Defying science, American parents are turning away from male circumcision

My wife and I are currently expecting our first child in late October, a boy, and we recently started discussing whether or not to circumcise. For those unaware, circumcision is the surgical removal of the foreskin covering the tip of the penis. I entered the discussion in favor, but with no strong feelings either way. However, after researching the scientific literature and expert opinion, I came out firmly for the procedure, and frankly somewhat frustrated at the recent trend against it.

It’s not hip to nip the tip

Circumcision has become an increasingly fraught topic over the past few decades, as new American parents have grown uncomfortable with the idea of severing a piece of their child’s body, minor though it may be. This is understandable from an ethical perspective: A newborn baby cannot consent to such an unalterable act. Anti-circumcision advocates argue that it is better to forgo the procedure in infancy and allow the child to make his own decision later on. As a result of this intuitive reasoning, rates of circumcision have fallen from about 85% in 1965 to roughly 58% in 2010, the latest year for which solid data is available.

Parents, however, also have the responsibility to do what’s best for their child, even if that decision causes personal discomfort. And the evidence for the health benefits of circumcision, accumulated over decades of research, is overwhelming.

Firm evidence in favor of circumcision

“Our risk-benefit analysis showed that benefits exceeded procedural risks, which are predominantly minor, by up to 200 to 1,” an international team of researchers reported in a 2017 systematic review of 140 studies conducted in the prior decade.

The myriad benefits include:

• A large reduction in urinary tract infections, which affect 1 in 12 circumcised males over their lifetime compared to 1 in 3 uncircumcised males.
• A large reduction in balantis — a painful, itchy, and potentially disfiguring swelling of the head of the penis — typically caused by fungal infection. The lifetime rate is 12% for uncircumcised men vs. 2% for circumcised men.
• A 15% to 50% lower risk of prostate cancer. Prostate cancer is the second leading cause of cancer death in U.S. men, killing 34,500 every year.
• An up to 70% lower rate of contracting HIV. (Though this was derived from studies conducted in Africa. The reduction in the U.S. is probably lower, potentially just 16%.)
• A 50% lower risk of contracting genital human papillomavirus.
• A greatly reduced risk of penile cancer (even though it is rare). The lifetime risk is approximately 1 in 1,000 for an uncircumcised man vs. 1 in 50,000 to 1 in 12,000,000 for a circumcised man.
• A reduced risk of giving female sex partners bacterial vaginal infections and sexually transmitted infections.

The moist, warm environment under the foreskin is a hub for fungal and bacterial growth. Proper penis hygiene can be a challenge for uncircumcised males.

In 2012, public health researchers at Johns Hopkins University tallied the national costs of falling circumcision rates in the United States.

“If U.S. male circumcision rates among men born in the same year dropped to European rates (~10%), there would be an expected 12 percent increase in men infected with HIV (or 4,843); 29 percent more men infected with human papillomavirus (57,124); a 19 percent increase in men infected with herpes simplex virus (124,767); and a 211 percent jump in the number of infant male urinary tract infections (26,876). Among their female sex partners, there would be 50 percent more cases each of bacterial vaginosis (538,865) and trichomoniasis (64,585). The number of new infections with the high-risk form of human papillomavirus, which is closely linked to cervical cancer in women, would increase by 18 percent (33,148 more infections).”

Flaccid objections

Critics contend that male circumcision reduces sexual pleasure later in life, leading to regret, that it causes harm and frequently results in adverse outcomes, and that it can easily be performed later in life at the son’s own choice. Accumulated evidence counters all these objections.

High quality studies show no difference in sexual function and potentially increased penile sensitivity after circumcision. A survey of circumcised and uncircumcised men published earlier this year found no differences between the groups in feelings of regret about their circumcision status or sexual satisfaction. Adverse events occur in about 0.4% of infant circumcision procedures, almost all of them minor with no long-term complications. Surgical providers in the U.S. now commonly utilize analgesia to numb any pain during the process.

Lastly, as Australian scientists wrote in 2019, compared to circumcision later in life, infant circumcision is “simpler, quicker, less expensive, with lower risk of complications, healing is faster, and the scar can be almost invisible.” They added, “There are substantial barriers to later circumcision. These barriers include the decision process, peer pressure, affordability, slower healing, pain during nocturnal erections, the need to abstain from sexual activity for ∼6 weeks, and a visible scar afterwards.” The simple fact is that the overwhelming majority of uncircumcised males do not choose to get circumcised later, even if it’s to their benefit, because the procedure is much more onerous, risky, and expensive.

As Missouri urologists Elizabeth A. Piontek, MD and Justin M. Albani, MD wrote in 2019, “Parents make countless decisions on their children’s behalf daily to keep them healthy and safe, and this routinely includes procedures as well. Clearly, circumcision and its medical benefits fall within this same scope.”

Parents are, of course, free to make their own decisions in regard to their young children. The American Academy of Pediatrics said as much in their latest position statement on circumcision, noting that the benefits do outweigh the risks, but ultimately parents should make the choice. However, the simple fact is that if parents choose not to circumcise, they are denying their sons clear medical benefits that will improve their health and the health of their future partners.