Circumcision and HIV
posted by Sarah Waldeck
Both The Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) are considering whether to recommend routine infant male circumcision as a means of reducing the spread of HIV. For me, the debate is a reminder of how the medical practice is deeply intertwined with societal norms. One example illustrates the point: American-born parents would dismiss as ridiculous (or worse) the suggestion that they cut off part of their infant daughter’s clitoris to help prevent HIV.
First, the science. Clinical trials in Africa have found that circumcision reduces a heterosexual man’s risk of contracting HIV from an infected female by up to 60 percent. It is unclear whether circumcision reduces the risk that a woman will contract HIV from an infected male and “little to no evidence” that it reduces the spread of HIV between homosexual male partners. But if circumcision reduces the overall prevalence of HIV among heterosexual males, that might ultimately lower the risk among other populations, particularly women. As for why circumcision status matters, most likely the foreskin tissue is more susceptible to HIV than other parts of the penis. (You can read more about the science here.)
Circumcision opponents argue that at most circumcision reduces risk. It does not prevent infection and no-one would suggest that circumcised males do not need condoms. They further argue that HIV spread patterns are different in the United States than in the parts of Africa where the studies were conducted; that American and African health systems are worlds apart; and that homosexual males are the individuals most at risk in the United States. They can also point to studies which challenge or contradict the finding that circumcision reduces the risk of a heterosexual male contracting HIV from an infected female. At present, however, opponents of circumcision appear to be losing the medical battle.
All of this must be terribly frustrating for those who advocate non-circumcision. First, they are well aware of the American medical establishment’s history of promoting circumcision as a means of combating a variety of conditions (my own favorites are the Victorian examples of bowleggedness and masturbation). Second, in recent decades circumcision opponents have achieved some partial victories. The current AAP recommendations are neutral on the question whether to circumcise infant males . The national circumcision rate has fallen to less than 65 percent from a high of more than 80 percent, with rates far below 50 percent in a few Western states. The cumulative result of many different policies that have the effect of discouraging circumcision—most notably, the refusal of many insurance companies to pay for the procedure—meant that non-circumcision may have been creeping, slowly, toward a tipping point. Indeed, this post originally had a sentence about how a woman of my demographic (white, Midwestern) was statistically unlikely to ever have seen an uncircumcised penis. But then I realized that I have seen some in recent years, in the locker room at my gym where many mothers dress their young sons.
The conundrum for advocates of non-circumcision is that it is possible to acknowledge that circumcision reduces the risk of HIV infection, but still argue that the procedure should not be routinely performed on all infants. But this argument is a non-starter unless the listener is really willing to consider that infant circumcision is painful and traumatic, that it changes the male sexual experience, and that there is always a chance, however remote, that the physician will botch the procedure. In a country where more than 60 percent of infant males are still routinely circumcised, our inclination is to dismiss these arguments. If legitimate, then what have we been doing to our children?
As I have written about elsewhere, parents who are deciding whether to circumcise care more about the social aspects of the practice than about its medical effects. The circumcision status of other males in the infant’s family matters a lot to American parents, as does whether boys in a locker room are likely to see circumcised or uncircumcised penises. Circumcision opponents should be fearful of what the CDC and AAP is likely to recommend, but not simply because these organizations may promote circumcision. Rather, the medical recommendation will reinforce the still-prevailing societal norm. Some parents who are conflicted about the practice will ultimately decide to circumcise their boys because of the medical recommendation alone. But more are likely to consider the recommendation and predict that other parents will circumcise and thus that they should as well, lest their child be the odd man out. Meanwhile, parents who were inclined to circumcise will be even more steadfast about the medical correctness of their decision. All of this makes it extremely unlikely that the norm will tip in favor of non-circumcision.
August 25, 2009 at 8:09 pm
Posted in: Culture, Sociology of Law
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Responses (4)
Scote - August 25, 2009 at 11:36 pm
” All of this makes it extremely unlikely that the norm will tip in favor of non-circumcision.”
Well, in America at least.
Good article. One wonders, though, if their are any other prophylactic pediatric excisions that can be justified on the basis that they might prevent harm to the child when he reaches adulthood. Perhaps prophylactic appendectomies? As it stands, circumcision does not benefit infants vis-a-vis AIDS even if circumcision may reduce STD’s sexually active adults–which may mean that circumcision falls outside the standard of care for pediatric surgery.
Paul - August 26, 2009 at 7:51 am
The more provincial Americans will most likely still opt for circumcision while the sons of parents who have passports and/or higher education levels will not be circumcised. This is true for the most part already.
Hugh7 - August 28, 2009 at 3:37 am
I hope you’re wrong, I’m afraid you’re right, but remarkably many of the responses to the current flurry of (sometimes ridiculously) pro-circ articles are pointing out their flaws. Maybe they’re just another self-selected sample and circumcising parents are not the blog-responding type. Or maybe the zeitgeist really is shifting. I’m sure the concensus was much more pro-circ a few years ago.
I think the Internet is bringing the news to many people that circumcision is not universal world-wide, and in fact 7/10 of the world’s men, including many they admire, such as most football stars, are intact. And we are not filling hospital wards either with horrible diseases or heart-attacks brought on by excessive sensitivity.
roger desmoulins - January 26, 2011 at 11:59 am
I live in a culture where grandfathers are usually circumcised, fathers may or may not be, and sons never are, unless their ancestors were from certain Polynesian Islands or are Moslem. These facts, on display in every locker room, go completely unremarked, and have had zero impact on women’s magazines and off-colour commentary.
“…the debate is a reminder of how the medical practice is deeply intertwined with societal norms.”
ME. Not just norms, but timorous and craven conformity.
“American-born parents would dismiss as ridiculous (or worse) the suggestion that they cut off part of their infant daughter’s clitoris to help prevent HIV.”
ME. Surgery to the clitoris rightly strikes us as most appalling than male circ. The female analogue of male circ is, in my view, the excision of the labia minora, a practice that is part of FGC in quite a few sub-Saharan cultures. A Tanzanian study done a few years back found that circumcised prostitutes were substantially less likely to be HIV positive. This study is been carefully downplayed, as you can imagine…
First, the science. Clinical trials in Africa have found that circumcision reduces a heterosexual man’s risk of contracting HIV from an infected female by up to 60 percent. It is unclear whether circumcision reduces the risk that a woman will contract HIV from an infected male and “little to no evidence” that it reduces the spread of HIV between homosexual male partners. But if circumcision reduces the overall prevalence of HIV among heterosexual males, that might ultimately lower the risk among other populations, particularly women. As for why circumcision status matters, most likely the foreskin tissue is more susceptible to HIV than other parts of the penis. (You can read more about the science here.)
ME. The African clinical trials are a scientific scandal for reasons that would take me too far afield. Several people in the intactivist community have written about this.
For one thing, the trials did not run long enough, so that one cannot rule out that male circ only delays the inevitable. Second, the circumcised subjects were given free condoms and an anti-AIDS pep talk. The intact controls were given neither.
In Africa, access to condoms, soap, and a daily shower are problematic. In the First World, they are not. Africans have curious notions about human sexuality, such as “dry sex,” notion absent from our world. Anal intercourse is very much implicated in HIV transmission, and there is a distinct possibility that African couples engage in more anal intercourse than they admit to.
“At present, however, opponents of circumcision appear to be losing the medical battle.”
ME. Only in the USA. Australia, Canada, and the Netherlands have reiterated that routine circ is not justified.
“Second, in recent decades circumcision opponents have achieved some partial victories.”
ME. In the UK and New Zealand, the victory was total. Over the past 40 years, Autralia and Canada have gone from majority cut to majority intact. Over the past 30 years in the USA, inact has gone from almost nonexistent among the children of the white middle class, to the majority choice west of the continental divide, and a common choice among the sons of progressive mothers everywhere.
The American circumcision rate is unknown, because no government body counts circumcisions done in doctor’s offices, which have risen as maternity ward circ has fallen.
“…most notably, the refusal of many insurance companies to pay for the procedure…”
ME. Over the past 15 years, intactivists have struggled to get state Medicaid programs to stop covering routine infant circ, and 18 states have done so. Intactivism in the 1980s sought to get BC/BS to stop covering it, but this is not talked about any more.
“…a woman of my demographic (white, Midwestern) was statistically unlikely to ever have seen an uncircumcised penis. But then I realized that I have seen some in recent years, in the locker room at my gym where many mothers dress their young sons.”
ME. I bet those mothers are fellow academics or spouses of academics! I surmise that nowadays, the probability that a boy is left intact is increasing in mother’s education and socioeconomics status. I suspect that it is still the case that your common garden midwestern woman with a cautious sex life has never seen an intact trouser snake in the flesh.
“…that infant circumcision is painful and traumatic, that it changes the male sexual experience, and that there is always a chance, however remote, that the physician will botch the procedure.”
ME. Many American doctors still refuse to inject lidocaine before circing. Many unsophisticated Moms still post and blog that their sons were not bothered at all by their circs. That circumcision detracts from the sexual pleasure of both genders, and from sexual functionality, has been making steady headway on the internet, altho’ not among American MDs or authorities on human sexuality. Finally, American research has not been honest at all about the complications of routine infant circ, especially on sexual satisfaction and performance after age 40.
“…parents who are deciding whether to circumcise care more about the social aspects of the practice than about its medical effects.”
ME. A conclusion I reached in the 1980s. American families have this haunting fear that a boy with a natural penis will be ridiculed and bullied in the locker room by boys with bald penises. They fear that American young women will not date a young man when they discover he has a Weird Dick. I have been told a half dozen times that lack of circumcision makes oral sex impossible!
“The circumcision status of other males in the infant’s family matters a lot to American parents…”
ME. This is a truly bizarre state of mind. For the record, I am intact, my father was not, and this was never talked about in my family.
“All of this makes it extremely unlikely that the norm will tip in favor of non-circumcision.”
ME. Sarah, I am more optimistic than you are, because more and more American mothers of your generation are posting and commenting that circumcision strikes them as cruel and sexually weird. They are also sharing with other women that they prefer sex with an intact penis, and are speaking from personal experience. It is important to realise that undergraduate life is, for many women, a bit of a sexual free for all, and to have a fling with a male student who is Latino or foreign born is not a rare experience nowadays.
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