Federal circumcision guidelines meet with opposition – San Francisco Chronicle

The federal government’s first guidelines on circumcision last week, stressing the benefits of surgically removing the foreskin of the penis, have angered Bay Area opponents of the once-routine procedure.

“Not only is foreskin not a birth defect, but children have an inherent right to body integrity,” said Jonathan Conte, 33, of San Francisco, who belongs to Bay Area Intactivists, an organization committed to ending circumcision.

In the new guidelines, the U.S. Centers for Disease Control and Prevention stopped short of recommending routine circumcisions. But the agency emphasized that the benefits outweigh the risks, recommended the procedure be covered by insurance, and suggested that males of all ages who are not circumcised should receive counseling about its potential health benefits.

Dr. Fung Lam, a gynecologist and obstetrician at San Francisco’s California Pacific Medical Center, said circumcision continues to be a “very heated issue.”

“Most people come in with a certain point of view. Either (they think) it’s better and it should be done, or it shouldn’t be done, it’s terrible,” Lam said. With the new guidelines, “this is the time for people to speak out on both sides.”

The guidelines, which are open for public comment until Jan. 16, contend that the procedure can lower a man’s risk of getting HIV or other sexually transmitted diseases, penile cancer and urinary tract infections. The CDC, in justifying its position, cited several studies conducted in Africa that found circumcision could help reduce the spread of the virus that causes AIDS.

In the U.S., circumcision has been falling out of favor for several decades, with the rate of newborn males being circumcised in the hospital decreasing nationwide from about 65 percent in 1979 to about 58 percent in 2010, according to CDC statistics.

West’s sharp plunge

The drop in the Western states has been more dramatic, with the rate falling from 64 percent to 40 percent over the 32-year period. Some statistics show that in California fewer than a quarter of infants undergo the procedure.

Some health experts attribute the decline in the U.S. to an increase in the number of people from countries where circumcision is not part of the culture. Those include people of Latino descent and from some Asian countries. But a growing number of people also object to the practice, arguing, as Conte does, that it violates a baby’s human rights because an infant can’t consent and that it’s akin to genital mutilation.

In 2011, members of the anticutting movement known as intactivists pushed for a ballot measure in San Francisco that would have barred the procedure on any male 17 or younger. But a San Francisco Superior Court judge removed it from the ballot after Jewish organizations, the American Civil Liberties Union and San Francisco’s Medical Society filed a lawsuit over the issue.

Conte, who was circumcised as an infant, said that the natural function of the foreskin is discounted by medical professionals and that the message that having the foreskin removed protects against sexually transmitted diseases creates a false sense of security.

He also objected to the CDC’s recommendation that insurers cover the procedure. California is one of 18 states where Medicaid no longer pays for circumcision because of its questionable health benefits, although doctors said the procedure is generally covered by insurance companies.

“I’m very concerned the CDC’s guidelines will continue to encourage spending tax money for unnecessary genital surgery on children and that insurance companies will continue to pay for it,” Conte said.

Attitudes shifting

Circumcision has long ties to cultural preferences and religious beliefs, especially among Jews and Muslims who view it as a covenant or a tradition. But some Bay Area residents say attitudes are shifting even among those groups.

“In the vast majority of cases, families that opt out of circumcision are accepted in the Jewish community. They’re already welcomed,” said Lisa Braver Moss of Piedmont, co-author of “Celebrating Brit Shalom,” a book about rituals to replace the traditional Jewish male circumcision ceremony, or bris. The book is scheduled to be released in March.

Tina Kimmel, a Jewish mother of a son and grandmother of two boys — all intact — said her anticutting feelings were first sparked by witnessing her brother’s bris in 1949. Although she was only 2, she remembered seeing the blood and becoming upset.

Kimmel, who lives in Oakland, said she has already written to the CDC, warning the agency to not let itself be “manipulated into coming out on the wrong side of this historic issue.”

“It is monstrous for (the) CDC to advise physicians to treat any US citizen as less than human,” Kimmel wrote. “It is your job to protect us, not subject us to excrutiating, permanent bodily disfigurement — with no medical justification — just because we are (temporarily) in a weak state and you can overpower us.”

For physicians, most said the CDC’s guidelines would not significantly change their practices.

The new recommendations basically mirror those of the American Academy of Pediatrics, which in 2012 concluded the benefits outweigh the risks.

California Pacific’s Lam said that he has seen more parents opting out over his 30 years of experience but that it’s not much of a debate.

“There’s usually a bias coming in,” he said. “When both the mom and the dad are on the same page, it’s really a nonissue. When one feels one way and the other feels another, then it becomes a problem and it’s a long discussion.”

Considering sexual health

Dr. Elizabeth Salsburg, pediatrician at Alta Bates Summit Medical Center in Berkeley, said the guidelines give doctors and parents the chance to talk about the future sexual health of their child.

“I don’t think the CDC recommendations or the AAP change the personal beliefs of the parents one way or another,” she said. “But these kinds of statements give us an opportunity to have the discussion not only about whether to circumcise or not but also to encourage behaviors that include using condoms and getting the HPV (human papillomavirus) vaccination.”

Even supporters of the procedure questioned the CDC for citing studies done in African countries, where the risk of contracting HIV and AIDS is significantly higher than in the U.S. They also wondered about the wisdom of considering having it done past the newborn age.

“I can’t imagine there are so many benefits for doing it outside the newborn period unless there’s some (medical) reason,” said Dr. Paul Protter, a pediatrician at the Palo Alto Medical Foundation who recommends the procedure for health reasons. “And it’s very hard to say what goes on in another country is what goes on here.”

But Protter said parents shouldn’t feel guilty or that they’ve done something wrong, no matter what they decide.

“This may change people’s opinions about newborn circumcision,” he said of the CDC’s proposed guidelines. “There are clear medical benefits to it; they’re just not that powerful.”

Victoria Colliver is a San Francisco Chronicle staff writer. E-mail: vcolliver@sfchronicle.com Twitter: @vcolliver

Online resources

For more information about the U.S. Centers for Disease Control and Prevention’s proposed guidelines for medical counseling on circumcision, visit www.regulations.gov/#!docketDetail;D=CDC-2014-0012.