Circumcision and HIV
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.