Male circumcision: a scientific perspective.

I n this issue, John Hutson has reiterated the conventional Western medical view that ‘‘the surgical argument for circumcision of all neonatal males at present is very weak’’ and he criticises many of the circumcisions performed in later childhood, without anaesthesia, as ‘‘physically cruel and potentially dangerous’’ [see page 238]. He is also of the opinion that ‘‘the diseases which circumcision is able to prevent are uncommon or even rare’’. But therein he errs, and greatly errs. He cites only two publications dealing with the protective effect of male circumcision against HIV infection, and makes no mention of the important recent metaanalysis of Weiss, Quigley, and Hayes which shows conclusively from a large number of studies that male circumcision at least halves the relative risk of HIV infection throughout sub-Saharan Africa. Would that we could share Hutson’s optimism that ‘‘we are not certain at present whether AIDS is going to be an even more widespread disease in the future or whether it will be abolished by some new treatment’’. At the 14th International AIDS Conference in Barcelona in July 2002 we were informed that currently 40 million people are infected with HIV, with five million new infections a year; the AIDS pandemic is only just beginning. There is no cure in sight, and vaccines still remain a distant hope. Faced with such dismal future prospects, is it ethical to dismiss a simple prophylactic surgical procedure that can halve male rates of infection? The case for male circumcision has been further strengthened by a recent multinational case controlled study in developed and developing countries in Europe, Asia, and South America, which has shown that circumcised men are two thirds less likely to have human papilloma virus infection of the penis, and their female partners less than half as likely to develop cervical cancer, when compared with uncircumcised men and their partners. As cervical cancer is the second commonest cancer of women worldwide, these results should surely make the most reluctant surgeons think again. But nevertheless, Hutson does have a point. Male circumcision is not without its risks. When is it best to perform the operation? Perhaps late in childhood, when the foreskin has separated from the glans penis, and the boy can give informed consent to the procedure. Such timing would also ensure a more immediate impact on the transmission of HIV. How should the operation be performed? The American PlastiBell device has one of the lowest complication rates, providing a ‘‘no scalpel’’ circumcision by means of a ligature tied around the base of the foreskin when it is stretched over a protective plastic cap which covers the glans penis. This device is now off patent, and could be mass produced at very low cost. Even if the rest of the world continues to reject male circumcision, there are a billion Muslims for whom it will remain a fact of life. Islamic nations such as Egypt, Sudan, Iraq, Iran, Pakistan, Bangladesh, and Indonesia have spectacularly low rates of HIV infection compared with their neighbours, due at least in part to male circumcision. Now would be an opportune time for the Western world to profit from this Islamic experience, while offering to help them improve their surgical procedures. If we believe in evidence based medicine, then there can be no debate about male circumcision; it has become a desirable option for the whole world. Paradoxically, this simple procedure is a life saver; it can also bring about major improvements to both male and female reproductive health. Rather than condemning it, we in the developed world have a duty to develop better procedures that are neither physically cruel nor potentially dangerous, so that male circumcision can take its rightful place as the kindest cut of all.