Kristin Palitza
Kristin Palitza

To cut or not to cut

Friends of mine had a baby boy a few weeks ago. When their doctor asked them if they wanted to circumcise their child, my friends asked if there were any health advantages to snipping off the foreskin. “None,” the doctor answered matter-of-factly. When they told me this story, I had to gasp for air.

I had just returned from the International Aids Conference in Mexico City where male circumcision was discussed as one of the hot topics for HIV prevention. Research has shown that men without a foreskin have 60% less chance of contracting the HI virus during heterosexual sex than their uncircumcised peers. (It’s still necessary to practise safe sex, of course!)

And this is not even particularly new — the research results had already been announced at the previous Aids conference, in Toronto in 2006. What has not been widely known is this: circumcision also lowers the risk of men getting the human papilloma virus (HPV) that causes genital warts and cervical cancer. This is good for men as well as for women who have sex with circumcised men — they run a much lower risk of contracting various sexually transmitted infections, not only HIV, and of getting cervical cancer.

Those who have been afraid that together with their foreskin they have to say goodbye to a whole lot of nerve endings can relax, too. Unlike commonly believed, studies have now shown that cutting off the foreskin has no effect on sexual sensitivity or performance.

All the above is not to say that circumcision is the right decision for everyone. The decision to cut or not to cut is not necessarily a straightforward one. Some people have cultural and religious aspects to consider, some want to let their child make an autonomous decision (later in his life) about opting for or against the procedure, and so forth.

But whatever people’s concerns are and whatever their final decision on the topic, it is important that a) doctors and health carers are aware of all the latest research regarding male circumcision; and b) they inform their patients in detail about the pros and cons so that they can make up their own minds.

Presenting them with one-sided, one-word answers to an extremely complex issue that, who knows, might one day be the deciding factor for someone’s health is simply not acceptable.

60 Responses to “To cut or not to cut”

  1. Jane #

    Tony, you claim that circumcision is beneficial to men because it gets rid of that moist environment under the foreskin.

    Well, then, why not promote circumcision for women? That moist environment under the labia traps all sorts of secretions and provides a perfect breeding ground for all sorts of disease, as demonstrated by the fact that women are far more prone to genital and urinary tract infections than either circumcised or intact men.

    Indeed, a research paper presented at the 2005 World AIDS conference showed that *independent of all other factors* female circumcision is associated with a reduced incidence of HIV. http://tinyurl.com/d9uom

    So, what’s sauce for the goose is sauce for the gander, right? Oh, no, never mind, I forgot — male circumcision is completely harmless while female circumcision is a human rights violation. Hmmmm, that’s not contradictory at all, is it.

    It’s not a “flat earth ostrich” position to take to recognize that a person’s genitals are theirs and theirs alone to decide to modify through surgery. It’s a simple, rational, CONSISTENT and logical position based on the premise that boys and girls alike have the fundamental human right to self-determination over their own bodies.

    August 21, 2008 at 4:23 am
  2. Joe #

    @RegalRadio

    You are right, I misspoke and actually for those four strains, it is estimated to be nearly 100% effective.[1] Even without this vaccine, HPV, penile cancer, and cervical cancer wasn’t considered a significant public health problem. There is even questions as to whether the use of the vaccine is reasonable.[2] The introduction of the pap smear reduced rates of cervical cancer significantly with only 11,000 diagnosed cases in the US in 2006 most of which, being caught in the precancerous stage, can be treated. This vaccine would reduce these number even further probably by more than half. As for penile cancer, it is the rarest form of male cancer and even the American Cancer Society does not recommend circumcision as away to prevent penile cancer saying in a July 2008 statement, “Most experts agree that circumcision should not be recommended as a way to prevent penile cancer.” [3] Broad use of circumcision for HPV protection wouldn’t even have been reasonable before there was a vaccine. So again I have to wonder why that excuse keeps getting brought up.

    At least we agree on the STD part. ;) I also believe that HIV protection is being over sold. It should be described, as Marge Berer suggested at the conference in Mexico City, this way: “circumcision should be publicly described as like a cheap condom that breaks 40% of [the] time.”[7] At least then people would know the truth as opposed to calling it a ‘surgical vaccine’. As far as rates in other countries go, at the very least it implies that low HIV prevalence is possible without the need for circumcision though I am pretty sure the US has a much worse HIV problem on all fronts then any other industrialized country. How much of this is due to condom compliance, in heterosexual cases, I don’t know but from an anthropological point of view places like Europe, the US, Australia, and New Zealand are essentially the same having similar access to education, resources, and other critical tools to reduce the risk of HIV.

    I know De Witte’s work was in vitro however, his conclusions were rational, applicable, and worthy of consideration. It is certainly possible that Langerin production is low in African populations for any number of reasons including but not limited to genetic or, more likely, living conditions and general health. All of which could serve to magnify the results seen in the RCT. It also illustrates why a decision to circumcise should be left to individual adults since it’s hard to know where research such as De Witte’s might take us in 15 or 20 years.

    This citation was updated:
    ” These results were similar to a recently published Australian study which found: “nearly all men who were circumcised after infancy reported some sexual dysfunction, erectile problems or premature ejaculation, and one in five reported some complication as a result of the circumcision. Particularly they were twice as likely to be bottoms.”[4] Perhaps the reason those circumcised in infancy didn’t report a problem was because they didn’t know any better, not a very ethical thought.”

    ” “When the boy is old enough, if the man that boy becomes find value in circumcision then he can get it.”

    This argument has some merit, but a child cannot consent to ANY potentially harmful or beneficial procedure done on their behalf. It is, after all, the parents’ role to determine what is in the child’s best interest. For some, the protective effects of circumcision may be compelling enough to have the procedure performed. ”

    This is true but there are limits to what the parents can authorize and what the physician can accept in the way of proxy consent. The AAP Committee on Bioethics report states, “Pediatric health care providers. . . have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses. . . . The pediatrician’s responsibilities to his or her patient exist independent of parental desires or proxy consent.” (p. 315)[6].

    To me, from an ethical perspective, this means that parents can only authorize, and physicians can only perform, procedures, by proxy consent, that are medically therapeutic. The Canadian medical ethicists, Dr. Margaret Sommerville, perhaps said it best: “A common error made by those who want to justify infant male circumcision on the basis of medical benefits is that they believe that as long as some such benefits are present, circumcision can be justified as therapeutic, in the sense of preventive health care. This is not correct. A medical-benefits or “therapeutic” justification requires that:

    1. Overall the medical benefits should outweigh the risks and harms of the procedure required to obtain them.

    2. This procedure is the only reasonable way to obtain these benefits.

    3. These benefits are necessary to the well-being of the child.

    None of these conditions is fulfilled for routine infant male circumcision.”[5]

    She goes on to discuss this in the context of HIV: “The most recent claim of a medical benefit from circumcision is a reduction in the risk of contracting HIV infection or other sexually transmitted diseases. The research on which this claim is based is being challenged, but even if it is correct, it would not justify circumcising infant boys. Even assuming that circumcision gave men additional protection from becoming infected with HIV, baby boys do not immediately need such protection and can choose for themselves, at a later stage, if they want it.”[5]

    For the most part, vaccines fit this description of therapeutic. They are the least invasive, most reasonable way, to protect oneself from a specific disease. Many of which can be caught from doing nothing more but circulating through the public, indicating an immediate need for this protection. Therefore, it can be rationally justified.

    Whether or not circumcision could be used as a HIV risk reduction technique in adult populations living in areas of high prevalence is quite irrelevant to an infant or a boy because, in addition to not fitting the definition of medically therapeutic, the value of that risk reduction is subjective. For me, the subjective value is 0 (I concede that other individuals might self evaluate this differently). On the other hand circumcision causes objective harm, every time. The subjective value of that risk reduction can only be evaluated by the individual. Therefore, going back to the original post, the Dr. was right in his/her assertion.

    1. http://tinyurl.com/5o338b
    2. http://tinyurl.com/5cp85v
    3. http://tinyurl.com/ddzuk
    4. http://tinyurl.com/6dc84b
    5. http://tinyurl.com/6c5jcw
    6. American Academy of Pediatrics Committee on Bioethics. “Informed Consent, Parental Permission, and Assent in Pediatric Practice.” Pediatrics 95 (1995): 314
    7. http://tinyurl.com/5d9u5o

    August 21, 2008 at 5:28 am
  3. Sunkenship

    I am not pushing anything, just giving facts that I know. I thought I made it clear – I have never considered this question seriously because I never had a son.

    But just to stir the pot a little, there was an article in the Weekend Argus of July 19 2008 by Melanie Peters “Circumcision can lead to mental illness” on the study by Medical anthropologist , Lauraine Vivian “”Psychiatric Disorder in Xhosa speaking Men following Circimcision”. Having read it – I would say either circumcise as a baby – or leave to the adult man to decide ( AND I do NOT mean at age 12/13).

    August 21, 2008 at 6:40 am
  4. Lyndall, seeing that i’m a Xhosa man circumized in his late teens; do you see any signs of insanity in any of my posts of blogs?

    As my man Ndumiso says, expert opinions are just bollocks. Get your “feedback” from people who have been circumsized in their adulthood (a whole generation of Xhosa men i know) and you learn much more.

    August 21, 2008 at 9:57 am
  5. Lisa #

    @Regalradio

    Education, in this case, supports common sense (just in case you haven’t being paying attention). You are avoiding common sense by splitting hairs.

    When I said :“Really this argument defies all common sense!” , I was clearly referring to your point that one cannot extrapolate what the effect on overall sexual pleasure would be as a result of removing the most sensitive region of the penis. I am asking for your common sense to kick in here, independent of comparisons with the clitoris. When nerves are gone, are you really arguing that sexuality can logically remain unaffected?
    And by stating that in studies of FGM victims “much of the sexual dysfunction these women experience can be resolved”, you make my point. Leave these children (boys and girls) in tact so that you do not have to address the issues of whether any damage has been done and how you may be able to resolve it (or not).

    August 21, 2008 at 11:32 am
  6. Mandrake

    Might it not depend on the leader of the school – there seem to be a lot of charletans out there.

    Also, from the article, it appears that the problem almost always occured with boys that had no fathers to guide them through the process. Was your father around?

    August 21, 2008 at 4:18 pm
  7. Don #

    Well! I can’t believe the rubbish I’ve been reading in this column and all the pro-circumcision comments that follow.

    There’s no arguing with the pro-circ lobby. These tragic people have an investment, usually a deeply personal one, in keeping the mutilation ball rolling, in much the same way that bullied children sometimes become bullies themselves.

    Try this little thought experiment. Suppose circumcision had not been invented; suppose every male in the world had an intact penis. How THEN would you respond to some dubious American scientists (almost certainly victims of circumcision themselves) urging you to have your penis mutilated?

    Right, I thought so.

    August 29, 2008 at 5:07 pm
  8. Kristin

    You stirred a lot of controversy on this one. However, Sol Plaatjies would have agreed with you. He was totally opposed to circumcision rituals. He said they were barbaric, had died out, and been reintroduced by colonialists and puppet chiefs to re-tribalise his people. If you are interested, I could look up the quote.

    November 23, 2008 at 12:40 pm
  9. Jane #

    I worked as a nurse in the 1970s and 1980s where we assited with hundreds of circumcisions. None with any pain relief. It was considered risky and most doctors would insist that it only takes afew minutes anyway. I must admit there were never any children who needed to come back in after difficulties. I have seen the discomfort of patients who have a tight forskin also. The doctors were very good at them and it was a very straight forward procedure. Now im 71 and in complete favour of infant circumcision. I guess I just have old fashion views.

    January 14, 2009 at 1:57 pm
  10. Wesley #

    What a complete lie this is : “Unlike commonly believed, studies have now shown that cutting off the foreskin has no effect on sexual sensitivity or performance”

    Made up by American Jewish doctors to promote circumcision. Many studies have been done that prove that thousands of nerve endings are cut off and with that goes a major amount of pleasure. The most sensitive parts of the penis are removed and the gland, which is an internal organ is uncovered and becomes hard and calloused reducing feeling even further.

    The studies for Aids are also not conclusive as there were a large amount of people that never came back for their study that were excluded from the results. In fact a recent study from another part of the world proved that circumcised men are more likely to get Aids. It doesn’t matter much, as in all cases a condom still has to be used to prevent contracting Aids or STDs. It is so stupid that this South African circumcision trial is so widely promoted when this is the case.

    There should be no option given by any doctor to remove a newborn boy’s foreskin, as it is his body and he can choose to do with it what he would like to when he is an adult. This is pure genital mutilation if it is done without the boys consent.

    I sure don’t appreciate it being done to me and having to be scarred for life with hardly any pleasure

    September 20, 2009 at 10:58 pm

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