Delicate decision

"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."