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.

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12 Responses

  1. Jim Maloney says:

    Nice topic for a post-holidays/new year post! Jesus of Nazareth, the anniversary of whose birth is widely celebrated on December 25, would accordingly have been circumcised on his eighth post-natal day, January 1. (There’s an interesting Wikipedia page on the topic here.)

    And yesterday’s New York Times article by Clyde Haberman mentions that old favorite, the “Feast of the Circumcision of Jesus.”

  2. Hugh7 says:

    “…it is unclear whether a circumcised HIV-infected male is less likely to infect his healthy female partner.” Or rather, it is clear he is no less likely, and the study that found that (Lancet 374:9685, 229-37) started to show that he could be a lot MORE likely to, but they cut it short before that could be established (for “futility”, not for any ethical reason).

    What’s left out of this discussion is a growing concensus that non-therapeutic infant circumcision is unethical. The expressions “bodily integrity” and “genital autonomy” are entering the lexicon. As President Obama said, “”Part of what our core constitutional values promote is the notion that individuals are protected in their privacy and their
    bodily integrity…” If adults want to have any part of their own body cut off, that’s one issue, but babies have a right to be left alone until they’re old enough to decide such intimate things for themselves.

    Yes Jim, and one of those articles mentions an old tradition that Mary gave Jesus’ foreskin back to him after his resurrection and he put it back on – so foreskin restorers can celebrate Easter Monday as the Feast of the Restoration.

  3. Sarah, I think parents are better informed than ever on the topic and many are realizing that circumcision is just a fad, and that’s a big reason the rates are dropping. To many, it is “their parent’s body mod.” Many parents want gentle births and circumcision trauma doesn’t work for them.

    If you want to support children’s rights to bodily integrity, check out Intact America.

    If you are considering circumcision, visit Circumcision Decision-Maker.

  4. Vernon says:

    Transmission of HIV during heterosexual intercourse is the fastest growing method of infection of one partner by another. That this is currently an insignificant proportion of all HIV infections in the USA is due entirely to the fact that the majority of American males are circumcised.

    Should the current slight trend towards leaving baby boys uncircumcised continue, or worse still increase, then there will be an explosion of heterosexually acquired HIV in around 20 years time. This is a biological time bomb that will hit insurers with a vengeance as a reprisal for their short-sightedness and penny pinching today.

    But the protection that circumcision provides is not confined to HIV (although that is the high profile STI that grabs the headlines) but embraces several others, the most important (especially to the female partner) is HPV – human papiloma virus – a major cause of cervical cancer. There are around a dozen strains of this virus, all of which cause genital warts and can cause cancer. The HPV vaccines currently being offered to teenage girls protects against only three of all these strains. It is also several times more costly to provide per girl than infant circumcision is per boy.

    Infant circumcision is a highly cost effective procedure affording the male a lifetime of high-level protection against HIV, HPV and several other STIs; a 10-fold reduction in the risk of infant UTIs; almost zero risk of penile cancer and total protection against phimosis, paraphimosis and balanoposthitis.

    Circumcision of infant boys is no different in ethical terms from injecting them with ‘poisons’ by immunisation – both are without the actual consent of the boy concerned and both significantly modify the body, it’s just that we cannot see the modifications made to the immune system.

    The ‘official’ figures for circumcision rates not only don’t show religious circumcisions performed after hospital discharge but also do not include any of the vast number of circumcisions performed in doctors’ offices, etc a few weeks after birth. This is a growing trend partly as a backlash against the ‘conveyor belt’ circumcision practices of some large maternity units but mainly since mother and baby are discharged from hospital so fast that there is no time to perform the circumcision at a sensible time after the birth.

    Today’s parents have mainly got past the ‘so he looks like his father’ phase and know that circumcision is highly beneficial for their son and his future partners. The vast majority of baby boys are still being circumcised, and this will continue despite folk like Hugh and Dan, so a circumcised boy will still match his peers – and long may they continue to do so for everyone’s health’s sake.

  5. Jimbino says:

    Vernon attributes the low rate of HIV in Amerika to the fact that most boys are circumcised. If so, I’d like him to explain the low rates of HIV in Scandanavia, Germany and most all the other European countries where circumcision is not common or is even illegal.

    Cutting off a sensitive body part for a small putative gain against infection is craziness to me. It’s like cutting off the balls and pecker to avoid unwanted pregnancy and risk of syphilis, gonorrhea, etc. Totally nuts.

  6. Jimbino says:

    Vernon really has to explain why it is that Japan has about the lowest rates of male circumcision and of HIV infection in the world?

    Apparently, South Africa and Australia have banned routine male circumcision. When I asked my father why I wasn’t circumcised, he merely responded that he wasn’t either and passed on the advice his mother gave him, “Son, you’ll just have to wear it off.”

    Many years later, I realize that foreskin is made of some really tough stuff.

  7. There are too many normal, healthy, intact boys in the USA today for people to begin believing myths about circumcision again. We are finally catching up with the other English-speaking countries where circumcision was adopted as a way to prevent masturbation. It didn’t work, nor has it worked to prevent any of the other excuses so widely promoted to perpetuate a cosmetic surgery on non-consenting minors. Now, the medical community had better recognize people are becoming more and more skeptical and less and less trusting of healthcare providers who promote a surgery most of the world has never even considered, especially when that unnecessary practice is a billion-dollar-a-year industry. Soon, the first wave of intact males will be our next doctors, lawyers, judges, and jurors. Times they are a changing…

  8. J James says:

    I completely agree circumcision is best. I waited until I was 26 before taking the plunge and have never regretted the decision to get circumcised. Who can even consider denying their sons the benefits of being circumcised? It is time the medical profession took account of the evidence of the benefits that follow from circumcision and strongly advocated it to all forthcoming parents. It should also be made easier for those unfortunate enough to still retain their foreskin to find a list of circumcisers so they can take action and obtain the benefits as quickly as possible

  9. cutmark says:

    In the Nortwest USA, most infant circumcisions are performed in the doctors office later after release from the hospital. Hospitals here are sending the mothers home very shortly after giving birth, many times after 24 hours. This is too soon for the boys system to be ready for circumcision. The national stastics do not include the circumcisions performed in doctors offices. To the best I can determine, talking to parents, the circumcision rate is still very high.

  10. myrick says:

    I thoroughly agree that we have no idea of the circumcision rate in recent American birth cohorts, because of dramatic rise in outpatient circs performed by pediatricians in their offices.

    If the natural penis were unhealthy, data from Europe and Japan would be very revealving in this regard. I discovered the intactivist position when I read Wallerstein (1980) and Romberg (1985) in the 1980s. Ever since, I have waited for a comparative study of data from urological pratices in circumcising and non-circumcising societies. I am still waiting.

    Advocates of circumcision such as Vernon above (who is the voice of Brian Morris of Australia) overlook the damage the practice can do to sexual pleasure and functionality. American medical and sexual research has been honest about only one aspect of this damage: meatal stenosis. Because it is hard to quantify sexual pleasure, it is easy to deceive ourselves into thinking that circumcision has no effect on sexual satisfaction, and that intactivism is a merely “emotional” stance. But this is an example of the scientistic and reductionist fallacy.

    The CDC and AAP know perfectly well that heterosexual AIDS is strongly correlated with socioeconomic deprivation. Hence there is no need to circumcise boys born into middle class families. But to advocate circumcision only for boys born to deprived mothers would seem racist. So the official stance is one of proposing to recommend routine circumcision for all boys. I am quite confident that the Powers that Be concede privately that circumcising the sons of crunchy and well-educated mothers is a lost cause. Such mothers will be grudginly allowed to keep their sons intact. But socioeconomically deprived mothers will get their arms twisted by hospital staff. A key factor here is that such mothers cannot afford to be out of pocket, and seldom have medical insurance. Medicaid covers the cost of parturition in the bottom quarter. I submit that the true but unacknowledged goal of the CDC-AAP is to overturn the bans in 18 states on Medicaid coverage of routine circ.

  11. John says:

    I think it is misleading to assume that HIV can be greatly reduced by circumcision. Most European men are not circumcised and they have low incidence of HIV. Responsible, safe sex along with knowing the risk factors and taking responsibility for your own actions will control HIV. It is totally wrong to circumcise infant males and I am so glad we are finally limiting this barbaric, neanderthal act.