Should all boys be circumcised?

By Jeremy Laurance

If you were the parent of a baby boy and were told a minor operation could provide him with protection against three diseases (at least) that kill millions worldwide, would you be interested? It is safe to assume that you would. When, however, you discovered that the operation in question was circumcision, would your enthusiasm dwindle?

Circumcision is the world's most common surgical procedure. But it is also among the most sensitive – politically, culturally and ethically. Even within the scientific community it is difficult to have a reasoned debate about the pros and cons, examining the evidence, without people taking sides. For several decades, the medical community has kept quiet about circumcision, mindful of the sensitivities around it. Doctors are broadly agreed that the operation is "not medically necessary" – except in a tiny minority of cases, for example where the foreskin will not retract. They say it is for parents and the public to decide about the ethics of circumcision for religious or other non-medical reasons.

Now that cosy consensus has been challenged by the emergence of evidence showing that the removal of the foreskin can prevent a number of sexually transmitted diseases. Three landmark randomised controlled trials conducted in South Africa, Kenya and Uganda between 2005 and 2007 demonstrated that adult male circumcision reduced the risk of contracting HIV by 50 to 60 per cent. This is well known and has led to the development of programmes offering circumcision in a number of African countries, backed by the World Health Organisation, with predictions that in the long term it could save millions of lives.

Now new evidence has emerged for the protective effect of circumcision against infection with Human Papilloma Virus (HPV), the chief cause of cervical cancer in women, which is reduced by 35 per cent, and against Herpes Simplex Virus (HSV), the cause of herpes, which is reduced by 25 per cent. Circumcision probably also protects against syphilis, but the findings, published in the New England Journal of Medicine in March, were based on too small a sample to be conclusive.

Both HPV and HSV are global health problems that far outstrip HIV in frequency, causing substantial death and suffering. Cervical cancer is responsible for thousands of deaths in western countries (and millions in the developing world). Herpes is seldom fatal, but it causes significant illness and costs millions of pounds to treat.

An editorial in the NEJM said that the findings were "a call to action for professional societies" to review the advice they give on circumcision. Two countries – the US and Australia – have already heeded the call. The American Academy of Paediatrics has established a taskforce to examine its policy on circumcision and a similar review is under way in Australia.

Susan Blank, chair of the US task force and a paediatrician with the New York City health department, says: "In the last few years a lot of data has come out that needs to be evaluated and policy developed. It is true that the data are compelling. Our task is to look at it in the context of our domestic situation. There are a lot of emotional overlays that go along with issues of babies and child health." Dr Blank says circumcision has been declining in some states in the US but the overall prevalence, at 65 per cent, remains high compared with the UK.

In the UK rates are much lower and have been falling for decades. They stand currently at 16 per cent, according to the Health Protection Agency (HPA). But the UK Royal College of Paediatrics has no plans to follow its sister organisations in the US and Australia by setting up a taskforce to review the evidence.

Professor Terence Stephenson, president, says HIV is uncommon in the UK and there is little heterosexual transmission within the country, and no evidence that circumcision is protective in men who have sex with men. There is a vaccine available against cervical cancer currently being rolled out in a national campaign, which is expected to significantly reduce the toll from that disease and the incidence of herpes in the UK is substantially lower than in the US. "As a public health measure, I doubt if the college or the Department of Health would be pressing hard for the introduction of neonatal circumcision. To carry out 300,000 a year in the UK on the NHS [the annual number of male births] would be a huge cost – money which could be used for other things." If a parent asked for information about the benefits of circumcision, he would spell them out, he says. But there are drawbacks, too, including the discomfort caused by the procedure, the need for antibiotics and, rarely, complications such as bleeding.

Barry Evans, consultant epidemiologist and specialist in sexually transmitted infections at the HPA says the value of circumcision as a defence against HIV in Africa is well established. "It is fantastic and has a real possibility of denting the Aids epidemic in Africa," he said. But in the West it is a different story. Debating the issue is difficult, however. There are entrenched views on both sides, he says. "Some people view it as tantamount to child abuse while others say that not to do it amounts to child neglect and that it should be regarded like vaccination. Very few say let's look at the evidence, weigh it up and decide if it is worthwhile."

There is a clear medical benefit to circumcision and if parents are considering the procedure for religious or other reasons, these should not be downplayed. But in terms of benefit to the population as a whole, the consensus in the UK is that efforts to increase the current rate would be hard to justify. It remains to be seen whether the US and Australia share that view.

Medical miracles: Historic cures

Leeches (Hirudotherapy): The first leech was used in 1000 B.C and in the mid 1800s were believed to cure any ailment, from colds to facial discolouring. The slug-like animal was placed on human skin as a way of draining blood congested areas in the body. Leeches are now used in micro-surgery for precision when draining wounds, as the anti-blood-clotting enzymes in their saliva allow an increased blood flow. The enzyme is part of drug trials where it is used as a preventive method for heart attacks and blood clots, but is yet to be used on humans.

Cupping: An Ancient Chinese and Arabic process that involves using fire to warm the air inside a glass cup placed over an incision on the skin. As the air cools, a vacuum creates a suction force that relieves the blood-congested area. In modern Chinese medicine cupping is used as an alternative therapy to clear the five meridian channels through which the body's life energy flows, removing toxins and promoting relaxation.

Trepanation: One of the oldest medical procedures, dating back to the prehistoric Neolithic era around 9500 BC. A hole was drilled into the conscious skull of a patient as a way of curing headaches that were thought to be caused by evil spirits. The technique is now used for the relief of subdural haematomas in neurosurgical procedures under anesthesia.

Maggots: Although visually gruesome, the use of flesh eating maggots has re-emerged as a cost-effective way of combating the new strains of "superbugs" such as MRSA that have become immune to our antibiotics. Maggots devour the rotting flesh of patients and can be used to clean severe wounds caused by these diseases.

The kindest cut?

* The earliest Egyptian mummies (1300 BC) were circumcised.
* The word derives from the Latin circum ("around") and cædere ("to cut").
* Early circumsicion was a sacrificial religious practice.
* 30 per cent of males are circumcised in the world, but the operation is mainly performed for religious and cultural purposes rather than for medical reasons.
* A Gomco clamp, Plastibell, and Mogen clamp are used to circumcise infants.
* Adult operations are done without clamps and sexual activity cannot resume for four to six weeks.
* Risks are generally rare but include infection, damage to the urethra and a loss of sexual sensation in the genital organ.