Circumcision is in the spotlight again after a German court ruling has pit those who support it for religious and health reasons against those who say boys should have the right to decide for themselves. Lost in the debate is a growing body of recent data that shows circumcision is helping prevent the spread of AIDS in Africa.
"The evidence is overwhelming, at least in low- and middle-income countries that have important HIV epidemics," said David Cooper, director of the Kirby Institute in Sydney, Australia's biggest HIV research center. "It's really important that, given there is a benefit, parents have a choice."
Since a Cologne district court in May opposed religious circumcision after a Muslim boy fell ill after having his foreskin removed, Muslim and Jewish leaders have denounced the ruling as an encroachment on freedom of religion. The controversy has been especially fraught occurring in a country whose history is shadowed by the deaths of an estimated 6 million Jews during the Holocaust in World War II. To diffuse the tension, German legislators on July 19 passed a resolution calling on the government to draft a law explicitly permitting the practice.
While the debate rages on, evidence is mounting that supports what some doctors already consider prudent medical reasons for having the procedure: It eliminates a hiding place for bacteria and viruses. A circumcision program in Orange Farm, South Africa, may have averted 536 infections last year among 52,000 men there, according to estimates presented at the International AIDS Conference last week. An earlier analysis showed the program had reduced the rate of new HIV infections by 76 percent.
Approximately 30 percent of boys and men are estimated to be circumcised globally, of whom an estimated two-thirds are Muslim, according to the Geneva-based World Health Organization.
Circumcision is picking up in Africa as a pragmatic health measure to ward off disease. More than 40 Zimbabwean lawmakers volunteered in June to be circumcised as part of a campaign to boost AIDS awareness. About 500,000 men have been circumcised in Africa since 2008 in programs funded by the U.S. President's Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria, according to Bertran Auvert, a public-health professor at the University of Versailles outside of Paris.
In addition to curbing HIV infection, the practice also reduces the chance of getting genital herpes and human papillomavirus, according to a study published in the New England Journal of Medicine. The results prompted Thomas Quinn, chief of the International HIV/STD section at the National Institute of Allergy and Infectious Disease, to urge U.S. policy makers to make circumcision available to all boys if their parents choose to have it done.
The same study also showed that women may benefit from a man's circumcision. The circumcised men in the study were 35 percent less likely to get HPV, which causes genital warts and cervical cancer in women. About three-quarters of U.S. adults have had at least one HPV infection, according to the 2009 study.
Circumcision also may reduce the risk of prostate cancer, according to research published in the journal Cancer in March. There is also "substantial evidence" that the procedure protects against urinary tract infections, syphilis and invasive penile cancer, the WHO said in a report.
Men shouldn't be denied circumcision if requested, as long as there is no medical reason to avoid it, the WHO has said. Removing the foreskin early in a child's life carries a lower risk of complications as well as lower costs compared with performing the procedure on adults, according to the United Nations health agency's manual on infant circumcision.
The WHO estimates that circumcision of newborns has a 0.2 percent to 0.4 percent rate of adverse events, noting differences between religious circumcisions in clinical settings, which it says are generally risk-free, and procedures undertaken in unhygienic conditions, which can result in serious complications and even death.
Two newborn boys died in New York between 2000 and 2011 after being infected with herpes simplex virus as a result of out-of-hospital ritual circumcisions, according to a June 8 report by the U.S. Centers for Disease Control and Prevention in Atlanta.
"One important advantage of infant male circumcision is that the procedure is simpler than that performed on older boys and men because the penis is less developed and the foreskin is thinner and less vascular," the WHO said in the manual. "Healing is quicker and complication rates are lower."
Circumcision of newborn boys is common in Israel, the U.S., Canada, Australia and New Zealand, and in much of the Middle East, Central Asia and West Africa, the WHO said.
Even in the U.S., where more than 50 percent of newborn boys were circumcised between 2000 and 2010, there is controversy. Efforts to ban circumcision in San Francisco and Santa Monica, California, were blocked in July 2011 by a state judge who ruled that cities have no power to regulate a state- licensed medical procedure. In October, Governor Jerry Brown signed a law prohibiting local governments from enacting such measures.
The American Academy of Pediatrics leaves the decision of circumcision up to the parents, neither endorsing nor opposing the practice, though it does say in its position statement that the procedure may reduce the risk of bladder infections and HIV.
The Kirby Institute's Cooper authored a paper in the Medical Journal of Australia in 2010 calling on the Royal Australasian College of Physicians to reverse its policy of recommending against the routine circumcision of newborn boys.
The Finnish Medical Association opposes circumcision of infants for non-medical reasons, arguing that it risks the health of the infant as well as his physical integrity. In the Netherlands, the Royal Dutch Medical Association opposes religious circumcision because it may lead to medical and psychological complications. If it helps prevent HIV, the association says, parents should delay circumcision until the male is sexually active and can decide for himself.
"Our departure point is that you are cutting healthy flesh from a minor who has not consented to it," Lode Wigersma, director of policy at the Dutch doctors' group, said in a phone interview. "When you remove that tissue, you can cause complications. We are aware that there are studies supporting prevention of certain diseases but there are many medical experts that find those studies inconclusive."
Some mild adverse effects may occur, especially when circumcision is done when the patient is older or when the practitioner hasn't been properly trained, according to a review of more than 50 studies published in 2010. Severe complications are rare, the review found.
While there is widespread concern that male circumcision can diminish male and even female sexual enjoyment, recent studies show no signs of that, according to WHO. Two trials that evaluated at least 4,000 adult males each found that circumcision didn't adversely affect sexual pleasure, WHO said in a manual for male circumcision.
In Germany, home to about 4 million Muslims and 110,000 Jews, the legal controversy began in November 2010, when a Muslim couple living in Cologne asked a doctor to circumcise their 4-year-old son. The doctor circumcised the boy using a local anesthetic and closed the wound with four stitches. Two days after the procedure, the mother rushed her son to the hospital after the wound began bleeding. The hospital contacted the police, who started an investigation that led to bodily harm charges against the doctor.
While the Cologne court acquitted the doctor in its decision because the law wasn't clear at the time, it ruled male circumcision, even when done properly by a doctor with the permission of the parents, should be considered as bodily harm if carried out on a boy unable to give his consent.
The child's body would be "permanently and irreparably changed," the court said in its decision. The procedure goes "against the interests of a child to decide for himself later on to which religion he wishes to belong."
Following the ruling, the German Medical Association asked its members not to perform circumcisions for religious reasons until the law was clarified. The group also warned that the decision may spur parents to turn to non-professionals to perform circumcisions, increasing the risk of infection through poor hygiene.
The controversy has spread to Switzerland and Austria. Two Swiss hospitals this month suspended the practice of performing circumcisions after the German court's decision, and the governor of Austria's Voralberg province told state-run hospitals to stop the practice until laws are clarified.
Many Turks living in in Germany with newborn male babies are flying back to their home country for circumcision, which is performed on boys ages 2 to 14 and is often accompanied by festivities, said Serdar Yazar, a member of the interest group Turkish Community in Germany.
European rabbis told Jews on July 12 they should keep circumcising their boys and ignore the court ruling. Circumcision "is a basic law of the Jewish faith," Pinchas Goldschmidt, who heads the Conference of European Rabbis, told reporters in Berlin after a three-day meeting.
Esra Weill, who has been circumcising Jewish baby boys for the past three years, said many Jewish families with newborn boys are apprehensive, holding off until they get a clarification from the German government.
"Why target this indelible part of our culture?" said Weill, a Basel, Switzerland-based mohel, or ritual Jewish circumciser, who is registered to practice in both Switzerland and Germany. "It's not necessarily bad that we are having a dialogue about this, but ultimately I don't think it could be stopped."