Is infant male circumcision an abuse of the rights of the child? No
BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39406.523762.AD (Published 06 December 2007) Cite this as: BMJ 2007;335:1181
Circumcision is one of the commonest surgical procedures performed on males, despite there being few absolute medical indications for it. The tradition of male infant circumcision accounts for this paradox. About 30% of men are circumcised; in most English speaking and Muslim countries circumcised men are in the majority, and most were circumcised in infancy.1 Although opponents argue that infant circumcision can cause both physical and psychological harm, recent strong evidence shows that circumcision is medically beneficial. If competently performed, it carries little risk.2 It cannot be compared with female circumcision, which has been shown to be no more than genital mutilation without medical benefit and with an unacceptably high likelihood of pain, immediate and long term medical complications, and psychosexual scarring.3
Although any surgical operation can be painful and do harm, the pain of circumcision, if done under local anaesthesia, is comparable to that from an injection for immunisation. Indeed, we urge parents to immunise their children, a procedure for which the infant cannot give consent and which carries the risk of adverse events ranging from fever to anaphylaxis and aseptic meningitis.
Evidence of benefit
The medicalisation of male infant circumcision in some countries in the 1940s and 1950s followed from a widespread belief that it reduced the incidence of urinary tract infections. However, a recent meta-analysis suggested the reduced risk conferred by infant circumcision, when taking into account the risks of complication, is meaningful only for boys with vesicoureteric reflux (for whom the number needed to treat is 4).4
Examination of data from seven case controlled studies of cervical carcinoma showed that circumcised men were less likely than uncircumcised men to have human papillomavirus infection.5 Male circumcision was associated with a reduced risk of cervical cancer in women with high risk sexual partners.
More robust research on HIV transmission has intensified the infant circumcision debate. A Cochrane review of observational studies in 2000, updated in 2005, confirmed that male circumcision was associated with a reduced risk of HIV infection.6 Stronger evidence has come from African randomised controlled trials investigating circumcision as an intervention to prevent HIV infection in heterosexual men.789 Two trials were stopped early at the interim analysis because they showed a reduced incidence of HIV infection among circumcised heterosexual men equivalent to a protection of more than 50%, after controlling for other factors.7
Male circumcision in a relatively high risk population gives protection from HIV that is equivalent to what a vaccine of moderate efficacy would have achieved.7 An AIDS expert, speaking at conference earlier this year, called for all boys born in South African public hospitals to be offered routine circumcision. “It is so blindingly obvious that there are real reasons for circumcision,” he said.
South Africa’s prevalence of HIV infection is one of the highest in the world, second only to India’s. The benefit would be less in other countries, but circumcision could still reduce the spread of HIV. An estimated 39.5 million adults and children worldwide live with HIV; 3.8 million adults were newly infected with the virus in 2006, only a third of whom live in sub-Saharan Africa, and every region of the world saw an increase in the number of people infected with HIV; 40% of new infections were in 15-24 year olds.10 In the absence of a vaccine, surely any other reasonable weapon of prevention seems worth considering?
What is more, a 2006 systematic review and meta-analysis showed that circumcised men have a significantly diminished risk of acquiring chancroid and syphilis, while data from a large New Zealand birth cohort followed up to age 25 years suggested that uncircumcised men are almost twice as likely to get a sexually transmitted infection.11 12
Where’s the harm?
Although the complication rate for infant circumcision is essentially unknown (because most operators are unregistered), considerable data from best practice environments suggests that it is between 0.2% and 3%, with most complications being minor.13 14 Case reports have associated circumcision with life threatening complications.
No robust research exists examining the long term psychological effects of male infant circumcision. Most evidence of psychological trauma in men is anecdotal. Until a large, representative study of sound methodology examines this issue, we cannot know for sure if men who grew up without a foreskin feel that they were assaulted. Only a tiny proportion of the billions of circumcised men have reported emotional distress as a result of it, in uncontrolled and retrospective studies.
What do the guidelines say?
Despite the fact that no medical body advocates routine infant circumcision, most agree that male infant circumcision is safe and acceptable and recommend that the procedure is carried out by a competent operator using adequate anaesthesia.151617 Male circumcision is not illegal anywhere in the world.
The most recent BMA guidelines state that where a procedure is not therapeutic but a matter of patient or parental choice, doctors have no ethical obligation to refer on.18 I disagree. It is far better to help parents to find a competent operator than to force them to navigate the unregulated circumcision services alone, which increases the likelihood of harm. Circumcision is a choice that parents will make on behalf of their male children, for cultural or other reasons, and regulating its provision is the wisest course of action.
Footnotes
Competing interests: None declared.