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Male circumcision: Leading health authorities debate benefits

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Rob Stein
Washington Post Staff Writer
Tuesday, January 19, 2010; 1:00 PM

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.

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Today's story: Debate on circumcision heightened as CDC evaluates surgery

Post User Poll: Should parents circumcise their sons?

Washington Post staff writer Rob Stein was online Tuesday, Jan. 19, at 1 p.m. ET to discuss the differing opinions of the CDC (Centers for Disease Control and Prevention) and the American Academy of Pediatrics. The two evaluations come in the wake of new research indicating that the procedure has more health benefits than previously thought.

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Rob Stein: Hello everyone. Thanks very much for joining us today to discuss the issue of circumcision. This is one of those subjects that seems to provoke a lot of intense emotions and a lot of controversy. I see there are already questions. So let's get started.

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Washington, D.C.: Seems like the precept of "my body, my choice" should apply here. If the concern is increase risk to future sexual partners, well, they have a choice too.

Rob Stein: Yes, that's one of the arguments that the opponents of circumcision make -- that parents should not be making this decision for their sons without their consent and for some future, possible benefits.

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Falls Church, Va.: The article says: "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."

Regarding gay men, why would their "risk be unaffected"? If the foreskin facilitates pathogen transmission, and is subject to tiny tears, then it would subject them to the same risk, right? Or are you saying that anal intercourse is not a transmission risk?

Rob Stein: The argument is that in the case of gay men circumcision would not protect the recipients of annal intercourse.

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Arlington, Va.: I find it rather suspicious that all the studies promoting circumcision are from places like Kenya and Uganda. The people in these African counties live in deplorably unsanitary conditions and suffer from poor personal hygiene. Comparing someone from one of these countries who might bathe once a week with dirty water is hardly an equal comparison to an American or European who bathes daily with clean water. If you bathe regularly you are not going to have germs accumulating under the foreskin. Even the issue of HIV is negated by using a condom which you should be using in any event.

Rob Stein: While it may be true that there differences in hygiene, the more important difference is in the prevalence of HIV. It's much higher in these African countries, which means the potential benefits of circumcision would be much greater.

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Washington, D.C.: Do we actually know what the recommendations are yet? Also, I see the article discusses reducing risk, but how much risk is being produced? To try and clarify -- if they say reducing risk by 5 percent, does that mean you have a 5 percent less chance over all, or if you had a 20 percent chance of an outcome in the first place do you now have a 19 percent chance? And either way how much risk do men have from what should be helped now? I know this can vary -- for instance the example of AIDS in Africa, unless my family moves to Africa is the findings there really relevant to my toddler son?

Rob Stein: We don't know what the recommendations are yet. The CDC is expecting to publish a draft of its recommendations sometime later this year. The draft will be subject to public comment and possible revision before becoming final. The American Academy of Pediatrics is also expecting to release its new policy statement some time later this year.

You're quite correct that the benefit certainly depends on the risk. And one of the arguments that opponents of circumcision make is that the risk for HIV infection in Africa is much higher than it is in the United States, and so the benefit in this country is much lower, especially for heterosexual men who are not abusers of injected drugs.

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Athens, Ga.: I have 2 boys. The older one is circumcised (my husband insisted); the younger one is not. It seems to me that many of the "benefits" of circumcision could also be achieved by practicing safe sex and basic hygiene. And that is why I decided not to have my second son circumcised: it is, basically, unnecessary surgery. My husband was harder to convince, but he ultimately agreed with me, and if we have any other sons, they will not be circumcised.

Rob Stein: You're right that many of the benefits of circumcision can be achieved through safe sex and hygiene. It's a personal decision that individual parents need to make for their children.

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Boston, Mass.: American circumcision researchers search for benefits and ignore the harm. Here are some potential effects of circumcision that have not been studied.

Infants: physiological, neurological, and neurochemical changes, immune response, behavioral response, temperament, excessive crying, attachment, withdrawal, mother-infant interaction, pain response, brain changes

Older children and/or adults: health problems, immune response, stress response, pain response, arousal level, emotional response, sexual response, sexual response to viewing sexual images containing violence and/or pain, sexual behavior, sadomasochistic behavior, sexual dysfunction, impotence, attitudes (e.g., toward women, female sexuality, rape, pain, parents, infants and children, emotion, authority), body image, self-esteem, shame

History of intimate relationships, relationship satisfaction, social prejudice, conformity, jealousy, loneliness, competitiveness, altruism, trust, empathy, depression, passivity, sensation seeking, ethical behavior, social behavior, attention deficit hyperactivity disorder, aggressiveness, withdrawal, effects of circumcision on parents and circumcisers, neurological (including magnetic resonance imaging scans of the brain to measure hippocampal volume) and neurochemical changes

Does circumcision affect the prevalence of autism and ADHD which both occur about four times more often in boys than in girls? We do not know.

Social studies: violent behavior, criminal behavior, domestic violence, rape, child abuse (victims and perpetrators), child sexual abuse, suicide, sudden infant death syndrome (SIDS), theft, marital status, divorce rate, unnecessary surgery, unprotected sexual behavior.

Rob Stein: That's a very long list of supposed potential harms. I have to say I've not seem much evidence supporting the idea that circumcision is related in any way to most of these. I have obviously heard the argument about the possible effects on sexuality, but many experts say even that remains far from known. In fact, men in the African studies reported increased sexual satisfaction after circumcision, but researchers quickly add that that remains very difficult to interpret. It could be that they were just less worried about getting infected with HIV.

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Springfield, Va.: What many don't realize is that it is much more painful with a longer recovery to be circumcised as an adult. That's one reason to have it done as an infant.

Rob Stein: It's clearly a much more difficult procedure to undergo as as adult. Nevertheless, one of the questions the CDC will address is the pros and cons of adult circumcision, especially for men at high risk for HIV.

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Washington, D.C.: As I posted on the blog section, there are now and always have been good, sound, medical reasons for circumcising male infants, and frankly, I can't understand the emotional uproar over this.

Rob Stein: It certainly has long been a highly charged, emotional subject. Clearly part of it has to do with debate over the impact the procedure has on sexuality.

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Durham, N.C.: Why are we not spending more time discussing risks? Last year, an Atlanta boy got $2.3 million settlement because part of his penis was cut off during a botched circumcision -- he will never be normal. In 2008, an SD newborn bled to death after circumcision -- there have been other reported deaths and permanent penile damage. Why would we place newborns at immediate risk of infection, bleeding, and surgical mishaps for a possible minor benefit in the distant future? Shouldn't we be discussing the risks to the infant now?

Rob Stein: There certainly are terrible stories of botched circumcisions, and when they happen they are obviously just terrible. But they are very very rare. The risk is very very small and usually at worst nothing more than a little extra bleeding.

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Woodbridge, Va.: What about the physical trauma (so early in one's life) "down there?" Does this trauma manifest itself psychologically?

Rob Stein: One of the problems is that questions like that are so difficult to answer. If you think about it, how would one design a study to really answer that question? Opponents of circumcision argue that there is lasting damage, but proponents say there's really no convincing evidence that's the case.

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College Park, Md.: How much sensation -- and therefore potential for sexual pleasure --does a man lose when his foreskin is removed?

My husband, who is not circumcised, says if he had to walk around with his foreskin drawn back, the stimulation would be constant, pleasurable -- and noticeable!

Rob Stein: Based on the physiology, it's possible to argue it both ways -- that being circumcised it more pleasurable and being uncircumcised is more please able. And, of course, how can you really get an objective answer to that question?

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Springfield, Va.: There is no way to measure the "pleasure" factor. If a man is uncircumcised and decides to become circumcised, his future sexual encounters will also be associated with the pain and recovery from the procedure. I still don't get the uproar. It's 99 percent cultural and cosmetic, like braces. Infants have no memory of it. The pain is short-lived, and they have much more pain from other procedures during the first few days of life.

Rob Stein: As I mentioned before, there is some data from the African studies that involved circumcising adult men that the men who got circumcised reported increased satisfaction with their sexual experiences after undergoing the procedure. But it could be that the increased satisfaction is the result of having less anxiety about becoming infected with the AIDS virus.

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Arlington, Va.: A boy's penis should look like his dad's. That is all.

Rob Stein: A lot of men feel that way, and base their decision to get the sons circumcised on that feeling. But more and more fathers in the United States have been forgoing the procedure for their sons, even if they themselves are circumcised.

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Virginia: Why is it legal to surgically alter boys' genitals in the U.S. while it is illegal to alter the genitals of girls?

People make the argument that one is more extreme then the other, but the underlying premise -- that children should have basic rights over their own bodies -- is the same.

I do not understand why infant circumcision is not considered a human rights violation. A healthy body part is being removed (HALF the skin of the penis -- look it up!).

Another question is, what is the statute of limitations for men to sue doctors who performed this procedure on them without their consent? I know plenty of men who are very unhappy that this was done to them without their permission. Do they have no recourse at all?

Rob Stein: That certainly is the argument that opponents of circumcision make. Proponents, however, say that in the case of male circumcision there are potential health benefits, whereas there are no possible health benefits to female circumcision.

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many of the benefits of circumcision can be achieved through safe sex and hygiene: Well, maybe in theory. But in reality, it's like birth control through the abstinence-only approach. Only takes one slip-up...

Rob Stein: That's the argument that proponents make -- that circumcision provides added benefit with very little, if any, downside.

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Insurance issues: As a pediatrician, I've done a few circumcisions (thought most of my patients were circ'd by an OB/Gyn). But one of the more interesting things is insurance coverage. Where I live, most private insurance covers a newborn circumcision. But Medicaid does not. And the circ is $350 cash if done within the first month, more afterwards (due to the need for general anesthesia). I knew quite a few poor parents who were livid that circs weren't covered. Now that the CDC recommends them, will that change?

Rob Stein: Thanks for this question. That is a very important point. Since the American Academy of Pediatrics backed away from recommending circumcision, many state Medicaid programs have stopped paying for the procedure. And circumcision rates have fallen in those states. While it's not guarantee, proponents hope that an endorsement by the American Academy of Pediatrics and the CDC will prompt more state Medicaid programs to pay for the procedure. They point out that the poor, who get their medical coverage from Medicaid, are often those at greatest risk for HIV and other STDs.

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Groton, N.Y.: Who are the 11 members of the new AAP Task Force on Circumcision, and where do they practice?

According to the American Religious Identification Survey, Jews make up 1.2 percent of the U.S. population and Muslims make up 0.6 percent. The percentage of self-identified Christians in the U.S. is 76 percent. Circumcision is a religious ritual for most Jews and Muslims, but Christianity teaches that circumcision is unnecessary. How many of the 11 Task Force members are Christians, and how many are Jewish or Muslim or a different religion or no religion? How many Task Force males are circumcised, how many are intact, and how many Task Force females are married to circumcised males or intact males? How many Task Force members circumcised their own sons, and how many left their sons intact? How many members of the Task Force have a personal, cultural and/or religious bias in favor of circumcision that could influence their judgment and objectivity on this issue?

Rob Stein: Interesting questions. I don't know the religious affiliations or circumcision state of the task force members.

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Alexandria, Va.: Circumcision is common in the U.S. but not in Europe, where I'm from. Are there any good comparisons of health data from different countries that demonstrate the alleged health benefits of circumcision? Or show them to be negligible?

Rob Stein: That is one of the arguments that opponents of circumcision make -- that while the United States has a much higher circumcision rate than many European countries it also has a much higher HIV rate.

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Silver Spring, Md.: My sons are not snipped, I was.

I just did not see the need for it.

And I distinctly remember hearing that, "his should look like his daddy's" line of thought.

Never made sense to me.

Rob Stein: That obviously is a very personal decision for each family to make. Some men feel very strongly about it, while others, like yourself, do not.

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Washington, D.C.: "I can't understand the emotional uproar over this": Me neither. Aren't circumcision opponents the same sorts of parents who are convinced they "know" what's best for their children (like the anti-vaccine militants) despite a lack of medical expertise?

Rob Stein: The debate over circumcision is a much closer call than the debate over vaccines -- I think most experts would agree that the benefits of vaccines have been much more clearly demonstrated.

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Sensitivity: The claim in the African studies that some men reported more pleasure also ignores the fact that in uncircumcised men the head of the penis is more sensitive because it has the foreskin to cover it (as comment about walking around with the head exposed reflects). After circumcision it slowly "hardens" or becomes less sensitive (like the palm of one's hand). So the African study participants could just be reacting the overly sensitive newly exposed heads. In 10 years it may not be the same.

Rob Stein: Could be. That's why this is a question that will probably never be answered to everyone's satisfaction.

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Alexandria, Va.: How are the CDC and other study different than the controversial mammogram study from a few months back? There, I thought the scientists staunchly said their findings and recommendations were totally divorced from economic considerations. Here, your article cites a CDC spokesperson as saying "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."

Rob Stein: I assume you are referring to the mammography guidelines issued by the U.S. Preventive Services Task Force. In that case, cost was not considered.

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Bellingham, Wash.: How do you respond to the men who are angry that they were circumcised without their consent? It is not something that can be taken back.

Rob Stein: I'm really not sure what to say about that. But an ethicist I interviewed for my story who was neither a supporter nor an opponent of circumcision said he was concerned about making men feel bad if they are circumcised when there is no convincing evidence that they are necessarily suffering in any way.

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Comparing male and female circumcision: Is not anatomically equivalent. Male circumcision removes the foreskin that covers the glans. Female circumcision removes the entire clitoris and sometimes the labia minora. The male equivalent of this would be to remove the foreskin and glans (the "mushroom" shaped tip). Totally different.

Rob Stein: good point.

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Fairfax, Va.: My son was born in Europe several years ago. The doctors recommended he not be circumcised because he was premature and they did not want him subjected to the stress of that procedure. It is not painless. I think that parents who have their babies circumcised should watch it being done.

Rob Stein: Many opponents of the procedure agree with you.

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Peoria, Ill.: Per the CDC, 80 percent of adult American males are circumcised. When HIV was first discovered, that number was closer to 90 percent. Western Europe has a circumcision near 0 percent and a fraction of the per capita HIV rates when compared with the United States.

Why does it make sense push circumcision when that experiment has already been tried? Wouldn't it make more sense to push for mandatory comprehensive sexual education and universal availability of condoms? Wouldn't it make more sense to determine what they are doing right overseas?

Rob Stein: This is one of the arguments that opponents make. Proponents, however, say that HIV is spread in the United States primarily among gay men and drug users, and circumcision would not reduce that. But it could help protect straight men.

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Washington, D.C.: Given it's mission and findings of some benefit in preventing transmission of disease, isn't it somewhat unsurprising that the Centers for "Disease Control" would come down on the side of circumcision?

Rob Stein: Just to be clear, the CDC has not issued any recommendations yet. The agency is still in the process of drafting its first recommendations on the issue.

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D.C.: "no possible health benefits to female circumcision"

Do we know this? Have there been studies? Would anyone even do a study since it is already considered a backwards and barbaric practice?

Rob Stein: I can't imagine anyone would.

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Atlanta, Ga.: Considering the USA presently has a law banning FGM (female genital mutilation) isn't it kind of disingenuous to propose mandating circumcision when to be honest this sounds like it just fear mongering? Since circumcision is fundamentally an amputation (to cut off (all or part of a limb or digit of the body), as by surgery) and at that is primarily viewed as a cosmetic procedure shouldn't the 14th Amendment of the U.S. Constitution take precedence here as as the ones making the cost/benefit analysis aren't the individual that undergoes the procedure (in most cases) as the 14th amendment mandates equal protections under the law?

Rob Stein: No one is considering mandating circumcision. The CDC is only considering providing guidelines to parents about the potential benefits of the procedure.

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Minneapolis, Minn.: There will never be an end to the question about sexual pleasure, because how do you objectively measure sexual pleasure? To avoid being too graphic I'll simply point out that "sensitivity" does not necessarily equal "pleasure."

Rob Stein: good point.

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Rob Stein: Well, we're just about out of time. Thanks to everyone for your provocative questions. Clearly, this is not a debate that is going to end soon. It will be interesting to see what ends up coming out of the CDC and American Academy of Pediatrics process.

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