Circumcision: To Snip or Not to Snip?

Circumcision is the surgical removal of the foreskin of the penis. It is part of religious custom for Jews and many Muslims, for reasons that have been lost to history. The popularity of circumcision in other groups of men has waxed and waned depending on prevailing notions of health, cleanliness and parental preference. For example, the percentage of US men who were circumcised rose steadily from about 30 percent in the 1930s to 90 percent in the 1970s. Since then, the rate has been dropping: about 64% of American male infants were circumcised in 1995.

Until recently, I was among those who viewed non-religious circumcision as a medically unnecessary procedure and, thus, one not worth the (admittedly minor) pain and risk of complications. But I've changed my mind about this in light of a number of recent studies showing that circumcision does have some clear medical benefits.

The most dramatic benefit is that circumcised men have a much-reduced risk of acquiring HIV from women, which is a significant factor in countries with a high general prevalence of HIV. (Whether circumcision reduces HIV transmission between men is still an open question.)

In addition, a recent study found that circumcision reduced the risk of genital herpes by 28 percent and the risk of human papilloma virus (HPV) by 35 percent. Other studies have shown that circumcision reduces the risk of penile cancer. Finally, removing the foreskin also allows men to avoid medical problems of the foreskin, the most common of which is phimosis, the inability of the foreskin to retract from the head of the penis. This can be a painful condition that can interfere with both sexuality and fertility.

Why removing the foreskin can help prevent some sexually transmitted diseases is still not certain, but is probably due to the fact that the inner foreskin is thinner and more permeable than the outer skin of both the foreskin and the penis itself. In addition, the inner foreskin's relative fragility means men may get small cuts or abrasions there, which would increase the chances of blood-to-blood transfer of diseases.

Circumcision has only been shown to reduce a few STDs, however. It doesn't protect against diseases such as syphilis, gonorrhea, or herpes simplex virus type 2. In no way should circumcision be seen as providing the kind of protection from STDs that a latex condom confers: condoms are the best protection against such diseases, whether you are circumcised or not.

Of course, infant circumcision is one thing - it is almost always safe, rapidly-healing and non-traumatic (particularly if anesthetic is used). Adult circumcision is a more involved matter - healing is much slower and can be complicated by erections. Adult circumcision typically requires abstinence from masturbation or intercourse for between 4 and 6 weeks. Still, I believe that adult circumcision may be medically warranted in populations at very high risk for the diseases (i.e. HIV) it is known to protect for. It is also, of course, advisable in cases of painful or dysfunctional phimosis or other, rarer, problems related to the foreskin.

The American Academy of Pediatrics has not yet revised its current stance against infant circumcision, but I believe the evidence in favor of circumcision is building and that the AAP may shift its position in the future. In the meantime, I'm comfortable with the position of the American Urological Association, which says that infant circumcision has potential medical benefits and advantages as well as potential disadvantages and some very small risks; therefore, the decision about whether to snip or not to snip should be left to the parents in consultation with their health-care provider.

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