What is the REAL effect of circumcising men?

Those who grow up in the U.S. are often surprised to find out that in many European countries almost no men are circumcised. In the U.S., where the majority of men have had the procedure performed on them, it is pretty common to hear people say that foreskin is unclean, ugly, or even unhealthy. On the other hand, Europeans tend to find the idea of circumcision bizarre. “Why would you cut off a healthy part of your body?”, they wonder. And “How would you feel about a culture that cut off their children’s ear lobes?”

Even medical experts in the U.S. and Europe can’t seem to agree about the benefits and costs. As one fairly recent paper put it:

The American Academy of Pediatrics recently released its new Technical Report and Policy Statement on male circumcision, concluding that current evidence indicates that the health benefits of newborn male circumcision outweigh the risks. The technical report is based on the scrutiny of a large number of complex scientific articles. Therefore, while striving for objectivity, the conclusions drawn by the 8 task force members reflect what these individual physicians perceived as trustworthy evidence. Seen from the outside, cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious, and the report’s conclusions are different from those reached by physicians in other parts of the Western world, including Europe, Canada, and Australia. In this commentary, a different view is presented by non–US-based physicians and representatives of general medical associations and societies for pediatrics, pediatric surgery, and pediatric urology in Northern Europe. To these authors, only 1 of the arguments put forward by the American Academy of Pediatrics has some theoretical relevance in relation to infant male circumcision; namely, the possible protection against urinary tract infections in infant boys, which can easily be treated with antibiotics without tissue loss. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts, and penile cancer, are questionable, weak, and likely to have little public health relevance in a Western context, and they do not represent compelling reasons for surgery before boys are old enough to decide for themselves.

When experts disagree we’re in a bind. We have little choice but to fall back on our own thinking and research to separate bias from the truth. There are, of course, many people who circumcise their children for religious reasons. For those who have no religious reason, is there any reason to do it?

It seems to me  that we can  formulate a pretty strong argument about circumcision, before we even start to dig into the evidence:  circumcision should only be performed routinely on all male infants if we can identify strong benefits to the child from doing so. That is, without a strong reason to perform the procedure, we should not do it. I conclude this for three reasons:

1. Some of the costs of circumcision are obvious to everyone and very real (e.g. the monetary cost to parents and insurance companies, the pain inflicted on the baby, and the very occasional surgical error, maiming and death). Performing the procedure only makes sense if there are compelling positives that outweigh these well-known costs.
2. The foreskin is a natural part of the human body, and therefore very likely promotes a useful survival or mating purpose. There have been different proposals for what this purpose might be (like keeping in moisture, protecting the penis, or increased sexual pleasure). But one can reasonably assume that foreskin is not merely a fluke, and therefore may well have some use we care about, even if we don’t know quite what that use is.  Because of this, it seems we should not remove the foreskin unless there is a pretty useful reason to do so.
3. Since adults can elect to get circumcised, we should be careful about forcing children to get this procedure at ages where they are too young to make such a choice. If a strong general reason to circumcise children is not found, it would make sense to let each person choose whether they want that procedure when they are old enough to make such a choice.

This line of reasoning leads us to ask: is there compelling evidence that circumcision adds significant value in the form of increased health, improved sexual function, or reduced disease transmission?

Well, you can take a look at the claims and evidence yourself. Here is a table I compiled of the many, many alleged pros and alleged cons of circumcision that I’ve heard made by people on the different sides of the debate. For each claim, I try to link to some studies that support or deny that claim. I focus on meta-analyses of randomized controlled trials, and randomized controlled trials themselves, since they provide far stronger evidence than other study designs. This does not provide a comprehensive set of all studies on male circumcision of course, nor is it a formal systematic review of the literature. But some conclusions quickly emerge:

• Some of the alleged pros and cons that people throw around have randomized controlled trials contradicting them, but continue to be used to support agendas anyway.
• A number of studies are themselves contradicted by other studies (for instance, various results about the impact of circumcision on sexual pleasure seem to point in opposite directions).
• Circumcision does seem to substantially reduce the rates of transmission of HIV from women to men in countries where HIV prevalence is very high.
• Even so, it’s not obvious that this HIV reduction effect is worth it for those who practice safe sex in areas of the world where HIV prevalence is low.
• There is some (small) amount of evidence that hints that male circumcision may make woman more at risk for HIV, but without more studies it’s hard to say.
• Many of the studies used to support claims on both sides are of low quality (for instance, a lot of the evidence of reduced urinary tract infections for circumcised infants is based on observational studies, which are very bad for answering this sort of question…we need randomized controlled trials).
• This topic is extremely complicated! There are tons of different claims being made and there are inconsistent research results for some of the claims. In many cases, few studies have ever been done in the first place, and even fewer high quality studies have been done (though keep in mind that this table is not anywhere close to a complete listing of all circumcision studies).

Click here for the complete table with studies that support and deny each claim.