A man lies on his back during a circumcision operation.
By Mark Roth Pittsburgh Post-Gazette
In the last 50 years, circumcision in America has been on a steady decline, and is now done on only 55 percent of baby boys.
But that may change if two major health groups adopt new recommendations based on striking results from African studies that show circumcised men are much less likely to get HIV.
The Centers for Disease Control and Prevention and the American Academy of Pediatrics are both considering whether to strengthen their recommendations on circumcision because of the HIV results.
The CDC plans to come out with a new policy by the end of the year, and the pediatrics group says it will weigh in on the topic sometime next year.
Yet changes in the recommendations are far from a done deal, and circumcision remains a controversial and complicated issue.
Special interest groups that campaign against the practice continue to call it "genital mutilation," and many doctors think the HIV epidemic in America is different enough from Africa's to raise questions about the value of circumcision as an AIDS prevention measure here.
Both groups say their recommendations will be voluntary guidelines. But if they make a stronger case for circumcision, it could have real-world impact.
Right now, for instance, 16 state Medicaid programs and several private insurers do not cover the costs of circumcision, based largely on the current American Academy of Pediatrics position, which says that the procedure has only minor benefits. Pennsylvania does cover the cost and at least in the Pittsburgh region, up to 80 percent of boys are circumcised.
If the academy upgrades the value of circumcision, it could expand Medicaid coverage, which would pay for circumcision in groups that tend to have lower rates, such as Hispanics.
Dr. Ronald Gray, a public health specialist who led one of the major African studies, and Dr. Mark Alanis, an obstetrics-gynecology professor who has written a history of circumcision in America, represent the two poles of the medical debate.
Dr. Gray's 2007 study in Rakai, Uganda, showed that 2,500 men who voluntarily underwent circumcision had less than half the HIV infection rate that a similar group of uncircumcised men did. The men in the study were so impressed by the results that about 80 percent of them ended up getting circumcised, said Dr. Gray, the Robertson professor of reproductive epidemiology at Johns Hopkins University in Baltimore.
Noting that current U.S. policies say there is not enough medical evidence to recommend circumcision routinely, Dr. Gray said "the evidence has changed substantially just in the last few years and that [policy] really can't hold when you take into account lifetime potential benefits."
But Dr. Alanis, who is based at the Medical College of South Carolina in Charleston, S.C., said that the HIV epidemic in America has several key differences from the one in Africa.
HIV is much less prevalent in America, he said, which means you would have to circumcise many more infants to prevent one case of HIV than you would in Africa.
"Prevalence is everything" in trying to figure out if the costs of routine circumcision would be worth the benefits in HIV prevention, he said. For those who say the policy should change, "I say, show me the data that this would be an important measure in preventing HIV prevalence."
Others point out that the primary benefit for circumcised men in Africa was to protect them from getting HIV from infected women.
In America, though, more than half of all new infections come from male-to-male sex, where circumcision doesn't seem to help as much, and many more come from intravenous drug use. The African studies also show that circumcision doesn't prevent women from getting HIV from infected males.
If circumcision undergoes a resurgence in America, it will only be the latest fluctuation in a practice that was once exceedingly rare.
Circumcision was hard to find in America until the late 1800s, Dr. Alanis said, and mostly existed among Jews. Then, doctors of wealthier patients began advocating it, making what he said were "ridiculous" claims that it could help prevent insanity, gout, epilepsy, paralysis and something called "reflux neurosis."
By the time the post-World War II baby boom generation came along, doctors often circumcised infants without even asking parents' permission.
In the last 50 years, that attitude has changed dramatically, and groups like NOCIRC -- the National Organization of Circumcision Resource Centers -- evolved to argue that circumcision was not only unnecessary, but a harmful civil rights violation.
Greg Hartley, a Franklin Park engineer who heads the local chapter of NOCIRC, became involved when he adopted a boy from Russia a decade ago and had to decide whether to circumcise him.
"When I found out what actually happens in a circumcision, I thought this was a complete violation of bodily integrity. I was lucky enough to save my son from an unwanted genital alteration. It's removal of healthy, functional erogenous tissue. Why not let him make the decision? It's his body and his right."
But surveys have not shown any evidence that circumcised men experience less sexual pleasure than uncircumcised men. In Uganda, Dr. Gray said that most men in the study reported just as much or greater sexual satisfaction after circumcision.
There are no clear signals on what either the CDC or the pediatrics academy will say about circumcision.
Dr. Peter Kilmarx, a CDC epidemiologist, told The New York Times recently that "we have a significant HIV epidemic in this country, and we really need to look carefully at any potential intervention that could be another tool in the toolbox we use to address this epidemic."
But last week, the CDC said its doctors would no longer comment on the issue, and issued a statement that "with respect to infant circumcision, it is important to recognize that many options are still being considered in this process, including simply recommending that health care providers educate parents about the potential benefits and risks to ensure that parents have the information they need to make an informed decision."
At the American Academy of Pediatrics, it is also too early to know what the academy will decide, said Dr. Douglas Diekema, a pediatrics professor at the University of Washington who is on the panel considering the policy.
But in the case of both the academy and the CDC, he said, the final recommendations are sure to be voluntary. "We still might not recommend routine circumcision," Dr. Diekema said, "but the ethical requirement is that parents get good, informed consent," and he already tells them about the HIV prevention benefits.
Dr. Harold Wiesenfeld, who performs circumcisions at Magee-Womens Hospital of UPMC, talks about HIV with parents here, too.
He also tells them that circumcision helps prevent urinary tract infections in baby boys and can help prevent some sexually transmitted diseases. He notes that there can be bleeding and infections after the surgery, which takes about five to 10 minutes, and, very rarely, damage to the penis that requires plastic surgery.
Dr. George Kaplan, a pediatric urology specialist at the University of California-San Diego who helped draft the current American Academy of Pediatrics policy, said he also tells parents a newer piece of information -- that circumcision can help prevent human papillomavirus infections, which could reduce cervical cancer cases in sexual partners as well as penile cancer.
Dr. Wiesenfeld also assures parents that doctors do everything they can to prevent pain during the procedure by using either an anesthetic cream or an injection. "By the time the circumcision is over, I can tell you the babies are usually consoled."
In the end, he said, most families make their decision based on cultural, religious and personal reasons -- not because of the health arguments. Or, as Dr. Alanis put it, "like father like son, which is the way it is all over America."
In the Pittsburgh region, that means that about eight out of every 10 parents Dr. Wiesenfeld meets decide in favor of circumcision, because that's the norm in their own families.
It also helps explain the low circumcision rates in California, Texas and other states with heavy Hispanic or Asian populations, which tend not to be circumcised.
In the end, the debate over circumcision might teeter between public health experts on the one hand and pediatricians and ob-gyn doctors on the other.
Dr. Donald Burke, dean of the University of Pittsburgh's Graduate School of Public Health and a world-renowned AIDS expert, said he favors making circumcision more common in the United States.
"Just protecting the males would be sufficient reason to recommend it, and whatever indirect effect there is on females [not getting HIV] would be of benefit, too," he said.
San Diego's Dr. Kaplan takes a more cautious view.
"Does circumcision convey some health benefits in and of itself? I think the answer is yes. The second question, which is harder, is, are those benefits of such magnitude that it's worth it from a public health standpoint encouraging everyone to be circumcised? In Africa, the answer is yes. In the United States, I'm not so sure."