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Circumcision can reduce the risk of urinary tract infections in infants, cut the risk of penile cancer and lower the risk of contracting HIV or the human papillomavirus, which causes cervical and other cancers. So why is the removal of a tiny flap of skin at birth – both an ancient religious ritual and an apparently pragmatic hygienic practice – causing controversy around the world?
The American Academy of Paediatrics may have concluded that the health benefits of circumcision outweigh the risks and the procedure is a matter of parental choice, but opponents call it male genital mutilation or child abuse.
Many parts of Europe concur. A court in Cologne, Germany, recently ruled that circumcision contravened the rights of a child to decide later in life on his religious beliefs. A German doctor has now filed charges against a rabbi for performing circumcisions on two infant boys, causing outrage in Jewish and Muslim communities – and a delicate debate about intolerance, religious freedom and children's rights in Germany.
Circumcision is an ancient ritual in Judaism and Islam, but there is no ritual circumcision in Hinduism and other religions that arose outside the Middle East. Aboriginal societies in desert areas of Australia also traditionally practised circumcision and historians believe the procedure was originally an early health measure to prevent balanitis, a swelling of the penis that can be caused by the accumulation of sand under the foreskin.
Infant circumcision is still legal with parental consent in Britain, but barely 5% are circumcised now for medical reasons, although some religious circumcisions may be unrecorded if undertaken outside mainstream medicine. The difference between Europe (in Scandinavia, the rate is as low as 1%) and the United States, where most men are circumcised, is striking.
In Europe, there is far less consensus on the medical benefits of the removal of a piece of skin filled with nerve endings.
"The medical harms or benefits have not been unequivocally proven," said the British Medical Association in its guidance for doctors. "It is essential that doctors perform male circumcision only where this is demonstrably in the best interests of the child."
The main principle of surgery, as Professor John Hutson, an Australian general surgeon, explained in a symposium on circumcision in the Journal of Medical Ethics, is that no operation should be undertaken if there is no disease and the risk of the procedure cannot be justified without the risk of a disease.
"The surgical argument for circumcision of all neonatal males at present is very weak," he said, "and with rising public health standards in the developed world is likely to remain weak."
Perhaps the most compelling evidence for the medical benefits for circumcision comes from a meta-analysis of studies that find male circumcision at least halves the relative risk of HIV infection throughout sub-Saharan Africa.
"Is it ethical to dismiss a simple prophylactic surgical procedure that can halve male rates of infection?" said biologist Professor Roger Short in the journal. However, these findings are not replicated in the West, where the reduction in the risk of sexually transmitted infections is generally 10%.
John Dalton, a researcher for the United Kingdom's National Organisation of Restoring Men, a charitable support group for circumcised men, said the studies showing that circumcision halved HIV infection had "no external validity"; in other words, they did not reflect what happened in the real world. These studies tend to recruit volunteers who want to be circumcised, perform the operation on half of the volunteers and then study both cohorts to see how each fares. Dalton questioned a number of potential biases in such studies: recruiting people who already believed circumcision would help to stop HIV and the premature termination of studies, which tended to overestimate the benefits of a treatment.
Dalton said the American Academy had "made a fool of itself" with its selective review of the evidence. For instance, it overstated the risks of penile cancer, which is extremely rare. An estimated 300 000 circumcisions may be required to prevent one penile cancer case a year. "They are saying that the benefits exceed the risks, but they haven't quantified the benefits and they haven't quantified the risks," he said.
Participants in the academy review said they considered ethical issues, including whether parents had the right to make the decision without the child's consent.
If circumcision has health benefits but ethically requires consent, why not carry it out later in life? According to the academy, evidence suggests the procedure is riskier later on when the foreskin is thicker. This finding, too, is disputed.
"There might be some partial protection against disease that is conferred by circumcision, but you don't cut off part of a child's body to prevent disease," said Dalton – © Guardian News & Media 2012