Patricia Nell Warren

To Cut or Not to Cut

Filed By Patricia Nell Warren | August 22, 2011 7:00 PM | comments

Filed in: Living
Tags: Doctors Opposing Circumcision, HIV prevention, NIH, San Francisco

Circumcision_central_Asia2.jpgRecently, the old circumcision controversy exploded into new intensity. The spark: two California cities introduced ballot measures banning the practice outright. In San Francisco, non-therapeutic circumcision of an under-18 male was going to get you a year in jail, with no religious exemption allowed. U.S. religious groups that practice ritual removal of the foreskin were outraged -- not only Jews and Muslims but also evangelical Protestants who identify with Old Testament law. They insist that their religious freedom is at stake. Jewish groups called the measures anti-Semitic. Evangelical Protestants felt equally threatened -- one evangelical blog called the ballot measures an "effort to enforce a secular society."

Interestingly enough, some of the protesters buttressed their age-old arguments about God's law with a recent theory that circumcision should also be public-health law, aimed at preventing HIV and STD infection. They lament the recent drop in U.S. circumcisions, and predict that this trend -- if it isn't turned around -- will mean disaster for the nation's health.

The circumcision controversy has a special interest for gay and bisexual men, who have their own set of pros and cons about whether "to cut or not to cut."

Amid the noise of debate, however, little is heard about the history of how conservative Protestant church groups successfully marketed male circumcision to the American public more than a century ago. Today, few people are talking about how this same sectish conservatism is helping to huckster circumcision as an HIV preventive. Worst still, many media reports give the impression that scientific research has proven, beyond a doubt, the effectiveness of circumcision against HIV infection.

From Egypt to America

In the West, religious circumcision seems to have started in ancient Egypt. As early as 2400 B.C., it was mainly upper-class men who had themselves cut, inspired by a belief that the sun god Ra had circumcised himself. When they died, their mummified bodies preserved the cut status in the tomb. From there, the practice spread to some tribes in the African interior. It also popped up in ancient Judaism, where it was viewed as a collective covenant with the Hebrew god. Every Jewish head of household was required to have his children, even his slaves, circumcised.

However, the ancient Greeks and Romans rejected this practice -- partly because of their fondness for male nudity. They viewed the foreskin as a natural and polite way to keep the glans covered in public.

When Christianity first appeared, a controversy flared as to how "Judaic" it was going to remain. Jesus was a Jew. So was circumcision required of any adult male who wished to become a Christian? The reluctance of many non-Jewish men to have this painful procedure done became a barrier to conversion. So early church leaders made a deft decision: as children of the New Testament, followers of Christ would not be obliged to follow Old Testament ritual practice. It was enough to undergo what Paul called "circumcision of the spirit."

This radical shift in doctrine, coming on top of Greek and Roman influence across Europe, ensured that European men would stay largely uncut through the centuries to come.

Meanwhile, in the 8th century CE, when Islam burst across the West as the next new major religion, circumcision was adopted widely by its own adherents, though it was usually done at puberty rather than at birth. The spread of Islam around the globe carried the practice as far as Indonesia, the Philippines, even some Pacific Islands.

Some Protestants, however, went a different route than Catholicism. Since most Protestant churches base their moral teaching on Old Testament as well as New Testament dictums, and since they reject most anything that is patently "Catholic," it was inevitable that many American Protestants would rediscover circumcision.

Red, White and Cut

In his landmark 1999 book Male and Female Circumcision: Medical, Legal and Ethical Considerations in Pediatric Practice, Jim D. Bigelow Ph.D. tells the forgotten story of how reformist U.S. Protestants launched the massive trend to adopt majority circumcision in America.

Bigelow traces the trend back to the 1870s, when Victorian medical experts began touting circumcision as a purveyor of many health benefits for men. These experts were influenced by "muscular Christianity," a powerful men's movement of the time that sought to rescue manliness from the alleged "feminization" into which Christian men had supposedly fallen. From sports to personal health, the MC movement had a deep impact on the U.S. with its heavily Protestant population. Among the claims for circumcision: it supposedly lessened male sexual pleasure and therefore helped men to stay "morally clean" (meaning no fornicating, masturbating or adultering).

On into the 1900s, the movement alleged that circumcision could even prevent sexually transmitted infections like syphilis and gonorrhea. In those days, there was no safe and effective cures for those infections -- not till antibiotics were discovered.

Today "muscular Christianity" is still alive and well in America's evangelical movement. According to Bigelow, "Most infant males circumcised in the United States for religious reasons are born to Christian parents -- particularly evangelicals."

Indeed, some adult born-again leaders grit their teeth and have themselves cut -- including history professor Hugo Schwyzer, who did it at age 37 and wrote about it glowingly in New York Magazine. Schwyzer says, "Circumcision is about dedicating one's body to God, and in particular, dedicating the very part of the body most renowned for inspiring men to act selfishly and destructively."

Some born-againers even preach circumcision as a Christian obligation for today. Example: influential minister Bill Gothard, founder of the Institute in Basic Life Principles. Gothard fumed: "The attack against circumcision in the United States coincided with the revolt against morality and authority in the 1960s. One of the chief reasons given for not having circumcision was that it decreased a man's sensual pleasure. Indeed, uncircumcised men have, as a group, been more promiscuous than circumcised men."

With the spiraling costs of medical care, some believers resort to DIY. Total costs of newborn circumcisions can run over $1500 (especially with anesthesia), and it used to be covered by private insurance and Medicaid. But all that is changing, with Medicaid going away and some insurance carriers dropping coverage, not to mention the growing numbers of families with no insurance. In Oregon recently, a woman Bible follower boned up by watching You Tube videos, then tried to circumcise her 3-month-old. After she mangled the job, her screaming, bleeding baby had to be rushed to the ER. She was subsequently charged with criminal mistreatment and sentenced to 5 years' probation and mental-health treatment.

The CDC Steps In

So, for well over a century, circumcision became routine for most American Christian men. But starting in the 1960s, male circumcision came under fire from growing numbers of progressive Christian and non-religious parents who are deeply concerned that babies can't legally consent to the operation -- that it's often done without anesthetic, and sometimes at risk of injury to the baby.

Nobody seems to have a head count of how many U.S. male babies are circumcised every year -- hospitals aren't required to report. The pro and con parties give different estimates, with the religious pros insisting that the 1960s saw the peak of 85% of boy babies being cut in the 1960s, and the cons putting that peak in the 50% range. But both sides agree that the number of circumcisions has fallen sharply from that peak, by 20% or more. And the U.S. stats are still way higher than circumcision stats in Europe (in Spain, for instance, only 2% of males are circumcised). According to the International Coalition for Genital Integrity, an estimated 117 U.S. babies die every year as a result of botched circumcisions. Progressive Jews and Muslims who do not circumcise their sons join in these human-rights concerns.

Up until three years ago, the CDC was officially neutral on circumcision, leaving it up to the parents' choice. But by 2009, it looked like the CDC might be moving towards recommending "universal circumcision" for all male newborns in the U.S.

While a CDC recommendation doesn't have the force of law, it would radically shift the way in which newborns and parents are dealt with. Right now, parents still have the ball in their court. It is their routine right to seek -- or not seek -- circumcision for a baby boy. But once the CDC recommends "universal," medical personnel would have the ball in their court. They would routinely circumcise a baby as part of routine postpartum procedures -- unless the parents objected and formally opted out. This is how things work with HIV testing now, following the CDC's stiffening of guidelines in 2006 -- an HIV test is now bundled with routine care of pregnant women and all other patients in healthcare settings, and a person can avoid testing only by formally opting out.

So a CDC recommendation would position circumcision as a bonafide medical strategy for HIV prevention.

Two years later, however, the recommendation still hasn't happened...which makes me wonder if the CDC is a little nervous about the reliability of three African studies said to prove that circumcision can reduce HIV infection by 60 percent. Right now, the agency is saying that its circumcision policy is still in "development."

Some of our community AIDS workers and activists go along with the official view that circumcision really does work as prevention. But some of our men reject the very idea of circumcision, affirming from their own experience that it reduces sensation and pleasure. Not to mention the envy that some feel, for the uncut grandeur of European males. Or the trepidation that others might feel, if the CDC comes through with a recommend for "universal circumcision" that would put social pressure on gay and bi adults to have it done.

Four Advocates of Circumcision

If the CDC does decide to advocate circumcision for all American boy babies, might it be as a result of influence by these powerful ultraconservative Protestant religious lobbies? After all, the ultra-Protestant lobbies are aiming to dictate every other aspect of U.S. policy. And they often do it in ways that disregard science -- as in the issues around evolution, global warming, etc. Why not influence on medical research?


It was the U.S. National Institutes of Health (NIH) that funded the three now-famous circumcision studies in Africa -- Uganda, Kenya and South Africa. NIH launched these studies after some previous studies, including one done in 1997, found no "prophylactic" evidence that circumcision is effective against HIV.

To head the studies, the NIH tapped four men who were known circumcision advocates -- thus creating an obvious bias. These circumcision advocates were: Bertran Auvert in the South African study, Robert C. Bailey and Stephen Moses in the Kenyan study, and Ronald H. Gray in the Ugandan study. According to Doctors Opposing Circumcision, all four men have been pushing circumcision for many years, since at least 1998.

The Ugandan and Kenyan studies were done in countries where U.S. ultraconservative missionaries have gained enormous leverage over indigenous government and pubIic-health policy. Uganda is the most notorious example -- an evangelical theocracy where harsh Bible-based laws like the notorious anti-gay bill, and death penalties for anyone who infects others with HIV, are touted. Even South Africa, which officially became a secular country after the fall of church-based apartheid, has become a target of intense missionizing by U.S. evangelicals -- to the point where the SA government has committed to getting 2 million of its male citizens circumcised as a task-force effort.

Yet another heavily missionized nation is Zimbabwe. There, the U.S. has actually spent $6.6 million on USAID programs that aim to circumcise Zimbabwean men, as reported in the Huffington Post.

Once missionized, African church leaders often translate imported AmeriChristian teachings and take them a step further. For example, in Rwanda, yet another country where U.S. proselytizing has penetrated deeply, the Evangelical Restoration Church is now actively teaching that parents have a religious duty to circumcise children as an HIV preventive. This is according to a recent report in AllAfrica.com.

Given the NIH's global leverage, along with the growing leverage of evangelical missionizing in the international sphere, it isn't surprising that the World Health Organization subsequently came out in favor of circumcision as a route for HIV prevention.

Where Is the Science?

With all this religious fervor in the air, is there any real science in these studies' claim that circumcision can prevent HIV infection?

Supporters of the idea say yes. All three studies were stopped early, with the investigators' insistence that early results provided sufficient evidence that the circumcised cohort had a way lower rate of HIV infection than the uncircumcised cohort -- by 50% or more. These were heterosexual men having sex with HIV-positive women.

But the opponents say no. Doctors Opposing Circumcision, an international advocacy group,
points out a number of flaws in the African studies in their HIV Statement paper. According to DOC, the early termination happened "before the incidence of infection in circumcised males caught up with the incidence of infection in the non-circumcised males. If the studies had continued for their scheduled time, it is probable that there would have been little difference between the circumcised group and the non-circumcised group."

Worse, DOC spotlights the glaring cultural bias in this NIH research. Four circumcision advocates could hardly be expected to lead three impartial studies of circumcision. Instead of accepting the NIH grants, DOC suggests, the four scientists should have recused themselves. Indeed, says DOC, the whole movement to push circumcision for HIV prevention was launched from the U.S. They say: "United States medical literature, as compared with the medical literature of other nations, is highly biased in favor of male circumcision. The scientific literature that supports such 'potential' benefits is written mostly by doctors who were reared in circumcising cultures."

Other experts have raked the African studies as well. In 2005, a group at the University of Michigan reviewed the three studies and found them flawed as to their procedures. This review is now posted at the NIH's PubMed website, suggesting that the NIH might be admitting the criticisms are valid.

Yet another cautionary PubMed posting is from the December 2010 Journal of Medical Ethics, titled "HIV/AIDS and circumcision: lost in translation." It states, "The understandable haste to find a solution to the HIV pandemic means that the promise offered by preliminary and specific research studies may be overstated."

The Cochrane Reviews

Last but not least, it's intriguing to look at the Cochrane Reviews on circumcision research.

The Cochrane Collaborative is an independent non-commercial group, founded in 1972, based in the UK but with branches around the world. Its ideal is to build an evidence-based "second opinion" approach for healthcare, in everything from arthritis to incontinence. Its team of scientists is analyzing the clinical trials done by others, aiming to get any bias there, so they can see what real evidence, if any, is there to support what is claimed. Cochrane publishes a vast library of pull-no-punches reviews on all kinds of medical research. They've been poring over HIV/ circumcision studies for years, and are not impressed.

For instance, Cochrane just published a comprehensive review of research involving MSM and circumcision, and had this to say:

"Current evidence suggests that male circumcision may be protective among MSM who practice primarily insertive anal sex, but the role of male circumcision overall in the prevention of HIV and other sexually transmitted infections among MSM remains to be determined. Therefore, there is not enough evidence to recommend male circumcision for HIV prevention among MSM at present. Further research should be of high quality and further explore interaction with the predominant sexual role."

Summing up, the DOC commented acidly, "The United States has the highest rate of HIV infection and the highest rate of male circumcision in the industrialized world. Male circumcision, therefore, cannot reasonably be thought to prevent HIV infection."

Back to San Francisco. A few weeks ago, a California judge stated that she intended to strike the circumcision measure from San Francisco's ballot. Her opinion: the proposed city law violates a California law reserving the regulation of medical procedures to the state alone.

But the controversy will surely rage on. It leaves me wondering if the jury is really in, scientifically speaking, on whether circumcision helps prevent HIV infection. Indeed, where -- in the current push of international HIV programs -- does public-health policy stop and religious policy begin?

_________________________

A shorter version of this story was published in the August 2011 issue of A & U Magazine.

Further reading:

Why the African Studies Are Unreliable

DOC: Facts About Alleged Medical Benefits of Circumcision

The Cochrane Collaborative

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If measures like these pass, I too want legislation removing from parents their children if they become overweight.

Health problems aside, being overweight because your parents provide a poor diet and no integration of physical activity into everyday life also leads you to ending up with stretch marks and the low self-esteem involved from being found unattractive.

Isn't it wonderful how people can compare cutting part of a boy's genitals off with overfeeding him (and haircutting, nailcutting, earpiercing, bedtimes and/or French lessons) but just try and compare it with cutting part (no matter how minimally, sterilely and painlessly) of a girl's genitals off and "Oh NO, they're COMPLETELY DIFFERENT!")

The other issue for using these three studies is that they are incomparable populations for a couple of reasons. The studies were performed on men in Sub-Saharan Africa, which has its own cultural and social context for sex and sexual practices. Automatically assuming that the results are worthy of "universal recommendation" for the context of any other region is poor practice.

Likewise, the studies were performed on grown men. That is an entirely different context and an entirely different population. Making a universal newborn recommendation based on studies that dealt with effects seen in grown men is alarming.

Finally, the studies, as they pertain to men who have sex with men, are basically useless. The studies only looked at heterosexual contact between men and women. Studies found that there was no protective effect for men who have sex with men (http://www.ncbi.nlm.nih.gov/pubmed/20595141 , http://www.ias2007.org/pag/Abstracts.aspx?SID=55&AID=2465 , Millett GA, Ding H, Lauby J, et al. Circumcision status and HIV infection among black and Latino men who have sex with men in 3 US cities. J Acquir Immune Defic Syndr. 2007 Dec;46(5):643-50). Likewise a two studies comparing risk of HIV based on circumcision found that the associated risk was not statistically significant compared to men who were uncircumcised (Telzak EE, Chiasson MA, Bevier PJ, Stoneburner RL, Castro KG, Jaffe HW. HIV-1 seroconversion in patients with and without genital ulcer disease: a prospective study. Ann Intern Med. 1993 Dec 15;119(12):1181-6 and http://cdc.confex.com/cdc/std2006/techprogram/P11223.HTM). If the CDC makes a "universal recommendation" (which I actually had never heard them making), it would be an unnecessary procedure for all those newborn boys who end up becoming grown men who have sex with men, at the sacrifice of their bodily autonomy, something irreversibly cosmetic.

And while I agree that all ideas should be considered, it's odd that we would seriously weigh preventative surgery on newborns as viable, considering that we don't strongly advocate preventative tonsilectomies, apendectomies, or mastectomies (though they do happen).

We also have to look at the differences of impact of the procedure, which has a clear 60% impact in a place with as high of an endemic as Sub-Saharan Africa. The US has its own endemic, but it is not comparable to Sub-Saharan Africa at all, so any effect you'll see will be diluted.

Suddenly, touting these studies as golden evidence in the US isn't as promising.

Let's stick with getting over our prudish issues with condoms and our fears of comprehensive sexual health education and the difficulties of condom negotiation for men and women and their partners before we decide to implement body violating procedures with limited and untested effect on all newborn baby boys.

circumcision is genital mutilation, pure and simple. My body should be MY choice and no one elses. I'm a post op trans girl but when I was a guy I had little to no feeling down there. Was circumcision the culprit? That I will never know, yet the question has crossed my mind more than once.

Having written on this subject before, I can't help but weigh in...

The part that interested me the most was at the end, when it was noted that the doctors who conducted the studies in Africa were "reared in circumcising cultures." One of the arguments I made was that routine circumcision in the United States is basically a cultural tradition. I remember being made fun of for being uncut when I was little, for no other reason than the other kids thinking, "You're not circumcised? Ewwww!" We're raised from an early age thinking that being circumcised is inherently more hygienic than not being circumcised, though through my ample experience with both cut and uncut guys, I've often found the opposite to be true (I would suspect that cut guys often think they don't need to put much effort into cleaning themselves).

Routine circumcision started in the Anglophone countries, but the US is the only one in which it hasn't died out - even Canadian boys are mostly uncut these days. An unusual exception is South Korea, where it has caught on thanks to American influence and become associated with masculinity, usually being performed in adolescence (not surprisingly, SK is also a major center for evangelical Christianity). It's slowly catching on in China as well, and I've met a number of gay men from there who voluntarily had it done because they thought it to be "cleaner."

But the idea of circumcision being recommended as a preventive measure against HIV or any other STD is extremely disturbing. Even if the results of the studies in Africa turn out to be true, there's another way to prevent HIV and most STDs with virtual 100% effectiveness: condoms. Education on proper condom usage would go a much longer way toward stamping out STDs and HIV among young people than "Worry not, my dear, I'm cut!"

And what would be the psychological effects of this? You're going to end up with a generation or more of young men who think that they're inherently protected from diseases because they're circumcised. Given teenage boys' propensity for acting on impulses and widespread ignorance about proper condom usage, I don't think it's unreasonable to assume that a "universal circumcision" campaign could result in a dramatic rise in STDs and HIV, not to mention teenage pregnancies.

For me the medical studies are irrelevant... mutilation and abuse of a baby is what it is. Attempting to justify it by wrapping it up in science is disgusting. What's next... should we test girls for BRCA 1&2 and, if positive, automatically remove their breasts when they turn 18?

I agree most hardheartedly with this comment. The "possibility"of STI infection and most definitely the diminishing of sexual pleasure as circumcision was used for boys who found themselves playing solo too much or at all, is not a reason for it to be done.
Who would ask for breast removal based on the appearance of genetic markers with a predisposition to breast cancer. How about ovarian or cervical cancer markers, prostate cancer, lung cancer? The list goes on and on.
Are we to become the movie "Gattica"?

I was born in 1955. My grandparents came from Europe. My father's side were Roman Catholics. My mother's side Russian Orthodox. Raised in an extended family situation, I had quite a lot of European thinking and lifestyle incorporated into my life and thinking.
My father was not circumcised, he was the youngest of his family. My younger maternal uncle was also not circumcised. This knowledge gained from showering together when I was a small boy after going to the beach.
That was when I noticed the difference between me and them. After pondering it for a while and trying to get my "foreskin"to be like theirs I asked my parents why I looked different. I was informed I was circumcised. And I found out my parents had no say one way or the other about it. The first time my mother bathed me she noticed it and asked why I was circumcised. Apparently, it was standard operating (pun intended) procedure to perform this on male babies. No opt out options. No discussion about it or even a passing mention of it. And I was born in the South! Circumcision was not that prevalent back then. So, I was operated on without my approval nor the approval of my parents.
As far as it being done to 85% of male babies at it;s peak. All I can say is except for one White boy and all the Black and Latino and Asian boys in my P.E. classes, all the other white boys were circumcised. Seems like it was a pandemic for White boys. Most of the Black, Asian and Latinos were born in the same hospital I was. They were not cut, but the White boys were. Talk about another impact of segregation.

I'm concerned that those who get circumcised for protection from STDs will think they're invulnerable and, as a result, having a higher rate of STDs because they neglect far more effective forms of protection (condoms). This is even assuming that it gives significant protection, which is dubious, in part because western nations that don't commonly circumcise (like Sweden) don't have STD epidemics, especially in comparison to western nations that do circumcise (USA). Most studies have been done in African nations where the rate is already fucking high and even if it is of benefit there it doesn't mean it is of benefit everywhere. It's a simple cost-benefit analysis. In one place the benefit is far greater so the high cost might be worth it, but that is not true in a place without an epidemic.

And this is completely ignoring the point that Gina brought up.