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Debate on circumcision heightened as CDC evaluates surgery

By Rob Stein
Washington Post Staff Writer
Tuesday, January 19, 2010; HE01

Circumcision, long one of the most emotionally charged surgical procedures performed in the United States, has become the focus of yet another intense debate as leading health authorities are about to issue major new evaluations of the potential health benefits of the operation.

The war of words over the procedure has been sparked by a decision by the federal Centers for Disease Control and Prevention to issue recommendations for the first time about whether newborn boys and possibly even adult men should undergo the common surgical procedure, just as the American Academy of Pediatrics is poised to revise its position of not recommending the operation.

The two evaluations, which are nearing completion, come in the wake of new research indicating that the procedure has more health benefits than previously thought, including reducing the risk for getting the AIDS virus and contracting other sexually transmitted diseases.

The rate at which U.S. male newborns are undergoing the procedure has dropped to about 56 percent since peaking at about 80 percent in the 1960s.

The new data on its health benefits have prompted supporters of circumcision to call for greater efforts to encourage the surgery, but opponents liken the operation to genital mutilation and have launched a lobbying campaign to preempt any possible endorsements.

"Circumcision is not an ethical medical procedure," said Georganne Chapin, executive director of Intact America, a Tarrytown, N.Y., advocacy group. "You are removing a perfectly normal body part. We don't allow people to do that to their daughters. We should not let them do it to their sons."

Circumcision, which has been practiced for centuries, involves removing an infant's foreskin. Although long motivated primarily by cultural and religious practices, evidence has been accumulating that it also has health benefits.

In addition to reducing the risk for urinary tract infections among infants, studies indicate that circumcision cuts the chances of adult men's getting penile cancer and becoming infected with a variety of sexually transmitted diseases, including syphilis, AIDS, herpes and the human papillomavirus (HPV), which causes genital warts in men and women and cervical cancer in women.

In 2005, the American Academy of Pediatrics reaffirmed a policy adopted in 1999 that backed away from routinely recommending circumcision, saying the evidence of benefits was insufficient to endorse the routine use of the procedure.

But evidence continued to mount about the possible benefits, most notably three large studies conducted in South Africa, Kenya and Uganda that concluded that circumcised heterosexual men were about half as likely to become infected with HIV as uncircumcised men.

"The evidence has gotten much stronger with the results of these trials of the potential benefits of circumcision," said Ronald H. Gray, a professor of reproductive epidemiology at Johns Hopkins University, who led two of the recent studies.

In addition to reducing the risk for HIV, research indicates circumcision cuts the risk of getting HPV and herpes by about a third, according to a review Gray published last week in the Archives of Pediatric & Adolescent Medicine. Although the procedure does not reduce the risk of HIV infection in the men's female partners, women who had sex with circumcised men were less likely to get HPV and bacterial infections.

"Higher rates of circumcision would certainly prevent a substantial number of infections," Gray said. "The risks are extremely small and the benefits are substantial."

Reduced infection risk

Circumcision appears to reduce the risk for infections because the foreskin contains cells that are more easily penetrated by viruses and has a moister environment more conducive to the growth of viruses and other microbes. The foreskin is also prone to developing tiny tears during sex that increase the risk for infections, Gray said.

"Men who are uncircumcised are more likely to have a variety of infections under the foreskin, and the inflammation from those infections could increase the risk of ulcerations, which could also increase the risk of infection," Gray said.

Other experts agreed.

"If we had a vaccine that was as effective as this at reducing the risk, we'd be jumping up and down with joy," said Arleen A. Leibowitz, a professor of public policy the University of California at Los Angeles.

Leibowitz conducted a study that found that circumcision rates tended to be lower in states where the procedure was not covered by Medicaid; at least 10 state programs stopped covering it in the wake of the academy's position. Medicaid programs in Maryland, Virginia and the District still cover the procedure. She and others hoped an endorsement by the CDC and the academy would prompt more states to cover the surgery.

The academy's 11-member task force met outside Chicago last week to begin finalizing the new position, which will be released later in the year. While noting that recent evidence strengthens the case for circumcision, the task force's chairman refused to indicate what the policy might be.

"It could end up being anything from: It ought to be done on every male; on only some males; or only if the parents want it to be done," said Susan Blank, the assistant commissioner on sexually transmitted diseases at the New York City Department of Health and Human Hygiene. "It could fall anywhere along the spectrum."

Similarly, the CDC plans to release a draft of its first recommendations on the issue by this summer, for both parents of newborns and uncircumcised adult men. Officials stressed that whatever the final recommendations are, they will only serve as guidance and in no way are designed to make the procedure mandatory.

"Given the HIV epidemic in this country, we really need to examine something that is emerging as a new HIV-prevention tool," said Peter Kilmarx, who is coordinating the CDC's look at the issue. "But we're not really just focused just on HIV or STDs [sexually transmitted diseases]. We are looking at safety and cultural concerns and other issues, such as cost-effectiveness. As a public-health agency, we are focused on the public-health aspects of it, but are cognizant of people's broader concerns."

A sign of modernity?

Critics question the relevance of the African studies, saying that most of the HIV transmission in the United States occurs among drug addicts and gay men, whose risk would be unaffected by whether they were circumcised. They also worry that it will give circumcised men a false sense of security. And they say it permanently diminishes the sexual experience.

"Over the history of circumcision, there's been one justification after another. Circumcision was supposed to keep boys from masturbating. Then it was hygiene. Then it became a sign of modernity," Chapin said.

Chapin's group is planning a variety of efforts to discourage the academy from changing its position and to persuade the CDC not to endorse circumcision, including a letter-writing campaign to academy task force members and a petition drive aimed at the CDC.

"We're getting bombarded," said Douglas Diekema, a professor of pediatrics at the University of Washington who is on the task force. "You're talking about a sexual organ, which automatically just by the nature of it gets people pretty upset."

Others charged that the push for circumcision is driven more by economic benefits to doctors than medical benefits to patients and that other methods have been shown to be much more effective, such as antibiotics for urinary tract infections and condoms for sexually transmitted diseases.

"It doesn't have any medical benefit. It's clearly unethical," said Robert Van Howe, a clinical professor of pediatrics and human development at Michigan State University.

Although proponents argue that the evidence that circumcision reduces sexual pleasure remains equivocal and that the risks are low and the benefits clear, others say the risks and benefits have been exaggerated.

"People care way too much about this little piece of skin," said Mark Alanis of the Medical University of South Carolina in Charleston, who has written a history of circumcision. "At the end of the day, it's unlikely to significantly change your child's life for better or worse."

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