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Male circumcision is one of the most enduring controversies in newborn medicine, partly because there is no clear evidence for or against routine circumcision, from a public health standpoint. Efforts to identify a research-based approach have been frustrating. However, an interventional study from South Africa, which involved 3,000 men, showed for the first time that circumcising adult men can dramatically lower their risk of becoming infected by HIV through heterosexual sex.1 The study seems to correlate with epidemiologic studies that found a link between lack of male circumcision and an increased HIV infection rate.
What are the medical risks and benefits?
For many parents, medical reasons are not the decisive factors; circumcision is performed within a cultural and religious context. In some locales, the super-majority of boys are circumcised, and to avoid the stigma of “being different,” most parents ask for the procedure. In some religious faiths, circumcision is a demonstration of a covenant with God.
Benefits. Clinical studies indicate a reduced risk of urinary tract infections, penile cancer, penile inflammation, and transmission of some sexually transmitted infectious disease. For example, in a cohort study of 58,000 infants, the rate of hospitalization for urinary tract infection among circumcised and uncircumcised males was 1.9 versus 7.0 per 1,000 boys, respectively.2
Other studies have demonstrated that circumcision not only reduces the risk of penile cancer, which is truly rare, but also reduces the risk that a female sexual partner will develop cervical cancer—which is not at all rare. Monogamous female partners of circumcised men have been found to have half the risk of cervical cancer compared to women with uncircumcised partners.3 This may be due to a lower rate of human papillomavirus in circumcised men.
Risks of circumcision are mainly pain, bleeding, and local infection. Small but vocal groups vociferously oppose circumcision because the newborn cannot consent4 and because they believe the procedure may cause long-term emotional harm.5
AAP and ACOG recommendations
Based on an evaluation of risks and benefits, the American Academy of Pediatrics advised: “existing scientific evidence demonstrates potential medical benefits of newborn male circumcision, but the data are not sufficient to recommend routine neonatal circumcision. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision.”6 The American College of Obstetricians and Gynecologists supports this policy and adds that analgesia such as a dorsal penile nerve block or subcutaneous ring block should be used routinely for the procedure.7
Interestingly, the rate of newborn circumcision is on the rise: 48% of newborn males were circumcised in the United States in 1988–1991 versus 61% in 1997–2000.8
Epidemiologic studies of HIV risk
The role of circumcision in preventing sexually transmitted diseases has great public health potential, especially in countries with high rates of HIV infection. Many epidemiologic studies have reported a reduced risk of acquiring HIV infection with circumcision. A review of 30 studies found that uncircumcised men had an increased risk of HIV infection of 1.5 to 8.4 compared to circumcised men.9
A remarkable surgery study
Now, an interventional trial strongly supports the epidemiologic studies. In a clinical trial1 led by Dr. Bertran Auvert, more than 3,000 South African men, aged 18 through 24, were randomized to surgical circumcision or a control group that was not treated. After 13 to 21 months, the circumcised men had a 65% reduction in the rate of acquisition of HIV; new HIV infection was detected in 51 men in the control group compared with only 18 men in the circumcised group.
The complete report is not yet published due to issues regarding the investigators’ decision, approved by the local human subjects protection committee, that the HIV-positive men would not be routinely informed about their HIV status.
Three additional surgical trials that are underway in Africa will help clarify the benefit and risk of circumcision for prevention of HIV infections.
The unanswered questions
If clinical trials confirm the finding that circumcision provides strong protection against developing HIV, then in regions with a high prevalence of the infection, a simple surgical procedure may be one of the best interventions to prevent a life-threatening disease.
Key research questions are:
- Does circumcision reduce the ability of HIV-infected men to transmit the virus?
- If circumcision is performed to reduce HIV risk, does it actually discourage “safe” sexual practices?
- How do we balance the lesser risks (pain, bleeding, local infection) with potentially lifesaving benefits?