Male Circumcision in 2011
The first few months of 2011 will be interesting for those who care about male circumcision rates in the United States. The American Academy of Pediatrics (AAP), which is currently neutral on the question of whether to circumcise, is expected to issue a new policy statement that will be more encouraging about the medical benefits of the procedure. Reports have also been circulating for some time that the Centers for Disease Control and Prevention (CDC) will issue recommendations promoting routine infant male circumcision as a means of reducing the spread of HIV.
On the medical front, new data about HIV is the big development since the AAP last affirmed its neutral stance in 2005. Studies from Africa have found that circumcision reduces the risk of a man becoming infected from an HIV-positive female partner and the evidence on this front is strong enough that the World Health Organization has deemed circumcision “an important intervention to reduce the risk of heterosexually acquired HIV.” It is not clear, however, what impact circumcision has on HIV rates in the United States, because the health systems are vastly different and the disease spreads through different routes here than in Africa. Most significantly, there is little to no evidence that circumcision protects men who have sex with HIV-infected men and it is unclear whether a circumcised HIV-infected male is less likely to infect his healthy female partner.
But let’s assume that the CDC issues its long-anticipated recommendations and that the AAP’s policy says that the medical benefits of male circumcision outweigh its risks. What I wonder is whether these official statements will make much of a practical difference, particularly in the short term.
Male circumcision rates are on the decline in the United States; one set of data suggests that fewer than half of all boys born in hospitals from 2006 – 2009 were circumcised. (The data does not account for boys who were circumcised outside hospitals in religious ceremonies.) Although this particular data set is still being analyzed and is therefore not definitive, the CDC confirms that circumcision rates declined during the last decade. Several reasons are commonly advanced to explain the decline: (1) some Medicaid and private insurers stopped covering the procedure after the AAP moved to its neutral position; (2) the United States has a growing Hispanic population that does not share a tradition of routine circumcision; (3) the message from anti-circumcision advocates has resonated with those parents who believe across a range of issues that “natural” signals “good.” (On this note, I’ve heard stories from different parts of the country about seeing bumper stickers that say, “Babies are born perfect. Say no to circumcision.”)
I’ve written a lot on this blog about how routine (non-religious) infant male circumcision is a cultural practice, not a medical one. Not surprisingly, then, it is also a practice where what others have done and are doing matter a great deal. Surveys of parents deciding whether to routinely circumcise show that two considerations loom largest: whether the boy’s father is circumcised and whether the parents anticipate that the boy’s peers will be circumcised. If in fact less than half of boys were routinely circumcised in the latter part of this decade, then a generation from now looking like one’s father is likely to mean that a child is uncircumcised, not circumcised. Moreover, today (particularly in the Pacific Northwest), if you want a boy to look like his peers, the safest bet may be not to circumcise.
I’m not suggesting that the trend can’t tip back in favor of routine circumcision or that non-circumcision advocates shouldn’t hope that the AAP remains neutral. But what health officials say about circumcision is only one piece of the puzzle. As such, recommendations from the AAP or the CDC are unlikely to have an immediate and dramatic effect on the trend towards non-circumcision, particularly if the statements are nuanced enough to convey the complexity of the data on the relationship between circumcision and HIV risk. What should worry non-circumcision advocates the most is that an increasing number of insurers may cover the procedure if the AAP and CDC change their positions. If lack of coverage has in fact contributed to the trend toward non-circumcision, a change in coverage may lead to slow reversal in favor of circumcision.