Lizzie and Matthew didn’t give circumcision a great deal of thought when their first son, Oliver, was born last November. They were always planning to have it done, not for any philosophical reason, but because it seemed like a sensible, routine thing to do. “I was neutral, and my husband was kind of keen,” says Lizzie. “He and his family thought it was the right thing to do, for hygiene reasons.”
The couple live in London, although both have American roots. Matthew was born and raised in Missouri. Lizzie is English but her mother hails from the US – and is Jewish. For them, the snip was just that – a part of the normal course of events. “Everyone in the States pretty much has it done,” Matthew says. “I just took it as a matter of course.”
But the couple’s London friends saw the whole thing in a very different light. When Lizzie raised the subject, their responses were overwhelmingly negative. “All my friends thought it was a bit barbaric,” she says. “They seemed really surprised we were considering it.”
Still, the new parents weren’t swayed. “I took it that it was more sanitary,” says Matthew. The issue became more troubling when they began looking for a clinic in London to carry out the procedure. They tried internet searches and telephone directories, and quizzed their healthcare providers – all to no avail. “Finally, I asked a maternity nurse who told me she knew of a place,” Lizzie says.
The couple learned that The Portland Hospital, a private facility in central London, had an arrangement with a doctor who came one day a week to perform circumcisions for a fee that ran to hundreds of pounds – considerably steeper than they would pay in the US. They made an appointment and turned up at the hospital on the day, only to discover nobody knew where they should go. “Even when we arrived, most of the hospital staff didn’t know about it,” remembers Lizzie. “It was such a behind-closed-doors thing, it was so strange.” Eventually, they found the doctor and the right room and little Oliver underwent the procedure.
It was hard to hear him crying during the event itself, Lizzie remembers, but he seemed to get over it without any lingering effects. If anything, it was Matthew who suffered. “Afterwards, I couldn’t change his diaper,” he says. “I couldn’t bear to see it, it was a kind of bloody stump.”
A couple of months after Oliver’s ordeal, the world’s media reported perhaps the most significant news about the health benefits of circumcision in recent decades. In March, the World Health Organisation and the Joint United Nations Programme on HIV/Aids (UNAids) urged countries to consider implementing circumcision programmes to combat Aids. The scientific basis for that statement was the combined evidence from three substantial clinical trials conducted in Africa that compared the rate with which circumcised and uncircumcised heterosexual men contracted HIV. The studies – one in South Africa, another in Kenya and a third in Uganda – showed that men who had been circumcised had a roughly 60 per cent lower risk of becoming HIV positive than their uncircumcised counterparts.
The evidence of a protective benefit was so compelling that researchers stopped the three trials early, the first in April 2005 and the others in December 2006. It would have been unethical, the researchers decided, to continue denying the uncircumcised men in the control group the protection offered by the procedure.
The strength of the result was remarkable, says Tim Hargreave, a urologist from Edinburgh, who has written the WHO/UNAids manual on performing circumcisions. “I do not know of any medical intervention, ever, where three randomised clinical trials had to be stopped early because it was so effective that it would be unethical to go on denying some people treatment,” he says. “It’s unprecedented.”
When I reached Hargreave by phone at his office in Scotland in early June, he was preparing to fly to Lusaka, where the WHO and its partners were planning to run the first field test for a programme to circumcise men aged between 18 and 22 years. “The age at which most men acquire HIV is 22 to 24,” he explains. “In countries with high prevalence of HIV, cost-benefit analyses would suggest circumcising this group is the most cost-effective thing that can be done.”
Circumcision is a procedure with a long history. Ancient Egyptian paintings on temple walls offer the earliest documentary evidence of men with their foreskins being removed, taking us back 4,000 years or more. But the practice probably existed long before that, among tribal cultures in places such as Australia, the Pacific Islands and parts of Africa, where the foreskin was removed at or around puberty as part of a ritualised passage to manhood.
Today, roughly one man in three worldwide is circumcised, according to UNAids. But the blanket figure hides a world of diversity, much of which can be explained by the religious and tribal roots of the practice. For example, circumcision is almost universal in north Africa and most of west Africa, but is seen in only 15 per cent or so of men in Botswana, Namibia, Swaziland and Zambia (UNAids estimates that 35 per cent of men in South Africa are circumcised). Similarly, almost all men in Muslim countries in the Middle East, central Asia, Indonesia and Pakistan are circumcised; about two thirds of all circumcised men are Muslims who have had the operation for religious or cultural reasons, says Catherine Hankins, chief scientific adviser to UNAids. (The rite is also practised on religious grounds by Jews and in some branches of Christianity.)
But there are other sources of variation in global circumcision rates, ones that cannot be explained by religion. According to UNAids, roughly 13 per cent of all men circumcised worldwide are American, while very few are European.
As those figures show, when it comes to circumcision, location is destiny. To understand why, historians look back to Victorian England, the era when circumcision for medical reasons first gained popularity. It was during the mid-19th century that substantial numbers of doctors in English-speaking countries first began performing circumcision, says Robert Darby, a medical historian whose book, A Surgical Temptation, charts the story of medical circumcision.
Darby describes how the medical fraternity turned against the foreskin at that time. Where previously it had been considered something normal and valuable, the Victorians began to view it as an appendage that was downright dangerous, blaming it for everything from syphilis to masturbation and bed-wetting. Absurd in hindsight, perhaps, but doctors in Britain’s former and current colonies seem to have listened with sympathetic ears; circumcision for “medical” reasons soon flourished in Australia, Canada, the US and beyond.
In Britain, the vogue seems to have been short-lived. By Christmas Eve 1949, when the British Medical Journal published an influential article on the disadvantages of the procedure (complications include infection and haemorrhage), circumcision was already well in decline, at least outside the upper classes. By the end of the 1960s, it had all but ended other than for religious reasons. In the US, however, and to a lesser extent, Australia, the decline of circumcision was slower. In Australia, it reached a peak in the 1950s, when the vast majority of boys had the operation, before declining to differing degrees across the country. The rate now stands at about 10 per cent.
In the US, its popularity was much longer lived, and 1999 circumcision rates nationally were about 65 per cent of newborns, according to the National Hospital Discharge Survey, below the peak rate of 80 to 90 per cent a few decades ago.
The rate at which newborns are circumcised may vary across the western world, but most mainstream medical societies’ positions on the practice broadly agree: in the UK, Australia, Canada, New Zealand and elsewhere, the relevant bodies say that, for the most part, there is no good clinical reason to subject infants to it. “There is no medical indication for routine neonatal circumcision,” the Royal Australasian College of Physicians says, although it adds that circumcision significantly reduces the risk of urinary tract infections (which affect fewer than 2 per cent of boys) and penile cancer, which affects one in 100,000 men in developed countries. Balanced against a complication rate from circumcision of up to 5 per cent, the Australian doctors say, it just isn’t worth it.
Medicare, Australia’s universal health insurance programme, will cover circumcision if the patient’s doctor considers it “medically relevant”, a spokesman said.
In the UK, the NHS will also only cover circumcision in cases where it is medically necessary. Members of the Muslim community have been unsuccessful in their attempts to have the NHS offer circumcisions to ensure their sons aren’t subject to unsafe procedures.
Even in the US, the American Academy of Pediatrics (AAP) changed its policy in 1999, from routinely recommending circumcision to a neutral stance that leaves it up to the parents to consider “cultural, religious and ethnic traditions”. But religion is not the only cause of variation. Hankins believes many parents are motivated by “social desirability”, including a feeling among new dads that they want their sons to look like them, or a concern that the boys become the butt of locker-room jokes for not fitting in with the crowd, be they circumcised or not.
The acceptability of male circumcision among women is just as important, says Hankins, citing research in Africa that shows that many women would be happy for their husbands to be circumcised. In the west, the issue of what women prefer when it comes to their partners’ privates is open to debate, though little sociological research exists on the subject.
Within the scientific community, meanwhile, circumcision – one of the most common surgical procedures in the world – spurs arguments that can tend toward the vitriolic. Brian Morris, a scientist from Sydney, Australia, and one of the most prominent members of the pro-circumcision camp, argues that HIV is just one item in a long list of conditions circumcision can prevent. Morris isn’t a medical doctor. He’s a molecular biologist who researches the basis of ageing, cardiovascular disease and cancer. But he became interested in circumcision in the 1980s when he was researching cervical cancer and came across evidence that circumcised men were less likely to pass the causative agent, human papillomavirus, on to their partners.
“That’s a major, major issue for Australia and other western countries,” he says. (Such an issue that Australia, along with other countries, has recently begun vaccinating girls against the relevant strains of the virus. The UK’s Department of Health has agreed, pending further cost-benefit analysis, to introduce routine vaccination of girls aged around 12 to 13 years. In the US, vaccination faces opposition from people who think it will encourage girls to have sex younger.)
As he looked into the issue, Morris says, he came up with more valid medical arguments for circumcision. He refers me to research papers showing that circumcised men are at reduced risk of prostate cancer, penile cancer and other conditions, and he argues that the policies of doctors’ groups do not tally with the evidence. “I’m a scientist and I want people to get the truth, rather than fiction,” he says. “There’s a lot of anti-circumcision propaganda that has affected doctors. These anti-circumcision people have killed a lot of people with their nonsense.”
Morris says he has the backing of many eminent scientists, but he also has his critics. Tim Hargreave says: “To my mind, he’s a good scientist, but he’s a bit of a fanatic and falls into the trap of coming on a little strong.”
Coming on strong is hardly limited to the pro-circumcision camp. One doctor I spoke to listed eradicating newborn circumcision as the fourth great human rights challenge in the history of the US – after slavery, women’s right to vote and equal opportunity education for minorities. George Denniston, a retired physician who has spent most of his life running family planning clinics in Seattle, Washington, says: “It’s a massive human rights violation ... inflicting pain on another human being is torture.”
Denniston founded the group Doctors Opposing Circumcision. He tells stories of young men who have contacted him unhappy, bitter and psychologically damaged by their circumcision. “I’ve had men come up to me and say, ‘if I could find the man who did this to me, I wouldn’t hesitate to put a bullet through his head,’” he says.
What of the millions of men who have been circumcised yet feel no murderous tendencies? They’re in denial about their loss, according to Denniston. What’s more, he dismisses the idea that circumcision can prevent HIV. “For the past 100 years, circumcisers have found the most scary thing they can find and used it as something to defend circumcision.”
Denniston falls well outside the pack on the subject of circumcision and HIV prevention, but another of his concerns is less outlandish: the question of whether circumcision has any impact on “sensation”. In recent months, two scientific papers have been published on the topic, with conflicting results. The first came from Kimberley Payne of the Riverside Professional Centre in Ottawa, Canada, and her colleagues. They tested the sensitivity of 20 intact and 20 circumcised men by touching their penises with filaments as the men watched erotic movie clips. Their paper in the Journal of Sexual Medicine reported no difference in penile sensation between cut and uncut men.
But when circumcision critic Robert van Howe, of Michigan State University, and colleagues used a similar method to measure sensitivity at 19 points along the penises of 163 men, they found just the opposite. Writing in the British Journal of Urology International, they said that the five most sensitive points were all in parts of the penis removed by circumcision.
In principle, the HIV trials in Africa shouldn’t have much impact on the foreskin furore in the west. Scientists, UNAids and other sensible agencies stress that the Aids epidemics in the developing and developed worlds are different beasts. The number of people infected is much higher in Africa, and transmission routes vary (mostly heterosexual in Africa, mostly homosexual and drug-use related in the west).
That may be the principle, but in practice the African HIV trials are creating noticeable ripples among public health authorities and in the media. Although Tim Hargreave points out that “circumcision is not really an effective HIV prevention strategy in countries with low prevalence of HIV,” he acknowledges that the results could increase circumcision rates in countries such as the UK. “I think you’ll find organisations such as the National Institute for Clinical Excellence [which gives guidance on the use of new and existing medicines, treatments and procedures within the NHS] are likely to change their stance,” he says.
So far there’s no evidence of that kind of shift taking place in the UK. However, in the US, the Centre for Disease Control and Prevention has taken notice. Earlier this year, it published a statement on HIV and circumcision saying that, despite differences between the US and Africa, the recent trials suggest “male circumcision may also have a role for the prevention of HIV transmission in the United States.” Meanwhile, New York City officials considered offering the procedure to uncircumcised men: Adam Karpati, assistant city health commissioner in charge of HIV and Aids programmes, told the Daily News, “we see this as a potential, additional strategy.” In April, however, the city’s health commissioner, Thomas Frieden, wrote to The New York Times clarifying that there were no plans for a campaign to encourage men to get circumcised. “Like other domestic health agencies, we are encouraging people to discuss and study this issue,” he said.
Canadian authorities are planning to rewrite their policy on circumcision to take into account the HIV data, although a spokesman for The Canadian Pediatric Society told the Toronto Sun that the basic line will remain the same: circumcision of newborns is unnecessary on a routine basis.
Just as medical organisations in the west are incorporating the new HIV data into their policies, it is easy to imagine new parents thinking about it when deciding whether to circumcise their sons. “As a parent you’d weigh the rare chance of penile cancer, the risk of urinary tract infections and probably the chance of HIV,” says Catherine Hankin of UNAids. “I’m not sure that HIV will be the tipping point, but it might be part of the equation.”
Whether, in the end, those deliberations have any noticeable effect on circumcision rates is unclear. Hankins recalls that when US medical authorities changed their stance on circumcision from supportive to neutral, there was less effect than might have been expected. “It seems to depend more on social factors and customs than on what medical people have to say,” she says.
I ask Matthew and Lizzie whether the HIV data would have been important in their decision. It’s hard for them to say, considering they were planning to have Oliver circumcised anyway. “But I remember when the report came out,” Lizzie says. “We read about it and thought, ‘Ha! It was a good idea after all.’”
