J.H. Kellogg, cereal mogul, believed circumcision was a sure-fire cure for masturbation—particularly if the surgery was performed without chloroform so the boy could feel it. In the 1870s, his and similar views on male sexuality and hygiene set scalpels slicing across the United States, where the practice had previously been uncommon.
Today, few countries circumcise their infant males with the same alacrity as the U.S.: About 56 percent of newborn American males undergo the surgery, compared to 31 percent in Canada, 10 to 20 percent in Australia, and even lower rates in New Zealand, the United Kingdom and other European countries. (Places where circumcision has been a religious custom for ages—including Israel, as well as predominantly Muslim countries such as Indonesia, Iran and Iraq—all have nearly 100 percent rates for the surgery.)
Yet circumcision is becoming less common in the U.S., and particularly in Washington state, where fewer than one-quarter of newborn males are now circumcised. While those who oppose the practice as unnecessary or cruel welcome the trend, some local health authorities aren’t so sure we should cut out the cutting altogether.
One reason for our state’s lowered rates may be that here, as in more than a dozen other states, including Oregon and California, Medicaid does not cover the cost of the surgery for low-income citizens. (Some local private health insurance companies do cover it, depending on the policy.) Medicaid recipients who want the procedure for their sons must pay out of pocket, a cost of several hundred dollars. That’s because current American Association of Pediatrics (AAP) and Centers for Disease Control and Prevention (CDC) guidelines state that the data are not sufficient to recommend routine circumcision, though they acknowledge potential medical benefits in the practice.
But that may change. New AAP and CDC guidelines (release date unknown at press time) are being re-evaluated with an eye on several studies that have shown that circumcision may lower the incidence of HIV infection in heterosexual males. Three randomized control trials in sub-Saharan Africa in the mid-2000s showed that circumcised heterosexual adult males had about a 60 percent lower incidence of HIV infection than study participants who had not been circumcised. There was also a one-third decrease in human papillomavirus (HPV) and herpes. No randomized control trials have been performed in the U.S., but an analysis in Baltimore of the visit records of heterosexual African-American males who underwent HIV testing from 1993 to 2000 concluded that circumcision was associated with a lowered risk of HIV infection.
Matthew Golden, director of the Public Health Seattle/King County HIV/STD Program and an associate professor of medicine at the UW Center for AIDS & STD, speculates that updated AAP and CDC guidelines are likely to advise that parents and guardians should have routine access to information about the risks and benefits of neonatal circumcision, and that “insurance status should not be a barrier.” The latter change in wording could push states like Washington toward covering the surgery under Medicaid.
“I think that’s a very reasonable position,” says Golden. “The best way to think of this is as a partially effective vaccine for preventing heterosexual HIV contraction in men.” Golden says removing the foreskin reduces transmission to the penis in part because the type of cell that is on the inside of the foreskin is “more susceptible to infection” than that on the head of the penis. Since the bulk of the studies have been in sub-Saharan Africa, some have argued that better access to clean water and hygiene in the U.S. may mean those data don’t apply here, but Golden says such theories don’t wash. “I am not aware that resources like clean water and soap have any impact on HIV transmission,” he says. “To me, it is much more likely that the biology of heterosexual HIV transmission is largely the same in the U.S. and Africa.” Golden does not advise circumcision as a means to protect female partners against HPV, saying the best protection for that is the readily available vaccine for women. And he reiterates that the U.S. data don’t suggest circumcision will protect gay men, the group in the U.S. at greatest risk of contracting HIV.
Golden sees medical coverage as an ethical issue, because another group at increased risk for HIV in the United States is likely to be unable to afford the procedure. “We have a huge disparity in HIV rates—in the U.S., the population which has the greatest risk of heterosexual HIV acquisition is African-American, and they are also disproportionately low income and thus insured by Medicaid. Are any of us comfortable with the idea that the population that is disproportionately at risk and disadvantaged are going to be exactly the people who can’t get the procedure that would potentially benefit their children? I am profoundly uncomfortable with that.”
However, others are outraged by the idea that circumcision might be encouraged, including John Geisheker, executive director and general counsel for one of the country’s most active anti-circumcision groups, the Seattle-based Doctors Opposing Circumcision (DOC). “A kid whose parents are too poor to afford a circumcision has been done a service entirely by accident,” says Geisheker. DOC believes the risks and harm of performing circumcision on an infant grossly outweigh any possible benefit. (According to the medical database Up to Date—a primary resource for medical professionals—the rate of procedure-related complications in the U.S. during and after infant male circumcision is approximately two to five per 1,000 cases. Usually, these complications are readily treatable, but uncommonly can be life threatening or fatal.)
“Amputating healthy tissue from infants to address an adult behavioral problem is not ethical,” says Geisheker. Further, DOC suggests that focusing on circumcision as HIV prevention provides a disincentive to use condoms, as those circumcised may feel overly protected and thus more inclined to engage in behavior that puts them at risk of contracting HIV. The group says health departments should instead pour money into sex education. “It’s an elective surgery and shouldn’t be done on someone under the age of consent,” Geisheker adds.
David Bolnick disagrees. One of 10 local mohels (observant Jews who have studied Jewish law and custom and also the physiology and pathology of the penis) who perform the bris milah, a Jewish circumcision ceremony, Bolnick is also the co-author and editor of a forthcoming medical textbook tentatively titled Surgical Guide to Circumcision. “Mutilation—it’s in the eye of the beholder,” he says. “From the beginning of time, humans have been modifying the body with makeup, piercings, tattoos, plastic surgery—circumcision is just another form of reshaping the body to suit culture and religious tradition.” Further, he says the custom is a “crucial aspect of Jewish identity.” At the bris milah, family and friends gather reverently to celebrate a 4,000-year-old tradition. “It is a way of binding people together ceremonially, physically and spiritually,” he says, and is a sign of the covenant between Jewish people and God. “It’s a reminder of the obligations incumbent upon Jewish people,” he says. “Some rabbis joke that men need more reminding than women.” A rare modern alternative to the ceremony called the brit shalom replaces the bris with a gathering where no cutting takes place. Bolnick says that doesn’t make the child any less Jewish, but such ceremonies are not “fulfilling their obligation to the covenant.” Male circumcision is also a regular part of most Muslim societies—including in Muslim communities here in the Northwest—but it is performed by health care providers.
While decisions by individual families take place mostly behind closed doors, the job of Seattle educator Amy Lang, who coaches parents in how to talk to their children about bodies and sex, remains complicated by conflicting opinions on the practice. Lang, who is not in favor of circumcision, has searched for the proper words to offer parents if boys ask why their fathers’ (or friends’) penises do not look like their own (a concern some parents cite as the reason they decided on circumcision). She suggests that circumcised fathers talking with uncircumcised sons should say, “Here’s the deal. The foreskin of my penis was cut off. Some do it for religious reasons; some think it’s healthier. In our family, we believe that the way your penis is now is the way it should be.”
Will a change in wording—or funding—really make a difference in local circumcision rates? Seattle doctor Charles Mayer, who has performed many circumcisions in the course of his work in family medicine, says even with health information provided, he believes most of the parents he sees finally base their choices more on culture and feelings than a weighing of health risks and benefits. “When it comes down to it,” he says, “most people make an emotional decision.” Which is how circumcision became common practice in the U.S. in the first place.