State may see push for circumcision after evidence shows health benefits

There may be a new push for circumcision in Washington, thanks to a review of national guidelines for the procedure.

Less than a quarter of all infant boys in Washington are circumcised — one of the lowest rates in the nation.

"The evidence is quite convincing that circumcision has significant health benefits in reducing heterosexual transmission of HIV, HPV and herpes," said Matthew Golden, director of the Public Health — Seattle & King County HIV/STD Program. "The older idea that there isn't enough scientific evidence to support circumcision is no longer true."

During the past five years, three independent randomized clinical trials on adult heterosexual men in sub-Saharan Africa have all shown the same result: Those who were circumcised were 60 percent less likely to acquire HIV, or human immunodeficiency virus.

These results prompted the World Health Organization and the Joint United Nations Program on HIV/AIDS to incorporate circumcision into their global HIV-prevention strategy. Particularly in southern and eastern African countries, these organizations are now encouraging infant and adult male circumcision.

But the results from these studies don't necessarily translate to the United States. In Africa, HIV is most prevalent in the heterosexual population, while in the U.S., it's most prevalent in homosexual men, who account for nearly half of the nationwide cases and more than two-thirds of the cases in Washington state.

Risk of HIV aside, data collected during the trials also showed reduced risks of genital herpes and HPV, the leading cause of cervical cancer. According to the Centers for Disease Control and Prevention (CDC), one in six Americans carry the herpes virus and almost half will encounter HPV, or human papillomavirus, in their lifetime.

"Most parents really want to do what's best for their kids," said Judith Wasserheit, professor of global health and medicine at UW. "But for most people when they deliver a child, they're not thinking about the child's risk of HIV or other STDs when they are 17, 18 or 19 years old."

The reasons why circumcision, in which all or part of the penile foreskin is removed, may help reduce STDs, sexually transmitted diseases, remains unclear. Some doctors and scientists suggest that the moist region below the foreskin is a more favorable environment for the virus or that the foreskin may increase a man's susceptibility to abrasion and infection during intercourse.

Currently, the American Academy of Pediatrics (AAP) and CDC guidelines, last revised in 2005, don't recommend routine circumcision, citing a lack of evidence that the procedure is medically necessary.

As a result, Medicaid doesn't cover the procedural cost in many states, which may have contributed to the slow but steady nationwide decline in circumcision rates over the years, according to the National Hospital Discharge Survey.

Washington has one of the lowest rates of infant circumcision, 23 percent, compared to 56 percent nationwide. For those on Medicaid, which doesn't pay for the surgery in Washington, the rate is only 9 percent.

Both the AAP and CDC have been scrutinizing the latest scientific data and hope to come out with new recommendations later this year.

"I think it's pretty clear if you look at the literature over the last 10 years, its moved toward supporting some medical benefit," said Douglas Diekema, professor of pediatrics at Seattle Children's hospital and a member of the AAP circumcision task force. "Whether it's enough to support routine circumcision, I'm not sure, but there might be a slightly stronger recommendation from the AAP."

"We're looking at all the best available science in updating our recommendations," said Jennifer Horvath, spokeswoman for the CDC.

The CDC is coming up with guidelines for infants, as well as adult homosexual and heterosexual men — an important distinction since for adults the surgery is much riskier, requiring anesthesia.

Once the new guidelines are published, King County health officials hope to distribute materials in multiple languages to providers, parents and guardians about the risks and benefits of circumcision. If the guidelines come out in favor of the procedure, circumcision rates likely will increase in the state of Washington, particularly if Medicaid begins paying for it, Golden said.

Regardless of which side of the issue the AAP and CDC fall on, the recommendations will be completely voluntary, so for parents and individuals can decide based on what they think is best for their child.

"These are completely personal decisions and there are a lot of religious, social and cultural considerations," Wasserheit said. "Nobody is trying to force anyone to get circumcised."

Health-care providers stress that condom use and sexual education are vital in preventing the spread of viral STDs and that circumcision does not in any way provide full protection.

But the evidence that the procedure helps reduce the risk is overwhelming, Golden said.

"All three studies in different regions of Africa showed the same medical benefit for circumcision," he said. "If you had a vaccine that was 60 percent effective for preventing HIV, wouldn't you deploy it?"

Cassandra Brooks: 206-464-2311 or cbrooks@seattletimes.com