The Centers for Disease Control and Prevention caused quite a stir last week when word slipped out that the agency was considering, for the first time, making public health recommendations concerning circumcision. In terms of a woman's health, circumcision makes sense because it lowers a man's risk of getting infected with HIV and other sexually transmitted diseases and, thus, decreases his likelihood of transmitting them to his female partner. That's probably why the editorial board of the San Francisco Chronicle has come out supporting recommendations, expected to be issued by the CDC next year, in favor of circumcision to "curb the spread of HIV and other infections." But those vehemently opposed to circumcision—who call themselves "intactivists"—have expressed outrage that the government is thinking about recommending that all newborn boys be circumcised. They contend it's a form of mutilation that destroys a man's ability to fully experience sexual pleasure.
I'm wondering why the CDC is choosing to tackle this controversial cultural issue at this particular time, when Americans' tempers are already flaring over healthcare reform, and rumors of so-called death panels that will determine whether you live or die just won't go away even though there's no mention of them in the legislation. There's just as much potential here for the spreading of misinformation. Case in point: One headline today reads "CDC Proposing Manditory [sic] Circumcision for Newborn Babies."
That, of course, is a far cry from the truth. As the CDC's Web site states, the "final circumcision recommendations will be completely voluntary." The agency says it hasn't decided yet on the final content of the recommendations and whether they will actually include wording that recommends the procedure for all newborns or merely recommends that doctors educate parents about the potential benefits and risks to help them make an informed decision. The CDC may also make special recommendations for adult men who are at high risk of contracting HIV due to having a female partner who's infected and for men who have sex with other men.
At the moment, the agency hasn't decided what to recommend or whether to issue any recommendations at all. CDC officials are reviewing the latest studies from Africa showing reduced rates of HIV infections in men who were circumcised as adults. These studies also found that circumcised men were less likely to become infected with the herpes virus and the human papillomavirus (HPV), which can cause cervical cancer in women. From this, many experts have drawn the conclusion that circumcised men are less likely to spread certain sexually transmitted diseases to women. Hence, some say, circumcision should be advocated in newborns as part of a public health campaign.
I think, though, that this issue is actually far more complex. Circumcision is not just a medical procedure but a religious and cultural one. Judaism prescribes it on the eighth day after birth, while in Islam, boys may be circumcised anytime from birth to puberty. As a cultural issue, most Americans have come to accept it as the norm (although it's less popular today than it was 20 years ago). Europeans, on the other hand, have never embraced it. In the Philippines, two thirds of teenage boys who responded to a recent survey said that they were choosing to get circumcised to avoid being different than their peers, according to this United Nations Web site. Same, too, in South Korea. The intactivists, who are growing in number, say that the procedure is barbaric and akin to genital mutilation in females.
In terms of the science, it's not clear how much circumcision will protect American men from being infected with HIV, where the virus is largely transmitted through homosexual contact. The studies involving African men suggest that it lessens the likelihood of infection through heterosexual intercourse, but research isn't clear as to whether it protects men from being infected by other men. Other research has shown that circumcised men already infected with HIV are just as likely to transmit the infection to women as uncircumcised men. And that leads to the larger potential pitfall of a public policy advocating circumcision: Men may mistakenly think that if they're circumcised, they're protected from sexually transmitted diseases and don't need to wear condoms—clearly not the message that the CDC wants to transmit. Even now, with all the publicity the African studies have received, I think many women wrongly believe they don't need to push a circumcised partner to use prophylactics.
Certainly, the debate isn't about mandatory snipping in the hospital cradle or whether circumcision will solve the AIDS crisis. But I do think CDC folks will have to evaluate the latest research carefully before deciding to take a cultural practice and turn it into a public health mission.