Prevention of sexually transmitted infections (STIs) has traditionally been one of the main selling points for circumcision of male infants and boys, both in the late nineteenth century and today - despite the facts that is adult men who get them and children don't. It seems that whenever a new disease involving the genitals appears, some people lose their heads and forget that diseases are not caused by normal anatomy, but by microorganisms abetted by human behaviour.
Based almost entirely on the dubious evidence of a single publication by the English syphilis expert (and posthephobe) Jonathan Hutchinson in the 1850s, Anglo-American doctors became convinced that circumcision would infallibly protect men from syphilis (the AIDS of that era). Beginning in the late nineteenth century, millions of baby boys in Britain, the USA and Australia were circumcised in the hope that it would overcome the health crisis then thought to be threatening the nation. As it turned out, circumcision had no impact on the incidence of syphilis at all, the prevalence of which was reduced by screening, early treatment, safe sex (especially condoms), and finally defeated when penicillin was introduced in the 1940s. The most important early measure in controlling syphilis was not medical at all but social: reducing the stigma attached to the disease so that people were no longer afraid to seek treatment. [1]
It is thus hard to see why circumcision would be a rational step even for a sexually promiscuous adult. Nearly all STIs (with the obvious exception of AIDS) can be quickly cured with antibiotics, and the few that cannot (such as genital herpes) are mild in effect and can be kept under control by other drugs. Chlamydia, for example, can be cured with a single pill, and even a serious disease such as syphilis is still eliminated from the body by a course of penicillin. An adult may choose to get himself circumcised instead if he thinks that would be more effective, but he or she has no right to impose that choice on sexually-inactive children.
In 2006 the United States journal Pediatrics published an article by David Fergusson et al purporting to show that circumcision reduced the risk of certain STIs (Chlamydia, genital warts, non-specific urethritis (NSU), gonorrhea and genital herpes, but not syphilis, genital ulcerative disease or HIV) by up to 50 per cent. The author’s modest suggestion that neonatal circumcision was thus a wise measure of public policy received massive publicity worldwide. Following a number of critical responses posted on the website of the on-line edition of Pediatrics, however, Fergusson was forced to moderate his claims, but the news services that picked up his breathless media release did not report the backdown, leaving readers with the false impression that a winning goal had been scored by the pro-circumcision team.
David M. Fergusson, Joseph M. Boden and L. John Horwood. Circumcision Status and Risk of Sexually Transmitted Infection in Young Adult Males: An Analysis of a Longitudinal Birth Cohort. Pediatrics 2006;118;1971-1977.
Critiques of the article and Fergusson’s response may be read here.
A year or so later another longitudinal study in New Zealand by Dickson et al found no such correlations. Although this was a much better study (because the sample size was much larger, the retention greater and the statistical analysis less shaky) it received almost no publicity. We shall try to make amends here.
Objective: To determine the impact of early childhood circumcision on sexually transmitted infection (STI) acquisition to age 32 years.
Study design: The circumcision status of a cohort of children born in 1972 and 1973 in Dunedin, New Zealand was sought at age 3 years. Information about STIs was obtained at ages 21, 26, and 32 years. The incidence rates of STI acquisition were calculated, taking into account timing of first sex, and comparisons were made between the circumcised men and uncircumcised men. Adjustments were made for potential socioeconomic and sexual behavior confounding factors where appropriate.
Results: Of the 499 men studied, 201 (40.3%) had been circumcised by age 3 years. The circumcised and uncircumcised groups differed little in socioeconomic characteristics and sexual behavior. Overall, up to age 32 years, the incidence rates for all STIs were not statistically significantly different – 23.4 and 24.4 per 1000 person-years for the uncircumcised and circumcised men, respectively. This was not affected by adjusting for any of the socioeconomic or sexual behavior characteristics.
Conclusions: These findings are consistent with recent population-based cross-sectional studies in developed countries, which found that early childhood circumcision does not markedly reduce the risk of the common STIs in the general population in such countries.
Reference: Dickson NP, Van Rood T, Herbison P, Paul C. Circumcision and risk of sexually transmitted infections in a birth cohort. J Pediatr 2008;152: 383-7.
National Health and Lifestyle Survey, USA, 1992 (N=1511)
“We find no significant differences between circumcised and uncircumcised men in their likelihood of contracting sexually transmitted diseases.” [2]
British National Survey of Sexual Attitudes and Lifestyles, Britain, 2000 (N=4762)
“We did not find any significant differences in the proportion of circumcised and uncircumcised British men reporting ever being diagnosed with any STI … We also found no significant associations between circumcision and being diagnosed with any one of the seven specific STIs.” [3]
Australian Study of Health and Relationships, Australia, 2001-2002 (N=10,173)
“No significant protective effect of circumcision is discernible for genital warts, chlamydia, genital herpes, gonorrhoea, non-specific urethritis or pubic lice.” [4]
References
1. For details of the nineteenth century campaign to enforce mass circumcision as a preventive of syphilis, see Robert Darby, Where doctors differ: The debate on circumcision as a preventive of syphilis, 1855-1914, Social History of Medicine, Vol. 16, 2003, 57-78; and his book, A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain (University of Chicago Press, 2005) Chapter 12.
2. Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States. Journal of the American Medical Association 1997;277(13): 1052-7.
3. Johnson AM, Mercer CH, Evans B. et al. Sexual behaviour in Britain: Partnerships, practices, and HIV risk behaviours. Lancet 2001;358(9296): 1835-42; and Dave SS, Johnson AM, Fenton KA, et al. Male circumcision in Britain: Findings from a national probability sample survey. Sex Trans Infect 2003;79: 499-500.
4. Richters J, Smith AMA, de Visser RO, et al. Circumcision in Australia: Prevalence and effects on sexual health. Int J STD AIDS 2006;17: 547-54.
A study of men attending a sexually transmitted diseases clinic has found that circumcised men reported significantly (but not greatly) more STDs in their lifetimes, were more likely to have been diagnosed with genital warts, and were more likely to have HIV. The 660 men in the sample were randomly sampled from an STD clinic waiting room. Almost a third of them were circumcised. Did you get that: despite what the circumcision promoters say, sexually transmitted infections and HIV were were more common in the circumcised men. The abstract of the article in the Journal of Sexual Medicine follows.
Introduction. Circumcision among adult men has been widely promoted as a strategy to reduce human immunodeficiency virus (HIV) transmission risk. However, much of the available data derive from studies conducted in Africa, and there is as yet little research in the Caribbean region where sexual transmission is also a primary contributor to rapidly escalating HIV incidence.
Aim. In an effort to fill the void of data from the Caribbean, the objective of this article is to compare history of sexually transmitted infections (STI) and HIV diagnosis in relation to circumcision status in a clinic-based sample of men in Puerto Rico.
Methods. Data derive from an ongoing epidemiological study being conducted in a large STI/HIV prevention and treatment center in San Juan in which 660 men were randomly selected from the clinic's waiting room.
Main Outcome Measures. We assessed the association between circumcision status and self-reported history of STI/HIV infection using logistic regressions to explore whether circumcision conferred protective benefit.
Results. Almost a third (32.4%) of the men were circumcised (CM). Compared with uncircumcised (UC) men, CM have accumulated larger numbers of STI in their lifetime (CM = 73.4% vs. UC = 65.7%; P = 0.048), have higher rates of previous diagnosis of warts (CM = 18.8% vs. UC = 12.2%; P = 0.024), and were more likely to have HIV infection (CM = 43.0% vs. UC = 33.9%; P = 0.023). Results indicate that being CM predicted the likelihood of HIV infection (P value = 0.027).
Conclusions. These analyses represent the first assessment of the association between circumcision and STI/HIV among men in the Caribbean. While preliminary, the data indicate that in and of itself, circumcision did not confer significant protective benefit against STI/HIV infection. Findings suggest the need to apply caution in the use of circumcision as an HIV prevention strategy, particularly in settings where more effective combinations of interventions have yet to be fully implemented.
Source: Rodriguez-Diaz CE, Clatts MC, Jovet-Toledo GG, Vargas-Molina RL, Goldsamt LA, García H. More than Foreskin: Circumcision Status, History of HIV/STI, and Sexual Risk in a Clinic-Based Sample of Men in Puerto Rico. Journal of Sexual Medicine, 15 August 2012 (Epub ahead of publication).
A large scale study of the relationship between circumcision and the risk of contracting a wide range of sexually transmitted diseases has found that circumcision makes very little difference, but that circumcised men are at greater risk of urethral infections such as gonorrhoea. Uncircumcised men are at greater risk for genital ulcers, but because urethral infections are far more common than ulcers, circumcised men are at greater risk of contracting an STD overall. For other infections, such as syphilis, herpes and human papilloma virus circumcision made no significant difference. The study by Robert Van Howe is what is called a meta-analysis: that is, it examines the methods and conclusions of previous published studies and surveys, and then systematically collates the results. In this case, Van howe identified nearly 100 studies and presented their findings in a series of tables, accompanied by commentary. It is one of the largest studies of the relationship between circumcision status and sexually transmitted disease ever published, with highly embarrassing conclusions for circumcision advocates, and particularly the American Academy of Pediatrics, which claimed in their recent policy statement that prevention of sexually transmitted diseases was a valid reason for circumcision of male infants. Compared with this analysis, the survey of the medical literature performed by the AAP’s “circumcision task force” is selective, unbalanced and skewed towards their bias in favour of circumcision. But as Van Howe comments, “the prevention of sexually transmitted infections cannot rationally be interpreted as a benefit of circumcision, and any policy of circumcision for the general population to prevent sexually transmitted infections is not supported by the evidence in the medical literature.”
ABSTRACT: The claim that circumcision reduces the risk of sexually transmitted infections has been repeated so frequently that many believe it is true. A systematic review and meta-analyses were performed on studies of genital discharge syndrome versus genital ulcerative disease, genital discharge syndrome, nonspecific urethritis, gonorrhoea, chlamydia, genital ulcerative disease, chancroid, syphilis, herpes simplex virus, human papillomavirus, and contracting a sexually transmitted infection of any type. Chlamydia, gonorrhea, genital herpes, and human papillomavirus are not significantly impacted by circumcision. Syphilis showed mixed results with studies of prevalence suggesting intact men were at great risk and studies of incidence suggesting the opposite. Intact men appear to be of greater risk for genital ulcerative disease while at lower risk for genital discharge syndrome, nonspecific urethritis, genital warts, and the overall risk of any sexually transmitted infection. In studies of general populations, there is no clear or consistent positive impact of circumcision on the risk of individual sexually transmitted infections. Consequently, the prevention of sexually transmitted infections cannot rationally be interpreted as a benefit of circumcision, and any policy of circumcision for the general population to prevent sexually transmitted infections is not supported by the evidence in the medical literature.
Source: Robert S. Van Howe, Sexually Transmitted Infections and Male Circumcision: A Systematic Review and Meta-Analysis. ISRN Urology, April 2013 (Article ID 109846); http://dx.doi.org/10.1155/2013/109846. The full article may be read at ISRN Urology on-line.
A new study by urologists shows no link between circumcision and reduced risk of sexually-transmitted infections. Researchers performing a clinical study on over 800 African American men found that circumcision does not prevent STIs (sexually transmitted infections). The most important factor was the number of sexual partners. The researchers say their results throw doubt on commonly held beliefs about the connection between circumcision and STIs, which they say are largely based on extrapolations from studies performed on men in Africa. These African studies and their policy implications, which includes the recent American Academy of Pediatrics' circumcision policy statement, were widely criticized by child health experts and human rights organizations. The latest American study was performed by urologists from the University of Michigan, Ann Arbor, the University of Illinois, Chicago, and Mount Sinai Hospital in New York. The study was presented at the Annual Meeting of the American Society for Reproductive Medicine, held conjointly with the International Federation of Fertility Societies in Boston in October.
Source: J.R. Gonzalez et al. A population-based study of circumcision and non-HIV sexually transmitted infections in a contemporary group of African American men: The flint men's health study. Fertility and Sterility 100 (3) Supplement, September 2013
Acknowledgements to IntactNews
Circumcision in Australia: Further evidence on its effects on sexual health and wellbeing
Jason A. Ferris, Juliet Richters, Marian K. Pitts, Julia M. Shelley, Judy M. Simpson, Richard Ryall, and Anthony M. A. Smith
Australian and New Zealand Journal of Public Health, Vol. 34 (2), April 2010, 160-64
OBJECTIVE: To report on the prevalence and demographic variation in circumcision in Australia and examine sexual health outcomes in comparison with earlier research.
METHODS: A representative household sample of 4,290 Australian men aged 16–64 years completed a computer-assisted telephone interview including questions on circumcision status, demographic variables, reported lifetime experience of selected sexually transmissible infections (STIs), experience of sexual difficulties in the previous 12 months, masturbation, and sexual practices at last heterosexual encounter.
RESULTS: More than half the men (58%) were circumcised. Circumcision was less common (33%) among men under 30 and more common (66%) among those born in Australia. After adjustment for age and number of partners, circumcision was unrelated to STI history except for non-specific urethritis (higher among circumcised men, OR=2.11, p<0.001) and penile candidiasis (lower among circumcised men, OR=0.49, p<0.001). Circumcision was unrelated to any of the sexual difficulties we asked about (after adjusting for age) except that circumcised men were somewhat less likely to have worried during sex about whether their bodies looked unattractive (OR=0.77, p=0.04). No association between lack of circumcision and erection difficulties was detected. After correction for age, circumcised men were somewhat more likely to have masturbated alone in the previous 12 months (OR=1.20, p=0.02).
CONCLUSIONS: Circumcision appears to have minimal protective effects on sexual health in Australia.
One of the most interesting findings of the study is that circumcision nearly doubles a male’s risk of non-specific urethritis (NSU). This result is consistent with Jonathan Hutchinson’s notorious syphilis study of 1854, which showed (though this point was never mentioned by circumcision enthusiasts) that circumcised men had a higher risk of gonorrhoea. Since NSU is a urinary tract infection, the finding must also cast serious doubt on the claim that circumcision significantly reduces the risk of UTIs in male infants. A study published in the USA in 1987 also found that "lack of circumcision" did not increase the risk of gonoccocal urethritis, but that the foreskin had a protective effect against non-gonoccocal urethritis: Smith GL, Greenup R, Takafuji ET. Circumcision as a risk factor for urethritis in racial groups. Am J Public Health 1987;77:452-4.
What is striking is how differently the media report these sorts of studies, depending on whether the foreskin has been found pathogenic, neutral or beneficial. There has been no coverage of this article in the Australian media, nor of the recent study by Adelaide researchers in Annals of Family Medicine, both of which conclude that circumcision is either useless for health or even harmful. But recall the numerous screaming headlines over the past decade every time some study or other showed that "lack of circumcision” was somehow associated with vastly increased risk of STDs, cancer, AIDS and tutti quanti. Actually, the reports rarely put it as cooly as that: usually they leave the impression, if they do not explicitly allege, that the mere presence of the foreskin is enough in itself to generate all these terrible diseases. Even a report on the Ferris/Richters study in 6Minutes does not escape the anti-foreskin prejudice: its headline is “Circumcision benefits not seen in Australia”, but why not write "Circumcision can double risk of urethritis"? And don’t forget to check out the responses to Prof. Morris’s comment.
It's interesting to compare the Canadian media, where newspapers reported the Adelaide study at length, and regularly carry opinion pieces critical of circumcision. In Australia, however, it seems to be impossible for anybody to utter a word against circumcision without being "balanced" - i.e. running through an exhaustive list of the "benefits" before muttering half-heartedly about a few remote risks or trivial disadvantages. Is everybody here too intimidated by Professor Voldemort and his “scientific” death eaters? If nothing else, they certainly seem to have mastered the Imperius and Confundus curses.
FURTHER INFORMATION
Writing in the New England Journal of Medicine, 22 June 2006, Markus Steiner and Willard Cates confirm that condoms offer the best protection against the whole range of sexually transmitted infections. After a review of current medical opinion and the various alternatives, they conclude that consistent condom use offers significant protection against most STDS, including syphilis gonorrhoea, chlamydia, herpes and HIV in both women and men, and against HPV (human papilloma virus – the cause of cervical cancer) in women. They recommend that more effort be made to encourage sexually active people (and especially those with multiple partners) to use condoms consistently
Markus Steiner and Willard Cates, “Condoms and sexually transmitted infections”, New England Journal of Medicine, Vol. 354, 22 June 2006, pp. 2642-43
There is nothing new or surprising in this. It has been well known since at least the 1850s that condoms were an effective barrier against infection by syphilis, and the radical English doctor George Drysdale urged their widespread adoption. Unfortunately, in the prudish atmospheres of the times, his suggestion was regarded as immoral and likely to encourage promiscuity, and most of the medical profession continued to preach against condom use and to recommend chastity instead. As a result, syphilis spread rapidly and reached such epidemic proportions that a Royal Commission had to be established to investigate ways of controlling it.
Further information
Robert Darby, A surgical temptation: The demonization of the foreskin and the rise of circumcision in Britain (University of Chicago Press, 2005)
Peter Baldwin, Contagion and the state in Europe (Cambridge University Press, 1999)
J. Miriam Benn, Predicaments of love (London: Pluto Press, 1992)
A study of the remarkable sexual libertarian and condom pioneer, George Drysdale.Drysdale's amazing tract, Elements of Social Science: Physical, Sexual and Natural Religion, advocating free love, contraception to avoid unwanted pregnancy and condoms to avoid venereal disease, was first published in 1854. A complete text is available from Google Books.
See also the essay on Drysdale at History of Circumcision.
Roger Davidson and Lesley Hall (eds) (2001), Sex, sin and suffering: Venereal disease and European society since 1870, (London: Routledge, 2001)
Jane Tolerton, Ettie: A life of Ettie Rout (Penguin 1992)
A biography of the courageous New Zealand woman who provided the diggers in World War I with safe sex advice and free condoms.
Use of condoms, along with regular check-ups, could have contained the syphilis epidemic long before the discovery of penicillin in the 1940s provided a reliable cure. It may be a long time before we have a cure or vaccine for HIV-AIDS, and in the meantime condoms offer the best and most reliable protection for those who are determined to brave the perils of sexual promiscuity - as the following article suggests.
Effectiveness of condoms in preventing HIV transmission
Abstract The consistent use of latex condoms continues to be advocated for primary prevention of HIV infection despite limited quantitative evidence regarding the effectiveness of condoms in blocking the sexual transmission of HIV. Although recent meta-analyses of condom effectiveness suggest that condoms are 60 to 70% effective when used for HIV prophylaxis, these studies do not isolate consistent condom use, and therefore provide only a lower bound on the true effectiveness of correct and consistent condom use. A reexamination of HIV seroconversion studies suggests that condoms are 90 to 95% effective when used consistently, i.e. consistent condom users are 10 to 20 times less likely to become infected when exposed to the virus than are inconsistent or non-users. Similar results are obtained utilizing model-based estimation techniques, which indicate that condoms decrease the per-contact probability of male-to-female transmission of HIV by about 95%. Though imperfect, condoms provide substantial protection against HIV infection. Condom promotion therefore remains an important international priority in the fight against AIDS.
Steven D. Pinkerton and Paul R. Abramson, “Effectiveness of condoms in preventing HIV transmission”, Social Science and Medicine, Vol. 44, No. 9, 1997, pp. 1303-1312
Further information
Steven Pinkerton and Paul Abramson, “Condoms and the protection of AIDS”, American Scientist, Vol. 85, July-August 1997, pp. 364-73
Roger Short and Malcolm Potts, “Condoms for the prevention of HIV transmission: Cultural dimensions”, AIDS, Vol. 3 1989, Supplement 1, pp. S259-63
This paper urges urging mass distribution of condoms to high risk groups in the Third World, especially areas of Africa with rates of HIV infection. This was before Dr Short got the bright idea that foreskins might be an easier target than the AIDS virus and became a fanatical evangelist for universal routine circumcision. In fact, circumcision may discourage condom use, for two reasons. The first is that circumcised men have less feeling in their penis (because most of the nerves have been removed), and a condom blunts sensation even further. Secondly, Australian researchers have found that normal (uncircumcised) men actually find condoms easier and more comfortable to use:
“Uncircumcised men were found … to be significantly less likely to report condoms slipping off than circumcised men. One possible reason might be that the increased bulk of the distal part of the penis provided by the presence of the foreskin helped to retain the condom.”
Juliet Richters, John Gerofi and Basil Donovan, “Why do condoms break or slip off in use? An exploratory study”, International Journal of STD and AIDS, Vol. 6, 1995, pp. 11-18
A common reason why condoms slip off is because the wearer loses his erection. The most likely reason why this occurs is because he is not getting enough sensation through the latex, and this blunting of feeling will be more severe if he is circumcised and thus deprived of the thousands of nerve endings found in the foreskin.