Circumcision, Science, and Religion: Part 3

[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.