Cutting to the chase on circumcision risks vs benefits

Dear Dr G,

I am a teenager hoping you can help me deal with my concerns as an adolescent.

I am 15 years old, and my parents recently took me to see a doctor as I often get urinary tract infections (UTI).

The doctor examined me and told me my foreskin is too long and too tight for retraction. Hence, it is resulting in regular hygienic (or lack of it) issues.

To cut to the chase, the doctor suggested I undergo circumcision to lower my risk of further infection.

He gave me time to consider my options, especially since I have just recovered from one episode of UTI.

He also asked me to investigate all the protective effects from infections without the foreskin, including sexually transmitted diseases.

My parents are cool as they reckon having the circumcision should really be my own decision, because I am old enough to consider the pros and cons of the surgery.

I can retract the foreskin for daily cleaning in the shower.

I would like to put Dr G on the spot for the issues related to the protective effects of circumcision.

Why is the foreskin such a source of infections in men?

What is the scientific evidence to support circumcision as a measure against getting sexually transmitted infections in the future?

I also understand circumcision is encouraged in Africa to reduce the transmission of HIV; can you elaborate on that please?

I am reluctant to get the cut, therefore I need to understand more before deciding.

Regards,

Reluctant Raymond

Circumcision is the oldest surgical intervention with records dated back to ancient Egypt. The exact origin and purpose of circumcision is uncertain, but various theories have been proposed as to its origin including a form of religious sacrifice or as a celebration of passage of a boy into adulthood.

In modern days, an estimated one-third of men in the world are circumcised, with most of the surgery done for religious reasons rather than medically indicated. Elective non-religious circumcisions are also commonly performed in countries like the United States and part of South-East Asia.

A 2004 Nationwide Inpatient Sample estimated that 55.9% of boys born in US hospitals are circumcised.

The population-based prevalence is likely closer to 79%, varying by ethnicity, ranging from 88% in white males to 73% in African American males to 42% in Mexican American males.

Circumcision is also highest among boys born to families of higher socioeconomic status, with unclear exact medical indication.

Although the removal of the foreskin is a simple centuries-old practice, it is still one of the most controversial and hotly debated subjects amongst major medical organisations.

The beliefs range from the opinion that elective circumcision has a modest benefit that outweighs the risks; to a stand that elective circumcisions carry significant risks with minimal long-term benefits.

Essentially, these arguments revolve around the protective effects of circumcision against sexually and non-sexually acquired infections.

The moist glans penis can create the ideal environment for pathogens to incubate, making it susceptible to infection.

This may include bacteria, fungus and sexually-transmitted infections such as herpes and HIV.

The World Health Organisation (WHO) recommends circumcision as part of HIV prevention based on large randomised controlled trials of more than 10,000 men conducted in South Africa, Kenya and Uganda.

The trials enrolled HIV-negative men and randomised circumcision among them. Results demonstrated circumcision significantly decreased HIV acquisition up to 60%.

Randomised trials have also evaluated circumcision for the prevention of other sexually-transmitted infections.

The trials concluded that circumcision decreases herpes simplex virus type 2 acquisition by 28% to 34%, and human papillomavirus prevalence by 32% to 35% in men.

Among female partners of circumcised men, bacterial vaginosis was reduced by 40%, and Trichomonas vaginalis infection was reduced by 48%.

Although the scientific evidence of the protective effects of circumcision against sexual and non-sexually acquired infections are mounting in recent years, the decision to undergo elective circumcision is often a dilemma for parents, and a nightmare for teenagers themselves.

Despite weighing the risks and benefits of a life without a foreskin, the decision is still difficult as it impinges on cultural experience and preconceived ideas about its long-term impacts.

American actor Gary Busey (The Buddy Holly Story) once warned: “If you take shortcuts, you get cut short!”

When empowered teenagers who are facing the knife put Dr G on the spot over the pros and cons of having the cut, he cuts to the chase and advises: Base your decisions on medical evidence and cutting short the skin will not get you cut short!