Circumcision (and prostate cancer) – the new debate

Can you think a few  controversial topics during the last year; religion? Human rights? How about health care economics?

Right up there on the list you would find male circumcision. Male circumcision is the most common surgical procedure in human history. In most developed countries this practice has been abandoned. Colorado is planning to ban coverage for this practice- other states may follow suit. However, circumcision is still heavily common among Jews and Muslims. Of interest, the Roman Catholic Church maintains a neutral position on this procedure.

Recent study by Wright et al suggests a correlation between circumcision and reduction of prostate cancer.

 

Summary of the study

 

• 1754 patients and 1645 control participants collected during 2 population-based, case-control studies of prostate cancer.
• Data included self-reported circumcision status, age at circumcision, age at first sexual intercourse, and history of STIs or prostatitis.
• Of the men who were circumcised, 91% underwent the procedure shortly after birth.
• 3.9% of patients were circumcised after the first sexual intercourse.
• Compared with uncircumcised men, men who were circumcised before first sexual intercourse had a 15% reduction in the risk for prostate cancer
• Circumcision after first sexual intercourse was not associated with the risk for prostate cancer.
• However, case patients were more likely than control participants to report a diagnosis of prostatitis (12.5% vs 8.0%; P < .001).
• On the basis of these findings, the investigators concluded that circumcision before first sexual intercourse was associated with a reduction in the relative risk for prostate cancer in this study population.
• They also noted that these findings are consistent with evidence supporting the infectious/inflammation pathway in prostate carcinogenesis.
• They suggest that circumcision might reduce the development of prostate cancer by decreasing prostatic exposure to infectious agents and the associated inflammatory changes that may enhance carcinogenesis.
• Limitations of this study include reliance on self-reported circumcision status rather than medical examinations; and possible underreporting of self-reported history of STIs, age of first intercourse, and number of sexual partners.

My take on this:

There seems to be good evidence that male circumcision reduces the risk infection of HIV , genital herpes and human papilloma virus (Tobian et al. 2010).

Those opposed to infant circumcision would argue for delay of this procedure until the male is 18 years old where he can make an informed decision. However, a counter argument is that parents provide consent for what they think is best for the well fare of their kids, vaccination for example (another debatable topic).

Lastly, circumcision also seems to protect from multiple infections, balantitis and a bunch of other  – itis’. Sexually, there seems to be minimal benefit from circumcision – one being higher sensitivity and more pleasurable orgasm’s in a small group of African circumcised men. (Krieger et al. 2008)

A small number of African women have also reported a more pleasurable experience when having intercourse with newly circumcised. (Kigozi et al. 2009)

Cosmetic benefits (it just looking more appealing) are a common reason’s why young adult male seek circumcision in my clinical experience, although I do not perform this procedure.

To make a direct claim that male circumcision prevents against prostate cancer is a stretch at this point. Intriguing concept, yes. Possible correlation, maybe – but a stretch for cause and effect none-the-less. Most disease’s that can potentially plague the uncircumcised male are adult diseases, therefore, it would make sense to allow males to opt for the procedure after the age of 18. This is my objective conclusion.

Subjectively, although I am not Jewish or Muslim, I think it seems reasonable to remove the foreskin immediately post birth. Just get it over with. There is minimal to lose and potentially some to gain – including the possible protection against prostate cancer. Some opponents of this practice claim there is potential psychological trauma to the infant. I am not sure I agree with this. There are many infants that undergo major surgical procedures, including heart surgery, that do not seem to be psychologically disturbed from the procedure as adults.  Lastly, having been circumcised as an infant myself I have not experienced any downside. Although some family members would argue that I can use psychological help, I do not think it’s related to my circumcised phallus. LOL

Bottom line: There is no consensus, its controversial, it may protect male adults, soon it may not be covered by insurance.

 

References:

http://www.historyofcircumcision.net/

Wright JL, Lin DW, Stanford JL.Circumcision and the risk of prostate cancer. Cancer. 2012 Mar 12

American Academy of Pediatrics Task Force on Circumcision. Circumcision policy statement. Pediatrics. 1999;103(3):686–693.

Krieger JN, Mehta SD, Bailey RC, et al. Adult male circumcision: effects on sexual function and sexual satisfaction in Kisumu, Kenya. J Sex Med. 2008;5(11):2610–2622.

Kigozi G, Lukabwe I, Kagaayi J, et al. Sexual satisfaction of women partners of circumcised men in a randomized trial of male circumcision in Rakai, Uganda. BJU Int. 2009;104(11):1698–1701.

Tobian AA, Gray RH, Quinn T. Male circumcision for the prevention of acquisition and transmission of sexually transmitted infections: the case for neonatal circumcision. Arch Pediatr Adolesc Med. 2010;164(1):78–84.