Fierce debates about male circumcision are taking place across the USA, with some groups claiming that the procedure is a human rights violation with no health benefit. Nellie Bristol reports.

For Lisa, a 35-year-old engineer from a suburb of Detroit, MI, USA, the issue was worth getting a divorce over. Pregnant and expecting a boy, Lisa's husband was insisting his newborn son undergo circumcision. “I just knew that I couldn't harm my baby like that. I didn't think it made sense”, she said.

She tried the rational approach to persuasion, researching circumcision on the internet and providing her husband with pages of highlighted material to read. Although he did not engage in either the research or conversation about the topic, he did finally agree to Lisa's approach and the procedure was declined.

Not all of the disagreements in the USA on whether to surgically remove the foreskin of newborn boys have been resolved so amicably. In California, anti-circumcision groups gathered more than 7000 signatures to get on the ballot in San Francisco a provision that would outlaw the practice. However, a judge blocked the proposal in July on the grounds that only a state can regulate a medical procedure. Democratic Governor Jerry Brown attempted to thwart any similar efforts by signing legislation in October prohibiting local governments from banning circumcision. Still, the debate continues—18 states have now eliminated Medicaid insurance for male circumcision.

Although precise figures are elusive, the proportion of infants who are circumcised in the USA is slowly falling, with in-hospital rates of about 55–57%, according to the US Centers for Disease Control and Prevention (CDC). WHO says 30% of males are circumcised globally. Two-thirds of those are Muslim. In Europe, the rate is less than 20%.

In the USA, the surgery generates heated battles, with those against it referring to it as genital mutilation and a human rights violation, but others arguing for it based on religious beliefs and potential medical benefits including fewer sexually transmitted and other diseases.

For an outspoken group of activists, the benefits absolutely do not outweigh the risks. “About a million people a year, newborn babies, lose a normal, healthy, functional, pleasurable, protective body part without their consent”, said Georganne Chapin executive director of of Intact America, an anti-circumcision advocacy group.

No doubt the debate will continue and likely intensify since both the CDC and the American Academy of Pediatrics (AAP) are reviewing their recommendations for the procedure, and could inch toward stronger support for it. Douglas Diekema, a paediatric bioethicist serving on AAP's Task Force on Circumcision, said a lot of new data have emerged since the group's last look at its recommendation in 2005 and this could at least result in a “change in tone” in the guidance. The current statement is fairly neutral. “Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision”, it says.

Although he does not expect a “radical departure” from earlier statements, Diekema said, “My sense is that the data that's new since [the recommendation] was written is more supportive of the preventive role of circumcision in regard to some sexually transmitted diseases like HIV and HPV.”

That stance is sure to provoke so-called intactivists who challenge African studies showing lower rates of HIV infection in circumcised men having sex with infected women. Chapin and others say that the studies were inadequately replicated, tinged with the cultural bias of circumcised men, and are less applicable in the USA where HIV rates are lower and weighted toward men who have sex with men. They say that doctors continuing to provide the procedure at an estimated US$200 per patient are driven by greed, an argument Diekema characterised as “a little ludicrous”.

recent commentary in the Journal of the American Medical Association noted that observational studies in the USA show that male circumcision is associated with a reduction in risk of men acquiring heterosexual HIV. Additionally, the authors drew attention to a 2010 cost-effectiveness analysis that showed that neonatal male circumcision in the USA was projected to increase the quality-adjusted life-years and was estimated to be cost-saving due to reductions in HIV infections and treatment costs.

Many Americans remain removed from the debate and continue to have the procedure done out of tradition or because their father was circumcised.

Diekema suggests a more thoughtful approach. “Parents should probably be wary of anybody who has a strong opinion”, he said. “What they really want is a physician who has a balanced view of this, who recognises and can share with them what the potential benefits are to their child, but also will share with them what the risks of the procedure are, which include the fact that it does take the choice away from the child.”

Copyright © 2011 Rich Pedroncelli/AP/Press Association Images