Male circumcision

Dec 10 2007

Circumcision is one of the commonest surgical procedures performed on males. Opponents argue that infant circumcision can cause both physical and psychological harm, while recent evidence shows that circumcision is medically beneficial.

Two doctors debate the issue in this week's BMJ.

There is now rarely a therapeutic indication for infant circumcision, yet ritual (non-therapeutic) male circumcision continues unchecked throughout the world, long after female circumcision, facial scarification, and other ritual forms of infant abuse have been made illegal, writes Geoff Hinchley, a consultant at Barnet & Chase Farm NHS Trust.

The law and principles pertaining to child protection should apply equally to both sexes, so why do society and the medical profession collude with this unnecessary mutilating practise, he asks"

In addition to religious justification, there have been many spurious and now unsupported claims for circumcision including the prevention of penile cancer, masturbation, blindness, and insanity, most of which relate to adult sexual behaviour and not to the genital anatomy or best interest of a child, he adds.

There may be a case that male circumcision reduces HIV risk in sexually active adults, however the decision on whether an individual wishes to have this procedure should be left until they are old enough to make their own informed health care choices.

Male genital mutilation is not a risk-free procedure, he adds. Far from being a harmless traditional practice, circumcision damages young boys.

And in terms of legal protection, he argues that both the US and the UK legal systems discriminate between the sexes when it comes to protecting boys and girls from damaging ritual genital mutilation.

The unpalatable truth is that logic and the rights of the child play little part in determining the acceptability of male genital mutilation in our society, he writes. The profession needs to recognise this and champion the argument on behalf of boys that was so successful for girls.

But Kirsten Patrick of the BMJ argues that, if competently performed, circumcision carries little risk and cannot be compared with female circumcision.

Although any surgical operation can be painful and do harm, the pain of circumcision, if done under local anaesthesia, is comparable to that from an injection for immunisation, she writes.

In terms of evidence of benefit, male circumcision has been associated with a reduced risk of sexually transmitted infections, such as human papilloma virus, chancroid and syphilis. Robust research has also shown that circumcision can reduce the spread of HIV.

And although the complication rate for infant circumcision is essentially unknown (because most operations are unregistered) data suggest that it is between 0.2% and 3%, with most complications being minor. Furthermore, she says, no robust research exists examining the long term psychological effects of male infant circumcision.

Despite the fact that no medical body advocates routine male infant circumcision, most agree that it is safe and acceptable and recommend that the procedure is carried out by a competent operator using adequate anaesthesia.

Male circumcision is not illegal anywhere in the world. It is a choice that parents will make on behalf of their male children, for cultural or other reasons, and regulating its provision is the wisest course of action, she concludes.

An accompanying clinical review concludes that medical indications for male circumcision in both childhood and adulthood are rare, but that complications can be drastic.