Circumcision and STDs

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This article discusses the claims that male circumcision reduces the incidence of STDs other than HIV/AIDS. For a discussion of the claims made regarding HIV, see Circumcision and HIV.

Circumcision promotion

Attitudes from the early days of opinion-based medicine that have long been disproved in the era of science-based medicine continue to influence thought today. Peter Charles Remondino's 1891 book said:

It is not alone the tight-constricted, glans-deforming, onanism-producing, cancer-generating prepuce that is the particular variety of prepuce that is at the bottom of the ills and ailments, local or constitutional, that may affect man through its presence. The loose, pendulous prepuce, or even the prepuce in the evolutionary stage of disappearance, that only loosely covers one-half of the glans, is as dangerous as his long and constricted counterpart. If we look over the world’s history, since in the latter years of the fifteenth century syphilis came down like a plague, walking with democratic tread through all walks and stations in life, laying out alike royalty or the vagrant, the curled-haired and slashed-doubleted knight, or the tonsured monk, we must conclude that syphilis has caused more families to become extinct than any ordinary plague, black death, or cholera epidemic. Without wishing to enter into a history of syphilis, it is not outside of the province of this book to allude to its frequency and spread.

The absence of the prepuce and the non-absorbing character of the skin of the glans penis, made so by constant exposure, with the necessary and unavoidably less tendency that these conditions give to favor syphilitic inoculation, are not evidently without their resulting good effects. Now and then syphilitic primary sores are found on the glans, or even in the urethra or on the outside skin of the penis, or outer parts of the prepuce; but the majority are, as a rule, situated either back of the corona or on the reflected inner fold of the prepuce immediately adjoining the corona, or they may be in the loose folds in the neighborhood of the frenum, the retention of the virus seemingly being assisted by the topographical condition and relation of the parts, and its absorption facilitated by the thinness of the mucous membrane, as well as by the active circulation and moisture and heat of the parts.[1]

Abraham Leo Wolbarst (1914), an ardent promoter of male circumcision, collected the subjective opinions of several physicians and published those unscientific comments as evidence for his unproven speculations that circumcision was beneficial and healthful. He published an opinion-based article that claimed that non-therapeutic neonatal circumcision prevented numerous diseases, including venereal disease (now known as sexually transmitted disease).[2]

These opinions were offered without any actual scientific evidence to support them.

The world at war

Wolbarst's paper was published in January 1914, just prior to World War I, which erupted in August 1914.

With the trumped-up false claims promoted by circumcision advocates such as Remondino and Wolbarst, many military commanders, knowing that soldiers may visit prostitutes, ordered their soldiers to be subjected to mandatory amputation of their foreskins (circumcision).

With the advent of World War II in September 1939, the situation was little changed and again circumcision of soldiers was ordered by many commanders.

This unethical practice was abandoned at least 60 years ago, but it left the impression in American minds that circumcision somehow prevented or at least reduced the likelihood of males contracting a sexually transmitted disease.

The immunological function of the foreskin

The foreskin's inner fold and the glans of the penis are comprised of mucous membrane tissue. These are also present in your eyes, mouth, and all other bodily orifices including the female genitals. These are the first line of immunological defense for the body's orifices. These mucous membranes perform many immunological and hygienic functions.

Certain components such as Langerhans cells,[3] plasma cells,[4] apocrine glands,[5] and sebaceous glands,[6][7][8][9], collectively secrete emollient lubricants.[10] Apocrine glands perform a crucial function by secreting enzymes such as lysosomal enzymes, cathepsin B, chymotrypsin, and neutrophil elastase.[11]

There is also some research to suggest that lysozyme may protect against HIV infection.[12] [13]

Apocrine glands also produce cytokine,[14] which is a very important non-antibody protein that generates immune response when in contact with specific agents. Plasma cells which increase in number in response to pathogens levels, secrete immunoglobulin.[4] It is also very important to note that Langerhans cells that are present in the foreskin produce Langerin, a substance that has been proven to kill human immunodeficency virus (HIV) on contact.[15]

All of these function to sequester and “digest” foreign pathogens. All these substances play an important role in protecting the penis from viral and bacterial pathogens. The immunological functions of the human prepuce have been extensively documented by respected researchers for quite some time.[13]

Circumcision destroys the natural immunological protections of the foreskin and results in increased risk of contracting infection.

Contemporary view based on medical science

Evidence-based medicine does not support the subjective opinion of the early circumcision-promoters.[16]

Circumcision advocates had falsely claimed that the sub-preputial space was a filthy cesspool of infection that was eliminated by circumcision. However, Parkash et al. (1982) showed that the sub-preputial moisture actually contained lytic material with antiseptic qualities that protected against disease.[17]

Smith et al. (1987) found evidence that the foreskin protected against acquisition of non-gonococcal urethritis, possibly "by affecting the physiologic milieu of the glans penis, by association with post-coital hygiene behavior, or by local immune defense mechanisms acting against the agent."[18]

Cook et al. (1993) reported their findings that circumcised men were more likely to have genital warts than intact men. The authors concluded, "the presence of the foreskin may confer nonspecific protection of the proximal penis from acquisition of HPV infection."[19]

Cook et al. (1994) compared the incidence of sexually transmitted disease in intact males with circumcised males who attend the STD clinic at the Harborview Medical Center in Seattle, Washington, USA. They reported that genitally intact men were more likely than circumcised men to have syphilis and gonorrhea and were less likely to have visible warts.[20]

Bassett et al. (1994) investigated the factors associated with HSV-2 infection in heterosexual men at a sexual disease clinic in Sydney, Australia. They reported that, "we found no evidence of the presence of an intact foreskin being a risk factor for HSV-2 infection."[21]

Donovan et al. (1994) also surveyed men at a sexual disease clinic in Sydney, NSW, Australia. They reported:

In this clinic-based prospectively collected survey we found no association between male circumcision status and STDs that are common in our population. Perhaps importantly, our study group was relatively racially homogeneous, lack of circumcision was not a marker of lower socioeconomic status (using the index of education level; Table 2), and we controlled for a major parameter of sexual behaviour (lifetime number of sexual partners).[22]

Laumann et al. (1997) used data from the National Health and Social Life Survey (NHSLS) (1992) to report on the effects of male circumcision in the United States. With regard to STDs, Laumann et al. reported:

With respect to STDs, we found no evidence of a prophylactic role for circumcision and a slight tendency in the opposite direction. Indeed, the absence of a foreskin was significantly associated with contraction of bacterial STDs among men who have had many partners in their lifetimes. These results suggest a reexamination of the prevailing wisdom regarding the prophylactic effect of circumcision. While circumcision may have an impact that was not picked up by the NHSLS data, it seems unlikely to justify the claims made by those who base their support for widespread circumcision on it.[23]

Van Howe (1999) carried out a review of the medical literature concerning sexually transmitted infection. He referenced no fewer than 104 published papers in his review and concluded:

What began as speculation has resulted a century later in 60-75% of American boys being circumcised with no clearly confirmed medical benefit. In the interim, no solid epidemiological evidence has been found to support the theory that circumcision prevents STDs or to justify a policy of involuntary mass circumcision as a public health measure. While the number of confounding factors and the inability to perform a random, double-blind, prospective trial make assessing the role of circumcision in STD acquisition difficult, there is no clear evidence that circumcision prevents STDs. The only consistent trend is that uncircumcised males may be more susceptible to GUD, while circumcised men are more prone to urethritis. Currently, in developed nations, urethritis is more common than GUD [34]. In summary, the medical literature does not support the theory that circumcision prevents STDs.[24]

Dave et al. (2003) studied data from the 2000 British National Survey of Sexual Attitudes and Lifestyles (Natsal 2000). They found "no significant associations between circumcision and being diagnosed with any one of the seven specific STIs."[25]

Morten Frisch and Jacob Simonsen (2021) carried out a large scale empirical population study in Denmark of 855,654 males regarding the alleged value of male circumcision in preventing HIV and other sexually transmitted infections in men. They found that circumcised men have a higher rate of STI and HIV infection overall than intact men.[26]

Circumcised men have more risky sexual behavior

Frequently overlooked when considering the effect of circumcision on sexually transmitted infection is the riskier sexual behavior of circumcised men as compared with intact men. Following amputation of the highly erogenous foreskin, circumcised men have significantly reduced sexual sensation, so therefore engage in a wider range of sexual practices in their quest to obtain sexual release. Hooykaas et al. (1991) reported that the sexual behavior of migrant circumcised men is more riskier than that of intact Dutch men.[27] Laumann et al. (1997), in a study of American men, reported that

NHSLS data indicate that circumcised men engage in a somewhat more elaborated set of sexual practices than do men who are not circumcised. For each of the practices examined, lifetime experience of various forms of oral and anal sex and masturbation frequency in the past year, circumcised men engaged in these behaviors at greater rates.[23]

Michael et al. (1998) compared sexual behavior in Britain with sexual behavior in the United States. They reported that condom use was "significantly higher" in the United Kingdom where most men are intact as compared to the United States where most men are circumcised.[28]

Van Howe (1999) commented:

Beaugé suggests that the loss of penile skin from circumcision frequently results in tightened skin over the erect penis. This increases friction during intercourse and increases the likelihood of abrasions through which a pathogen can be introduced systemically, making the circumcised penis more likely to contract an STD. The increased likelihood of circumcised men engaging in active anal sex may also increase a circumcised man's susceptibility to STDs.[24]

Conclusion

The idea that circumcision could prevent sexually transmitted infection started with the subjective speculations of Victorian doctors in the 19th century and was reinforced by military orders to have servicemen subjected to circumcision during the 20th century.

Professor Van Howe (2013) has provided a magisterial systematic review and meta-analysis citing 199 documents relating to circumcision and STDs. Van Howe's paper appears to be conclusive. His meta-analysis concludes as follows:

Most specific STIs are not impacted significantly by circumcision status. These include chlamydia, gonorrhea, HSV, and HPV. Syphilis showed mixed results with prevalence studies suggesting intact men were at great risk and incidence studies suggesting the opposite. Intact men appear to be at greater risk for GUD while at lower risk for GDS, NSU, genital warts, and the overall risk of any STIs. It is also clear that any positive impact of circumcision on STIs is not seen in general populations. Consequently, the prevention of STIs cannot be rationally interpreted as a benefit of circumcision, and a policy of circumcision for the general population to prevent STIs is not supported by the evidence currently available in the medical literature.[16]

Claims of prophylactic prevention of STDs and STIs can no longer be used to support the harmful practice of destructive male circumcision.

External links

References

  1. REFbook Remondino PC (1891): Chapter XVI, in: The History of Circumcision. pp. iii. Philadelphia: F. A. Davis. Retrieved 22 May 2020.
  2. REFjournal Wolbarst AL. Universal Circumcision as a Sanitary Measure. JAMA. 10 January 1914; 62(2): 92-97. Retrieved 22 May 2020.
  3. REFjournal Weiss GN, Sanders M, Westbrook KC. The distribution and density of Langerhans cells in the human prepuce: site of diminished immune response?. Isr J Med Sci. January 1993; 29(1): 42-43. Retrieved 20 October 2019.
  4. a b REFjournal Flower PJ, Ladds PW, Thomas AD, Watson DL. An immunopathologic study on the bovine prepuce. Vet Pathol. March 1983; 20(2): 189-201. Retrieved 20 October 2019.
  5. REFjournal Ahmed A, Jones AW. Apocrine Cystadenoma: a report of two cases occurring on the prepuce. Br J Dermatol. December 1969; 81(12): 899-901. Retrieved 20 October 2019.
  6. REFjournal Hyman AB, Brownstein MH. Tyson's "glands": ectopic sebaceous glands and papillomatosis penis. Arch Dermatol. January 1969; 99(1): 31-36. Retrieved 20 October 2019.
  7. REFjournal Delbanco E. Über das gehäufte Auftreten von freien Talgdrüsen an der Innenfläche des Präputiums [About the increased occurrence of free sebaceous glands on the inner surface of the prepuce] (German). Monatshefte für praktische Dermatologie. 1904; 38: 536-538. Retrieved 20 October 2019.
  8. REFjournal Piccinno R, Carrel CF, Menni S, et al. sebacous glands mimicking molluscum contagiosum. Acta Derm Venerol. 1990; 70: 344-345.
  9. REFjournal Krompecher S. Die Histologie der Absonderung des Smegma praeputii [Histology of allocation of a smegma praeputii] (German). Anatomischer Anzeiger. 1932; 75: 170-176.
  10. REFjournal Parkash S, Jeykumar S, Subramanyan K, Chaudhuri S. Human subpreputial collection: its nature and formation. J Urol. August 1973; 110(2): 211-212. Retrieved 20 October 2019.
  11. REFjournal Frohlich E, Shamburg-Lever G, Klesses C. Immunelectron microscopic localization of cathepsin B in human apocrine glands. J Cutan Pathol. February 1993; 20(1): 54-60.
  12. REFweb Hill, George (7 September 2003). Summary of evidence that the foreskin and lysozyme may protect against HIV infection. Retrieved 20 October 2019.
  13. a b REFjournal Fleiss PM, Hodges FM, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Infect. October 1998; 74(5): 364-67. PMID. Retrieved 27 October 2021.
  14. REFjournal Ahmed AA, Nordlind K, Schultzberd M, Liden S. Immunohistochemical localization of IL-1 alpha-, IL-1 beta-, IL-6- and TNF-alpha-like immunoreactivities in human apocrine glands. Arch Dermatol Res. 1995; 287(8): 764-766. Retrieved 20 October 2019.
  15. REFjournal de Witte L, Nabatov A, Pion M, et al. Langerin is a natural barrier to HIV-1 transmission by Langerhans cells. Nat Med. March 2007; 13(3): 367-371. Retrieved 20 October 2019.
  16. a b REFjournal Van Howe RS. Sexually Transmitted Infections and Male Circumcision: A Systematic Review and Meta-Analysis. ISRN Urology. April 2013; 2013: 109846. PMID. PMC. DOI. Retrieved 25 May 2020.
  17. REFjournal Parkash S, Raghuram R, et al. Sub-preputial wetness - Its nature.. Ann Nat Med Sci. July 1982; 18(3): 109-112. Retrieved 24 May 2020.
  18. REFjournal Smith GL, Greenup R, Takafuji E. Circumcision as a risk factor for urethritis in racial groups. Am J Public Health. 1987; 77: 452-4. PMID. PMC. DOI. Retrieved 24 May 2020.
  19. REFjournal Cook LS, Koutsky LA, Holmes KK. Clinical presentation of genital warts among circumcised and uncircumcised heterosexual men attending an urban STD clinic. Genitourin Med. August 1993; 9: 262-4. PMID. PMC. DOI. Retrieved 24 May 2020.
  20. REFjournal Cook LS, Koutsky LA, Holmes KK. Circumcision and sexually transmitted diseases. Am J Public Health. February 1994; 84(2): 197-201. PMID. PMC. DOI. Retrieved 24 May 2020.
  21. REFjournal Bassett I, Donovan B, Bodsworth NJ, Field PR, Ho DWT, Jeanssome S, Cunningham AL. Herpes simplex virus type-2 infection of heterosexual men attending a sexual health centre. Med J Aust. June 1994; 160(11): 697-700. PMID. Retrieved 25 May 2020.
  22. REFjournal Donovan B, Bassett I, Bodsworth NJ. Male circumcision and common sexually transmissible diseases in a developed nation setting. Genitourin Med. October 1994; 70: 317-20. PMID. PMC. DOI. Retrieved 24 May 2020.
  23. a b REFjournal Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States.. JAMA. 1997; 277(13): 1052-7. PMID. Retrieved 24 May 2020.
  24. a b REFjournal Van Howe RS. Does circumcision influence sexually transmitted diseases?: A literature review. BJU Int. January 1999; 83 Suppl 1: 52-62. PMID. DOI. Retrieved 25 May 2020.
  25. REFjournal Dave SS, Johnson AM, Fenton KA, Mercer CA. Male circumcision in Britain: findings from a national probability sample survey. Sex Trans Infect. December 2003; 79(6): 499-500. PMID. PMC. DOI. Retrieved 25 May 2020.
  26. REFjournal Frisch, Morten, Simonsen, Jacob. Non-therapeutic male circumcision in infancy or childhood and risk of human immunodeficiency virus and other sexually transmitted infections: national cohort study in Denmark. Eur J Epidemiol. 26 September 2021; Published online ahead of print PMID. DOI. Retrieved 20 October 2021.
  27. REFjournal Hooykaas C, van der Velde FW, van der Linden MM, van Durnum GJ, Coutinho RA. The Importance of Ethnicity as a Risk Factor for STDs and Sexual Behaviour Among Heterosexuals. Genitourin Med. October 1991; 67(5) PMID. PMC. DOI. Retrieved 24 May 2020.
  28. REFjournal Michael RT, Wadsworth J, Feirleib J, Johnson AM, Laumann EO, Wellings K. Private sexual behavior, public opinion, and public health policy related to sexually transmitted diseases: a US-British comparison. Am J Public Health. May 1998; 88(5): 749-54. PMID. DOI. Retrieved 25 May 2020.