It will probably come as no surprise that male circumcision, the removal of the foreskin or prepuce of the penis either immediately after birth or at a later life stage, has been practiced by mankind since antiquity. This is evident from its depiction in carvings belonging to the tomb of the Egyptian priest Ankh-Mahors which dates back to around 2,400 B.C.E. Among the ancient Hebrews, circumcision has its “origins” with the covenant they believed Abraham made with God. In contrast, the ancient Greeks and Romans took a rather dim view of circumcision. This is evidenced by the laws against it that were enacted by rulers such as Antiochus IV Epihanes (175-164 B.C.E.) and Emperor Hadrian (117-138 A.D.). Hadrian’s actions are believed by some historians to have sparked the famous “Jewish revolt” of 132 A.D.
In “Unsafe Sex Worries? Try Kink!” Spanking FIT, Nov. 2014, I conjectured that some biblical taboos may be based on the empirical observations of learned men over time who connected certain activities of a sexual nature with increased incidence of disease. While there is no explicit reference in the Bible to a link between the lack of circumcision and sexually transmitted diseases (S.T.D.s), there is evidence that the ancients were aware of the latter in Leviticus 15: 2-23. At the very least, a perception that the circumcised penis provided better male hygiene may have been part of their rationale.
Nevertheless, the debate: to cut or not to cut, rages on into the modern era as the practice continues. Estimates of circumcision rates among U.S. men are about 79% overall, and 88% among non-hispanic “whites”. (See “Prevalence of circumcision and herpes simplex virus type 2 infection in men in U.S.: the National Health and Nutrition Examination Survey (N.H.A.N.E.S.) 1999-2004” by F. Xu, et al., Sexually Transmitted Diseases; July 2007, 34 (7) 479-84.) On the other hand, the Canadian Health Agencies have over the years reported around a 50% circumcision rate among their citizens. European nations have today’s lowest circumcision rates with countries like Finland reporting less than a 2% figure for their males. Needless to state, circumcision rates also vary tremendously based on religion, with an estimated 95% of Muslims worldwide believed to be presently circumcised.
Today, the circumcision question is at the center of much controversy within the online medical community. Those who advocate for it such as Professor Brian J. Morris of circinfo.net, allege increased S.T.D. incidence, including H.I.V. infection, among the non-circumcised . Its opponents on the other hand are many. George Denniston, M.D. of Doctors Opposing Circumcision (doctorsopposingcircumcision.org) states:”the case in favor of male circumcision is based on specious literature largely created to satisfy the emotional compulsions of wounded circumcised men.” He goes on further to say: “claimed health benefits are illusory and do not offset proven risks, complications, and disadvantages.” Some have even put male circumcision in the same category as female circumcision and regard it as a form of genital mutilation. The U.S. Centers for Disease Control (U.S.C.D.C.) states their position at cdc.gov: “male circumcision reduces the risk that a man will acquire HIV from an infected female partner and also lowers the risk of other S.T.D.s”. They also state that in female partners it “reduces the risk of cervical cancer and H.P.V..” C.D.C. draft recommendations include that all uncircumcised adolescents and adult males should be informed about “the significant, but partial efficacy of male circumcision in reducing risk of acquisition of H.I.V. and some S.T.D.s” For parents and guardians, they advise that “male circumcision is a proven effective prevention intervention with known medical benefits”. These C.D.C. claims were widely popularized by Scientific American in December 2014 with the publication of “Male circumcision benefits outweigh risk, C.D.C. says“.
Such intense disagreement among “experts” can be quite confusing for parents of newborns trying to make an informed decision on whether “to cut or not to cut”. Consequently, Spanking FIT felt obligated to carefully examine the claim that circumcision significantly reduces risk of H.I.V. infection and other S.T.D.s. We also examined the claim made by some of the critics that it diminishes male sexual pleasure. We begin by analyzing its effect specifically on risk of contracting two major S.T.D.s- Syphilis and Gonorrhea:
Can male circumcision prevent non-H.I.V. related S.T.D.s?
Syphilis
Syphilis is among the most serious of the so-called “genital ulcer diseases” and ravaged Europe in the 15th century A.D.. Although treatable today, around “113,00 fatalities may be attributed to it in 2010 alone” according to “Global and regional mortality from 235 causes of death_.” by R.Lozano. (The Lancet 380: Dec. 2012) Spanking FIT reviewed the principal reference cited by U.S.C.D.C. supporting the claim that circumcision reduces its risk: “Male circumcision and risk of syphilis, chancroid and genital herpes” by H.A. Weiss and published in Sexually Transmitted Infection, 2006, April, 82 (2), 101-9. Here are the results of the review:
The Weiss study falls into the category of “meta-analysis” meaning that its conclusions are based on a synthesis of the results of a number of different relevant studies, in this case precisely 26. Weiss concludes his analysis by stating:” the first systematic review of male circumcision and S.T.D. strongly indicates that circumcised men are at a lower risk of chancroid and syphilis”. However, upon review of all 26 studies, Spanking FIT uncovered that in two of them only did the researchers record safe sex practices among study participants, including prevalence of condom use. (It is a fact that uncircumcised men often report greater difficulty in fitting the condom on their penises which suggests that there may be a lower rate of condom usage among them. This phenomenon could easily bias study results.) Consequently, we focused our evaluation on those studies where condom usage was recorded, including one by R.H. Gray:”Male circumcision and the risk of sexually transmitted infections and H.I.V. in Rakai, Uganda” published in A.I.D.S. 2004 Dec. 3, 18 (18), 2428-30. Our findings: circumcised men had a marginally statistically significantly higher syphilis incidence rate than uncircumcised ones, the opposite of the C.D.C. claim!
Similar problems existed with other cited studies that Spanking FIT reviewed including a more recent one which was funded by Gates Foundation:”Association between circumcision and incidence of syphilis in men and women: a prospective study in HIV-1 serodiscordant heterosexual African couples“, by J. Pintye and published in The Lancet, Nov. 2014. v. 2 no.11, 664-671. Gray reported no significant differences between circumcised and uncircumcised men who were HIV negative to start (in fact, I detected a marginally significantly higher syphilis rate among uncircumcised men) , and a highly statistically significant one among uncircumcised men who were HIV positive to start. However, the researchers also reported that a greater percentage of the uncircumcised than the circumcised engaged in unprotected sex in the study group prior to enrollment. Additionally, the uncircumcised males also reported greater sexual activity with “additional partners”. The researchers should have included relevant data on sex practices of the subjects after study commencement and during the follow-up period which would have made possible more accurate comparisons between the circumcised and the uncircumcised regarding syphilis susceptibility.
Gonorrhea
Spanking FIT‘s evaluation of studies asserting that circumcision reduces gonorrhea risk turned up similar problems regarding the possible confounding effects of condom use and frequency of sexual encounters upon incidence of disease. We included in the review a classic study “Circumcision and venereal disease” by R.A. Wilson published in Canadian Medical Association Journal ,1947 Jan. 56(1):54-56. which made use of a large sample of diseased and non-diseased (control) servicemen. Their findings were that a statistically significantly higher percent of uncircumcised men were among those with gonorrhea, versus those free of disease (73.6% versus 52%). Researchers postulated that the foreskin of uncircumcised men retain infectious mucus from intercourse that contaminates urethol mucosa causing gonorrhea. However, they concede the possibility that results could be explained by a higher rate of what they refer to as “promiscuous experience” among the uncircumcised. In contrast, the previously cited Gray work found no statistically significant differences between circumcised and uncircumcised African subjects with respect to gonorrhea incidence.
Does male circumcision reduce risk of HIV infection?
Circumcision is presently being vigorously promoted by some medical bodies for H.I.V. infection control in the third world, including Africa. The unproven theory behind this is that the H.I.V. virus targets so-called Langerham cells located in the mucosal surface of the foreskin of uncircumcised men (see: “How does male circumcision protect against H.I.V.?” by R. Szabo; B.M.J. June 10, 2000, 320 (7249 )) Consequently, The Male Circumcision Partnership, with substantial funding from the Bill and Melinda Gates Foundation, launched a massive male circumcision campaign in Africa. As of September2014, their “network” had circumcised over a million men and boys according to their web page psi.org/program/voluntary-medical-male-circumcision/.
The principal reference used to justify circumcision as a preventative measure for HIV infection is “Male circumcision for H.I.V. prevention in men in Rakai, Uganda: a random controlled trial” by R.H. Gray published in The Lancet 2007 Feb. 24; 369, 657-666. In this study, 4,998 HIV negative men were randomly assigned to treatment (immediate circumcision) or control (circumcision delayed until 24 mos. later) The results were a statistically significantly higher HIV positive incidence rate among the uncircumcised men ( 1.33% per person year versus 0.66% per person year, translating into about a “50% efficacy rate for circumcision”). However, the researchers noted that a full 38% of study participants reported “no condom use during sex”, so that one would expect the efficacy of circumcision in preventing H.I.V. infection to be considerably lower than this among regular condom users.
Surprisingly this study, which was funded by U.S. National Institute of Allergy and Infectious Diseases (N.I.A.I.D.), also appears to have a “Tuskegee-like” quality to it; because, experiment participants may not have been adequately informed of the dangers of unprotected sex and, therefore, may have been denied knowledge that could have prevented disease. (Readers may recall that the original Tuskegee experiment went further. Participants with syphilis were deliberately denied available treatment.) Also, by inadequately emphasizing condom use among participants, researchers held themselves open to accusations of having deliberately biased results in favor of circumcision.
Given the seriousness of H.I.V. infection, why not focus on safe sex/ condom usage instead of circumcision?
Let us assume that circumcision reduces H.I.V. risk in a population that includes significant condom non-users. The question naturally arises as to whether the emphasis should instead be placed on correct and consistent condom usage, in lieu of circumcision. But, just how reliable are condoms in preventing H.I.V. infection among heterosexuals? Best estimates again come from African studies that involve serodiscordant couples; i.e., those in which one partner and not the other is positive. For example, “Condom effectiveness in reducing heterosexual H.I.V. transmission” by S. Weller; Cochrane Data Base 2002 sys rev 3 cited by C.D.C.. Conversion rate estimates vary from 0.9-1.1% per person year for both women and men. In other words, a man who is H.I.V. negative and who has sex with an H.I.V. positive woman on a regular basis for one year has the above chance of becoming H.I.V. positive himself, if he regularly uses protection. Keep in mind, however, that these estimates are derived based on African sex practices, and that the studies did not take into account the condom quality or correctness of condom use. It may be anticipated that correct use of high-quality latex condoms results in a significantly lower rate of conversion.
Spanking FIT next performed a comparative risk analysis for circumcised condom users versus uncircumcised ones using the previous findings and available data from “National Survey of Sexual Health and Behavior (N.S.S.H.B.)” Indiana University Journal of Sexual Medicine, vol. 7, supp. 5. We also made use of C.D.C. estimates on the number of U.S. H.I.V. positive women and computed a probability of approximately 0.2% (upper estimate) that a U.S. male randomly encounters an H.I.V. positive sex partner. Using standard binomial probability procedures, we estimate that a heterosexual non-circumcised male who conscientiously uses condoms whenever the H.I.V. status of his partner is unknown or when it is known positive, has approximately a 99.89% probability of remaining free of H.I.V. in his lifetime. For a circumcised male, this probability increases slightly to 99.95% . In other words, the uncircumcised American male who fits the “average” heterosexual profile presented in the above Indiana survey, has only a rather insignificant six one hundredths of one percent greater risk of contracting H.I.V. in his entire lifetime. It should be noted that in conducting the analysis, we gave benefit of the doubt to the Weller study and assumed full 50% circumcision efficacy even among conscientious condom users.
How effective are condoms in preventing other S.T.D.s besides A.I.D.S.?
Condoms seem to be highly effective in protecting both the circumcised and uncircumcised penis from H.I.V. infection. It has been conjectured that the foreskin of uncircumcised men plays a significant role in retaining and/ or absorbing other S.T.D. micro-organisms, also. So how effectively do latex condoms provide a barrier to them? To answer that question, Spanking FIT began by acquiring data on microbial size of S.T.D. pathogens. Inquiries using an electron microscope reveal that the size of an H.I.V. retrovirus ranges between 100-150 nanometers(nm). The H.S.V virus that causes herpes is relatively larger ranging from 120-300 nm.. Syphilis and gonorrhea are caused by bacteria that are much larger, ranging between 0.6-15micrometers. Clearly, latex condoms can be expected to provide effective barriers against foreskin contamination by these. The H.B.V. virus that causes Hepatitis B is smaller than H.I.V. , and has an average diameter of about42 nm.. So is H.P.V., the human papilloma virus at 52 nm. However, important laboratory tests conducted and reported by G.Y. Minuk in “Efficacy of commercial condoms in the prevention of herpes infection” and published in Gastroenterology 1987, Oct. (93) 710-14 , indicate that synthetic (as opposed to natural) condoms do provide an effective barrier against H.B.V. virus even when using testing fluids containing “far more virus than human physiologic fluid” and when the condoms are subjected to stresses exceeding those expected to result from normal sexual activity. It may be inferred from this that synthetic condoms provide an effective barrier to the larger H.P.V. virus also; and, therefore can be expected to adequately protect the uncircumcised foreskin from contamination if properly used .
Circumcision and risk of diminished sexual enjoyment
There is also currently a heated medical debate regarding who experiences greater sexual enjoyment: circumcised or uncircumcised men? Those who believe that circumcision has no effect on pleasure such as B.J. Morris of University of Sydney, point to the randomized controlled trial conducted in Africa:”The effect of male circumcision on sexual satisfaction and function_” by G. Kigozi, et al., published in B.J.U.I., Dec. 7, 2007. (Dr. Morris has been criticized as having a conflict of interest because he performs circumcisions.) In the study, 4,456 men who were H.I.V. negative were randomly assigned to either a treatment group (immediate circumcision) or control group (delayed circumcision after 24 months). At the end of the 24 month period each was surveyed regarding their perceived sexual satisfaction. Contrary to claims made by study authors, there was actually a very statistically significantly lower degree of sexual satisfaction among the circumcised group, although the magnitude of that difference was quantitatively quite small (98.4% satisfaction among circumcised, compared with 99.9% satisfaction among uncircumcised).
Those on the opposite side of the issue who claim circumcision decreases sexual satisfaction, often point to the detailed experimental work :”Fine-touch pressure thresholds in the adult penis” by M.L. Sorrells published in B.J. Urology International; April 2007, 99 (4), 864-9. In it, the fine-touch pressure thresholds for each of 19 penile positions were measured and comparisons made between a group of 68 non-circumcised males, and 91uncircumcised ones. Multivariate analysis of the data revealed that the uncircumcised penises were overall more sensitive than the circumcised ones at locations which both have in common, including the head or glans area. Another interesting discovery made was that the circumcised penis has its greatest sensitivity near the circumcision scar on its dorsal side, but that the outer rim of the uncircumcised prepuce is comparatively more sensitive than it. An amusing observation made by Spanking FIT which was overlooked by study authors and their critics was the following: according to the statistical regression results, both circumcised and uncircumcised men who wore briefs experienced greater sensitivity which actually exceeded the difference in the non-circumcision effect. In other words, study results imply that it may be possible for a man to significantly increase his penis sensitivity just by wearing briefs, in lieu of boxers or no underwear at all.
Spanking FIT also came upon non-experimental or anecdotal evidence that men who have their foreskins intact may be able to achieve what some have dubbed “ridged band orgasms“. The ridged band is a ring of highly enervated ridges on the inside of the foreskin tip noted above. (See Canadian Foreskin Awareness Project at can-fap.net for more information.)
Finally, to cut or not to cut?
Spanking FIT’s review of both sides of the circumcision controversy indicates that among populations where condom usage is inconsistent and both quality and correctness of use is in question, male circumcision may significantly reduce incidence of S.T.D.s, including A.I.D.S. Nevertheless, it is unclear whether resources allocated to circumcision programs might not be better spent on safe sex education and in supplying high quality condoms to affected populations.
For the educated parents of newborns considering circumcision, basically it comes down to this: if you can raise your son to appreciate the urgency of using protection whenever he engages in coital sex with a partner of unknown S.T.D. status, there appears to be very little gained through circumcision. Why remove a portion of the male anatomy provided by evolution and risk diminished sexual enjoyment later in life? It is possible that the ancient Hebrews advocated circumcision based on a suspected link between foreskin possession and higher S.T.D incidence and saved humanity from an apocalypse. However, the drastic measure they initiated of amputating the male prepuce may no longer, in fact, be warranted in the modern age of bathroom amenities and high quality latex for sexual purposes. There are also those who argue that the circumcision decision should be left out of the hands of parents and pediatricians altogether, and placed entirely in the hands of the affected individual at a later stage in life. Those wishing to go that route will also, hopefully, find the previous risk analysis helpful. As a final note, you may wish to consult “Unsafe Sex Worries-Try Tantric Massage!“, Spanking FIT, Nov. 2015, to discover how other non-western societies that did not commonly practice circumcision, cleverly dealt with the issue of safer sex. As usual, I look forward to your feedback. Dr. Garrett