March 26, 2009 -- Some doctors are calling for a slight change in America's thinking about circumcision after the latest -- and largest -- study in a series of investigations in Africa showed that circumcision may significantly reduce the risk of contracting herpes and HPV.
Doctors followed 5,534 men in the rural Rakai region of Uganda, periodically surveying their sexual risk-taking behavior. Half the participants were immediately circumcised, while the other half remained uncircumcised until the end of the study.
Over two years, the men who were circumcised had a 28 percent reduced risk of infection with the herpes virus and a 35 percent reduction in HPV infection. An author of the study called it a "double whammy" of an effect for women's health, too.
"Men are at risk for genital warts and things like discharge. Women are at risk for cancer," said Dr. Anthony S. Fauci, a co-author of the study appearing in the New England Journal of Medicine and the director of the National Institute of Allergy and Infectious Diseases.
"The idea that you can prevent HPV in the male, then you would almost certainly, although not formally proven, prevent the male from infecting an uninfected female," he said.
In an accompanying editorial, authors of the study beg the question of whether Medicaid should uniformly cover circumcision across the country. As of now, Medicaid in 16 states does not cover circumcision, and more private insurance companies are following suit.
"Data like this may then sway the opinion of leaders," said Fauci. "It may actually have an impact on certain policy decision in the United States."
What Doctors Recommend for Circumcision
By the looks of it, Fauci may be right.
When people, especially doctors, make a decision about a procedure, they often look to official guidelines from professional medical academies.
The last new set of circumcision guidelines outlining the risks and benefits of circumcision came out of the American Academy of Pediatrics in 1999. The same guidelines were upheld in 2005. In sum, the guidelines were quite neutral about the controversial topic.
"Basically, it's considered a non-essential medical procedure," said Dr. Susan Blank, chairwoman of the American Academy of Pediatrics Task Force on Neonatal [male] Circumcision. "It does have health benefits, but it is not essential."
But guidelines do change. Blank said the academy noticed some "really very compelling data" that should be included on the next guidelines.
"It began with three very compelling studies that came out of Africa," she said. "The academy felt it was time to look at the full body of literature and see and what was out there."
Yet, as mounting evidence points to circumcision's health boons, new social movements and circumcision numbers show Americans are slowly abandoning the practice.
In 1979, the rate of circumcision nationally ranged around 65 percent. More recently, that rate had dropped, especially in some regions and among some ethnic groups, according to data from the National Hospital Discharge Survey.
By 1999, the most recent year of data available, only 36 percent of babies born in the West were circumcised.
Certainly, some of the change has been a social movement brought forth by groups, such as Mothers Against Circumcision and Intact.
However, some of the change might have simply been a matter of funding.
"It's definitely true that the cost is important, especially if you think of Medicaid," said Arleen Leibowitz, professor of public policy at the University of California in Los Angeles.
This January, Leibowitz published a large study investigating circumcision choice, insurance coverage, common cultural choices, and economic status of young parents. Without coverage, Leibowitz said, a circumcision will cost $300, and that made a difference to some parents.
"If you're controlling for all sorts of things that influence circumcision -- race, economic standing, culture -- the study still shows babies who are not covered are less likely to be circumcised," said Leibowitz.
Which Parents Decide for Circumcision?
Yet, outside of costs, Leibowitz can't say whether parents would choose circumcision for any newfound benefits in preventing sexually transmitted infections.
"I think that we already knew from observational studies in the U.S. that HPV was lower in circumcised men," said Leibowitz. "I think we knew that, but I think it's nice to have it confirmed in a randomized trial.
"Whether individuals may relate this information to this decision-making, I really don't know," she said. "I think increasingly what people do before making the decision is they go to the Net -- they Google."
However, a handful of professors in the wake of the HPV vaccine have tried to study whether parents value cultural and belief systems over efforts that can reduce sexually transmitted diseases.
Although quite different from circumcision, Norman Constantine of the University of California at Berkeley said his research on HPV vaccines and sexual education indicated parents tend to be quite pragmatic.
"Most parents are pragmatic and realize that a large percentage of teens by the time they've reached their 20s are sexually active," said Constantine, the senior research scientist and director at the Center for Research on Adolescent Health and Development.
Constantine and other scientists did a statewide California survey of parental attitudes when the HPV vaccine was first approved by the Food and Drug Administration.
Self-identified Asian, African American, Latino, white, liberal, conservative, religious and secular individuals all were asked. Constantine said 75 percent of parents surveyed supported the HPV vaccine, and 89 percent supported comprehensive sexual education in the classrooms.
"This was remarkably similar across different groups," he said.
Religious groups, liberal people, conservative people, Christians, secular -- all responded with a pragmatic approach, Constantine said.
"We had a very small subset of parents," he said. "Three-point-five percent gave moral values reasons to objecting to vaccination and the comprehensive sex education."
With new evidence supporting circumcision, Constantine said he would consider it as a cost effective public health strategy.
"I think we need support for it, we need coverage, but we have to be careful," he said. "I am in favor of mandating funding, but don't mandate circumcision."