Aug. 21, 2000 -- In the 1960s, when I was born, cutting the foreskin of a newborn American boy was about as routine as cutting his umbilical cord. I didn't really think much about circumcision until I was faced with the prospect of having it done to my own son. After the amazing ordeal of his birth, my wife and I agreed that the last thing we wanted was to send him into surgery to have the end of his penis cut off. A nurse bolstered our sentiments, telling us -- wrongly, it turns out -- that there was really no medical advantage to being circumcised. Without a compelling medical or religious reason, we felt, why would we choose to have this done to our son?
Today, a growing number of people are looking at the issue as my wife and I did. While two-thirds of Americans still choose to have their sons circumcised, according to 1997 data from the National Center for Health Statistics, there is a strong counter-trend among people like us: educated, middle-class folks in sophisticated urban areas like San Francisco and New York. For these people, amputating the healthy erogenous tissue of newborns who have no say in the matter seems unfair and unnecessary. Indeed, in recent years, some activists have turned their opposition to circumcision into a crusade for the human rights -- and future sexual pleasure -- of infant boys.
Opponents of circumcision have long argued that there was little justification for routinely inflicting the procedure on newborn boys; the purported medical benefits, they contended, were either so unproven or so minor that they amounted to little more than poor excuses for perpetuating an outdated practice. And the medical establishment hasn't been a big help, either. The American Academy of Pediatrics, for example, has recently changed its position so that it no longer takes a stand on circumcision.
But an interesting thing has happened in the last decade: Quietly, and with little fanfare, a body of research has emerged suggesting that there may be some compelling medical reasons after all. Circumcised boys, the new research has found, seem to be at lower risk for a number of infections and diseases. For those who have been influenced by the arguments of the anti-circumcision movement, this new information creates an agonizing dilemma: Should they cut and join the brutal status quo, or leave their sons' foreskins intact, perhaps exposing them to avoidable diseases?
A Link That Couldn't Be Denied
The first evidence that uncircumcised boys may have a higher risk of avoidable diseases began to emerge in 1987. At the time, Tom Wiswell, MD, a neonatologist then at Walter Reed Army Medical Center in Washington, D.C., was an outspoken critic of circumcision. When a report from Texas came across his desk, suggesting a high rate of urinary-tract infections (UTIs) among uncircumcised boys in the first year of life, Wiswell set out to shoot the foreskin explanation down. He employed the Army's huge database of 200,000 boys to see if there was any association between circumcision and UTIs in the first year of life. To Wiswell's surprise, his study, published in the July 1986 issue of the journal Pediatrics, showed uncircumcised boys to be far more likely to have UTIs than their circumcised counterparts. He looked at the data every way he could. The association was undeniable.
In the 14 years since Wiswell's study, at least nine others have confirmed the connection between UTIs and circumcision. Taken together, the studies suggest that an uncircumcised boy is 10 times more likely than a circumcised one to contract such an infection in his first year of life. Other research suggests that possible kidney scarring caused by these early infections could also increase the risk of severe kidney problems and high blood pressure later in life, according to Edgar Schoen, MD, a researcher and clinician at Oakland, California's Kaiser Permanente Medical Center.
But the risks don't end with UTIs. Sexually transmitted diseases (STDs) like genital herpes and syphilis also seem to strike uncircumcised men more frequently than those without foreskins, according to numerous studies.
And then there's invasive penile cancer, an agonizing disease that often leads to amputation and death. In the United States, about 1,300 men a year are diagnosed with the condition, and virtually all of them are uncircumcised (see the March 2000 issue of Pediatrics). And it is far more common in Europe and in parts of the developing world where circumcision is less common.
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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