Sexually Transmitted Infections (STIs)
Despite the fact that infants and children are not sexually active and thus not at risk for any sexually transmitted infection (STI) (and that adults can take appropriate precautions), the idea that circumcision significantly reduces the risk of STIs is a rationale commonly given for the practice. However, this notion is a piece of medical folklore dating back to Victorian-era medicine, before a modern understanding of the causes of disease and before the advent of evidence-based medicine.
In the 1910s, an article was published in the Journal of the American Medical Association criticizing ritual circumcision because of the number of cases of tuberculosis acquired through the open wound. In response, physician Abraham Wolbarst published a defensive reply in which he cited the prevention of ‘venereal disease’ (along with prevention of masturbation and many other problems) to justify his call for “universal circumcision as a sanitary measure.”
However, modern science has not confirmed Wolbarst’s claims. Since his time, dozens of studies have sought to determine whether circumcision makes a meaningful difference in the risk of STI acquisition, with inconsistent and contradictory results.
When the results of STI studies are considered in aggregate using meta-analysis, circumcision has been shown to have no significant impact on the risk of gonorrhea,[67,68] chlamydia,[67,68] genital herpes simplex virus infections, human papilloma virus (HPV), or chancroid.[67,68] Being circumcised is associated with an increased risk of non-specific urethritis,[67,68] genital discharge syndrome (which includes gonorrhea, chlamydia, and non-specific urethritis),[67,68] and an increased risk of contracting any STI (as opposed to having no STIs). Being circumcised is associated with a slightly lowered risk of genital ulcerative disease (which includes chancroid, syphilis, and genital herpes infection)[67-69] and syphilis (primarily in Africa).[68,69] However, prospective studies have found a slight increase in the incidence of syphilis in circumcised males.[70,71]
In the case of HPV, sampling bias can occur if only the glans of the penis is tested. Several studies have shown that circumcised men are more likely than intact men to harbor the HPV virus on the shaft of the penis as compared to the glans.[72-77] As a result, sampling only the glans will miss more HPV infections in circumcised men than it will in intact men, thus overestimating the association between having a foreskin and genital HPV.[68,78] For example, several recent HPV studies from Africa only sampled the glans.[79,80] When adjusted for sampling bias, the results of these studies were no longer statistically significant.[81,82]
There is no evidence that circumcision has reduced the incidence of STIs in the United States. While the prevalence of chlamydia, gonorrhea and syphilis has declined steadily in (non-circumcising) Europe since 1980, in the (circumcising) U.S., the incidence of syphilis has increased, and the incidence of chlamydia has soared. The incidence of gonorrhea in the U.S. is 20 times higher than in Europe, while the incidence of chlamydia in the U.S. is 45 times higher than in Europe. A recent study of men visiting public STI clinics found that circumcised men were less likely than intact men to use condoms, which may in part explain these STI trends.
The medical evidence does not support the practice of neonatal circumcision to prevent sexually transmitted infections. In fact, the evidence indicates that circumcision may actually increase the overall risk of STIs. Even if circumcision did reduce the risk of STIs, pre-emptive amputation is not a preferred approach to diseases that can readily be cured with a short course of antibiotics, or prevented by simple safe-sex behaviors. An adult male can choose to have his foreskin removed, if he prefers, but it is neither medically reasonable nor ethically acceptable to force this choice on not-at-risk children.
6. Wolbarst AL. Universal circumcision as a sanitary measure. JAMA. 1914;LXII(2):92-7.
65. Darby R. A surgical temptation: the demonization of the foreskin and the rise of circumcision in Britain. Chicago: University of Chicago Press; 2005.
66. Holt LE. Tuberculosis acquired through ritual circumcision. JAMA. 1913;LXI(2):99-102.
67. Van Howe RS. Genital ulcerative disease and sexually transmitted urethritis and circumcision: a meta-analysis. Int J STD AIDS. 2007;18:799-809.
68. Van Howe RS. Sexually transmitted infections and male circumcision: a systematic review and meta-analysis. ISRN Urol. 2013:109846.
69. 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 Infect. 2006;82:101-10.
70. Tobian AAR, Serwadda D, Quinn TC, Kigozi G, Gravitt PE, Laeyendecker O, et al. Male circumcision for the prevention of HSV-2 and HPV infections and syphilis. N Engl J Med. 2009;360:1298-309.
71. Mehta SD, Moses S, Parker CB, Agot K, Maclean I, Bailey RC. Circumcision status and incident HSV-2 infection, genital ulcer disease, and HIV infection. AIDS. 2012;26:1141-9.
72. Weaver BA, Feng Q, Holmes KK, Kiviat N, Lee SK, Meyer C, et al. Evaluation of genital sites and sampling techniques for detection of human papillomavirus DNA in men. J Infect Dis. 2004;189:677-85.
73. VanBuskirk K, Winer RL, Hughes JP, Geng Q, Arima Y, Lee S-K, et al. Circumcision and the acquisition of human papillomarvirus infection in young men. Sex Trans Dis. 2011;38:1074-81.
74. Aynaud O, Piron D, Bijaoui G, Casanova JM. Developmental factors of urethral human papillomavirus lesions: correlation with circumcision. BJU Int. 1999;84;57-60.
75. Aynaud O, Ionesco M, Barrasso R. Penile intraepithelial neoplasia. Specific clinical features correlate with histologic and virologic findings. Cancer. 1994;74:1762-7.
76. Oriel JD. Natural history of genital warts. Br J Vener Dis. 1971;47:1-13.
77. Hernandez BY, Wilkens LR, Zhu X, McDuffie K, Thompson P, Shvetsov YB, et al. Circumcision and human papillomavirus infection in men: a site-specific comparison. J Infect Dis. 2008;197:787-94.
78. Van Howe RS. Human papillomavirus and circumcision: a meta-analysis. J Infect. 2007;54(5):490-6.
79. Tobin AAR, Serwadda D, Quinn TC, Kigozi G, Gravitt PE, Laeyendecker O, et al. Male circumcision for the prevention of HSV-2 and HPV infections and syphilis. N Engl J Med. 2009;360:1298-309.
80. Auvert B, Sobngwi-Tambekou J, Cutler E, Nieuwoudt M, Lissaouba P, Puren A, et al. Effect of male circumcision on the prevalence of high-risk human papillomavirus in young men: results of a randomized controlled trial conducted in Orange Farm, South Africa. J Infect Dis. 2009;199:14-9.
81. Storms MR. Male circumcision for the prevention of HSV-2 and HPV infections. N Engl J Med. 2009;361:307.
82. Van Howe RS. Sampling bias explains association between human papillomavirus and circumcision. J Inf Dis. 2009;200:832.
83. Sexually transmitted diseases across space and time. OnlineDoctor (UK) website. n.d. Available at: onlinedoctor.superdrug.com/std-us-eu/
84. Crosby R, Charnigo RJ. A comparison of condom use perceptions and behaviours between circumcised and intact men attending sexually transmitted disease clinics in the United States. Int J STD AIDS. 2013;24(3):175-8.