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Circumcision in boys and girls: why the double standard?

BMJ 2011; 342 doi: (Published 16 February 2011) Cite this as: BMJ 2011;342:d978

Finally a Medical Journal with the Courage

Congratulations to the editors of BMJ for having the courage to publish an article on this topic. This is a topic that even Oprah Winfrey is afraid to address. The comments in the article are directly on target and hopefully a serious discussion can begin. Unfortunately, some of the comments in the rapid responses indicate there are still some obstacle to be overcome.

The answer to Dr. Gordon's question is "no." Two recent studies have found that when controlled for phimosis (presumably from balanitis xerotica obliterans) circumcision as an infant has no impact on penile cancer risk.

The protections from HIV that circumcision provides are dubious. In the randomized clinical trials suggesting protections from heterosexually transmitted HIV infection, it is quite likely that half of the men in the studies did not get HIV through heterosexual sexual contact (most likely iatrogenic spread). Moreover, there appears to be a lack of external validity. If you look across Africa, in many countries circumcised men have a higher prevalence of HIV than men who are not circumcised. Finally, these studies were of circumcision performed on adult men. There has been no studies that have shown that circumcision in infants has any impact on HIV-infection risk.

Ms. Zimmerman puts forth a false comparison and then fails to make a comparison between male genital cutting and female genital cutting. The false comparison is that she compares the most invasive forms of female genital cutting to the moderately invasive, more commonly performed, form of male genital cutting. For the comparison to valid, anatomically similar procedures would need to compared. In the case of female genital cutting, this would be removal of the clitoral hood. Ms. Zimmerman needs to look into the complications of male genital cutting more carefully. All of the complications she listed for female genital cutting, other than blood trapped in vagina and obstetrical complications that are impossible for a male to experience, also are complication for the male. One study found that female genital cutting was associated with a lower risk of HIV infection. There is plenty of material in the medical for proponent of both forms of cutting to justify their cultural practices. If you believe that the Langerhans cells are the gateway for HIV into the body, then cutting the outside of the female genitals is the wrong approach, it should be the cervix that should be remove. Of course this is absurd. The only differences between female and male genital cutting is that female genital cutting is performed on females, it is performed by females in Africa (male cutting is primarily performed by men), and it includes a wider array of practices and amounts of tissue damage.

The question that needs to be asked is whether the infant has a right to bodily integrity that all other humans enjoy. Parental preference and cultural practices are insufficient justifications to override this basic right.

There is no harm in waiting until adulthood to make a decision regarding circumcision. The adult male can consider his options. He can keep his foreskin, choose his partners wisely, use condoms when indicated and be nearly completely protected from STIs and HIV infection. He can get circumcised, choose his partners wisely, use condoms when indicated and be nearly completely protected from STIs and HIV infection. Most adult males will have figured out what the foreskin does and how it feels and that with the other precautions in place circumcision does not have any additive value. The only role for circumcision is for the male who wants to engage in high risk behaviors with high risk partners and doesn't want to use a condom. For these men, circumcision may, at best, delay infection. There are better choices to avoid infection that do not involve cutting off the most sensitive portion of the penis, so when presented with accurate informaion it is unlikely that circumcision will be chosen.

Competing interests: None declared

Competing interests: No competing interests

01 March 2011
Robert S. Van Howe
Michigan State University College of Human Medicine