The Great Circumcision Debate with Daniel Halperin, PhD

Welcome! Today we will be discussing circumcision with Daniel Halperin, Ph.D. Dr. Halperin an Assistant Professor at the Center for AIDS Prevention Studies and Medical Anthropology Program of the University of California, San Francisco.

This event is the second of a two-part series on circumcision that began with an interview with Dr. Paul Fleiss.

Moderator Welcome, Dr. Halperin!

Dr. Halperin Thank you


Moderator Let's start off with the obvious question: Why tamper with what we're given? Isn't the penis formed the way it is for a reason?

Dr. Halperin Good question.

To make a very long question very brief (books and doctoral dissertations have been written on the subject), several authors have  postulated that in evolutionary terms, it "made sense", for example in a tropical environment (with sharp thorns, bushes, stones or other protrusions, etc.) and men walking around essentially naked, to have the protection of the foreskin sheath. Beginning some 8,000 to perhaps 10,000 years ago (and it is possible, though not documented, even earlier) particularly in desert environments where there is a lot of sand and high winds,., people began practicing male circumcision.

For example, in Egypt and elsewhere in the Middle East, as well as in the Kalahari desert, among Australian aborigines, etc. It has been speculated that in such an environment it would make sense to remove the foreskin, as balanitis and various other infections can occur, sand often gets caught behind the foreskin, and so on. In the present day, with men walking around the streets of hot, humid cities in Eastern Africa, South Asia, etc, wearing underwear and polyester pants...there, it may no longer offer the same "evolutionary" protection; in fact, may be health-impeding rather than protective, at least in certain aspects (infections, HIV, etc.)

Moderator Obviously, when you do a web search for good info on circumcision, one generally comes up with a ton of anti-circ sites. Do you know of any pro-circumcision sites?

Dr. Halperin I know of several:


Moderator One of Dr. Fleiss's major claims is that the foreskin helps keeps the penis clean and free of infection. How would you respond?

Dr. Halperin Well, to summarize the medical literature and what uncircumcised men (as well as previously uncircumcised men) report, decent hygiene can be maintained with the foreskin, but it requires a certain amount of effort and diligence.

In certain environments, such as that in many developing countries (where, for example, HIV is today hitting the hardest), where clean water and other sanitary facilities are substandard, this is not always easy. Bacterial, yeast, fungus, and various other types of infections often find a "friendly" environment in the foreskin, especially (but not only) when hygiene is poor. 


Moderator How dangerous are these infections?

Dr. Halperin Some are not major, some lead to more serious infections, which in some cases may necessitate adult circumcision or other procedures. HIV, of course, is life-threatening, and is much more common in uncircumcised men.


Moderator How often do complications from circumcision occur, compared to complications that it can help avoid?

Dr. Halperin According to the 1989 American Academy of Pediatrics' Task Force on circumcision (and the 1999 AAP report varied very little in this regard), complications are rare and/or minor. They estimated the rate of post-op. complications as ranging from .2 percent to .6 percent, and the vast majority of these were minor.  However, two deaths from the procedure did occur in the US over a 25 year period. The health "cost/benefit" ratio  you ask about depends a lot on the particular population in question. In this country, although it is well documented that circumcised boys have far less (about 11 times less) urinary tract infections and are much less likely to develop penile cancer as older men than do uncircumcised males (not to mention various somewhat less severe foreskin-related problems such as phimosis and balanitis), an argument can be made that since (at least for most heterosexuals in the US) HIV and most other STDs are relatively uncommon, it may not be worth doing the procedure here.

There is also a large "grayer" area involving questions of aesthetics, sexual functioning, and so on, where there are as yet unproven advantages argued on both sides of the issue. However, as Robert Bailey and I argue in a recent editorial in the medical journal Lancet,  in some parts of the world, particularly some African and South/Southeast Asian countries, where heterosexual (including female to male) transmission of HIV is very common, along with other sexually transmitted infections such as chancroid, syphilis, and herpes, that in such an environment it may make a lot more sense for men/teenagers to seek out circumcision, as in fact they are now doing in increasing numbers in some countries. 


Moderator Dr. Fleiss suggested a possible connection between circumcision and AIDS, stating that the U.S. has the highest rate of circumcision and the highest rate of AIDS in the world. What is your response to this?

Dr. Halperin First of all, the US does not have nearly the highest rates of either of these two. In most West African countries, all Muslim countries (representing some one billion men in the world), and the Philippines, for example, virtually all men are circumcised. In California today, probably less than half of newborn boys are being circumcised, it is declining. The rate of HIV prevalence in the US is now estimated to be .75 percent of the adult population, and the vast majority (over 99 percent) of even that amount is not female to male transmission, but male to male, drug related, and some male to female transmission.

Where male circumcision makes a difference in HIV infection, particularly, is in terms of partially impeding female to male transmission. Rates in several African countries are over 20% of the adult populationwhich is at least 30 times higher than in the US, and there a lot of it is, in fact, female to male transmission. 


Moderator Can you tell us a little bit about your recently published research?

Dr. Halperin The Lancet article (in the Nov. 20, 1999 issue) deals with HIV transmission, as I've mentioned, and also somewhat with other STDs. In addition to reviewing the extant epidemiological literature on the relationship between lack of male circumcision and HIV, we present some of the plausible biological mechanisms for the higher prevalence of HIV/AIDS among uncircumcised men.

So far, out of 46 studies from 11 countries (counting the recent Belgian group/UNAIDS findings), 33 have found a statistically significant relationship between lack of circumcision and HIV infection, 7 found a trend towards an association, 5 found no association, and only one reported an increased risk of HIV infection in circumcised men (this latter one was a self-report survey of women in Rwanda). Most importantly, there have been to date 9 prospective studies studying this relationship (8 on heterosexual transmission, one of gay men here in San Francisco), and 7 of the 9 found relative risks between 2.3 to 8.2 (the other two found ones over 3.0, but the sample sizes were not large enough for statistical significance).

In other words, these were studies where a cohort of men were followed over time, generally a year, to see who would become infected with HIV, and what factors (after a "multiple regression analysis") could be linked to infection.

The studies found that the uncircumcised men were over two to over eight times more likely to become infected, everything else being equal.


Moderator Is it common for circumcisions to be performed improperly (too much skin removed, lack of symmetry, etc.)?

Dr. Halperin This can sometimes occur, particularly with untrained practitioners. Relatively speaking, it is a fairly simple and straight-forward procedure; even in adults taking 10-15 minutes or less. One of the reasons we wrote the Lancet editorial is to say: Hey, lots of men in certain developing countries are having the procedure done, but at the hands of untrained practitioners, and in some case this has resulted in injury, even amputation or death in some publicized cases in Africa.

So therefore we call for more availability of safe and affordable resources, as well as more and better information on the risks and benefits of male circumcision. 


Moderator Should the decision to circumcise be left up to the patient himself, in which case the operation would need to be performed later in life?

Dr. Halperin That's another good and difficult question. Some make that argument , saying it's a human rights issue and so on. I respect that stance, and do believe there may be some ethical questions to consider. So I can only speak here for myself.

Personally, I have spoken with a number of men who have complained that because they were not circumcised as infants, they must now undergo a significantly more involved procedure as an adult, and they really wish it could have been taken care of earlier on.

Some have argued that it can be likened to vaccination, which also carries a (usually very minor, but real) risk of complications or pain, but is probably in the best interests of the child/future adult.  Certainly, the risk of urinary tract infections will be much less for the circumcised boy, and his chances of getting penile cancer later in life will be greatly reduced. As I said, in this country the issue is (obviously) a fiercely debated one.

But in an environment with a high prevalence of HIV and other sexually transmitted diseases, there could be even more rationale for doing it. Of course, in most countries the decision remains a primarily religious and/or cultural one, and that is quite important.


Moderator Would you agree that most circumcised men are unhappy with the appearance of their penis?

Dr. Halperin That's a new one (for me). It certainly is not my experience! Or, if they feel that way, it's not because of missing their foreskin. On the contrary, as an anthropologist, I have been told many times by men (and women) in cultures where circumcision is "normal" that an uncircumcised penis is "ugly" or "abnormal looking." In fact, research both in this country and in Kenya (carried out by Bob Bailey and his Kenyan colleagues) has found that even among those groups Not practicing circumcision that women prefer (for example, by way of a photo) the appearance of the circumcised penis. Of course, beauty is in the eye of the beholder.


Moderator Does circumcision reduce penis size?

Dr. Halperin Another "interesting" question...It does, only in the obvious sense that the flaccid circumcised penis lacks the tip of the foreskin -- or length in that sense. But the erect penis is the same size in either case; except for some men (and there are actually a number of them, this is not so rare) who have phimosis or other problems where the foreskin is overly tight or otherwise impedes the full retraction of the glans. Some of these men report that after adult circumcision their (erect) penis is (or at least feels to be) somewhat "longer" or "larger"... 


Moderator What do you make of the current foreskin restoration movement?

Dr. Halperin Well, I have not studied it, but it does seem interesting to me, in the sense that evidently some circumcised men in this country feel such a "loss" over their foreskins that they will even go to the point of using weights, etc. to try to get some back.

It's kind of interesting to me, because the men I've spoken with (in this country, Latin America, Africa,and elsewhere) who've had adult sex lives as uncircumcised men and then get circumcised, they report (with only two exceptions, and they were men involved with the anti-circumcision movement who as I recall had legal cases against doctors) no loss of sexual/sensual satisfaction; in fact, virtually all of them report "better sex...." It's an interesting phenomenon, though, and I certainly would not criticize anyone who wants to try restoring their foreskin...


Moderator What is your view on female circumcision? Do you think it's much different in terms of its meaning and impact from male circumcision?

Dr. Halperin Yes, much different. Though in places where it's done (some African societies) , the culture may view the two as somewhat equivalent parts of their "initiation" rituals...But whereas a number of "circumcised" women come to feel they were mutilated, I have yet to meet a man who says this. (Ie, an African man who had it done as a child/teenager for traditional religious or cultural reasons who now feels he has been "mutilated.").

Men, in those societies, do not say they have "lost" some fundamental aspect of their sexuality; on the contrary, they say it "makes them a real man." Some have argued, though, that in those societies where only the clitoral hood is removed, this is somewhat akin to removing the male prepuce, but I doubt there are significant health benefits to the former procedure.


Moderator Are there ways to make circumcision less painful, or is anesthesia unsafe in these situations?

Dr. Halperin Yes, the current recommendation (for example, contained in the 1999 AAP Report) is to use local anesthesia, usually a dorsal nerve block. This is quite effective normally, and in the vast majority of cases free of complications. And there are physicians currently developing even safer/more benign techniques. I have observed newborn circumcisions with use of dorsal nerve block, and the babies did not seem to register any pain, in fact seemed unaware of the cutting. (It reminded me of painkiller at the dental office; it's more the idea than the actual pain once the anesthesia has taken effect.) So the  parents grimace and so on, the babies cried a little when the injection was given, then were quiet. This is the experience of practitioners I've spoken with. Though in rare occasions the anesthesia may not fully take hold, and more will need to be applied, etc.


Moderator I'd like to thank Dr. Halperin for joining us today. This has been a very interesting and informative discussion. Thanks, Dr. Halperin!

It's been a pleasure!

Moderator Have a great night.

Chat Transcript