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Delicate decision

To circumcise or not? As the practice grows less common in the U.S., parents weigh the medical, social and religious pros and cons.

March 31, 2008|Marnell Jameson | Special to The Times

The American Academy of Pediatrics and the American Urological Assn. offer little guidance. The AAP policy states, "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision." The statement goes on to advise parents to determine what's in the best interest of the child and adds that it's legitimate to take cultural, religious and ethnic traditions into account along with medical factors.

The urological association's policy is equally noncommittal: "Neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks. . . . Medical benefits and risks, and ethnic, cultural, religious and individual preference should be considered."

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New studies on HIV

However, both medical associations, as well as the Centers for Disease Control and Prevention, are reevaluating their positions based on new findings out of Africa. Three randomized controlled studies conducted in South Africa, Uganda and Kenya over the last several years, found that circumcised male adults were 51% to 60% less likely to acquire HIV from heterosexual vaginal sex with an infected woman.

Though these studies are significant, physicians warn that you can't directly apply these findings in the U.S. In sub-Saharan Africa, the HIV epidemic is much greater, and the primary mode of HIV infection is through male-to-female sex, not male-to-male sex as it is in the United States.

Dr. Peter Kilmarx, chief of epidemiology in the CDC's division of HIV/AIDS prevention, says the CDC is looking at how the findings apply here. "The early opinion from the consultants -- and not the position of the CDC, which involves a peer review process and public comment -- is that, given all the previous data on circumcision plus the recent HIV African studies, the medical benefits of male infant circumcision outweigh the risks and that any financial burden barring parents from making this decision should be lifted," he said.

The American Academy of Pediatrics developed its current guidelines on circumcision in 1999 and reviewed and upheld them in 2005. Last year, the association formed a task force to study the matter further in light of the new data. Freedman and Diekema sit on that task force, and say the refreshed guidelines should be out next year.

"The HIV data is the most compelling to date that circumcision can help prevent the transmission of the virus in male-female sex," Freedman says. "While this is important to sub-Saharan Africa, the question is how many infant boys need to be circumcised in the United States to prevent one case of HIV transmission 25 years from now? Factoring in even the rare complication that can occur with circumcision may render this study insignificant."

The idea of performing circumcision for medical reasons is uniquely North American, Freedman adds. Worldwide, only 25% of males are circumcised, and that is mostly for religious or cultural reasons. In Jewish and Islamic faiths circumcision is customary.

"The procedure is so ancient, and steeped in cultures, I'm not surprised that the rate of adult circumcision in civilized countries doesn't track with medical evidence," Kilmarx says. "But as scientists, we don't solely rely on what other countries do as a guideline."

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Strong family influence

In homes, the pivotal factor seems to be not science but what that family does. Says Freedman: "It's a decision that for most people comes down to the question of: What tribe do I belong to?"

When Elisabeth Rettenwender, of Santa Cruz, had her son five years ago, the decision not to circumcise him was easy. The 38-year-old single mom weighed the possible pain and risk with the potential benefits, but ultimately decided to follow what her father and brother had done. Her family moved here from Germany when she was a girl. Neither her father nor her brother is circumcised. As a consequence, she said, she's had to give her son a hygiene lesson. "I've had to teach him how to open up his foreskin and clean it. I've talked to him about the fact that some boys are circumcised and some aren't, so he'll understand when he starts noticing."

Robert and Cara Moffat of Los Angeles, who are expecting their first child, a boy, in May, had no trouble deciding, and plan to have their son circumcised. Robert, who is 30 and circumcised, said, "I grew up with it, and my wife has a preference for it, so that's what we'll do. We're doing what the family is comfortable doing."

For the Mouallems, family tradition and religion were not factors. "We kept those separate and focused only on the scientific reasons," says Tony Mouallem, who was against circumcising his son because he didn't think it was necessary. Plus, he's not circumcised. "You have to work a little harder to keep it clean, but that's not a big deal."

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