By Roni Caryn Rabin
Doctors should start telling sexually active teenage boys who aren’t circumcised that if they have the surgery, they can reduce their risk of contracting H.I.V. and other sexually transmitted infections from their female partners, federal health officials propose.
Similar counseling is urged for adult heterosexual men who remain uncircumcised and for expectant parents who will be making a decision about newborn circumcision if they have a boy, according to the new recommendations, proposed by the Centers for Disease Control and Prevention.
Most American boys are circumcised as newborns, but the percentage of parents having their infants circumcised in hospitals has fallen in recent years, even as evidence from African studies suggests that it may be protective.
Circumcision has also come under fire, in part because babies cannot give their consent to the operation, with some critics saying the practice constitutes genital mutilation.
The draft of the recommendations, which will undergo peer review and be subject to public comments for 45 days before being finalized, note that teenage boys should be counseled along with their parents and have a say in the decision-making process, an element that may neutralize some opposition.
“Our role is to provide accurate information so people can make informed decisions,” said Dr. Jonathan Mermin, director of the National Center for H.I.V./AIDS at the C.D.C.
“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. Mermin said.
He emphasized, however, that circumcision did not entirely eliminate the risk of infections, and circumcised men must continue to take other precautions, such as using condoms and limiting sexual partners.
Whether teenage American boys or men will be persuaded to go under the knife is another question.
The C.D.C.’s own background report summarizing the scientific evidence cited a consumer study that found that only 10 percent of 709 heterosexual uncircumcised adult men said that they were “likely” or “very likely” to undergo circumcision, even if told it would reduce their risk of H.I.V. More than 80 percent said they were “unlikely” or “very unlikely” to undergo circumcision.
“It’s hard to imagine very many adolescents deciding to have a circumcision done,” said Dr. Douglas S. Diekema, a member of the American Academy of Pediatrics’ task force on circumcision, which in 2012 changed its neutral stance on infant male circumcision to say that the health benefits outweighed the risks. That report stopped short of recommending routine circumcision for baby boys.
While older adults may be more likely to opt for circumcision especially if they are engaged in a lot of risky sexual behavior, Dr. Diekema said, “It’s a difficult thing to get the adolescent brain to make that kind of calculation.” The conversation itself may also be extremely awkward for health care providers and their young patients, he said.
The C.D.C. report notes that circumcision also has risks that increase with age. An analysis found that fewer than 0.5 percent of newborns suffer complications from a circumcision, compared with 9 percent of children age 1 to 9 years, and 5 percent of those 10 and older, including adults. The most common complications included bleeding, inflammation, the need for corrective procedures and wounds, although there was no specific data about the rate of complications for teenagers.
While circumcision may protect men from infection by H.I.V.-positive women, it does not protect women from infection by men, and there is no definitive data that it protects men who have sex with men from infection.
Critics who oppose circumcision pointed out that the randomized clinical trials on which the C.D.C. is basing its recommendations were done in sub-Saharan Africa, where heterosexual transmission of H.I.V. is far more common than in the United States. Only about one in 10 new H.I.V. infections in the United States are transmitted heterosexually, according to the C.D.C. report.
Georganne Chapin, founding director of Intact America, a national group that opposes circumcision, argued that the United States had historically had much higher rates of circumcision than European countries, “but we still had comparable or even higher rates of sexually transmitted diseases than in European countries, where there is virtually no circumcision.”