Male circumcision from an infectiological point of view

Abstract

In May 2012 a German regional court (Cologne) declared circumcision on religious grounds in minor boys an illegitimate bodily harm. This led to substantial political and religious discussions, because Jews as well as Muslims consider circumcision as an indispensable element of their religion. Still in 2012 a "circumcision law" was passed by the Federal Council of Germany, which continues to allow circumcision in boys "performed under strict medical conditions". How male circumcision is assessed in terms of infectiology (pros and cons)? Electronic databases were searched for articles about the infection risks of foreskin surgery, and the efficacy of circumcision in reducing the risks of sexual transmission of HIV, herpes viruses, HPV, treponema pallidum, chlamydia, hemophilus ducrey and Neisseria gonorrhoeae. Contra circumcision: The highest risk of neonatal circumcision is hemorrhage (35 %). Among infections surgical wound infection (10 %), meatitis urethrae (8-20 %) and urinary tract infections (2 %) are frequent (depending on the surgical technique). Severe complications like penile necrosis or lethal sepsis are rare (1:20,000). Pro circumcision: Circumcised boys have a reduced risk for urinary tract infections in childhood (1:10). Compared to uncircumcised men circumcised adults have a 50-60 % reduced risk of becoming infected with viral sexually transmitted infections (STIs; HIV, HPV and HSV). This advantage of circumcision is also discussed for the transmission of bacterial STIs (e.g. syphilis and chancroid), but the analysis of different clinical studies is still controversial. Neonatal circumcisions (and circumcision in early childhood) are irreparable interventions in the physical integrity, with very few medical indications. The risk of complications is dependent on the education of the circumciser (ritual, medical), analgesia and hygiene. Circumcisions should be performed under optimal surgical and hygienic conditions in informed and self-determined young men only. In adolescents and adults circumcision reduces the risk of the transmission of viral STIs (HIV, HSV, HPV) and there is also probably some effect on the sexual transmission of treponema pallidum and hemophilus ducreyi (insufficient, controversial data). The role of circumcision as an effective procedure to reduce the transmission of STIs is still under discussion, because important additional factors like sexual risk behavior (e.g. unprotected sexual intercourse, promiscuity) have a strong influence on STI epidemiology.