Circumcision Debate Cuts Deep
Each year, at least 1.2 million American infants lose their foreskin—that retractable fold of skin and mucous membrane that covers the end of the penis—to a doctor's scalpel. Though circumcision is one of the most commonly performed procedures in the country, it's also among the most controversial. That particular patch of skin happens to lie at the intersection of conflicting notions about personal hygiene, sexually transmitted diseases, masculinity, sexuality, and religion.
Controversy over the foreskin's role in sexuality recently flared anew. A study published last week in the Journal of Sexual Medicine suggests that circumcision, contrary to popular belief, does not reduce the sensitivity of the penis. It follows on the heels of another study, sponsored by critics of circumcision and published in the urology journal BJU International in April, that reached the opposite conclusion.
Against this backdrop, the medical community is digesting research from recent trials in Africa that show circumcision can cut the risk of HIV transmission from infected women to uninfected men by as much as 60 percent. Other research has linked circumcision to slightly reduced risk of certain other infections, including human papillomavirus, which causes cervical cancer. Recent findings have prompted the American Academy of Pediatricians, an influential medical organization that represents some 60,000 doctors, to re-evaluate its policy on circumcision. The revised policy, expected within a year, could affect the availability of funding to cover the controversial operation.
The pediatrics group's existing position states that scientific evidence demonstrates potential benefits as well as drawbacks to circumcision but that those benefits are not sufficient to recommend routine circumcision. Since 1999, when the AAP adopted that stance, Medicaid programs in 16 states have stopped covering the procedure. In 2006, two states—Hawaii and Vermont—introduced resolutions questioning the need for public funding of male circumcision. Western states, which have long had lower rates of circumcision than other parts of the country, have been especially apt to drop coverage, which may have hastened the plunging rate of circumcision there: Only 32 percent of newborns are circumcised in the western United States, in comparison with 80 percent in the Midwest and 57 percent nationally, one study found.
Jewish and Muslim people have practiced circumcision for millennia, and many consider it an essential ritual. But various groups oppose the practice. "A child has a right to his own body. That's the bottom line," says Marilyn Milos, the founder of the National Organization of Circumcision Information Resource Centers, a nonprofit "intactivist" organization that maintains circumcision is an unnecessary procedure and not unlike female circumcision.
"Sorting through this has turned out to be a bit more time consuming than we may have initially thought," says AAP President Jay Berkelhamer. "The thing that makes this a difficult issue is that it's not just science. There is a level of emotion and passion on both sides of this issue."
Beyond the ethical realm, scientists are also debating the relevance of the evidence from Africa to the American context. "You have to be careful about taking data done in one environment and extrapolating them to another," says Patrick Sullivan, a branch chief in the Division of HIV/AIDS Prevention at the Centers for Disease Control and Prevention. He and other scientists emphasize that the AIDS epidemics in Africa and the epidemic in America are two very different beasts: While heterosexual sex accounts for the majority of transmission in Africa, men having sex with men drives transmission here. Scientists have not yet determined whether circumcision would reduce the latter mode of transmission, though some evidence suggests it may. His bottom line: Even people at high risk of contracting HIV shouldn't necessarily race out and get either themselves or their children circumcised.
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