Oct. 8--Circumcision has long been a personal decision left up to parents. Doctors say the risks and benefits are negligible. The American Academy of Pediatrics does not take a stance.
But now a health agency is preparing recommendations on circumcision based on new findings regarding HIV transmission. The proposal from the U.S. Centers for Disease Control and Prevention is expected this year.
The focus on circumcision follows findings from sub-Saharan Africa, where death rates from AIDS are highest and studies have shown that circumcised men reduce their risk of infection by half.
Early reports from the CDC have stressed that any recommendations will be voluntary, and may only include advice for doctors on educating parents about infant circumcision. Experts at the CDC could also issue guidelines for uncircumcised adults who may be at risk for HIV infection.
Critics say the information from Africa does not apply to the U.S., where any benefits to promoting circumcision would be modest at best. In Africa, men primarily contract the virus through sex with infected women. Circumcision has not been shown to be effective in preventing transmission of HIV through homosexual contact, which is the most common cause of infection in American men.
Other medical benefits have been deemed minimal. Circumcised boys develop fewer urinary tract infections in their first year (about 1 in 1,000) compared to uncircumcised boys (1 in 100). The risk of penile cancer is reduced in circumcised men, although the overall risk of the disease remains very low.
Circumcision, or removal of the foreskin surrounding the tip of the penis, involves pulling and clamping the skin to cut off blood flow before making the incision. The 10-minute procedure is usually done before the baby leaves the hospital. Doctors routinely use anesthesia to reduce pain, and complications are rare.
Some doctors worry that advocating circumcision as a prevention against a sexually-transmitted disease could backfire by discouraging condom use and promoting a false sense of security.
"There is certainly a significant risk that individuals will think, 'If I'm circumcised I don't have to worry about HIV,' " said Dr. Ericka Hayes, a director of the HIV clinic at St. Louis Children's Hospital. "You still have to do all the same precautions to prevent HIV transmission as before."
The recommendations on circumcision will arrive at a time when the procedure is becoming less common in the U.S. In the 1960s, circumcision rates peaked at 85 percent. Now, about half of American baby boys are circumcised, according to the Agency for Healthcare Research and Quality.
Circumcision rates vary widely by region, partly due to immigration trends. In St. Louis, local hospitals report circumcision rates of 75 percent to 90 percent. But doctors here say parents have started to ask more questions about the procedure.
Most parents who opt not to circumcise their sons see it as an unnecessary or unnatural intervention. Those who choose the procedure generally do so for reasons related to religion or social conformity, doctors say.
One local doctor doubts that any medical recommendations from the CDC will impact parents' decisions.
"Safe sex is a better prevention for STDs," said Dr. Joseph Kahn, chief of pediatrics at St. John's Mercy Children's Hospital.
Circumcision is not the only intervention for children that can have implications on their sexual health down the road. Infants get vaccines to prevent hepatitis B, which is generally transmitted the same ways as HIV. Pre-teen girls can be inoculated against some forms of human papillomavirus (HPV), a sexually-transmitted disease that can lead to cervical cancer.
Parents ask more questions about hepatitis B than any other vaccine, Kahn said, mostly on why an infant needs to be protected from a disease transmitted through drug needles or sex.
Kahn tells parents the vaccine is safe and highly effective.
"Universal immunization has made a big difference in hepatitis B," Kahn said. "From a public health standpoint, it makes sense to immunize babies against illnesses."
Most parents agree. Kahn estimates that more than 99 percent of babies born at St. John's receive a hepatitis B shot before they leave the hospital.
The HPV vaccine is a tougher sell. Parents don't want to think about their daughters catching a sexually transmitted disease, doctors say.
Hayes said there is no data to support the theory that the HPV vaccine promotes promiscuity, a concern among some parents. Sexual activity among teenagers has been on the decline. Still, one-half of high school students report having had sex, according to the Centers for Disease Control and Prevention.
"You can either stick your head in the sand, or say there is a possibility that this could occur to my child so let me take the steps to protect them," Hayes said.
By some estimates, more than half of eligible pre-teen girls receive the HPV vaccine.
Pam Singer of Chesterfield said she did not want her children, now 18 and 21, to receive hepatitis B or HPV vaccines because she had concerns about the long-term safety and effectiveness of the vaccines.
"I felt like if my kids are having sex or using needles in middle school I have a lot bigger concerns than hepatitis B," Singer said. "You don't put more chemicals in someone's body, you should be putting good information in their head."
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