diseases that are almost 100% preventable to begin with. No one ever caught an std or hiv because of an intact penise, they catch them due to inappropriate sexual contact (which does include non consentual sexual contact which I why I said almost 100% preventable). So instead of preventing the diseases (almost) 100% of the time by harmless behavior choices, they are pushing for very minor reductions in risk that carry other risks of complications and is not harmless. Making a case for an invasive medical procedure on a male infant because they may decide to be stupid someday in the furture and practice risky behavior is no different than saying we should fit all prepubescent girls with a chastity belt because, once they hit puberty, they might be stupid and engage in risky sexual contact if we don’t. Actually the chastity belt would be worlds more effective in reducing std/hiv rates in both women *and* men and would make unmarried pregnancies almost impossible. It also has no serious medical risks and can be 100% reversed once the woman is ready to engage in safe sex. But we recognize that as utterly absurd. It makes a whole lot more sense risk/benefit wise than infant circumcision and uses the exact same logic as circumcision for the confired reduction in behavior-based diseases.

    • says

      I love your point – it’s so true. It seems ridiculous to suggest a procedure because there may in the future be a need that is also preventable via other means.

      • Jespren says

        I think I may have to be snarky and ask the next person who tells me they circumcised for std reduction if they are planning on a chastity belt for their daughters. ;) it really just amazes me sometimes how little people trust children/adolescents and how low their bar is for expectations.

        • says

          It’s something I had never thought of so I’m so glad you brought it up :) I mean, I’m all for adult circumcision in places like Africa where HIV is rampant (or even here if an adult wants to do it), but as a rationale for children? Really???

          • Chris says

            So I’ve been checking out this series and perhaps I’m missing it, but have you anything to say of the STI rates in America? It’s not HIV in South Africa or the Congo, but it looks as bad as or worse than HIV anywhere else in Africa. I think you might be dismissing the STI landscape too quickly, or rather, not giving it due respect. Let me give you a couple quick numbers to demonstrate: there were roughly 2O Million new STI’s in the U.S. in 2011 compared to roughly 2 Million new HIV infections in sub-Saharan Africa in the same year. STI’s lurk, especially in the south, where institutions don’t seem to be interested in informing our young people about them. I just don’t think we’re in position to wave off that set of benefits so easily. That said, I really don’t disagree otherwise about anything except your reading of some of the literature, but really only because some of that work is intimate.

          • says

            I’m not sure what you’re referring to. The STI research I’ve read has also been done in Africa and the few studies I’ve seen trying to replicate the effect in the US hasn’t been able to. Is there specific research you’re thinking of??

  2. says

    I was circumcised at birth. I had a tight circumcision. In my early 50s I started restoring my foreskin. Although I cannot replace all of the structures removed by my circumcision, I regained the lost sensitivity of my remaining mucosal tissue. I also got the gliding action, something I did not know existed before I started restoring. The difference before and after restoring is amazing. My sexual pleasure is through the ceiling compared to before restoring. I now have whole body orgasms for the first time in my life.

    Unfortunately, studies are only done when there is financing. Male circumcision makes more money than leaving babies intact. So, there are few studies that are aimed at supporting intact men. Even still, there are studies that show a significant number of men circumcised as an adult suffer a loss of sexual pleasure, regardless of the reason for being circumcised. The recent Dutch study supports this.

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