Delicate choice just got tougher

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Times Staff Writer

Once a routine procedure for newborn boys, circumcision is falling rapidly out of favor in the United States -- even as growing evidence suggests that the surgery may reduce the transmission of HIV and other sexually transmitted diseases.

In recent years, many doctors and medical groups, including the influential American Academy of Pediatrics, have stopped recommending routine circumcisions because they believed there wasn’t enough evidence that it’s medically necessary.

More states also have been cutting Medicaid funding for circumcisions, which typically pays for about a third of all circumcisions each year. Sixteen states -- including California, Florida and Maine -- no longer cover the surgery. A number of private insurers also have stopped paying for the procedure.


As a result, overall circumcision rates in the U.S. have fallen to the lowest level in more than half a century, from 63.5% in 1993 to 55.9% in 2003, the last year for which federal data are available.

Removing the foreskin from the penis can’t prevent transmission of sexually transmitted diseases. The best prevention techniques remain reducing the number of sexual partners and using condoms.

But as new HIV cases remain at a stubborn 40,000 a year and infections continue to disproportionately affect minorities (especially minority women) and the poor, some prevention experts again have begun urging doctors to recommend circumcision for newborns. A small number are even advising uncircumcised adult men at high-risk for HIV to undergo the procedure.

In the first random trial on the topic, published this month in the Public Library of Science Medicine, researchers tracked for nearly two years more than 3,200 men in South Africa who were randomly assigned either to be circumcised or not. Only 20 men in the first group became infected whereas 49 in the second did. Researchers halted the experiment early because the results were so convincing.

Other, smaller studies done over the last several years strongly suggest that circumcision also protects against gonorrhea and syphilis. In 2003, a review of 2,000 men who visited an inner-city STD clinic during a one-year period found that uncircumcised men were as much as twice as likely to have either or both infections.

For parents of newborn boys, the question ultimately comes down to one question: Do they believe their child will ever be at high enough risk of contracting a sexually transmitted disease to warrant having him circumcised? For many the answer may be no, but for others it’s a clear possibility.


“Other than condoms and antiretroviral drugs that block transmission during childbirth, circumcision is the next best tool we have to [slow] infections,” said Dr. Thomas Coates, a professor of infectious diseases at UCLA’s David Geffen School of Medicine and a well-known HIV prevention expert.

Although circumcision is not routine in most countries, the procedure to remove the foreskin from the penis has been popular here since the late 19th century. At that time, a number of well-known physicians and religious activists said the surgery promoted hygiene and was a possible cure for sexual “perversions.” By the 1960s, nearly 9 of 10 U.S. boys were circumcised.

Nonetheless, it’s unclear just what medical benefit circumcision brings. There’s evidence that it helps reduce urinary tract infections in infants and penile cancer in adults, but both conditions are relatively rare. There also have been numerous studies in recent decades on the role circumcision plays in STD transmission, but they were either too small or not rigorous enough to sway doctors that all young men should be circumcised.

The American Academy of Pediatrics declared circumcision an “elective” surgery more than a decade ago and has reiterated its position several times, including earlier this year. Dr. Alan Fleischman, a member of the American Academy of Pediatrics task force that makes recommendations on circumcisions, said the committee probably wouldn’t change its position.

The reason: Rates of HIV and other STDs remain relatively low in the U.S., making routine circumcisions for everyone in this country unnecessary. Still, said Fleischman, a clinical professor at Albert Einstein College of Medicine in New York, “parents have to assess their own situations and decide if they believe their child would be at risk and if this surgery is worthwhile.”

Kate Anthony of Los Feliz chose not to circumcise her newborn son, Emmett, this summer after her doctor recommended against it. Although she and her husband may have deliberated further if they’d known about the recent research, she says, they won’t reconsider their choice now. “I think we’re better off providing him with good sex education down the road,” she said.


Some researchers say they know why circumcision may help protect men from contracting some STDs. A 2002 study done at the University of Illinois at Chicago found a male’s foreskin is packed with cells that are highly susceptible to the HIV virus. They say the foreskin also traps fluids, allowing HIV and other pathogens more time to infect.

“One of the benefits [circumcision] has is that it is permanent and protects every time,” said Robert Bailey, professor of epidemiology at University of Illinois at Chicago and the lead researcher on the 2002 study.

Coates, of UCLA, is most concerned that reduced Medicaid funding for the procedure could lead to even greater HIV and other STD rates among minorities and the poor, who already have disproportionately higher infection rates. In some communities, rates are as high as 30% in some populations, such as gay African American men.

Said Coates: “When these children grow up, and start having sex, we are guaranteeing they will be at a greater risk. Why would we want to do that?”