The CDC Dives Into the Great American Circumcision Debate. 07/01/2015
Published at POZ Health, Life and HIV
Written by Benjamin Ryan
2 January 2015
Studies conducted in sub-Saharan Africa have shown that male circumcision lowers men’s risk of acquiring HIV and other sexually transmitted infections from women. Do those findings belong in U.S. health policy?
The Centers for Disease Control and Prevention (CDC) is weighing whether to make its first-ever recommendations on the sensitive and divisive subject of male circumcision. On December 2, the federal agency issued a draft proposal that, if put into effect, would advise clinicians to counsel men, boys and expectant parents that removing the penis’s foreskin reduces the risk of female-to-male transmission of HIV and other sexually transmitted infections (STIs), as well as a number of other health problems.
The proposal grew out of the findings of a trio of large, placebo-controlled randomized controlled trials (RCTs, the gold standard of medical research) conducted in sub-Saharan Africa and published between 2005 and 2007, which found that heterosexual men who were circumcised during the studies had a 50 to 60 percent reduced risk of acquiring HIV from vaginal sex. These trials have led to a massive push to circumcise men in 14 priority African nations in an attempt to stem the tide of the HIV epidemic in that part of the world, with nearly 6 million circumcisions performed between 2008 and 2013.
The African trials also found that circumcision lowered the participants’ risk of contracting herpes simplex virus-2 (HSV-2) and human papillomavirus (HPV) by about 30 percent. There was further evidence that removing the men’s foreskins lowered rates of bacterial vaginosis in women as well as genital ulcer disease in both men and women.
Additional research has shown that circumcised males are less likely than their uncircumcised counterparts to develop penile and possibly prostate cancer, and that they are less likely to experience urinary tract infections during infancy.
The CDC has proposed that clinicians weave these numerous findings into discussions with parents about whether to circumcise newborn boys, as well as with older male patients. In particular, this would include sexually active males having high-risk heterosexual sex—for example, with an HIV-positive woman, female sex workers or injection drug users, or multiple female partners. The CDC makes clear that adolescent males should be included in the decision-making process when clinicians counsel them and their parents on the subject.
The proposed recommendations underline the fact that circumcision does not eliminate the chance of contracting HIV or other STIs, and that sexually active men should still take measures to lower their risks, such as reducing their number of sexual partners and using condoms.
The proposal also addresses the fact that research has not found that circumcision protects men from contracting HIV through sex with other men—which is how nearly two-thirds of all new U.S. cases of the virus transmit. Nor has research shown that circumcision helps prevent STI transmission resulting from male-to-male sex. While the lack of a foreskin may in theory offer protection from HIV to the insertive partner (the top) during anal sex, its presence is irrelevant in the case of receptive anal intercourse, which is by far the most likely way that men who have sex with men (MSM) contract the virus. Furthermore, research suggests that MSM who are only ever the insertive partner during sex (exclusive tops) are a distinct minority.
The proposed recommendations state that adult men who are circumcised “generally report minimal or no change in sexual satisfaction or function.” Such a claim is met with derision by anti-circumcision activists, sometimes known as “intactivists,” who typically maintain that removing the foreskin significantly reduces enjoyment of sexual activity. However, the CDC’s position is backed up by the African RCTs, which included over 10,000 participants, as well as by some small U.S. studies.
The review period for the CDC’s proposed recommendations, during which the draft is open to public comments as well as clinician experts’ feedback and potential requests for more information, runs through the middle of January. At that point, the CDC will consider any possible changes and decide whether to put a finalized policy in place.
The proposal comes at a time of rising American ambivalence, and often fierce opposition, to circumcision. While about four in five adult males in the U.S. report being circumcised, newborn circumcision has become less common over the past few decades. Today perhaps a bit more than half of all American baby boys are circumcised. U.S. health policy, on the other hand, has begun to shift in the other direction. Long neutral on the topic, the American Academy of Pediatrics (AAP) stated in 2012 that the potential benefits of newborn circumcision outweigh the risks—a position that the CDC cites in its draft proposal. The AAP stopped short of an actual recommendation of the procedure, however, as does the CDC.
Groups opposed to circumcision, which typically consider the removal of a newborn’s foreskin a cruel and unnecessary act of genital mutilation, posit that the AAP, and now the CDC, is engaging in coercive attempts to buck a trend that is flagging for very good reason.
“Bottom line: Do we have the right to remove normal tissue from the body of a non-consenting minor or does that body belong to its owner?” says Marilyn Milos, founder and director of the anti-circumcision organization NOCIRC. “Parents cannot consent to amputation of normal body parts of their child.”
The CDC’s proposed recommendations state that an argument for circumcising during infancy as opposed to when a male is old enough to consent is the reduced chance of potential complications, as well as the certainty of providing the health benefits before sexual activity begins. Newborn circumcision has a 0.4 percent complication rate, compared with 9 percent among boys between the ages of 1 and 9. The most common complications include bleeding, inflammation and the need for corrective procedures. For boys older than 10, who experience a 5 percent complication rate, the potential problems also include wounds of the penis. There is no data on complications among teenagers.
The CDC looked to the three African RCTs for statistics about adult males, who, the recommendations state, experience a 2 to 4 percent complication rate, most commonly pain, bleeding, infection and lack of satisfaction with the penis’ appearance.
Meanwhile, leaders in the anti-circumcision camp have long lambasted the science supporting the health benefits of circumcision as flawed and, further, don’t accept that studies conducted among sub-Saharan Africans apply to American males.
Robert Bailey, PhD, MPH, a professor of epidemiology at the University of Illinois at Chicago, who led the African RCT that was conducted in Kenya, allows that exposure to malaria, parasites or other microbes in Africa may increase susceptibility to HIV among the cells in the foreskin that the virus targets.
“Nevertheless,” Bailey says, “the evidence that we have from the few studies in the U.S. of heterosexuals are consistent with the results in Africa. I really think the 50 to 60 percent protective effect is applicable anywhere in the world.”
The Americans studies in question aren’t RCTs, however, so they can’t offer as dependable a quality of evidence as the three African trials. Nor are researchers ever likely to conduct an RCT in the United States that is comparable to the African trials. Because American heterosexual males have such a vastly lower risk of being exposed to HIV from sex with women than African males, a U.S. RCT that could yield results with sufficient statistical heft would require an impractically enormous number of participants. Also, scientists believe it would be unethical to have a placebo group in such a trial, given what is now known about the benefits of circumcision.
Considering that only an estimated 4,100 out of 50,000 new cases of HIV in the United States transmit from women to men, skeptics also question how encouraging male circumcision would have much of a practical effect on reducing the actual number of annual new HIV cases.
One particular 2010 CDC paper, which informed the development of the draft recommendations, sheds some speculative light on that question. In the study, researchers used mathematical modeling to project the effects of newborn circumcision on U.S. HIV rates and associated health care costs—assuming that the lack of a foreskin reduces female-to-male transmission by 60 percent. Beginning with the statistic that all American males (not just heterosexuals) have a 1.87 percent lifetime chance of becoming HIV positive, the study projected that circumcision reduces this risk by 15.7 percent. Black males, who have an estimated 6.23 percent lifetime risk of contracting HIV (compared with just 0.96 percent among white males), could expect a 20.9 percent lifetime reduction in risk from circumcision at birth.
Considering that circumcision rates are lower among African-American males (as well as Latinos), encouraging the procedure among that population in particular may therefore have a more appreciable effect on the epidemic in the long run.
“It’s important to understand that there is a black epidemic that is dramatically different than the white epidemic in America,” says Phill Wilson, president and CEO of the Black AIDS Institute. “In black America, we have a generalized epidemic, and in white America, we have a concentrated epidemic.”
While the white HIV epidemic is generally concentrated among MSM, Wilson says, “In black America, for various reasons, it is a disease among gay men, among women, among injection drug users, and among heterosexual men.” Consequently, Wilson believes that both newborn and adult male circumcision “would make a huge difference to HIV transmission in black communities.
“At the end of the day, when we want to get to zero [HIV infections], this is a percentage game,” Wilson adds. “Twenty percent lifetime change is significant for this intervention when you combine it with the other [HIV prevention] tools in our toolbox.”
U.S. health officials are careful to state that the ultimate goal is not to force circumcision upon American males. Michael Brady, MD, a member of the task force on circumcision at the AAP, says, “I don’t think anybody is saying that everybody should be circumcised. I think what the CDC and the AAP are trying to say is that it’s very reasonable for people to understand what the risks and the benefits are.”
“We believe clinicians need complete information on all proven strategies in order to effectively talk to their patients about HIV and [STI] prevention options,” says Eugene McCray, director of the Division of HIV/AIDS Prevention at the CDC. “The guidance is designed to help health care providers provide accurate information to individual men, as well as to parents of male infants, to help them make informed decisions about circumcision.”
Georganne Chapin, executive director of the anti-circumcision group Intact America, counters, “There are far more effective ways to achieve a protective effect than the amputation of healthy, functional sexual tissue.”
To read a POZ feature about the debate over the findings of the African RCTs, click here.