Opinions vary widely on the practice of circumcision, or the surgical removal of the foreskin. In an uncircumcised infant male, the foreskin is fused to the glans—colloquially referred to as the “head”— and should not be separated forcefully. Separation should occur naturally over time. In an uncircumcised adult male, the foreskin covers the glans when the penis is flaccid and retracts when the penis is erect, exposing the glans.

Circumcision status is not an either/or matter; there is a wide range in amount of foreskin among uncircumcised men. In some, the foreskin barely covers the glans when the penis is flaccid and virtually disappears when the penis is erect. In others, the foreskin hangs well over the glans when the penis is flaccid and needs to be pulled back manually to expose the glans when the penis is erect.

Circumcision is a sensitive topic; beliefs as to whether one ought to undergo the procedure, or subject one’s children to the procedure, are indexed on religious practices, cultural norms, and personal values. Some believe the circumcised penis is more attractive, others are partial to the natural form of the uncircumcised penis, and many have no preference, considering the distinction unimportant. Neither side of the debate comes without complications and potential drawbacks.

Proponents of the procedure often cite hygienic concerns as a reason for circumcision; the foreskin can make the penis more difficult to clean and an uncircumcised penis is prone to collect smegma, a cheese-like substance. Circumcision allows for continual, direct contact with the glans—which is the most sensitive part of the penis—and proponents believe this can enhance sexual pleasure.

Opponents consider circumcision to be a form a genital mutilation and reason that people are meant to preserve the natural form of their bodies. They point to the purpose of the foreskin as a lubricating sleeve, buffering the penis from friction, and they claim that the foreskin adds sensation, as it rubs back and forth over the glans. They express concern that removing skin containing nerve endings can result in a slight loss of sexual sensation.

Regardless of personal preference, many believe that the procedure, if performed at all, should be put off until later in life when a man, himself, can make the decision. It should be noted that adult circumcision is considerably more risky, takes longer to heal, and confers fewer benefits than infant circumcision.

Circumcision is widely considered to bear personal, religious, and cultural significance. Recent scientific developments have further problematized the issue; clinical trials have yielded results indicating differential medical outcomes among circumcised and uncircumcised men. These studies suggest that circumcision is also a matter of medical relevance. 

Circumcision and HIV

In December 2006, the National Institute of Health was compelled to halt clinical trials in Kenya and Uganda, after results confirmed that circumcision substantially lowers the risk of acquiring HIV infection. Accounting for the robust results, the researchers reasoned that failing to offer circumcision to all of the men participating in the study would have been unethical.

During the clinical trials—involving approximately 3,000 HIV-negative, heterosexual men in Kisumu, Kenya and 5,000 in Rakai, Uganda—men were divided into circumcised and uncircumcised groups, given safe sex advice and tested for HIV regularly. The National Institute of Health’s Data Safety and Monitoring Board stopped the trials after the data evidenced a 53 percent reduction in new HIV infections among circumcised Kenyan men and a 48 percent reduction among circumcised Ugandan men. These results mirrored those of a French government-funded trial, completed the previous year in South Africa, evidencing a 60 percent reduction in HIV acquisition.

Scientists believe that uncircumcised men are more susceptible to infection because the underside of the foreskin is concentrated with Langerhans cells, which are the immune system’s sentinels and readily attach to the immunodeficiency virus. Furthermore, the fragile foreskin can suffer abrasions and microscopic tears during sex, increasing the opportunity for transmission.

Following the release of the results, the two largest organizations dedicated to fighting the AIDS crisis—the Global Fund to Fight AIDS and the Emergency Plan for AIDS relief—offered that they would be willing to provide financial support for sterile circumcisions recommended by world health agencies. Previously funding for circumcision had not been considered because evidence that it could reduce the risk of transmission in high-risk countries was only speculative. 

Dr. Kevin M. De Cock—director of HIV/AIDS for the World Health Organization—offered his endorsement with qualifications: “[Circumcision is] not a magic bullet, but a potentially important intervention.” Although circumcision reduces the risk, it must be used in tandem with other prevention methods, such as condoms. Dr. Anthony S. Fauci—AIDS researcher and director of the National Institute of Allergy and Infectious Diseases—cautioned “this does not mean that you have an absolute protection.” He noted that circumcision does nothing to prevent the spread of HIV through receptive anal sex or intravenous drug use, two of the ways in which the virus is commonly transmitted in the United States.

After the Kenyan trial was ended in 2006, participants were informed of the study’s results and were offered the option of circumcision as a protective measure. At that point, researchers continued monitoring the number of new infections among the circumcised and uncircumcised groups. Data analysis was completed three-and-a-half years after the inception of the study and results were presented at the 17th International AIDS Conference in August 2008. In the circumcised group, 2.6 percent of the men had acquired infections compared with 7.4 percent in the uncircumcised group. This represents a 64 percent reduction in HIV rates among circumcised, heterosexual men and attests to circumcision’s lasting, protective effects. Critics had previously been skeptical that the benefits would decline if the trial had been allowed to continue past the initial two years.

In March 2007, the World Health Organization and UNAIDS officially recommended circumcision as a method of protection against heterosexual transmission of HIV. Although, at this point, no countries had adopted circumcision as part of their AIDS prevention plans Dr. Kevin De Cock offered, “I hope this recommendation will lead some to do so.” His comments were presented in light of the fact that large donors had already indicated a willingness to fund circumcisions, if countries made a request and demonstrated an ability to perform operations safely and with proper counseling. The World Health Organization emphasized that the procedure would be the most effective in locations where AIDS prevalence is high and circumcision rates are low.

It is crucial that training and monitoring be done to ensure a sanitary environment, proper handling of equipment, and counseling stressing that circumcision is by no means a cure-all measure. Men must be taught: 1. circumcision reduces the risk of transmission, 2. one can still catch the virus and pass it on regardless of circumcision status, and 3. one can further reduce the risk by abstaining from sex altogether, having sex with fewer partners, and using condoms correctly and consistently. Circumcision should be considered an additional intervention as part of a multifaceted prevention plan; it is in no way intended to replace the preventative efforts already in place. Catherine Hankins—of UNAIDS—clarified, “Male circumcision does not provide complete protection against HIV. Men and women who consider male circumcision as an HIV preventive measure must continue to use other forms of protection such as male and female condoms, delaying sexual debut, and reducing the number of sexual partners.”

Circumcision and STDs

A study published in The New England Journal of Medicine, in March 2009, evidences that circumcision reduces transmission of both herpes simplex virus Type 2 (HSV-2) and human papillomavirus virus (HPV). In a clinical trial, more than 3,000 uncircumcised Ugandan men—who were not infected with HSV-2—were randomly assigned to either an experimental condition where they were circumcised immediately or a control condition where they were to be circumcised two years from the onset of the experiment. A subgroup of this sample was evaluated for HPV in a similar manner.

After two years, when the men were reevaluated, 153 of the uncircumcised men tested positive for HSV-2, while only 114 of the uncircumcised men tested positive. Controlling for health and behavioral factors, the researchers estimate that circumcision had reduced the risk for acquiring HSV-2 by 25 percent. The results were even more dramatic for the types of HPV that can lead to genital cancer. Approximately 28 percent of the uncircumcised men tested positive at the end of two years, compared with only 18 percent of those who had been circumcised. After adjusting for health and behavioral factors, the researchers estimate circumcision had reduced the risk of infection by 35 percent.

It is unclear what mechanisms produced this pronounced effect. The researchers posit that when the foreskin retracts during intercourse, the penis is exposed to infection, and when the foreskin rolls back over the glans, the moist area under the foreskin could serve as an incubator in which viruses thrive and proliferate. Because the men were evaluated only initially and after a two-year period, it is also unclear whether the lower rate of HPV infection among circumcised men was due to a reduced rate of acquisition or an increased rate of infection clearance. The researchers point out that subjects in both the experimental and control groups had chosen to participate in the study, and cooperative subjects could be at lower risk for infection than people in the general population, to begin with. This suggests that the results could represent an underestimation of the effect.

This study confirms the results of two previous studies conducted in South Africa. Its senior author, Dr. Ronald H. Gray—professor of reproductive epidemiology at John Hopkins University—states, “There is no reason to believe that this is in any way unique to Africa.” Considering the aggregate of the results provided by the three studies, the researchers conclude that circumcision should be accepted as an effective intervention against both HSV-2 and HPV acquisition. They emphasize that the procedure is only partially effective and should be used in conjunction with other protective measures. Dr. Gray, who believes that these studies have significant implications for public health, imparts, “I think it’s important that pediatricians consider the lifelong benefits that might accrue from circumcision when they are advising parents on whether the procedure should be performed in baby boys.”

Circumcision and Penile Cancer

Circumcision protects against penile cancer when it is done soon after birth. Men who were circumcised as babies cut their risk of penile cancer by more than 50 percent. Having the foreskin removed later in life does not reduce this risk.

It is unclear what exact mechanisms cause uncircumcised men to be more susceptible to penile cancer than their circumcised counterparts. The American Cancer Society proposes the theory that having a foreskin may expose uncircumcised men to intermediate risk factors. For example, men who are uncircumcised are more likely to acquire HPV—even after adjusting for differences in sexual behavior—and HPV can lead to cellular changes that develop into cancer.

Additionally, uncircumcised men sometimes develop a condition called phimosis, and men with phimosis are at increased risk for developing penile cancer. Phimosis is a condition in which the foreskin becomes tight and difficult to retract. It is normal for the foreskin to remain adhered to the glans of the penis in infanthood and even throughout early childhood, but if it does not separate and is unable to move freely by adolescence, it becomes problematic. Someone with phimosis is prone to have trouble cleaning the entire penis, because it is painful or wholly impossible to pull the foreskin all the way back.

Secretions may build up underneath the intact foreskin, and if the area is not cleaned well, the build-up can develop into smegma, a thick substance with an unpleasant smell resembling cheese. Smegma is composed of oily skin secretions, dead cells, and bacteria. Although it hasn’t been proven, some studies have suggested a link between smegma and penile cancer. The build-up of secretions is easily avoided—in men with retractable foreskin—by retracting the foreskin and engaging in proper hygiene.

Penile cancer is one of the least common forms of cancer. As of July 2008, neither the American Academy of Pediatrics nor the Canadian Academy of Pediatrics recommends routine circumcision to reduce the risk. Adult men can lower their risk of developing penile cancer by avoiding other risk factors, such as smoking, taking certain medications, and acquiring AIDS, which can lead to a compromised immune response and an increased susceptibility to acquiring HPV.

Is Circumcision Right for You?

For many years, circumcision was exclusively considered to be a matter of personal taste, cultural practice, and religious edict. In the wake of the recent scientific developments, illuminating the potential medical benefits circumcision confers, circumcision is now recognized to be a matter of medical relevance, additionally. In all likelihood, parents—who do not have strong preexisting orientations with regards to the procedure—will seriously consider circumcision as an option for their baby boys.

Of course, circumcision is a surgical procedure, and although it is relatively safe, no surgical procedure comes without potential risks. Furthermore, the results are irreversible, so the decision as to whether to circumcise one’s children should not be taken lightly. Some people believe it is up to parents to decide whether to circumcise their children, and others believe that it should be left for the children themselves to determine. When considering the potential costs and benefits of circumcising one’s children, one should keep in mind that the healing time is much quicker and the medical benefits are more pronounced if the procedure is undergone in infancy, as opposed to adulthood.