In 2012, the American Academy of Pediatrics published a policy statement in which they said that the benefits of male circumcision outweighed the risks of the procedure.  They cited health benefits, which, while not great enough to warrant a recommendation for all males to undergo the procedure, were significant enough in their minds to make sure that all who wanted it could get it and that it should be covered by insurance.  Not long after, the CDC concurred.  But what is the evidence for and against circumcision?  That's the topic of this week's Healthcare Triage.

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For years, pediatricians have cited studies that showed that being uncircumcised is a risk factor for developing a urinary tract infection.  They point to research that shows that penises that are circumcised have lower levels of yeast and bacteria on them.  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 circumcised.  

That's a relative rate difference, though, not an absolute difference.  The actual rates of urinary tract infection were 1.1% versus 0.1%, for an absolute rate difference of about 1%.  This means  that the number needed to treat is 100, or that 100 boys would need to be circumcised to prevent one urinary tract infection.  Other studies say the number might be even higher.

It's really hard to argue that 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 about boys who were circumcised against those who were not, especially since the vast majority, more than 80% of boys in those studies were circumcised.  

Regardless, this amount of benefit seems to pass the threshold for coverage by insurance, which is low, so it's available to any who want it.  

Another benefit sometimes touted for circumcision is a reduced risk of penile cancer.  Case control studies have reported that men who are uncircumcised have a three times greater chance of developing penile cancer.  Again, that's relative, though.  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 each year.

Some will 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 or syphilis or chancroid.  There might be some protection against herpes, but it's less significant.

The strongest case can be made for a benefit against the transmission of HIV.  In Africa where HIV is much more prevalent, randomized controlled trials of circumcision have been performed.  The results are quite convincing: absolute rate reductions of 1-2% over 1-2 years were seen.  Some estimate that for every 10-20 males circumcised, one fewer man might contract HIV over a lifetime.  One study compared circumcision to a vaccine of high efficacy.

Again, though, these results apply to countries with a much higher prevalence of HIV than we might see in the United States.  The protection afforded, therefore, is much less significant.  Those who oppose circumcision point to its potential downsides.  Surgical complications, while greater than 0, are quite rare.  Pain is a concern as well, although evidence exists both to support and refute the claim that male infants recover quickly from the procedure.

More prominent concerns focus on the sexual function and satisfaction of those who have been circumcised.  Opponents argue that the foreskin, like much of the penis, contains many nerve endings.  It also protects the head of the penis, and without it, the penis might become less sensitive over time, but does it?

A recent study in The Journal of Urology measured penile sensitivity in circumcised and uncircumcised men and found no real difference.  This wasn't the first nor the best such study to look at this, though.  A randomized controlled trial of more than 2,700 men in Kenya found that after circumcision, they experienced increased, not decreased, sensitivity, and that they had an easier time reaching orgasm.  A systematic review and meta-analysis found that circumcision was unrelated to sexual dysfunction, premature ejaculation, erectile dysfunction, or difficulty achieving orgasm.

Overall, the evidence arguing for and against circumcision unfortunately fails to make a compelling case in either direction.  The benefits, while arguably real, are small.  The harms are the same.  When that's the case, we usually leave the decision to the patient.  

There is, of course, an ethical problem here.  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, but the procedure has an ethnic and spiritual weight in my community and when confronted by people who use such language, I generally recoil.

Circumcising my boys was a personal decision for my wife and me and I understand thoroughly all of the various arguments made for and against the practice.  The anger directed by some of this choice imagines that we haven't thoroughly considered the decision for our children.  I also live with the knowledge that it's possible that one of my boys might have come to a different conclusion, but we also have to acknowledge that parents make many, many decisions for their children that have a greater and more meaningful impact on them than circumcision.  That's what parents do.  

Imagining that this is the most consequential decision we might have made about our boys' lives and focusing so much tension on it when evidence makes the value of either choice unclear, seems out of proportion, but that doesn't mean that opponents don't have a point.  Circumcision is much rarer in most other industrialized countries.  Health organizations in those countries don't advocate for the procedures as we do here.  An argument can also be made that we might wait until boys are old enough to make a decision for themselves before they undergo the practice.  A number of factors make that difficult though.  It's a much more complicated procedure then, with greater risks and it costs more.  

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 and while we may disagree with them, we should do so with respect, not derision.

Healthcare Triage is supported in part by viewers like you through patreon.com, a service that allows you to support the show through a monthly donation.  We'd especially like to thank our research associate Joe Sevits and our surgeon admiral Sam.  Thanks Joe!  Thanks Sam!  More information can be found at patreon.com/healthcaretriage.