Sexually Transmitted Infections (STIs)
Despite the fact that infants and children are not sexually active and thus not at risk for any sexually transmitted infection (STI) (and that adults can take appropriate precautions), the idea that circumcision significantly reduces the risk of STIs is a rationale commonly given for the practice. However, this notion is a piece of medical folklore dating back to Victorian-era medicine, before a modern understanding of the causes of disease and before the advent of evidence-based medicine.
In the 1910s, an article was published in the Journal of the American Medical Association criticizing ritual circumcision because of the number of cases of tuberculosis acquired through the open wound. In response, physician Abraham Wolbarst published a defensive reply in which he cited the prevention of ‘venereal disease’ (along with prevention of masturbation and many other problems) to justify his call for “universal circumcision as a sanitary measure.”
However, modern science has not confirmed Wolbarst’s claims. Since his time, dozens of studies have sought to determine whether circumcision makes a meaningful difference in the risk of STI acquisition, with inconsistent and contradictory results.
When the results of STI studies are considered in aggregate using meta-analysis, circumcision has been shown to have no significant impact on the risk of gonorrhea,[67,68] chlamydia,[67,68] genital herpes simplex virus infections, human papilloma virus (HPV), or chancroid.[67,68] Being circumcised is associated with an increased risk of non-specific urethritis,[67,68] genital discharge syndrome (which includes gonorrhea, chlamydia, and non-specific urethritis),[67,68] and an increased risk of contracting any STI (as opposed to having no STIs). Being circumcised is associated with a slightly lowered risk of genital ulcerative disease (which includes chancroid, syphilis, and genital herpes infection)[67-69] and syphilis (primarily in Africa).[68,69] However, prospective studies have found a slight increase in the incidence of syphilis in circumcised males.[70,71]
In the case of HPV, sampling bias can occur if only the glans of the penis is tested. Several studies have shown that circumcised men are more likely than intact men to harbor the HPV virus on the shaft of the penis as compared to the glans.[72-77] As a result, sampling only the glans will miss more HPV infections in circumcised men than it will in intact men, thus overestimating the association between having a foreskin and genital HPV.[68,78] For example, several recent HPV studies from Africa only sampled the glans.[79,80] When adjusted for sampling bias, the results of these studies were no longer statistically significant.[81,82]
There is no evidence that circumcision has reduced the incidence of STIs in the United States. While the prevalence of chlamydia, gonorrhea and syphilis has declined steadily in (non-circumcising) Europe since 1980, in the (circumcising) U.S., the incidence of syphilis has increased, and the incidence of chlamydia has soared. The incidence of gonorrhea in the U.S. is 20 times higher than in Europe, while the incidence of chlamydia in the U.S. is 45 times higher than in Europe. A recent study of men visiting public STI clinics found that circumcised men were less likely than intact men to use condoms, which may in part explain these STI trends.
The medical evidence does not support the practice of neonatal circumcision to prevent sexually transmitted infections. In fact, the evidence indicates that circumcision may actually increase the overall risk of STIs. Even if circumcision did reduce the risk of STIs, pre-emptive amputation is not a preferred approach to diseases that can readily be cured with a short course of antibiotics, or prevented by simple safe-sex behaviors. An adult male can choose to have his foreskin removed, if he prefers, but it is neither medically reasonable nor ethically acceptable to force this choice on not-at-risk children.