Between San Francisco's attempted ban on infant circumcision and the move by 19 state governments to defund Medicaid coverage for the procedure, the millennia-old act of removing a newborn boy's foreskin has undoubtedly become a point of controversy in America.
Twenty years ago as much as 67 percent of all infants born in U.S. hospitals were circumcised. Today, that number hovers around 32 percent, in part because of decreased funding for the poor and a rise in controversy over the merits of the practice. Opponents of circumcision, who call themselves "inactivists" because they wish to leave the foreskin alone, lampoon the practice as a violation of human rights, a form of genital mutilation and as medically unnecessary.
This spring ABC News tracked the war waged on the procedure in San Francisco as circumcision opponents put forth a ban on it. Though they succeeded in getting the anti-circumcision bill on the ballot, it was later struck down by a judge over a legal technicality.
Campaigns to withdraw state Medicaid funding for infant circumcision were more successful with two new states, South Carolina and Colorado, adding such defunding measures this year. Though state officials cite economic reasons for the defunding, a 2009 UCLA study suggests that the withdrawal of coverage to the poor will have a large impact on circumcision rates: In the study, hospitals in states without Medicaid coverage for circumcision were half as likely to perform the procedure as a matter of routine.
Ironically, increased public doubt about the long-routine practice of circumcision comes at exactly the time when there is the most medical evidence to support its health benefits, says Dr. Aaron Tobian, an epidemiologist at the Johns Hopkins University School of Medicine. Along with his colleague Dr. Ronald Gray, a professor at the Bloomberg School of Public Health at Johns Hopkins, Tobian puts forth an argument for the medical benefits of infant circumcision in the October edition of the Journal of the American Medical Association, released Tuesday.
"The anti-circumcision campaign is very similar to the anti-vaccination campaigns -- the more vocal you are, the more press coverage, and people believe what people are yelling, despite what the medical evidence shows."
"The foreskin is there for a reason," Lloyd Schofield, who spearheaded the San Francisco anti-circumcision bill, told ABC News in May. Shofield called circumcision an "unnecessary surgery" with no "sound medical evidence" behind it.
Recent studies, especially in the past five years, suggest otherwise, Gray and Tobian say. As recently as 2005, when his first child was about to be born, Tobian considered not circumcising him (his firstborn was a girl, so it didn't end up mattering). By the time his son was born in 2008, there was no question in his mind that they would circumcise for both the child's immediate urinary health and for his future sexual health of his sexual partners.
Tobian was part of a Ugandan study published this year that tested the effect of circumcision on STD transfer in married Ugandan couples. When comparing those who were circumcised for the study with those who remained uncircumcised, researchers found that circumcision reduced the risk of HIV infection risk by 60 percent, genital herpes by 30 percent and cancer-causing human papillomavirus by 35 percent in men.
Female sexual partners of the circumcised men benefited from a 40 percent or greater reduced risk of bacterial vaginosis or parasitic trichomonas spread during sex, as well as HPV infection, which can lead to cervical cancer. Sexual satisfaction for the men, the long-standing bugaboo among opponents to circumcision, was reported to be just as great or more so after circumcision.
Though this study was done in Africa, the results closely match the observational studies done in the U.S., Tobias says. What's more, there are U.S. studies that show how the infant of circumcision can benefit, as it reduces the chance of penile infections.
"Boys who are circumcised have fewer urinary tract infections during infancy," Dr. Douglas Diekema, director of education for the Treuman Katz Center for Pediatric Bioethics at Seattle Children's Hospital told ABC News during the San Francisco anti-circumcision bill controversy in May. "These are serious infections that require hospitalization," he said.
Circumcision is yet to get full support of major health organizations, however, as the Centers for Disease Control and Prevention and the American Academy of Pediatrics remain neutral on the practice.
"No medical association promotes circumcision," said Schofield. "If there was sound and repeated scientific evidence, there'd be a medical association promoting it."
And that is the impasse that proponents like Tobian and Gray find themselves at – as long as major medical associations remain neutral, it will be hard to change health policy or change public opinion. In their editorial, Tobian and Gray call for these agencies to review the "overwhelming medical evidence" and reconsider their stance on male circumcision.