Circumcision from a medical perspective: analysis of risks, potential benefits and bioethical dilemmas

Medical circumcision is a surgical procedure for the removal of the foreskin of the penis. Its evaluation from the perspective of evidence-based medicine presents a complex and ambiguous picture, where potential health benefits must be weighed against the risks of the procedure, its irreversibility, and the lack of medical necessity for the overwhelming majority of newborns. The medical community in different countries holds various positions based on epidemiological data and cultural context.

1. Potential medical benefits: what does evidence-based medicine say?

Research, mainly epidemiological, indicates several areas where circumcision may reduce risks:

Reduction of urinary tract infections (UTIs) in infants: The risk of UTIs in circumcised boys under one year of age is 5-10 times lower. However, the absolute risk of UTIs in uncircumcised boys is already low (about 1%). To prevent one case of UTI, approximately 100-200 infants would need to be circumcised. Most UTIs are successfully treated with antibiotics.

Reduction of the risk of certain sexually transmitted infections (STIs): Large randomized controlled trials (RCTs) conducted in Africa have shown that circumcision in adult men reduces the risk of heterosexual HIV transmission by 50-60%. Also, there is a reduction in the risk of high-risk HPV and herpes simplex virus type 2 (HSV-2). Mechanism: The keratinized mucosa of the glans after circumcision is less susceptible to microtrauma and viral penetration. Important: This effect has been proven for high-risk groups in specific epidemiological conditions (sub-Saharan Africa) and does not negate the need for barrier contraception methods.

Prevention of phimosis and paraphimosis: Circumcision prevents pathological phimosis (inability to uncover the glans due to scar changes in the foreskin) and its acute complication - paraphimosis (strangulation of the glans by a constricted foreskin), requiring emergency surgical intervention. However, physiological phimosis (natural adhesion of the foreskin in small children) is normal and does not require intervention.

Reduction of the risk of penile cancer: This is an extremely rare disease (1 case per 100,000 men in developed countries). The risk for men circumcised in infancy tends to zero. However, the main risk factor is HPV infection and poor hygiene, making circumcision not the only method of prevention.

Ease of hygiene: The absence of the foreskin makes it easier to wash the glans of the penis, which may reduce the risk of balanitis (inflammation of the glans) and balanopostitis (inflammation of the glans and foreskin).

Interesting fact: The position of the American Academy of Pediatrics (AAP) is illustrative of the discussion. In 2012, after analyzing all available data, AAP stated that potential health benefits outweigh risks, but not to the extent that it recommends routine circumcision of all newborns. This position was softened in 2021 in favor of a more neutral one, emphasizing that parents should make an informed decision, weighing small benefits and small risks. In contrast, most European national pediatric associations (United Kingdom, Germany, Scandinavian countries) do not recommend routine circumcision, considering it not a medical necessity but a choice of parents based on cultural, religious, or personal preferences.

2. Risks and complications of the procedure.

Circumcision is a surgical procedure associated with standard risks:

Bleeding and infection: The most common early complications (0.1-1% of cases).

Unsatisfactory cosmetic result: Removal of too much or too little tissue, asymmetry.

Damage to the glans of the penis or the urethra.

Pain syndrome: Even with the use of local anesthesia (which is now the standard), the procedure and the postoperative period are painful.

Metabolic stress for the newborn, including changes in behavior and sleep patterns.

Long-term risks: Some studies (mainly observational) indicate a possible association with increased sensitivity of the glans, changes in sexual function, although the data are conflicting and ambiguous. The main ethical complaint is the irreversibility of the procedure and the inability to obtain the consent of the patient.

3. Bioethical dilemma: informed consent and bodily autonomy.

This is a central medical and legal issue. Circumcision performed for non-medical reasons on a newborn or child violates a key bioethical principle - the priority of patient autonomy.

The object of intervention is the body of a person unable to give consent.

The procedure is not of urgent necessity and can be safely postponed until the person is old enough to make a decision (the principle of "deferred consent").

Parental decision in this case is surrogate and may be challenged from the perspective of the child's future right to the integrity of their body.

From this perspective, many bioethicists and human rights defenders consider non-medical circumcision of boys as a violation of the right to bodily integrity. This distinguishes it from vaccination, which, also performed without the child's consent, is aimed at preventing serious diseases and carries benefits directly to him, protecting from direct threats.

4. Medical indications for circumcision.

There are clear situations where circumcision is a medical necessity (therapeutic circumcision):

Pathological phimosis, refractory to conservative treatment (steroid creams).

Recurrent balanopostitis.

Paraphimosis (in an emergency).

Disease (sclerotic atrophic lichen).

In these cases, the procedure is aimed at treating a specific disease and is carried out for medical reasons.

Conclusion.

From a purely medical point of view, neonatal circumcision is a procedure with negligible potential health benefits on a population scale and small but existing risks. It cannot be classified as necessary from a medical point of view for all, but it cannot be called absolutely harmful.

Key conclusions:

Benefits are real, but modest and mainly relate to reducing the risks (not guarantees) of certain diseases, many of which can be prevented by other methods (hygiene, safe sex, HPV vaccination).

Risks are low when performed by a qualified specialist, but not zero.

The main discussion has shifted from a purely medical plane to the plane of bioethics and human rights: does a parent have the right to subject a child to an irreversible, non-functional surgical procedure without their consent, even if motivated by good intentions or cultural traditions?

Thus, the modern medical position is increasingly inclined to the idea that the decision on circumcision should be an informed choice of the person themselves, upon reaching the age of majority. In the case of children, the procedure should only be performed under strict medical indications, and routine circumcision of newborns is no longer considered a standard of medical care, remaining a cultural and religious phenomenon that medicine can only provide technically with minimal risks.

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