CDC Offers Confounding Counsel on Circumcision

by Kait Scalisi | Dec 18, 2014 | News, Sex Stories

By Kait Scalisi, MPH

Circumcision has long been controversial, and new guidance from the CDC that clearly supports the practice may make it even more so.

Rarely will you find someone who feels indifferent about circumcision. More likely, the conversation will devolve into an argument and the topic of circumcision will be banned from future discussion. Many people have strong feelings about foreskin. Those who favor circumcision offer the following arguments:

• The health argument—”It’s cleaner and protects against STIs, including HIV.” (Maybe valid.)
• The aesthetic argument—”Have you ever seen an uncircumcised penis?! EW!” (Shaming much?)
• The daddy argument—”We want to make sure he looks like his father.” (Because every child has a dad…)
• The what’s-it-for argument—”I don’t know what to do with it!” (Valid + enlightening to the need for more comprehensive sex education.)

Recently, the CDC codified the first argument as fact in their latest guidance on the topic. Specifically, CDC recommends that healthcare providers counsel all uncircumcised, sexually active, straight males, adolescent males, and parents of newborn males on the risks and benefits of circumcision. One big thing to note here: As written, the guidance assumes that physicians are discussing sexual behavior with their patients. Research shows this is not the norm, especially for adolescents.

Now on to the risks and benefits. The CDC guidance concludes that the latter outweigh the former, citing the following compelling statistics in favor of circumcision:

Being circumcised reduces a man’s risk of getting

• HIV from a female partner by 50-60%
• herpes by 45%
• cancer-causing strains of HPV by 30%.

Women also are less likely to become infected with HPV, bacterial vaginosis, and trichomoniasis if their partner(s) are circumcised. There currently is no research showing that circumcision reduces STI risk among men who have sex with men (MSM) or reduces HIV risk to women.

On the other hand, the risk is minimal, with adverse events occurring in 0.5% of newborns, 9% of children, and 55% of adults.

The CDC also echos the sentiment that the procedure should be voluntary and take into account personal, cultural, religious, and ethical beliefs. While this is all well and good, you have to wonder whether this is just rhetoric given both that most circumcisions are done before a baby can consent and that many people take healthcare provider’s recommendations as law, particularly if such recommendations align with their other beliefs.

My biggest issue with this whole topic is the hypocrisy when citing this research. Public health is constantly poo-pooing studies for not being representative or generalizable, yet these guidelines are based on research performed in the developing world. This article provides a wonderful discussion of whether such research can and should be applied to US policy. Of note:

“If you consider the argument that circumcision might prevent HIV among ADULT men in third world country settings, it becomes a bit abstract to make the same conclusion for newborn boys in a developed world. This has always been the intangible factor, when the AAP changed its tone towards encouraging circumcision for newborns in the U.S. As such, having an adolescent make that choice, when presented with the possibility of a health benefit, does make more sense. The HIV prevention argument is far more relevant to an adolescent than to a newborn, so to encourage the inclusion of the adolescent population into this forum is appropriate.”

Another major issue is the message this guidance sends to uncircumcised adolescents. It feels contrary to the decades of messaging around condom use to prevent STIs. If all a teen boy needs to prevent STIs is a circumcised penis, then why deal with condoms at all? (Especially if condoms seen as reducing sensation and pleasure.) In other words, the CDC’s heavy focus on STI prevention as the motivator for this guidance gives teens one more excuse to skip condoms.

Lastly, given that the rates of HIV remain higher among MSM and circumcision offers no protection for such sex, it will be interesting to see whether this guidance ultimately impacts HIV rates overall.

The CDC guidance is currently open to public comments. To add your opinion, click here.

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