The Cut

04.04.14

Circumcision Has Health Benefits, but Doctors Should Leave the Decision Up to Parents

The debate is a hot one among parents, and the health benefits are questioned by medical professionals. Some “pro-circers” liken “anti-circers” to anti-vaxxers. Is that a stretch?

As a physician, part of my job is giving my patients and their parents as much information as I can to help them avoid illness and injury. Preventive medicine is a mainstay of quality care, and I would be failing in a major obligation if I didn’t help mothers and fathers make the best decisions they can to keep their children healthy. I talk about bicycle helmets and safety belts and childproofing their homes. And of course, I talk about vaccines.

But when the subject of circumcision comes up, I really don’t have much to say. I tell parents the decision is more a personal one than a medical one. Though there are some health benefits to circumcision, in my opinion, they are not significant enough for me to endorse the procedure for parents who would not otherwise choose it. My opinion aligns with the policy of the American Academy of Pediatrics, which does not go so far as to recommend routine circumcision but does consider the health benefits sufficient to make it available to those who want it.

Thus it was with some alarm that I read comments from the author of a new study about circumcision and its benefits. Dr. Brian J. Morris likens circumcision to vaccination, and reports that half of uncircumcised men will require some kind of treatment during their lifetimes that would have been otherwise prevented by the procedure. “Just as vaccination, failure to circumcise will put your son at serious risk of adverse medical conditions and he could indeed die from some of them,” he said in a recent article for The Daily Beast.

Having reviewed Dr. Morris’s study, I find his statements about the benefits of circumcision as a routine procedure overblown, and the comparison with vaccination baseless.

With regard to life-threatening health conditions that may be prevented by circumcision, HIV infections are at the top of the list. There have been studies that demonstrated a clear preventive benefit for circumcised males. However, all such studies I have seen have been conducted on men in Africa, where epidemic HIV among heterosexual men is part of an ongoing health crisis. Generalizing those data to the United States, which has vastly different HIV prevalence and where sexual mores are significantly different than in places like Kenya, is intellectually problematic at best. The two populations are not similar enough to draw conclusions for both.

Other health benefits that Dr. Morris cites are reduction in risk of penile and prostate cancers. The former is already so fleetingly rare that recommending circumcisions to prevent it is absurd on its face, as it would take over 900 circumcisions to prevent a single case. While there are data that suggest circumcision lowers the risk of prostate cancer, as of now there is an insufficient body of evidence to show how many infants would need to be circumcised to make any appreciable dent in its prevalence.

Dr. Morris likens circumcision to vaccination by comparing the risk to others caused by refusing either intervention. But this comparison doesn’t withstand scrutiny. Most of the health risks borne by uncircumcised men fall solely on them, rather than the population at large.

Having reviewed Dr. Morris’s study, I find his statements about the benefits of circumcision as a routine procedure overblown, and the comparison with vaccination baseless.

Dr. Morris mentions life-threatening illness caused by oncogenic (cancer-causing) HPV infection, but circumcision would only lower risk of transmission on an individual-by-individual basis, and only those engaged in an activity known to entail risk of infection. Contrast that with an unvaccinated individual who can expose everyone who went shopping at the same store within a two-hour window to a possibly deadly infection.

Furthermore, though circumcision does lower risk of transmitting herpes or HPV, that risk can be mitigated by safer sex techniques, and there is an effective vaccine against the latter. Implying that declining to circumcise one’s son is as irresponsible a threat to public health as failing to vaccinate him is frankly preposterous.

Of all the health benefits conferred by circumcision that Dr. Morris mentions, in my opinion, he is on the soundest footing when discussing urinary tract infections (UTIs). Though very uncommon in male children and adults, both infants and the elderly have some risk of infection, which can cause more serious problems if not properly treated. However, while circumcision will lower risk of UTIs (I have never personally treated a circumcised male for one), the number of circumcisions needed to prevent a single UTI has been calculated as 111. Given that the vast majority of these infections are uncomplicated and easily treated, I do not look on those numbers as an unambiguous reason to recommend the procedure.

That said, some parents might see these benefits and decide that they are worth having their child circumcised. Or they may choose it for purely unrelated reasons. That choice is theirs, and there’s certainly enough benefit to justify keeping the procedure available. But when Dr. Morris says that to deny an infant male circumcision is to deny him his rights to good health, he grossly overstates his case.

For parents who choose not to circumcise their sons, I see no reason to counsel them otherwise, and nothing in this new study says anything to change my mind.