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.
History. In the early part of the Twentieth Century, many 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 opinion. 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.3Laumann 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 UnitedKingdom.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 (which is 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 lysozyme, 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.9 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.9Cook 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.
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
Longitudinal studies. Dickson et al. in Dunedin studied a cohort of New Zealand children born in 1972. This cohort, who are now adults, have been followed since birth. The males in the group included both intact (not circumcised) and circumcised males. 201 or 40.3 percent of the male subjects were circumcised. Dickson et al. found no relationship between circumcision status and HPV infection.15 In a second study of the same New Zealand cohort through age 32, Dickson et al. found more STDs in circumcised subjects, although the difference was not statistically significant.17 There were 24.4 STD infections per 1000 person-years among the circumcised group and 23.4 STD infections per 1000 person-years among the non-circumcised group.16
Cross-sectional studies. Cross-sectional studies have been carried out in the United States,9 the United Kingdom,14 and Australia16 to determine the effects of circumcision upon STDs. All studies have found no significant effect of circumcision on the incidence of STD. Laumann et al. reported that circumcised men are slightly more likely to have both a bacterial and a viral STD in their lifetime.9 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 Richters et al. found that non-circumcised men are slightly more likely to have penile candidiasis (yeast).17
Conclusion. The evidence does not support non-therapeutic circumcision to prevent STD infection. On balance, non-circumcision is to be preferred because of the freedomfrom complications and other adverse effects.
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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