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.
Why the African Studies Are Unreliable
DOC: Facts About Alleged Medical Benefits of Circumcision
The Cochrane Collaborative