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Circumcision Pros And Cons: 'Intactivists' Take On Traditional Ritual

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CIRCUMCISION INTACTIVISTS

A video begins with tight shot on a young man in his thirties, wearing a grey hooded sweatshirt and brown cap pulled down over his ears. His voice is quiet, but steady, and he smiles shyly as he speaks, his goatee curling slightly at the corners.

"I consider myself a normal guy, who was born in the 70's and grew up in a very modest, or poor background, out in rural America and came up in that normal, traditional lifestyle," he says. He spent some time in the military, he adds, went to college, got a job and started a family.

But several minutes in, the tone shifts.

"If I were to say -- since I'm a veteran and I've been to combat -- if I were to say to someone else that it's a common practice in war that we take our prisoners and strip them down against their will, strap them to a table against their will, and we cut off half the skin of their penis," the young man says, looking into the camera. "If I were to say that, I would be charged with a war crime, but yet this is one of the most common practices in the U.S. ... and it's torture."

"Confessions of a Circumcised American Dad" is just one of many videos posted on YouTube by the group The WHOLE Network, which bills itself as a grassroots network of "intactivists." Though definitions vary slightly from group to group, intactivists generally define themselves as people who stand in opposition to the practice of genital circumcision in both girls and boys.

In the U.S. there are several such groups, but perhaps the most visible is Intact America, a non-profit founded in 2008. On its website the group claims to stand in opposition to "medically unnecessary genital alteration, whether carried out for cultural conformity or profit, in medical or non-medical settings."

Currently, the three most common methods of circumcision in newborn males are the Gomco clamp, the Plastibell device and the Mogen clamp. Though the exact procedure varies, in each the skin covering the tip of the penis (or foreskin) is removed. Circumcisions are often performed for religious or cultural reasons, but they are also widely performed as a means of preventive health care. And it this last concept that groups like Intact America most vehemently oppose, saying there is absolutely no medical reason to perform circumcisions, and even some risk. (The Kaiser Medical Group estimates that the complication rate associated with circumcision is around 2 percent and can include infection, bleeding, pain and injury to the penis, as well as rare, more serious problems.)

"The rest of the world doesn't do this for medical reasons." said Georganne Chapin, executive director of Intact America. "Countries that have better health status and spend far less on healthcare would no more line up their baby boys and cut off their foreskins than they would poke out their eyes."

In 2007, the World Health Organization estimated that only six percent of the male population age 15 and older (and non Jewish or Muslim) in the UK was circumcised, versus 75 percent in the U.S. But establishing an accurate domestic rate is difficult. The best source of data is the National Hospital Discharge Survey (NHDS), a collection of inpatient records from 239 non-federal, short-stay hospitals across the country. However, it fails to include data from circumcisions performed in a doctor's office or by a mohel -- a person trained to perform Jewish circumcisions.

At a 2009 AIDS conference in Vienna, a Centers For Disease Control researcher made a presentation that put the current U.S. infant male circumcision rate at 33 percent. Intact America pounced on that figure, saying it was much more in line with their perception and was indicative of a shift away from circumcision. But Scott Bryan, a media representative in the CDC's Office of Planning and Policy Coordination says that the figure was never meant to serve as an official estimate. "The data used to create the estimate has several limitations and gaps for calculating overall prevalence," he wrote in an e-mail, "It has been erroneously reported as a new CDC prevalence estimate, however, it was never intended to be an official CDC estimate of infant male circumcision."

The most recent NHDS estimate put the prevalence of infant male circumcision at 56.5 percent at the end of 2008, and Bryan said that does represent a decline in the last decade; the rate was closer to 60 percent in 1998.

"Given that it is a fairly modest decline, we [the CDC] don't have a definitive answer on what all the factors are," Bryan said. But he listed some possibilities, including shifts in parental preferences as well as the fact that fewer Medicaid plans cover circumcision.

For her part, Chapin believes that much of the decline in infant circumcisions is also due to groups like hers, which actively campaign against it. Intact America is spearheading a "Put Down The Knife" campaign, during which it claims to have sent e-mails to more than 100,000 members of the American College of Obstetricians and Gynecologists and American Academy of Pediatrics (AAP), urging doctors to reconsider performing circumcisions. With more than 60,000 pediatrician members, the group holds great sway over health care for children in the U.S.

It is not the first time the group has targeted the AAP, which is in the process of revising its official stance on circumcision. In its current form, it states that there are potential medical benefits, but not enough data to recommend routine, neonatal circumcision.

The process of revision is involved and has been ongoing for several years. The AAP convened a task force to examine all new pertinent medical studies.

"What's new since the last time a policy was written?" asked Douglas Diekama, director of education at the Treuman Katz Center for Pediatric Bioethics in Seattle and a member of the task force. "The strongest data is whether there's a benefit with regard to certain infectious disease and circumcision status. The data from Africa is pretty clear that under that setting, which is admittedly very different from than in the U.S., but in the African studies, there's a reduction in the transmission of HIV that's pretty substantial."

According to the CDC, those studies -- which were published in several journals -- looked at groups of adult males in various parts of Africa to determine whether or not medical circumcision reduced their risk for HIV infection. Researchers reported that in Uganda, participants who underwent the procedure had a 55 percent reduction in the risk of HIV infection compared with their non-circumcised counterparts, while those in Kenya had a 60 percent reduction and those in South Africa had a risk reduction rate of 76 percent.

Chapin claims that these studies are "bogus" saying that they should not be extrapolated to larger populations, particularly to the U.S. where conditions are entirely different. But Diekama says that the task force subjected all studies to exhaustive scientific review. It also considered those that made claims for other potential benefits, like reduced risk of Urinary Tract Infections. Once finished, the task force will put together recommendations and conclusions, which will then be subject to further review by the AAP and its board -- a process Diekama says can take up to another three months.

When the new policy eventually comes out, Diekama predicts that there will be no significant changes.

"I think what you'll find is that the committee is not going to make a strong recommendation one way or another. There are some small medical benefits, I think, but they're not substantial enough for us to recommend circumcision," he says. "And there are complications, too, so I think the real issue here is informed consent. Parents will have to make the decision that seems right to them."

For her part, Chapin believes that parents play a key role in ending what she and other intactivists see as an unethical and dangerous practice.

"People are getting wise," she said. "They see that their neighbor's baby is intact and that his foreskin didn't run through the house at night causing mayhem. As more babies are left intact, as more parents tell their stories, the culture will change."

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