Circumcision and Sexually Transmitted Infections

This index page provides information about the relationship between circumcision and sexually transmitted disease (STD). The materials are indexed in chronological order of publication.

Note: The consideration of STDs and AIDS prevention does not apply to neonatal circumcision. Children are not sexually active. Kept intact, they can weigh the issue for themselves when they are old enough to consent.

(See also: Circumcision and HIV )

Introduction

History. In the earlier part of the Twentieth Century, many American doctors formed the opinion that circumcision would reduce the chance of a male contracting sexually transmitted disease (STD). This opinion was based on popular considerations of sexual hygiene. There were no scientific studies or documentary evidence to support this position. Regardless, countless males were circumcised by military services of the U.S. and other nations during World Wars I and II in an attempt to reduce the chance that they would contract a STD.

In a self-published pamphlet, Circumcision: A Parent's Decision for Life, the late circumcisionist Aaron J. Fink made the suggestion that the dried-out, cornified circumcised glans and mucosa would be "tougher," and somehow therefore less prone to infection, than those of intact men. This claim was even published in The New England Journal of Medicine, but, in fact, there is no evidence to support Fink's theory.5,10,13

Behavior. It is documented that circumcised adult males exhibit a greater tendency to engage in risky sexual behavior. Hooykaas and colleagues reported that circumcised men in the Netherlands engage in more risky sexual behavior and have markedly higher rates of STDs.3 Laumann and colleagues reported more risky sexual behavior amongst circumcised men in the United States and have higher rates of STDs.9 Michael et al. reported more variability in sexual behavior, less condom usage, and more STD amonst the predominantly circumcised population of the United States as compared with the predominantly non-circumcised intact males of the United Kingdom.12

Immunology. Fleiss et al. have described the many natural immunological protective mechanisms provided by the prepuce against infection.10 The prepuce has many immunological protections against disease.10 These mechanisms may explain why surgically-altered, circumcised men seem to have a greater incidence of many different STDs. Dried-out mucous membranes are more prone to infection than naturally moist ones (the reason people tend to get more colds in the wintertime!).

The foreskin naturally moisturizes the glans penis, keeping it in optimum healthy condition to resist infection. The subpreputial moisture also contains lyzosyme, an enzyme that attacks and destroys the cell walls of bacteria.1,10

Laumann et al. reviewed data from the National Health and Social Life Survey.8 They found no evidence of a prophylactic role for circumcision. In fact, there was a slight tendency in the opposite direction.9 The absence of the foreskin was significantly associated with bacterial STDs among men who have had many sexual partners in their lifetimes. A rate of 25.4/1000 for chlamydia was found in circumcised men compared with a rate of zero in intact men; herpes was 14.9/1000 in circumcised males compared with 8.1/1000 in intact males.9

Tanne reported on the epidemic of STD, including herpes, human papillomavirus infection, hepatitis B, and HIV infection in the United States.11 The incidence of STD in the United States is amongst the highest in the industrialized world. This should not be surprising, considering the high incidence of circumcision in the US: According to Laumann et al., data from the National Health and Social Life Survey indicate that, in 1992, of 1511 men surveyed who were between 18 and 59 years of age, 77 percent of U.S. born men were circumcised.9 This high percentage is unique among the industrialized nations.8

Natural protection. While the entire body of medical literature gives no clear indication one way or the other whether circumcision protects against STD, the more recent studies have shown that the natural intact penis may offer some protection against the contraction of various STDs.2-7, 12, 13 According to Storms:

Recent studies have demonstrated that circumcised men are at increased risk of contracting gonorrhea, syphilis and genital warts. Men are at equal risk for developing human papillomavirus lesions and herpesvirus infections regardless of circumcision status. At least four studies have shown human immunodeficiency virus infection to occur more commonly in circumcised men.8

Recent studies have demonstrated that circumcised men are more at risk of contracting urethritis,2 gonorrhea,8 syphilis,9 genital warts4,8 and chlamydia.9 Cook discovered that, when genital warts occur in intact males, they tend to occur near the distal (tip) end of the penis4--the region where the foreskin's protection would be least effective.

Van Howe's survey of the medical literature is recommended. Van Howe concludes that:

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 [genital ulcer disease]. In summary, the medical literature does not support the theory that circumcision prevents STDs.13

The British National Survey of Sexual Attitudes and Lifestyles reported that circumcised males have slightly more STDs but the difference was not judged to be statistically significant.14

The evidence does not support circumcision to prevent STD infection. On balance, non-circumcision is to be preferred.

References

  1. Prakash S, Raghuram R, Venkatesan, et al. Sub-preputial wetness - Its nature. Ann Nat Med Sci (India) 1982; 18(3):109-112.
  2. Smith GL, Greenup R, Takafuji ET. Circumcision as a risk factor for urethritis in racial groups. Am J Public Health 1987; 77: 452-4.
  3. Hooykaas C, van der Velde FW, van der Linden MM. et al. The importance of ethnicity as a risk factor for STDs and sexual behaviour among heterosexuals. Genitourin Med 1991; 67(5): 378-83.
  4. Cook LS. Koutsky LA. Holmes KK. Clinical presentation of genital warts among circumcised and uncircumcised heterosexual men attending an urban STD clinic. Genitourin Med 1993; 69: 262-264.
  5. Cook LS, Koutsky LA, Holmes KK. Circumcision and sexually transmitted diseases. Am J Public Health 1994; 84: 197-201.
  6. Donovan B, Bassett I, Bodsworth NJ. Male circumcision and common sexually transmissible diseases in a developed nation setting. Genitourin Med 1994; 70: 317-20.
  7. Donovan B, Bassett I, Bodsworth NJ et al. Herpes simplex virus type 2 infection of heterosexual men attending a sexual health centre. Med J Aust 1994,160:69-70.
  8. Storms MR. AAFP Fact Sheet on neonatal circumcision: a need for updating. Am Fam Physician 1996;54(4):1216-17.
  9. Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States: prevalence, prophylactic effects, and sexual practice. JAMA 1997;277:1052-7.
  10. Fleiss PM, Hodges FM, Van Howe RS. Immunological functions of the human prepuce. Sex Transm Inf 1998;74:364-7.
  11. Tanne JH. US has epidemic of sexually transmitted disease. BMJ 1998;317:1616. (Link to www.bmj.com)
  12. Michael RT, Wadsworth J, Feinleib J, et al. Private sexual behavior, public opinion, and public health policy related to sexually transmitted diseases: a US-British comparison. Am J Public Health 1998;88(5):749-54.
  13. Van Howe RS. Does circumcision influence sexually transmitted diseases?: A literature review. BJU Int 1999; 83, Suppl 1:52-62.
  14. Dave SS, Johnson AM, Fenton KA, et al. Male circumcision in Britain: findings from a national probability sample survey. Sex Trans Infect 2003;79:499-500.
(Last revised 13 December 2003)

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