Should Your Son Be Circumcised? (cont.)

The X-Factor? Finally -- and most intriguing of all -- circumcision may help unravel a medical mystery that has puzzled AIDS researchers for years. Having a foreskin just might be the elusive "X-factor" that explains, at least in part, the huge differences in HIV infection rates in otherwise similar regions. Why, for instance, is the infection rate in Thailand 40 times higher than in the nearby Philippines? In most important respects, both countries are quite similar: They have lots of STDs and prostitution, as well as a bias against condom use. But there is one big difference -- and some researchers think it may be key: In the Philippines, newborn circumcision is the rule. In Thailand, it is very rare.

A decade of research -- largely neglected by the media -- shows a powerful connection between circumcision and high rates of AIDS among heterosexuals, especially in Asia and Africa. In early June, the British Medical Journal published a review of more than 40 studies over the past 10 years, all of them demonstrating a close association between heterosexual HIV transmission and lack of circumcision. The journal Lancet published another similar study in May.

Why would circumcision affect HIV transmission? According to the authors of the British Medical Journal review, published in the June 10, 2000 issue, there are three key reasons. The foreskin is made of specialized tissue with a high concentration of Langerhans immune cells, which are entry portals for the transmission of HIV. Also, the delicate mucous membrane of the foreskin is much more likely to incur lesions during sex than is the rest of the penis. Finally, an intact foreskin increases the risk of contracting an STD like syphilis, which in turn can boost the chances of spreading HIV.

No one suggests that foreskins cause HIV infection, only that they may be an important factor in transmission. Obviously, most European men are not circumcised, and HIV is not raging across the continent, as it is in sub-Saharan Africa, where circumcision is also rare. That may be because it takes a combination of factors to create an explosive heterosexual AIDS epidemic, including poverty and chronically untreated STDs, according to Daniel Halperin, a medical anthropologist at the University of California at San Francisco (see the November 1999 issue of the Lancet).

An Agonizing Dilemma

So where does all this leave new parents who want to make the right decision? Probably quite confused and ambivalent, at least if you judge by one couple I met in the course of researching this article. Until very recently, Roger Hand and his wife, an El Cerrito, Calif., couple, were clear on their plans for their son, who is due to be born this month: They could see no compelling reason to have him circumcised. "We'd heard from a few people that doctors didn't recommend circumcision any more," Hand told me. "And I'd also heard that circumcision removes a lot of sensitive tissue and might decrease sexual pleasure. It just didn't seem necessary."

Then he and his wife began to hear about the new research. And suddenly, he says, they weren't so sure what to do. The couple followed press accounts from the AIDS conference last month in South Africa, where researchers highlighted circumcision as a potential means of slowing the epidemic. And they've become well aware of the higher risks faced by uncircumcised males.

"Those risks can be minimized by daily cleaning of the foreskin," says Hand, a computer programmer and musician. "But they can't be eliminated. And I can't be sure my son is going to clean himself every day, either. There were times in my life when I didn't bathe every day."

Still, Hand and his wife remain reluctant to put their son through such a painful and permanent procedure. "Now, sometimes we lean toward circumcision," Hand says. "Other times we lean away from it. We'll just have to wait till the baby's born till we decide for sure."

My wife and I opted against cutting our boys a few years ago -- and we're content with our decision -- I think. Still, I am anything but self-righteous about our choice. And if I had it to do over again? Well, let's just say I'm glad that I don't.

Gordy Slack is a freelance journalist specializing in science, health, and the environment. He is a contributing editor to California Wild, the science and natural history magazine published by the California Academy of Sciences.

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