Good Bye, Foreskin!

13. October 2008
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A small cut for him, a large step for mankind? In Africa the scalpel on the preputium saves millions of lives. What helps there against HIV infections causes hot debates in Germany: esthetic infection protection or genital mutilation?

It is one of those procedures most frequently made by surgeons worldwide. In addition it is one of the oldest surgeries – even in ancient Egypt it was custom. And at the time being it probably is the most effective method to curb the HIV pandemic in Africa. Even in highly developed countries, circumcision protects from sexually transmitted diseases, urinary tract infections or penis carcinoma.

All around the globe about 670 million men in the age over fifteen lost their perputium by circumcision with or without their approval – that’s almost every third man. While the rates go down in the US and in the UK, it is supposed to increase in Africa if the WHO does get what it wants. Because the uncovered penis provides protection against HIV. Three large studies in South Africa in 2002 and the following years in Uganda and Kenya were interrupted prematurely. According to an interim analysis, the risk to catch the deadly virus dropped by more than 60 percent – reason enough to stop the exposure of the uncircumcized to a higher risk. Bertran Auvert, author of the first study, estimates that by circumcision prior to the first sexual intercourse about 6 million deaths of AIDS victims could be avoided until 2026.

The virus sneaks through a loop hole

The inside of the perputium appears to be the loop hole the HIV virus uses as the gateway into the body. It contains less keratin than the penis shaft or the outer foreskin. The Langerhans immunocompetent cells gathering there are just what the pathogen is waiting for. Thus the WHO program UNAIDS urges that as many as possible of the endangered men get circumcized. In Kenya medical personnel gets trained for the cut, in Sambia about 500 men has this surgery over the past few months. But whenever circumcision is part of the initiation rites for native tribes it starts getting difficult to transfer the procedure to a doctor’s office or hospital for hygienic reasons. In other nations, men are afraid that the foreskin amputation might cause a limitation of their virility. In addition the willing need to know and understand that circumcision is no insurance against AIDS and that the virus still can be transferred.

If this procedure really is that effective against infections – not just HIV – why did the quota decrease from 91 to 79 percent in the US? And why are just about 15 percent of the German boys circumcized? The use of the scalpel on the male sexual organ is highly controversial. The psychologist Richard Goldman even sees a connection between the high criminal rate in the US and the shock of cutting a piece of the body off in early childhood. The German organization Eurocirc puts ample protection together with improved esthetics into the argument. A short while ago, the Canadian Urological Association Journal published a juxtaposition of contentions of both sides.

One risk banned, another crops up

According to the latest studies the risk for penis carcinoma is about twenty times higher for men not circumcized than for men with an uncovered glans. Also the risk of developing genital warts and thus the risk of cervical carcinoma for the woman is much higher with an intact foreskin. So Israel has the lowest rate of incidences worldwide.

But the opponents argue that the risk of a penis carcinoma would be nullified by the rate of complications during circumcision. And an appropriate hygiene in the intimate regions would provide an efficient protection. The money for circumcision would be invested here just as well. Unquestioned is the fact that the cut sometimes cannot be avoided for children with phimosis, although minor forms of the narrowing of the preputial orifice can be treated well with steroids also.

Eurocirc reports about an increasing number of women turning to this organization to convince their partner to have the surgery made.

Nonetheless reports and studies of a withering sex life and new highlights balance each other. A biennial prospective study published recently in the British Journal of Urology did not find any significant difference between those two groups.

If the health insurance doesn’t pay

Experts see a definite economic medical advantage only in regions where HIV is spread by heterosexual contacts. So the health insurances pay only in clear indications of phimosis. But in day-to-day life, a solution normally can be found to accommodate parents and grown up men despite the controversial legal situation. In fact many urologists appreciate that for example many muslims take their sons to the physician or the hospital rather than lend a hand themselves with the knife.

May the experts still argue about circumcision of men and boys for medical and religious reasons, yet all groups agree on one thing: For girls this surgery is nothing but an unnecessary and painful mutilation of the female genitals. And according to unconfirmed sources about 7,000 victims still suffer from this destiny in Germany.

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