This week, the Centers for Disease Control and Prevention released new draft recommendations for health-care providers on how to counsel patients and parents through the decision on whether to circumcise.
The underlying message in the document was clear: the benefits of the procedure — including reducing one's risk of acquiring HIV, herpes virus, and human papillomavirus — outweigh the harms.
While CDC officials emphasized that the choice is still left to patients, the document suggests the parents of newborn boys, as well as heterosexually active men of all ages, be told about those benefits. (No definitive data exist on the benefits or harms of circumcision for men who exclusively have sex with men.)
We spoke to Rick Elion, an HIV specialist and clinical-research director at the Whitman-Walker Clinic in Washington, DC, for some clarity on the draft recommendation.
Julia Belluz: If this draft guidance is passed, how would it change the public-health discussion about the impact of circumcision?
Rick Elion: For the longest time, there was all this discussion that there’s no medical benefit to circumcision. Over the last five to seven years, there's an increasing amount of evidence that circumcision has its benefits for health. Of course, there's a cultural barrier, independent of that, which is maybe a strong enough reason not to do a circumcision. But you can’t now say circumcision as a whole doesn't confer some health benefit.
JB: One of the benefits cited in the CDC document is a 50 to 60 percent risk reduction in contracting HIV. But the studies the CDC cites have come from Sub-Saharan Africa, where HIV is widespread. Do those results really apply to the US population?
RE: The absolute risk of acquiring HIV is way less here because there's less HIV. You can say that people in Africa have this great benefit. It's possible that people in the US could have a comparable benefit but it's difficult to extrapolate in a situation where the overall prevalence is so much lower.
We have learned from Africa that this procedure is helpful, we know it has value and benefit, and people should consider it. But CDC is not saying everybody should get it. You can’t look at that data and say it’s better that people don't get circumcised. Circumcision is absolutely better for health. But does that mean people should go run and do it? No. It doesn't mean that. I think the point of the CDC guidance is for individuals and families to look at the role of circumcision in preventing disease.
JB: Can you briefly describe why are circumcised penises are less infectious than uncircumcised penises?
RE: The secretions — it's called the smegma, or the gook that stays in the nook and cranny between the penis and foreskin — serves as a focus for low-grade inflammation. Any cells that are inflamed are more susceptible to HIV infection compared to uninflamed cells. So the nature of that obstruction, the geography there, make it hard to clean everything out and avoid inflammation. Circumcision removes that obstruction.
JB: One of the strange things about the proposed CDC guidance is that they suggest adolescent — and even adult — males consider the procedure. But research has shown that the risk of complications in infants (0.4 percent) increases more than ten-fold in boys and adolescents. How should grown males interpret this data?
RE: The morbidity, discomfort, and pain of having a circumcision for an adult is not insignificant. So people need to think about that before they decide what to do. That's different than for the newborn. With newborns, it's a much smaller scale operation, there are less nerves. The pain is still an issue — having performed circumcisions myself — but babies get over it quickly. For sexually active adults, they have to do a risk-benefit analysis and look at the role of other preventive strategies besides circumcision and find out what's best for them.