It is the world’s most commonly performed surgical procedure – but more than any other it now divides global medical opinion.
Male circumcision – the removal of the foreskin, normally performed soon after birth or at puberty – has become the subject of a bitter dispute between medical authorities on either side of the Atlantic.
At issue is a small sheath of double folded skin and muscle, rich in blood vessels and nerve endings, whose function remains unclear. Claims have been made that its removal leaves the head, or “glans”, of the penis exposed, reducing sensation and sexual pleasure, but no consensus on this, or on much else, exists. The World Health Organisation says of the foreskin, there is “debate about its role”.
Supporters of circumcision say its removal brings significant medical advantages that outweigh any risks. Last month alone two studies appeared extolling its health benefits, with one specialist claiming that it provides protection (against urinary tract infections and sexually transmitted diseases) on a par with childhood vaccination and that to fail to offer it to the parents of newborn boys should be regarded as unethical.
Yet last October, the Council of Europe passed a resolution condemning the practice as a “violation of the physical integrity of children” and calling for a public debate with the aim of banning the practice “before a child is old enough to be consulted”. Norway, Sweden, Denmark, Finland, and Iceland joined forces to call for a ban, following the lead a year earlier from a German regional court in Cologne, which ruled that the practice amounted to bodily harm and banned it for infants and young boys below the age of consent.
That provoked an angry reaction from Jewish and Muslim leaders, among whose communities ritual circumcision has been performed for centuries, which was reignited by the Council of Europe resolution. They blamed the attacks on left-wing secularists and right wingers fearful of the influence of immigration from Muslim countries.
In March, leaders of the Council of Europe tried to calm the debate with a letter advising parliamentarians against further attempts to target ritual circumcision on the grounds that “the protection of children is provided by existing international instruments”.
The issue is so sensitive that looking at the evidence, weighing it up and deciding what is best for children, as doctors are supposed to do, is virtually impossible.
Recognising this, most medical organisations have for decades stayed aloof from the issue, noting merely that surgery is rarely medically necessary, except in the tiny minority of cases where the foreskin will not retract. They have preferred to leave it to parents and the public to decide whether the procedure is ethical when carried out for religious or other non-medical reasons. However, in 2008, an editorial in The New England Journal of Medicine, the world’s premier medical journal, put an end to that cosy consensus by noting the accumulating evidence that removal of the foreskin could protect against a number of sexually transmitted diseases.
Circumcision reduces by 35 per cent the risk of infection with human papilloma virus, a cause of genital warts in both sexes and the principal cause of cervical cancer in women. It also provides protection against the herpes virus, reducing the infection risk by 25 per cent. It is thought likely to protect against syphilis, too, but the sample size in the NEJM report was too small to be significant.
By far the most dramatic effect, however, is its protective effect against infection with HIV, with a 50-60 per cent reduction in risk among circumcised men. Adult male circumcision is now widely seen as among the world’s best defences against the spread of Aids, and is being used across sub-Saharan Africa in huge campaigns backed by millions of dollars.
Although HIV is a smaller problem in Western countries (and there is no evidence that circumcision is protective for gay men), human papilloma virus and herpes virus cause a heavy burden of disease and, in the case of cervical cancer, thousands of deaths (and millions in the developing world).
The NEJM concluded that the new evidence was strong enough to serve as a “call to action” for professional societies to re-examine their policies on circumcision. The American Academy of Paediatrics was the first to respond by establishing a taskforce and in 2012 it published an updated position statement.
Having previously advised against the routine circumcision of boys, the Academy now said parents should be educated about the benefits and risks and it should be up to them to decide. It urged insurance companies to pay for the procedure, adding: “The benefits of newborn male circumcision justify access to this procedure for those families who choose it.”
This was in stark contrast to the Royal Dutch Medical Association, which, two years earlier, had concluded that the benefits claimed for circumcision were unproven, the risks underestimated and the procedure was “medically unnecessary” and violated the human rights of underage boys on whom it was imposed. It advocated a “strong policy of deterrence”.
That view was subsequently adopted by the Scandinavian countries and Iceland following advice from their children’s ombudsmen. The anti-circumcision lobby finally triumphed in October when the parliamentary assembly of the Council of Europe passed the resolution condemning male circumcision as a “violation of the physical integrity of children” by a margin of 78 votes to 13.
The resolution also called for a public debate with the aim of “reaching a consensus on the rights of children” and adopting “specific legal provisions to ensure that certain operations will not be carried out before a child is old enough to be consulted”.
Following the vote, the children’s ombudsmen from Scandinavia and Iceland issued an unprecedented joint resolution calling for a ban. Thus, the US and mainland Europe are now deeply divided over male circumcision. The differing views reflect the differing prevalence of the practice on either side of the Atlantic. Around 80 per cent of men in the US are circumcised, with higher rates in whites and lower rates in Hispanics.
In the UK, the rate is 16 per cent according to a national survey in 2000, with lower rates in France (14 per cent) Germany (11 per cent) and Spain (less than 2 per cent). Circumcision is near universal in Muslim countries. Worldwide, about 30 per cent of men are circumcised according to the World Health Organisation. Rates are falling in all Western countries. In the US, it is estimated that infant male circumcision has declined to 55 per cent (from 79 per cent in the 1970s). In 2012, researchers predicted that if the rate fell to one in 10 – in line with Europe – it could add more than $4bn in health costs from avoidable sexually transmitted infections.
In the UK, about a third of men were circumcised in the 1930s, with higher rates among families of higher social class. The rate dropped sharply after an influential paper appeared in the BMJ in 1949 which attacked the routine performance of circumcision on the grounds that the foreskin was naturally fused to the glans at birth and hence inability to retract it was no grounds for removal until age five and that the procedure had a small but significant fatality rate.
Today, medical organisations in the UK continue to stand aloof from the growing rift between Europe and America over the issue. The British Medical Association says the consent of both parents should be obtained for a circumcision carried out for religious or cultural (ie, non-therapeutic) reasons and supports the right of doctors to conscientiously object to being involved in a non-therapeutic procedure.
The UK Royal College of Paediatrics has declined to follow its US counterpart by setting up a taskforce to review the evidence. It argues that HIV is relatively uncommon in the UK and there is little heterosexual transmission within the country. There is a national campaign to vaccinate girls against cervical cancer, which is expected to significantly reduce the incidence of the disease, and the incidence of herpes is substantially lower than in the US. On public health grounds, it would therefore be difficult to justify the costs of carrying out 300,000 neonatal circumcisions a year – the annual number of male births – when the money could be more effectively used in other ways.
For individuals, however, the judgement is more difficult. British parents with connections in sub-Saharan Africa might consider circumcision for their baby sons worthwhile if it seemed likely that when they grew up they might spend time there as sexually mature adults. The operation is simpler and less traumatic when performed in infancy – but at that age, of course, the child himself has no say.
A decade ago, as evidence for the preventive effect of circumcision was starting to emerge, some specialists predicted that it would lead to a sudden leap in demand across the world. A minor op that offered protection against three diseases that killed millions worldwide would surely be hard to resist, they said.
It hasn’t happened. There has been a surge of interest in circumcision among parents in South Africa, the country with the highest number of Aids cases in the world, and in other parts of Africa devastated by the disease.
But enthusiasm has not spread. Arguments over human rights have increasingly come to trump arguments over health – at least in Europe. What is noteworthy is how, on the basis of the same evidence, medical authorities in different countries have reached fundamentally different views. The vast majority of circumcisions are carried out not for health reasons but for religious reasons, to incorporate a child into a community or because some parents want their sons to be like their fathers. That, it seems, is unlikely to change.