Should Infant Male Circumcision be Mandatory?

The Centers for Disease Control and Prevention is reportedly considering mandatory circumcision for all male infants born in the United States, as some studies show that uncircumcised males have a much higher rate of HIV infection than those who are circumcised. Advocates of mandatory circumcision believe this step will significantly reduce the incidence of HIV and subsequently, AIDS.

Circumcision is a surgical procedure in which the foreskin, a hood of skin that covers the head of the penis, is removed. The procedure is typically performed within the first ten days of birth. Circumcision that is performed later in life is a more complicated event.

Reasons parents choose to circumcise their sons include religious beliefs, concerns about hygiene, and cultural or social reasons. Hispanics, blacks, and foreign-born Americans are less likely to undergo circumcision than white Americans. For both Jews and Muslims, male circumcision is deeply ingrained in religious tradition.

According to the National Hospital Discharge Survey, which is produced by the National Center for Health Statistics (an agency of the Centers for Disease Control and Prevention), the overall rate of circumcision in the United States in 1994 was 62.7 percent and 56.1 percent in 2006. The western region has consistently shown the lowest rates, while the north central states have the highest.

Concerns about hygiene and disease transmission are the reasons being raised in the current debate; specifically, transmission of HIV, as some observational studies have reported an association between male circumcision and a reduced risk of HIV infection in female sex partners. In a study conducted by Johns Hopkins University in Uganda and recently published in Lancet (July 2009), researchers did not find this to be true, however. Circumcision of HIV-infected men did not reduce HIV transmission to female partners over a two-year period.

Other studies, however, have focused on whether African heterosexual men were less likely to acquire HIV after circumcision, but did not investigate whether they were more likely to transmit the virus to women. Most studies have also concentrated on heterosexual transmission of HIV in African men, but in the United States the higher risk is among men having sex with men.

Currently, the American Academy of Pediatrics and the American Academy of Family Physicians do not endorse circumcision as a way to prevent sexually transmitted diseases, urinary tract infections, penile cancer, or various inflammatory conditions that affect the penis. The procedure is considered to be neither essential nor detrimental of a male’s health. Rather than make male circumcision mandatory, a better route may be to present parents with information about the pros and cons of the procedure, including what researchers know and don’t know about the transmission of HIV related to circumcision, and let parents make up their own minds.

SOURCES:
American Academy of Family Physicians
American Academy of Pediatrics
National Hospital Discharge Survey
New York Times, August 29, 2009
Siegfried N et al. Cochrane Database of Systematic Reviews 2009 Apr 15(2):CD003362
Wawer MJ et al. Lancet 2009 Jul 18; 374(9685): 229-37