Are there medical benefits to male circumcision?

SUPPOSE a vaccine were available that reduced HIV risk by 60%, genital herpes risk by 30%, and HR-HPV risk by 35%? Would such a vaccine be rejected, debated or embraced?

Clearly, the medical community would rally behind the immunization. It would be promoted as a game-changing public health intervention.

Well, there is no such vaccine, but there is a medical procedure with the same results: male circumcision.

This is one of the conclusions of an article in the Journal of the American Medical Association, “The Medical Benefits of Male Circumcision,” by Aaron A. R. Tobian, MD, PhD, and Ronald H. Gray, MD, MSc (Oct. 5, 2011, vol. 306, no. 13). I thank Dr. Herzl Melmed for calling this article to my attention.

Let me share its conclusions with you (often in the words of the authors themselves).

Their conclusions, such as those mentioned in the first sentence of this article, are relevant to state policies that eliminate Medicaid insurance for male circumcision, and relevant to ballot or court initiatives that would eliminate male circumcision.

The authors write:

“Three randomized trials in Africa demonstrated that adult male circumcision decreased human immunodeficiency virus (HIV) acquisition in men by 51% to 60%, and long-term follow-up of these study participants has shown that the protective efficacy of male circumcision increases with time from surgery.

“These findings are consistent with a large number of observational studies in Africa and the US . . . ” Results may vary for homosexual relations.

Male circumcision has been shown to reduce significantly the risk of other heterosexually acquired sexually transmitted infections (STIs), such as herpes (28-34%), genital ulceration (47%), and oncogenic high-risk human papillomavirus (HR-HPV) (32-35%).

One trial reported derivative medical benefits for female partners of circumcised men, significantly reducing the incident of three female diseases.

NO large-scale randomized controlled trial has assessed the benefit of neonatal male circumcisions throughout several decades, which is when many of the potential health benefits would be realized, and which, according to the authors, is probably not feasible.

However, “observational data of men predominately circumcised during childhood support the findings of the three randomized trials conducted in Africa and the long-term benefits of male circumcision.”

Furthermore, “neonatal male circumcision provides other potential benefits during childhood such as prevention of infant urinary tract infections, meatitis, balanitits and phimosis, as well as protections from viral STIs” — the latter hardly a minor consideration, given that traditional morals are widely observed in the breach by high school students younger than 18.

Not to mention, male circumcision is a simple procedure. The complication rate is only between 0.2% and 0.6%, and the vast majority of complications are minor and easily treated, write the authors.

The complication rate of neonatal male circumcision is substantially lower than adult male circumcision. Delaying the procedure adds to the surgical risk.

ARE trials of male circumcision conducted in Africa applicable to the US?

Observational studies in the US show that male circumcision is associated with reduced risk of men acquiring heterosexual HIV and HR-HPV infection (the latter causes penile and cervical cancer).

Nonetheless, STIs are a persistent problem in the US, with millions of cases, disproportionately found among populations such as blacks and Hispanics, “who have the lowest rates of male circumcision.”

Medicaid, which disproportionately provides health insurance for black children, is decreasing coverage for male circumcision, making the procedures less accessible.

“Using mathematical models and cost effectiveness analyses, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization adopted a policy advocating male circumcision in countries and regions with heterosexual HIV epidemics.”

SHOULD male circumcision be banned until age 18 in order to give males free choice in the matter? Should parents be banned from circumcising their male newborns or youth?

Is male circumcision merely mutilation?

It would hardly seem to constitute mutilation, given the demonstrable health benefits. Any surgery that causes pain, discomfort and temporary disability — but which improves or even saves human life — is not defined as mutilation.

But should circumcision be postponed until age 18? Not for consistency’s sake. Parents make many medical decisions for children all the time that no one objects to.

For example, children born with deformities are operated on, based on parental consent alone. Everything from children with deformed faces and ugly smiles to children with spina bifida — and an almost limitless number of other medical conditions — are treated surgically based on parental consent alone.

Another example: “Parents provide consent for preventive procedures, such as immunizations, including hepatitis B vaccination, acting in the best interests of their children.

“UNAIDS recommends providing information on risks and benefits of early infant neonatal male circumcision so parents and guardians can make informed decisions on behalf of their children with the best interests of the child as the primary consideration.”

To ban male circumcision until age 18 would “deprive parents of the right to act on behalf of their children’s health,” the authors write.

TWO P.S.’s: 1. The day after I decided to write this article, I went to shul at a morning minyan after which a bris was scheduled. To my surprise and delight, the father asked me to be the sandak, the person holding the baby during the bris. It was a very holy and inspiring moment.

The incomparable halachic authority, the Rosh, writes that it is permissible to invoke G-d’s name in front of the naked, eight-day-old male child because the bris is a holy procedure. Jews have known this for thousands of years. Jews do not need a medical defense of male circumcision.

But Jews do need to be prepared to argue circumcision’s medical benefits in the marketplace of ideas, even though religious freedom should be sufficient to sustain Jews’ (and anyone’s) right to have his or her child circumcised.

2. The day after I actually wrote this article, I learned of an important article on circumcision and religious freedom from an unexpected source, The National Catholic Reporter, from Martin Nussbaum of Colorado Springs. The article is by his wife,  Melissa Musick Nussbaum, “Religious protections are worth keeping” (Nov. 9-22, 2012).

She points out that laws are suspended in the name of religious freedom; for example, underage children (and even infants) are offered wine in weekly Catholic rites. Government-imposed parental consent is not and should not be required to practice this religious rite, even though in other circumstances those who offer wine to a minor may be sued or prosecuted.

Nor, Ms. Nussbaum argues, should government-imposed consent be imposed for performing a bris in any of its practices. She writes: “Religious bodies have constitutinal protection by the government from the government.”

Copyright © 2012 by the Intermountain Jewish News