What are the pros and cons of circumcision and does it have proven health benefits?
Circumcision is an ancient religious practice still prevalent today involving the surgical removal of the foreskin. Many parents choose to have their sons circumcised for religious or health reasons. But what are the pros and cons of circumcision and does it have proven health benefits?
GP Dr Roger Henderson looks at the pros and cons of circumcision in boys for medical reasons and explains how the procedure is carried out:
What is circumcision?
Circumcision is a surgical procedure that involves partial or complete removal of the foreskin (prepuce), the fold of skin that covers the head of the penis.
How common is circumcision?
About one-fifth of men worldwide have been circumcised, mostly for religious and cultural reasons when the procedure is commonly performed shortly after birth or around puberty.
Adults are occasionally circumcised as an act of religious dedication, but adult circumcision is most commonly performed for medical reasons.
How the foreskin develops
Should a non-retractable foreskin be circumcised? Contrary to common belief, in almost all newborn babies the foreskin cannot be pulled back (retracted). About 50 per cent of one-year-old boys will have a non-retractable foreskin, 30 per cent of two-year-olds, about 10 per cent of four-year-olds and about 5 per cent of 10-year-olds.
The small percentage of adults who have a persistently non-retractable foreskin have a slightly increased chance of developing phimosis (see below). But this persistence is not a reason for circumcision. A non-retractile foreskin does not of its own accord require circumcision unless it’s causing symptoms.
⚠️ It’s not necessary to try cleaning under the foreskin until it has become fully retractable of its own accord, because attempts to pull back a non-retractable foreskin can result in pain and possibly injury.
How is circumcision performed?
Circumcision is usually performed as a day case procedure under a general anaesthetic. There are many different techniques to achieve the same effect, which is to remove the foreskin and suture the skin on the shaft of the penis to the remaining mucosal lining beneath the head of the penis. The sutures used are absorbable and do not need removal.
Complications of circumcision are relatively rare, although they may be under-reported following religious or cultural circumcision. Complications may include:
- Swelling of the penis which may last a few days (common)
- Reduced penile sensation (less common)
- Tenderness in the scar
- Poor cosmetic outcome (rare)
Reasons for circumcision
The reasons for circumcision fall into three broad groups:
- For a medical indication
- To prevent future disease
- For religious reasons
Circumcision for medical reasons
It’s rare for circumcision to be recommended for medical reasons, because other less invasive treatments are often available. But common medical reasons for circumcision include phimosis, acute balanoposthitis or paraphimosis.
In phimosis the opening of the foreskin is narrowed, preventing retraction. Occasionally, the edge of the foreskin has a white, scarred, inelastic appearance and will not pucker open as it is retracted. Between 1 and 1.5 per cent of boys will develop this condition by the time they are 17 years old.
Symptoms can include irritation or bleeding from the edge of the foreskin (particularly during sexual intercourse or masturbation), stinging or pain on passing urine (dysuria) and inability to pass urine if the foreskin is very tight. Circumcision is advisable in most cases.
• Acute balanoposthitis
This condition involves redness and swelling of the foreskin, together with a discharge of pus from the space between the foreskin and the glans. Sometimes the whole penis may be swollen and inflamed. Between 3 and 10 per cent of boys will develop this condition, depending on how the condition is defined.
Balanoposthitis is very occasionally the first sign of diabetes. If there is no underlying cause, simple hygiene measures, mild painkillers and the avoidance of tugging the foreskin are the only necessary treatments. Most cases will recover without further intervention and circumcision is only done for recurrent and troublesome cases.
This condition is caused by pulling back the foreskin behind the coronal ridge of the glans or head of the penis, without its subsequent replacement to its normal position. The foreskin then forms a tight tourniquet around the glans, causing severe pain. The condition can sometimes be treated by firmly but gently squeezing the trapped glans until the foreskin can slip over it again. If this is not possible, the paraphimosis needs to be reduced under a general anaesthetic.
Circumcision is not usually performed at this stage because of the associated inflammation, but may be required later if the foreskin remains tight.
Circumcision to prevent future disease
Prevention of disease is the second most commonly given reason for circumcision after religious reasons, although the evidence that it has any beneficial effect on future health is very poor.
• Circumcision to prevent penile cancer
Cancer of the penis is an extremely rare disease and, in the early part of the last century, was almost unheard of in circumcised men. However, there is some evidence that circumcision may only offer protection from penile cancer if done in childhood, and adult surgery may not offer any protection. However, poor personal hygiene, smoking and exposure to the wart virus human papilloma virus (HPV) increase the risk of developing penile cancer more than being uncircumcised.
Circumcised men are more at risk from penile warts than uncircumcised men, and the risk of developing penile cancer is now almost equal in the two groups. Therefore, routine circumcision cannot be recommended to prevent penile cancer.
• Circumcision and sexually transmitted infections
Sexually transmitted infections (STIs) that cause ulcers on the genitals (such as syphilis and herpes simplex) are more common in uncircumcised men.
However, urethritis or inflammation of the tube that carries urine through the penis (caused by gonorrhoea and non-gonococcal urethritis) is more common in circumcised men, as are penile warts.
• Circumcision and candida
Yeast infection (caused by candida or thrush) is equally common in circumcised and uncircumcised men, although circumcised men are less likely to have symptoms with this infection so they are more likely to unknowingly pass on thrush to their sexual partners.
Far more effective and reliable methods than circumcision exist to reduce the risk of contracting sexually transmitted infections, such as the use of condoms and adoption of safer sexual practices. Thus circumcision cannot be recommended to prevent these infections.
Circumcision as an act of religious dedication
The circumcision of male children is a central feature of both Judaism and Islam. It is also important in many African and New World cultures but a number of committed Jewish and Muslim people reject circumcision on ethical grounds. Circumcision on religious grounds is not available on the NHS.