Newsletter

New Anti-Circumcision Tactic—Target the Poor

The high rate of newborn circumcision in the United States (U.S.) continues in spite of the dominance of activist anti-circumcision groups in the media and on the Internet over the past 25 years. Clinical research indicates that about 80% of middle class American males are circumcised. Among this group percentages vary from 76% in San Francisco to 92% in a Wisconsin city, and include those circumcised as newborns as well as later in life. Statements from the American Academy of Pediatrics discouraging newborn circumcision seem to have had no effect on the public. A published survey from Southern California showed parents choosing circumcision were later more satisfied by their decision than those who left their infants uncircumcised. Low circumcision rates from certain parts of the country, particularly in California, reflect the large number of immigrants, particularly Hispanics, in these areas. Most immigrants to the U.S., particularly Hispanics and Asians, come from cultures where circumcision is not performed. More than half of newborns in California are now Hispanics, so it is apparent that even if 100% of non-immigrant boys were circumcised the State rate would be under 50%.

Since the anti-circumcision groups have been unsuccessful in decreasing circumcision among the middle class in the U.S. (in mid-Western states the newborn circumcision rate has actually increased to over 80% over the past 20 years), they have turned their attention to the most vulnerable and defenseless population group – poor children. Parents on welfare have no political or economic power, and are at the mercy of State beaurocracies and legislatures for decisions on the medical care of their children. Knowing this, 22 anti-circumcision groups have banded together and formed a lobbying organization – the International Coalition of Genital Integrity (ICGI) – which has been pressuring State legislatures to eliminate newborn circumcision coverage for Medicaid recipients. The argument that eliminating payment for newborn circumcision would save money has resonated with legislative bodies faced with increasing budgetary deficits. Over the past few years this callous, insensitive activism has been successful, and 13 states now refuse to pay for newborn circumcision for welfare recipients regardless of the parents wishes. These include Arizona, California, Florida, Maine, Mississippi, Missouri, Montana, Nevada, North Carolina, North Dakota, Oregon, Utah and Washington.

With the great majority of mainstream, middle class boys in the U.S. being circumcised, an uncircumcised boy in this country is marked as either an immigrant, a son of recent immigrants or a child of poverty (with the exception of a few middle class followers of the anti-circ movement) . To cope with this social disadvantage of the foreskin, some poor parents, sadly and courageously, have scraped together enough money to pay for newborn circumcision from their meager assets, in order to give their sons the appearance of mainstream American boys.

The anti-circumcision groups argue that by agreeing to have their newborn sons circumcised parents are robbing the infants of their human rights. In a brazen example of hypocrisy they apparently feel that newborns themselves should have the right to choose or refuse circumcision, but poor parents should not.

There are now about 40 million people in the world infected with HIV, the cause of AIDS. The great majority of the current cases are in sub-Saharan Africa where there have been over 20 millions deaths since the start of the AIDS epidemic in the mid 1980’s. The epidemic continues unabated with about 5 million new cases and 3 million deaths annually. Since 1988 it has been known that the penile foreskin is a risk factor in the acquisition of HIV infection. The foreskin acts as a magnet to HIV through special target cells which trap the virus. Over 30 separate research studies have shown that uncircumcised men are between 2 and 7 times more likely to become HIV-positive after sexual exposure than are circumcised men. The World Health Organization (WHO) found that in those African countries where most males are uncircumcised (Zimbabwe, Botswana, Namibia, Zambia) 19-26% of the population was HIV-positive, while in countries where circumcision is widely performed (Cameron, Nigeria, Liberia, Sierra Leone) only 3-5% of the population was HIV-positive. In certain African communities adult circumcision is now being performed with the cooperation of the local men who have seen the protective effect of removal of the foreskin. Had widespread newborn circumcision been instituted 15-20 years ago, when the relationship between the foreskin and HIV infection was first shown, there would be a much smaller at-risk sexually active male population today. It has been estimated that if all African males were circumcised there would have been 8-10 million fewer HIV –positive people.

Although the HIV prevalence rate in Asia is 5 times less than in Africa it has been increasing rapidly in the past few years, particularly in India. It is estimated that there are currently 5 million HIV-positive Indians. As in Africa, the protective effect of circumcision is obvious in India, where Muslims are circumcised and Hindus are not. In Pune, India, 2300 men were seen in clinics for sexually transmitted diseases (STDs) from 1993-2000. All were initially HIV-negative and were followed to see how many became HIV-positive over the 7 year period as related to their circumcision status. Uncircumcised men were found to be 7 times more likely to acquire HIV infection than were those who were circumcised. It was concluded that the foreskin is an important risk factor in the transmission of HIV, mirroring the African data.

Since the start of the AIDS epidemic about 2 decades ago repeated attempts to develop an effective vaccine have failed, and the use of anti-viral drugs has been stymied by costs and the rise of drug resistance. As the AIDS epidemic spreads in India and other Asian countries, circumcision should be considered as one preventive intervention along with the use of condoms and other weapons to fight this devastating lethal disease.

On April 8, 2003, in his widely viewed TV program, Dr. Phil McGrawreassured a distraught young mother who was agonizing about having had her son circumcised 2 years ago, as a newborn. She had become convinced by anti-circumcision groups that circumcision “changed some of the wiring in his brain” and would lead to permanent emotional and sexual problems. She felt her son would later blame her for having allowed him to be circumcised.

In reassuring the mother Dr. Phil pointed out that millions of boys have been circumcised but don’t hate their mothers. He cited an anti-circumcision author who stated that newborns remember traumatic events, and if they are subjected to pain they will later blame the mother, regardless of her intent. Dr. Phil’s response to this unsupported claim was: “What a load of crap!” He noted that one-day-old infants don’t encode pain messages to long-term memories. If they did remember distressing newborn events they would be much more damaged emotionally by the traumatic and life-threatening experience of being born than by having the foreskin removed.

Reinforcing Dr. Phil is current practice which dictates that local anesthesia be used in performing newborn circumcision. In 2003 a properly done circumcision should be painless. Unfortunately, Dr. Phil did not rebut the mother’s erroneous claim, again gotten from anti-circumcision forces, that there are no medical benefits from newborn circumcision. Among the advantages proven by published medical evidence are protection against severe infant urinary infections, penile cancer, HIV and other sexually transmitted diseases, local foreskin infections, inability to retract the foreskin, and cervical cancer in female partners of uncircumcised men. But Dr. Phil did graphically debunk the phony pseudo-psychological theories of the anti-circumcision groups. Right on, Dr. Phil!

Recent statistical evidence from the Center for Disease Control (CDC) (see figures below) indicates that in the United States (U.S.) newborn circumcisions among non-immigrant boys have increased over the past 2 decades. There are over 100 million circumcised U.S. boys and men, encompassing about 70% of the total male population in this country. Currently 65% of U.S. baby boys are being circumcised in the hospital as newborns, and at least another 5 – 10% of males will be circumcised later for foreskin problems and cultural reasons.

The CDC found that the total U.S. newborn circumcision rate rose very slightly (from 64% to 65%) over the two decade period, from 1979-1999, but the breakdown of these statistics is revealing. There have been increases in circumcision among blacks (from 56 to 64%) and in newborns from the Midwest (from 74 to 81%) and the South (from 56 to 61%), areas of the country with the fewest new immigrants. In specific communities very high circumcision rates are being reported: 84% in Atlanta, Georgia, 85% in Houston, Texas, and 92% in a Wisconsin community served by a pediatrician opposed to circumcision. In the Georgia survey the medical record face sheet reflected only 84% of the circumcisions actually done (O’brien, Southern Med J 1995); prevalence would have appeared to be only 70% using the face sheet diagnosis alone, as the CDC does suggesting that the CDC figures underestimate the true prevalence of newborn circumcision.

In view of these specific high and increasing circumcision rates why have the overall percentages not increased more? The answer lies on the West Coast, particularly in California, where the circumcision rate fell from 64% in 1979 to 37% in 1999. In 1979 the majority of births in California was among non-immigrant whites. By 1999 Hispanic infants constituted the largest group (46.5% of newborns); only 31.2% were non-immigrant whites and 6.2% were black; most of the rest were Asians. Hispanics and Asian immigrants rarely have their newborn boys circumcised. Since these 2 ethnic groups make up over 56% of California newborns, even if 100% of non-immigrant white and black infants were circumcised, the overall prevalence of circumcision in California would be under 40%, an explanation for the 37% Western circumcision rate reported by the CDC. In the East there is a similar though less marked effect, since there are proportionally fewer immigrants.

The rising non-immigrant circumcision rate in the U.S. probably represents growing public awareness of the compelling published medical evidence favoring circumcision. Since the 1980’s more than 15 separate studies have shown that uncircumcised male infants are about 10 times more likely to get serious kidney infections in the first year of life. Uncircumcised men are 22 times more likely to get devastating, invasive penile cancer. Over the past 15 years evidence, mainly from Africa, has shown that uncircumcised men are 2 – 5 times as likely to get human immunodeficiency virus (HIV) infection on exposure. Public response in Africa has resulted in a call for adult male circumcision. In the face of this increasing proof of the health benefits of circumcision, it seems likely that the newborn circumcision rate in the U.S. will continue to increase.

For details, documentation and references of the recent CDC data confirming rising circumcision and for medical publications regarding circumcision logon to www.medicirc.com or www.medicirc.org.

As compelling evidence accumulates on the medical benefits of newborn circumcision, the anti-circumcision forces are now left only with the unsupported argument that sex is better with a foreskin. Now, even this claim is discredited. Recent published evidence indicates that circumcised sex is better. A previous survey of sexually active mid-Western women found that 75% preferred the circumcised penis. The reasons given included improved genital cleanliness and appearance. Interestingly, most of the women felt a circumcised penis looked “more natural”. Similarly a report from London found that 90% of the prostitutes surveyed preferred a circumcised penis, again because of better genital hygiene. Published findings in the Journal of American Medical Association (JAMA) indicated that circumcised men engage in more varied sexual practices, and that older uncircumcised men were likely to have diminished sex drive compared to older circumcised men.

Within the past year 2 studies in the Journal of Urology found that adult circumcision does not adversely effect male sexual function. One study found no difference in sex drive, erection, ejaculation or overall satisfaction 12 weeks or more after adult circumcision, while the other found that more men reported benefits than harm from adult circumcision, and 62% were satisfied with having been circumcised as an adult. The current evidenced- based benefits of circumcision include protection against kidney infections, HIV and other sexually transmitted diseases, and penile and uterine cancer, not to mention local penile infections, skin disorders and genital hygiene. These documented advantages should be measured against anecdotes and testimonials of the anti-circumcision groups claiming the sexual advantage of the foreskin, contentions that now have been contradicted by the medical facts.

Infection of the penile foreskin and glans (balanoposthitis) is a painful and troublesome condition which effects about 2.5% of uncircumcised males, most often 2-5 years old, and is the commonest medical reason for performing circumcision after the newborn period. Recently British investigators, (Mallon et al., Arch Derm 2000) found that circumcision has a protective effect against many skin disorders in addition to penile cancer. Overall, uncircumcised males (average age 42 yrs) were 3 times as likely to get a wide variety of penile skin disorders. The most common of these were psoriasis and local infections. Other disorders more common in uncircumcised males were genital herpes, mollusca, candida, seborrheic dermatitis, lichen sclerosus, lichen planus, eczema and plasma cell balanitis.

In addition to the increased prevalence of skin disorders in uncircumcised males, the presence of a foreskin makes proper diagnosis more difficult. For instance, a plaque of psoriasis on an exposed glans is easily recognizable but loses its characteristic scale when covered by a foreskin.

The authors suggest a mechanism for this increased risk of skin disorders in uncircumcised men. The deep fold at the junction of the foreskin and penis (near the coronal sulcus) is subject to irritation from skin debris and glandular secretions, predisposing the region to skin disorders.

This convincing evidence adds to an increasing body of data on the multiple medical benefits of circumcision. These include prevention of infant kidney infection, infection with HIV and other sexually transmitted diseases, penile cancer, and cervical cancer in the female sexual partner of uncircumcised men.

Sexually active women prefer the circumcised penis, mainly because of genital hygiene and the opportunity for more varied sex, according to previous published evidence from London and the U.S. Midwest. Now it has been shown that circumcision in their male sexual partners helps women by preventing cancer of the cervix, one of the most common and deadliest cancers in women worldwide.

It has long been noticed that cervical cancer is much less common in women sexual partners of men circumcised for religious reasons, mainly Moslems and Jews. In these same circumcised men penile cancer is rare compared to uncircumcised men. The link between penile and cervical cancer was found to be the human papilloma virus (HPV). Data from 1987support the concept that cervical cancer in women was associated with genital HPV in their male partners. In 1993 a study from India, where only Muslims circumcise, found decreased cervical cancer in Muslim women compared to Hindu women. Among 311 penile cancer cases none were in Muslim men.

Evidence published recently in the New England Journal of Medicine (2002) established the link between circumcision, penile HPV infection and cervical cancer. The report summarizes findings from 1913 couples, from 7 separate case controlled studies in 5 different countries. Penile HPV infection was found to be 3 times as common in uncircumcised men, and there was a significantly reduced risk of cervical cancer in the female partners of circumcised men.

Newborn circumcision has been shown to protect males over a lifetime from multiple disorders-including infant kidney infections, HIV and other sexually transmitted disease, local penile infections and dermatoses, and penile cancer. Now we know that male circumcision benefits women as well by helping to prevent cervical cancer, a widespread, deadly disease.

Multiple reports comparing uncircumcised vs circumcised infants in the first year of life have found that uncircumcised baby boys are about 10 times more likely to develop severe kidney infections. Studies from Europe, where infants are not circumcised, have described an interesting syndrome, predominately in uncircumcised baby boys. The combination of findings includes infant urinary tract infection (UTI), very high levels of certain hormones associated with high blood pressure (aldosterone and renin), and salt abnormalities (low blood sodium, high potassium). These hormonal and salt abnormalities return to normal following treatment of the UTI. We recently reported this syndrome in 2 United States infants, one girl and one uncircumcised boy (Schoen et al, J. Urol 2002). The suggested mechanism for this condition is that the bacterial infection acts on the immature kidney to cause increased sodium loss, which leads to high secretion of the adrenal hormones, aldosterone and renin, which can result in high blood pressure.

It has been found that about 40% of infants with UTIs have evidence of kidney scarring on imaging studies done one year after the acute infection. In view of the potential for future renal damage, diminished kidney function and, possibly, for hypertension, blood sodium and potassium levels should be measured in all infants with UTIs. If low sodium/high potassium is present, aldosterone and renin should be determined. These hormonal and salt values could serve as a basis for follow-up of possible long term complications in infant UTIs, including future kidney failure and high blood pressure.

Over 15 years ago, studies published in leading medical journals on AIDS in Africa, found that uncircumcised men were about 3 times as likely as were circumcised men to be infected with the human immunodeficiency virus (HIV). These findings have been confirmed in more than 40 separate studies. Currently almost 40 million people worldwide are infected with HIV, mostly in sub-Saharan Africa and 22 million have died of AIDS. The AIDS epidemic is rapidly spreading in Asia and Eastern Europe. Professor Malcolm Potts (Lancet. 2000) of the University of California estimated that if all HIV-exposed men in Sub-Saharan Africa and Asia had been circumcised there would have been 8 million fewer deaths from AIDS; 6 million fewer in Africa and 2 million fewer in Asia. In a review article in a leading British journal (Halperin, Lancet. 1999) alluded to the lack of response of the international community to the knowledge of the effect of circumcision on preventing HIV infection in spite of these convincing figures. Public knowledge in Africa of the protective effect of circumcision against HIV infection, has resulted in private store-front clinics offering adult circumcision under suboptimal conditions. Governmental involvement is required in order to assure that these circumcisions are properly performed by qualified personnel. It should also be emphasized that circumcision itself is most effective when used in association with condoms.

In the U.S. there has been some official recognition of the protective effect of circumcision against HIV. Dr. Anthony Fauci, head of the HIV Research Division of the NIH, stated that “the link between male circumcision and lower HIV infection rates is now absolute fact.” In March 2002 a group of internationally reknowned scientists concluded that affordable, safe, voluntary circumcision should be developed to help fight the AIDS epidemic and that “such efforts must commence now, lest the opportunity for a potentially important prevention measure be further delayed.” Randomized controlled trials are now under way in Africa, supported by the NIH, the Canadian and the French governments, on the effectiveness of adult medical circumcision in preventing HIV transmission.

Parents who decided to have their babies circumcised were more likely to be satisfied with their decision than were parents of uncircumcised boys. A California survey of 149 families (81 had babies circumcised, 68 did not), published in the Journal of the American Academy of Pediatrics, found that parents who failed to have their sons circumcised were significantly more likely to feel they made the wrong decision when questioned at the offspring age of 6 to 36 months. Compared to parents of circumcised boys those parents felt they had not been given adequate information about the procedure or been asked if they wanted circumcision. The parents of the circumcised infants tended to be white (83% circumcised) and better educated (63% college graduates) while Hispanic parents most often chose not to circumcise (16% circumcised) and were less well educated (9% college graduates).