The CDC vs Penises

The latest federal medical guidelines for circumcision are now out, and they emphatically want to return to the era in which infant boys are routinely subjected to the surgical removal of their foreskins – and even adolescent and adult men encouraged to cut their penises. A couple of things need to be emphasized, it seems to me. The core argument is about lowering the risk of HIV infection:

“The first thing it’s important to know is that male circumcision has been associated with a 50 to 60 percent reduction of H.I.V. transmission, as well as a reduction in sexually transmitted infections such as herpes, bacterial vaginosis and the human papilloma virus (H.P.V.), which causes penile and cervical cancer,” Dr. Jonathan Mermin, director of the CDC’s National Center for HIV/AIDS, told The New York Times.

The evidence for this is entirely with respect to heterosexual sex, and in sub-Saharan Africa, where, unlike in the US, heterosexual sex accounts for the vast majority of HIV infections. It refers, moreover, only to those cases where men are infected by HIV-positive women – a small fraction of the total HIV cases in the US. You wouldn’t know this from Mermin’s statement – which seems to me designed to scare parents with the HIV boogeyman, rather than present them with a clear sense of the tiny potential health benefits involved. (There’s no evidence that circumcision can reduce the chances of HIV infection in gay sex, which accounts for the big majority of US HIV infections.)

To flesh out its case, the CDC cites a statistic that estimates that 10 percent of HIV infections in men can be attributed to female-to-male transmission in the US. It’s worth reiterating that these statistics are estimates, not actual numbers. And the actual number of men estimated to be at risk from this kind of infection is a mere 4,000 a year. Around 2 million boys are born in the US every year. So the future risk of an infant boy getting infected with HIV by a woman, using the CDC’s own argument, is 0.2 percent, or two in a thousand baby boys. And remember, we cannot know that these men were infected by women – it’s an inference – and self-reporting on the matter is extremely unreliable.

We have some other circumstantial data with respect to HIV transmission and circumcision in the West. The AIDS epidemic was far worse in the US – with much higher rates of circumcision – than in Europe, where the infant mutilation was far less prevalent. We’ve also seen a major shift downward in circumcision rates in the US and no sudden upsurge in infection rates. Then there’s the simple fact that we now have a non-surgical preventative daily pill that prevents HIV infection, as well as condoms, providing a way for men to protect themselves from HIV without permanently scarring their dicks.

Somehow, none of this context is spelled out in the recommendations. Neither is any non-medical concern – such as not having your body permanently mutilated without your consent. The impact on sexual sensitivity is also unmentioned – because pleasure has no place in assessing mere medical costs and benefits. The reductions in the risk of getting herpes or HPV are also minimal. If I were to offer any recommendations for the final report on this, it would be for the real and minuscule potential medical benefits of circumcision to be spelled out more clearly, and the non-medical costs to be weighed at least in part. When the potential benefits of this are so marginal, the case for doing nothing – and doing no actual harm – seems to be a powerful one.

(Cropped sidebar image by Flickr user Shira Gal)