Circumcision: From Covenant to Cure?

By Alexandria Vickery

In Genesis 17:11, God commands Abraham: “You are to undergo circumcision, and it will be the sign of the covenant between me and you.” Ritual circumcision symbolizes a commitment to the participation in and perpetuation of the Jewish faith. Jewish law states that Jewish-born males and uncircumcised male Jewish converts must undergo circumcision, or removal of the foreskin, in order to fulfill the contract necessary to be a Jew. Those who are circumcised are thought to have undergone a mitzvah aseh, or “positive commandment,” and have therefore created a personal connection to a divine source and the Jewish nation. On the eighth day after the birth of a Jewish male, he undergoes a Brit milah ceremony, or “covenant of circumcision,” presided over by a rabbi and performed by a mohel, a Jewish person specifically trained for the procedure.

While circumcision has been a Jewish religious commandment for over 3000 years, it has also been practiced for health and sanitation reasons for just as long and has had profound importance outside religious practices¹. Recently, the procedure has shown itself to be beneficial in a completely secular arena. Many researchers have become interested in the out-of-the-box idea of using clinical circumcision to reduce human immunodeficiency virus (HIV) transmittance to heterosexual men. Most research has been focused on using the procedure as a preventative method in Africa, where HIV prevalence and risk are highest.

The effect of circumcision in reducing disease acquisition is biologically likely. The United States Center for Disease Control (CDC) has reported laboratory studies showing the inner mucosa of the foreskin has a higher density of Lagerhans cells, the target cells for HIV infection, than do other genital tissues². It may also be more susceptible to microscopic tears during intercourse that would allow pathogens into the male’s bloodstream³. Additionally, the microenvironment between the foreskin and the glans penis may be one in which the virus is able to survive and thrive⁴. Uncircumcised males are perhaps at greater risk for contracting viral infections such as HIV.

A 2000 systematic review and meta-analysis of the heterosexual transmission of HIV in circumcised men in sub-Saharan Africa has shown a significant protective effect with risk of infection anywhere from 44% to 71% lower than that of uncircumcised men (the strongest association was seen in high-risk patients at STD clinics)⁵. Another study in 2003 showed a 42% lower infection rate, and several ecologic studies have shown potential links between circumcision and infection at the population level⁶. Randomized controlled clinical trials have also been conducted in three African countries to determine how circumcision of the adult male population affects HIV infection rate; the results showed a 76% reduction of risk in South Africa⁷, 60% in Kenya⁸, and 55% in Uganda compared to those males who were not circumcised⁹. While these studies show that circumcision reduces the risk of male HIV infection, there has not been conclusive data showing that circumcision reduces the rate of transmission of the infection from seropositive males to their female partners.

Additional studies have also shown that male circumcision may not only reduce HIV risk and infection rates, but that it may also show positive effects on sexually transmitted genital ulcer disease, chlamydia, syphilis, urinary tract infections, human papillomavirus (HPV), and HPV-related penile cancer and cervical cancer in female partners⁴.

As with any issues, opponents of circumcision exist for both the religious and health-related aspects of the procedure. New Reform and Reconstructionist Jewish movements view circumcision as a barbaric practice and movements such as Humanistic Judaism argue that it should not be required to maintain Jewish identity. As for its use in reducing HIV risk, it has been argued that the procedure itself is too high-risk, may cause reduced sensation and sexual function, or may lead to social ostracism in cultures where it is seen as abnormal or unnatural. Studies have shown, however, that the most common risks associated with the procedure are minor pain, bleeding, or infection, with no reported cases of death or long-term or serious symptoms¹⁰. Additionally, studies of sexual aspects circumcision have shown that there is no significant reduction in sensitivity resulting from the procedure, and that some men report improved function¹⁰. No matter what conclusions result from research, however, circumcision and personal decisions surrounding the procedure imply societal consquences.

For those interested in learning more about the use of male circumcision in reducing HIV transmission risk, the CDC has compiled and summarized the studies mentioned in this article, along with several others, at the following web site: http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm

1. Chronology of the foreskin and circumcision. History of circumcision. Web. 10 February 2011. <http://www.historyofcircumcision.net/index.php?option=content&task=view&id=31&gt;

2. Patterson B.K., Landay A., Siegel J.N., et al. Susceptibility to human immunodeficiency virus-1 infection of human foreskin and cervical tissue grown in explant culture. Am J Path. 2002 Sep; 161(3):867-73.

3. Szabo R, Short RV. How does male circumcision protect against HIV infection? BMJ. 2000 Jun 10; 320(7249):1592-4.

4. Alanis MC, Lucidi RS. Neonatal circumcision: a review of the world’s oldest and most controversial operation. Obstet Gynecol Surv. 2004 May; 59(5):379-95.

5. Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub- Saharan Africa: a systematic review and metaanalysis. AIDS. 2000 Oct 20; 14(15):2361-70.

6. Siegfried N, Muller M, Volmink J, et al. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database Syst Rev. 2003; (3):CD003362.

7. Auvert B, Taljaard D, Lagarde E, Sobngwi- Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005 Nov;2(11):e298. Erratum in: PLoS Med. 2006 May;3(5):e298.

8. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet. 2007 Feb 24; 369(9562):643-56.

9. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet. 2007 Feb 24; 369(9562):657-66.

10. Kigozi G, Watya S, Polis CB, et al. The effect of male circumcision on sexual satisfaction and function, results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakai, Uganda. BJU Int. 2008 Jan; 101(1):65-70.

Published on page 55 of the Winter 2011 issue of Leviathan.

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