BMJ  2007;335:1181 (8 December), doi:10.1136/bmj.39406.523762.AD

Head to head

Is infant male circumcision an abuse of the rights of the child? No

¹ BMJ, London WC1H 9JR

doi: 10.1136/bmj.39406.520498.AD

Most circumcisions take place for religious rather than medical reasons. Geoff Hinchley believes that the practice is harmful and should be stopped but Kirsten Patrick argues that the future sexual health benefits justify parental choice

Circumcision is one of the commonest surgical procedures performed on males, despite there being few absolute medical indications for it. The tradition of male infant circumcision accounts for this paradox. About 30% of men are circumcised; in most English speaking and Muslim countries circumcised men are in the majority, and most were circumcised in infancy.¹ Although opponents argue that infant circumcision can cause both physical and psychological harm, recent strong evidence shows that circumcision is medically beneficial. If competently performed, it carries little risk.² It cannot be compared with female circumcision, which has been shown to be no more than genital mutilation without medical benefit and with an unacceptably high likelihood of pain, immediate and long term medical complications, and psychosexual scarring.³

Although any surgical operation can be painful and do harm, the pain of circumcision, if done under local anaesthesia, is comparable to that from an injection for immunisation. Indeed, we urge parents to immunise their children, a procedure for which the infant cannot give consent and which carries the risk of adverse events ranging from fever to anaphylaxis and aseptic meningitis.

Evidence of benefit

The medicalisation of male infant circumcision in some countries in the 1940s and 1950s followed from a widespread belief that it reduced the incidence of urinary tract infections. However, a recent meta-analysis suggested the reduced risk conferred by infant circumcision, when taking into account the risks of complication, is meaningful only for boys with vesicoureteric reflux (for whom the number needed to treat is 4).⁴

Examination of data from seven case controlled studies of cervical carcinoma showed that circumcised men were less likely than uncircumcised men to have human papillomavirus infection.⁵ Male circumcision was associated with a reduced risk of cervical cancer in women with high risk sexual partners.

More robust research on HIV transmission has intensified the infant circumcision debate. A Cochrane review of observational studies in 2000, updated in 2005, confirmed that male circumcision was associated with a reduced risk of HIV infection.⁶ Stronger evidence has come from African randomised controlled trials investigating circumcision as an intervention to prevent HIV infection in heterosexual men.⁷⁸⁹ Two trials were stopped early at the interim analysis because they showed a reduced incidence of HIV infection among circumcised heterosexual men equivalent to a protection of more than 50%, after controlling for other factors.⁷

Male circumcision in a relatively high risk population gives protection from HIV that is equivalent to what a vaccine of moderate efficacy would have achieved.⁷ An AIDS expert, speaking at conference earlier this year, called for all boys born in South African public hospitals to be offered routine circumcision. "It is so blindingly obvious that there are real reasons for circumcision," he said.

South Africa’s prevalence of HIV infection is one of the highest in the world, second only to India’s. The benefit would be less in other countries, but circumcision could still reduce the spread of HIV. An estimated 39.5 million adults and children worldwide live with HIV; 3.8 million adults were newly infected with the virus in 2006, only a third of whom live in sub-Saharan Africa, and every region of the world saw an increase in the number of people infected with HIV; 40% of new infections were in 15-24 year olds.¹⁰ In the absence of a vaccine, surely any other reasonable weapon of prevention seems worth considering?

What is more, a 2006 systematic review and meta-analysis showed that circumcised men have a significantly diminished risk of acquiring chancroid and syphilis, while data from a large New Zealand birth cohort followed up to age 25 years suggested that uncircumcised men are almost twice as likely to get a sexually transmitted infection.^{11 12}

Where’s the harm?

Although the complication rate for infant circumcision is essentially unknown (because most operators are unregistered), considerable data from best practice environments suggests that it is between 0.2% and 3%, with most complications being minor.^{13 14} Case reports have associated circumcision with life threatening complications.

No robust research exists examining the long term psychological effects of male infant circumcision. Most evidence of psychological trauma in men is anecdotal. Until a large, representative study of sound methodology examines this issue, we cannot know for sure if men who grew up without a foreskin feel that they were assaulted. Only a tiny proportion of the billions of circumcised men have reported emotional distress as a result of it, in uncontrolled and retrospective studies.

What do the guidelines say?

Despite the fact that no medical body advocates routine infant circumcision, most agree that male infant circumcision is safe and acceptable and recommend that the procedure is carried out by a competent operator using adequate anaesthesia.¹⁵¹⁶¹⁷ Male circumcision is not illegal anywhere in the world.

The most recent BMA guidelines state that where a procedure is not therapeutic but a matter of patient or parental choice, doctors have no ethical obligation to refer on.¹⁸ I disagree. It is far better to help parents to find a competent operator than to force them to navigate the unregulated circumcision services alone, which increases the likelihood of harm. Circumcision is a choice that parents will make on behalf of their male children, for cultural or other reasons, and regulating its provision is the wisest course of action.

doi: 10.1136/bmj.39406.520498.AD

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Competing interests: None declared.

References

1. Gatrad AR, Sheikh A, Jacks H. Religious circumcision and the Human Rights Act. Arch Dis Child 2002;86:76–8.[Free Full Text]
2. British Association of Paediatric Surgeons, Royal College of Nursing, Royal College of Paediatrics and Child Health, Royal College of Surgeons of England, Royal College of Anaesthetists. Statement on male circumcision. London: RCS, 2001. www.baps.org.uk/documents/Circumcision%20statement%20RCS.htm.
3. WHO. Female genital mutilation. Geneva: WHO, 2000. www.who.int/mediacentre/factsheets/fs241/en/.
4. Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch Dis Child 2005;90:853-8.[Abstract/Free Full Text]
5. Castellsagué X, Bosch FX, Muñoz N, Meijer CJ, Shah KV, de Sanjose S, et al. Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. N Engl J Med 2002;346:1105-12.[Abstract/Free Full Text]
6. Siegfried N, Muller M, Deeks J, Volmink J, Egger M, Low N, et al. HIV and male circumcision—a systematic review with assessment of the quality of studies. Lancet Infect Dis 2005;5:165-73.[ISI][Medline]
7. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Med 2005;2: e298.
8. Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007;369:643-56.[CrossRef][ISI][Medline]
9. Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007;369:657-66.[CrossRef][ISI][Medline]
10. UNAIDS. AIDS epidemic update: special Report on HIV/AIDS. Geneva: UNAIDS, 2006.
11. Weiss HA, Thomas SL, Munabi SK, Hayes RJ. Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Inf 2006;82:101-10.[Abstract/Free Full Text]
12. Fergusson DM, Boden JM, Horwood LJ. Circumcision status and risk of sexually transmitted infection in young adult males: an analysis of a longitudinal birth cohort. Pediatrics 2006;118:1971-7.[Abstract/Free Full Text]
13. Christakis DA, Harvey E, Zerr DM, Feudtner C, Wright JA, Connell FA. A trade-off analysis of routine newborn circumcision. Obstet Gynecol Survey 2000;55:546-8.[CrossRef]
14. Palit V, Menebhi DK, Taylor I, Young M, Elmasry Y, Shah T. A unique service in UK delivering Plastibell circumcision: review of 9-year results. Pediatr Surg Int 2007;23:45-8.[CrossRef][ISI][Medline]
15. American Academy of Pediatrics Task Force on Circumcision. Circumcision policy statement. Pediatrics 1999;103:686-93.[Abstract/Free Full Text]
16. Beasley S, Darlow B, Craig J, Mulcahy D, Smith G. Position statement on circumcision. Sydney: Royal Australasian College of Physicians, Paediatrics and Child Health Division, 2004.
17. British Association of Paediatric Surgeons. Religious circumcision of male children: standards of care. BAPS, 2001. www.baps.org.uk/documents/RELCIRC.htm.
18. BMA. The law and ethics of male circumcision—guidance for doctors. June 2006. www.bma.org.uk/ap.nsf/Content/malecircumcision2006.

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