Let’s cut to the chase: What’s the deal with circumcision?

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Circumcision – one of the most commonly performed surgical procedures worldwide – is the removal of some or all of the penile prepuce (which you probably know as foreskin). In North America, circumcision shortly after birth is common practice. In fact, the American Association of Pediatrics recently released a statement reporting “the benefits of circumcision outweigh the costs”1. Now, this represents yet another flip in the decades of public policy flip-flopping on circumcision, which means that we can expect an increase in the number of infant boys losing their foreskin in North America2,3. So the question that comes to mind is… what’s the deal with circumcision, anyways? Why are we doing it?

To answer this question, we first turn to the ancient reasons for this ritual. Circumcision is said to have first appeared in Native Australian tribes as a right of passage into adulthood4. Later, it was popularized as a way to eliminate man’s ungodly desire to… uh… play with it. Around the early 1900s, the excision of the foreskin was thought to prevent a range of sexually transmitted infections (STIs). Medical reasons, in combination with religious reasons (circumcision is commonly performed by Jewish and Muslim cultures), lead to the rising popularity of this procedure4. But what does the research tell us? Foreskin or not; does it really make a difference?

One of the big reasons in favor of circumcision that we hear in the Sex Lab is cleanliness! There are folds of skin that stuff can hide in (see: smegma); so eliminate the foreskin and you eliminate the buildup, right? Indeed, research shows us that this may be true… for infants5. Intact boys (boys with a foreskin) tend to have much higher rates of hospitalization due to urinary tract infections (UTIs) in infancy compared to their circumcised counterparts, or girls, for that matter. However, as soon as the boy becomes a toddler, this difference disappears and girls secure the position for “most likely to get a UTI”5. But can’t teaching boys proper cleaning techniques offer a cheaper solution with less bloodshed? Research says it’s likely. So scratch UTIs as reason for continued circumcision…

Alright, let’s ask the parents! There must be some secret parental wisdom there. Great idea! Only this doesn’t reveal any more of a telling tale than the cleanliness argument. We know that parents aren’t using their doctor’s recommendations to decide to circumcise or not. It appears they tend to base their decision on gut feeling, or on the father’s circumcision status. People want Richy Jr. to look like Richard Senior (despite the huge difference in size, hairiness, and wrinkliness)6. Great. But should this be the primary justification for the procedure? I’m not convinced. Let’s dive further...

I’ve got it! Health! Less wrinkly skin around the genitals means less surface area for a nasty sexually transmitted infection (STI) to grab hold of during intimate encounters, right? There’s been a ton of research on this question and the results are… mixed. Circumcision appears to reduce the likelihood of contracting certain STIs (such as HPV, herpes), but the connection doesn’t seem to be present for other STIs (like syphilis)7. Still further analyses of aggregated data suggest that the link between circumcision and STI transmission may not exist after all8.

Ok, you say, but what about HIV? The World Health Organization (WHO) seems pretty confident that circumcision reduces HIV transmissions. That must be it! I mean, it’s the WHO! Indeed, there are at least 3 massive randomized-control trials that have gotten a lot of publicity for saying that having one’s foreskin removed reduces risk of HIV transmission9,10,11. These studies recruited thousands of men in Africa for circumcision; half were circumcised immediately, and the other half (the control group) waited up to 2 years before they were circumcised. The investigators of this study became very excited when they found the circumcised men were about 60% less likely to contract HIV than the control group. They were so excited, in fact, that the studies were stopped early and everyone was allowed to get circumcised because the researchers felt that they couldn’t ethically keep the men in the control group from getting circumcised and reaping the protective benefits themselves. And this is great news! Except, there are some holes in the interpretation of these studies...

The studies mentioned above were used to inform North American standards of practice, but the way the procedure was performed in these studies differs on some critical aspects compared to North America, and thus may not necessarily be applicable to the US or Canada12. For example, these studies look at circumcision performed on adults not neonates, on populations where HIV is primarily transmitted via heterosexual and not same-sex intercourse (HIV is transmitted via different mechanisms in the two populations). It also fails to look at alternative methods of HIV prevention, such as condom use (which has much higher adherence rates in North American compared to Africa, and is much more effective at reducing HIV transmission…and is cheaper…and has fewer risks…). Finally, there are some huge methodological shortcomings of these projects themselves; for example, researchers failed to address the fact that men who are circumcised in the study need to abstain from sex for months to allow for their penis to heal, while their intact counterparts are able to continue being sexually active (read: were at risk of transmitting HIV for longer periods of time).

Alright, alright – let’s move on from health reasons then. I heard that circumcised penises are less sensitive than intact ones, so maybe circumcised penises just… you know… feel better? Despite widespread belief, the issue of differences in sensitivity across circumcision status has received very little attention in the research12. A recently published paper from our lab looked at just this question. We assessed the sensitivity of men’s penises (half of whom were circumcised, half of whom were intact). We made sure to test nerve fibers in the penis that are likely important for sexual touch, and what did we find? No major differences to speak of13. Circumcision doesn’t seem to lead to the head of the penis getting less sensitive. Nor does the foreskin seem to be the most sensitive to sexual touch compared to other parts of the penis (which some people thought was true). When we took a similar group of circumcised and intact men and assessed their sexual functioning, we also found no differences across the group14… so no. Circumcised penises don’t seem to be less sensitive than their turtleneck-donning counterparts. And regardless of sensitivity, their functioning in the bedroom doesn’t seem to differ, either.

An even bigger mystery in the circumcision debate is the effect of circumcision on men’s partners! It seems that the impact of surgical alteration to a key factor in having sex with a man has been all but ignored. And a lot of people are having sex with men!! We wanted to shed some light on this question, too, so we surveyed women and men who were in a sexual relationship with a man. Our results were pretty awesome. Women seemed to prefer circumcised men overall, while men seemed to prefer intact men. That being said, circumcision status did not seem to have any impact on respondent’s sexual functioning. And not only that, but despite their preference for circumcised or not, everyone seemed to be very happy with their partner’s penis, and wouldn’t change their circumcision status. 15

Let’s recap: the question of why male circumcision remains such a popular procedure in North America remains unanswered. Yes, it reduces the likelihood of UTIs in babies and some STIs in adults, but when you compare the costs and risks associated with surgical removal of the foreskin to proper cleaning techniques and safe sex practices, who comes out the winner (no… seriously. Who? We don’t know the answer to that). And despite the critical role of the penis in men’s sex lives, we know even less about how circumcision impacts men’s sexual functioning or penile sensitivity. What’s a man (or parent) to do?!

Fear not! Researchers at the Sex Lab are on it! We have been working on online and in-lab studies using state-of-the-art equipment to try and fill some of the gaps that we’ve outlined here. We’ve published a few papers already, and more still are in the works. Shortly we will be able to cut to chase and answer some important questions about neonatal circumcision. In the meantime… stay tuned!

Resources:

1. Blank S, Brady M, Buerk E, Carlo W, Diekema D, Freedman A, ... & Wegner S. Circumcision policy statement. Pediatrics 2012;130:585-586. 2. National Hospital Discharge Survey, National Center for Health Statistics, Centers for Disease Control and Prevention [database on the Internet]. Retrieved from: http://www.cdc.gov/nchs/nhds/nhds_tables.htm#male 3. National Ambulatory Care Reporting System [database on the Internet], Ottawa, ON: Canadian Institute for Health Information; 2010. Available from www.cihi,ca/cihiweb/dispPage.jsp?cw_page=services_nacrs_e#03. 4. David Gollaher (28 February 2001). "Chapter 1: The Jewish Tradition". Circumcision: A History Of The World's Most Controversial Surgery. Basic Books. ISBN 978-0-465-02653-1. 5. Morris BJ, & Wiswell TE. Circumcision and lifetime risk of urinary tract infection: a systematic review and meta-analysis. J of Urol 2013;189:2118–24. 6. Walton, RE, Ostbye, T, & Campbell, MK. Neonatal male circumcision after delisting in Ontario. Survey of new parents. Can Fam Physician 1997;43;1241. 7. Weiss H, Thomas SL, Munabi SK, & Hayes RJ. Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect 2006;82:101–9. 8. Van Howe RS. Sexually Transmitted Infections and male circumcision: A systematic review and meta-analysis. ISRN Urology, 2013. 9. 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 Medicine 2005;2:298. 10. Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger, JN, … Ndinya-Achola JO. Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial. Lancet 2005;369:643–56. 11. Gray RH, Kigozi , Serwadda D, Makumbi F, Watya S, Nalugoda F., … Wawer MJ. Male circumcision for HIV prevention in men in Rakai, Uganda: A randomised trial. Lancet 2007;369:657–66. 12. Bossio JA, Pukall CF, & Steele S. A review of the current state of the male circumcision literature. J Sex Med 2014;11:2847-2864. doi: 10.1111/jsm.12703 13. Bossio JA, Pukall CF, & Steele S. Examining penile sensitivity in neonatally circumcised and intact men using quantitative sensory testing. J Urol 2016. doi:10.1016/j.juro.2015.12.080 14. Bossio JA. Sexual correlates of neonatal circumcision in adult men. Dissertation 2015. 15. Bossio JA, Pukall CF, & Bartley K. You either have it or you don’t: The impact of male circumcision status on sexual partners. Can J Hum Sex 2015;2:104-119. doi: http://dx.doi.org/10.3138/cjhs.242-A2