Should I circumcize my son?

[Eroberer]

Just to throw my two cents in. By a remarkable coincidence I was thinking about this the other day. The girls I like really would not care which way I was anyway, 'cus that's how I choose them. I'm snipped, and I can quite honestly say that I do not know what I'm missing, and there's enough sensation there as it is.

If I could pick on my own, I'd go with the obvious and not do it, 'cus it's a lot of pain. But I don't/can't really care that it happened to me anyway.

My suggestion is to make a choice and then have no regrets. I still can't see any reason to do it, though.

On a side note, babies are not even given pain killers even for open-heart surgery. This operation cannot be that bad.

[Asher]

They aren't given pain killers for many operations, not because it doesn't hurt, but because there's too many complications for giving babies anesthetic.

Doctors have monitored vital signs and done studies on extreme pain during circumcisions, these are areas previously done only in a lab with rats...

[Boris Godunov]

Originally posted by SuperSneak
Hate to break it to you guys, but the last person I'm going to entrust my son's future penile health to is a gay man.

As a gay man, I can assure you that I am quite well versed on current data regarding penile health. I take it very seriously, thank you very much. Dismissing my arguments because of my sexual orientation is offensively bigoted.

Since we're going down that road, I think you are just hell-bent on justifying your decision so you don't have to fret over whether or not you subjected your son to a needless bodily mutilation.

And should your son happen to be gay, then the penile health of a gay man will certainly be very relevant.

[tandeetaylor]

Originally posted by SuperSneak
How about the fact that our OBGYN suggested it strongly, as in her opinion the evidence was inconclusive enough to warrant caution?

Exactly.

I suppose you know more about babies than a woman who has delivered hundreds of them, eh?
Is there no end to your magnificent supply of wisdom?

I don't think it's ever a good idea to just rely on what an "expert" says. On a related subject, I once saw a story on one of those evening magazine shows about two twin boys that were circumcized and one of them had too much cut off, so they decided to take the rest off and raise him as a girl. One of their biggest reasons for doing this was the popularity of a psychologist who said that gender was based on upbringing, therefore your children could be whatever you wanted them to be. Of course, this was years ago. The boy grew up as a girl, always knowing he was a male. He's pretty messed up right about now. It was also a story about children who are born with abnormal genitals. Usually they quickly have surgery to make them look normal. There was girl who had a clitoris so large that it almost looked like a penis. Her parents decided to leave it that way, and she is very glad they did. She turned out to be a lesbian, and said that it resulted in much more sexual pleasure for her and her partners. Most doctors still think you should have surgery to fix these abnormalities (imagine how much those people would get made fun of, right?). I think it's always best to make up our own minds. And OBGYNs walk out the door after the baby is born. If there are complications from circumcision, the parents would call the pediatrician, not the OBGYN.

[SuperSneak]

Hmmmm....you must be the exception and not the rule, otherwise, all your preaching about penile health, condoms, etc, would be universally accepted and the evidence of a massive plague among gay men wouldn't be there to confront us...out of all the sexual subgroups, I certainly wouldn't take the advice of a representative of a community that is dying in droves due to irresponsible prevention of sexual diseases.

Here's another study...seems pretty well researched as well:

How does male circumcision protect against HIV infection?
Robert Szabo, medical resident a, Roger V Short, professor b.

a Faculty of Medicine, Monash University, Wellington Road, Melbourne 3168, Australia, b Department of Obstetrics and Gynaecology, University of Melbourne, Royal Women's Hospital, 132 Grattan Street, Melbourne 3053, Australia

Correspondence to: R V Short


In his otherwise excellent review of the AIDS epidemic in the 21st century, Fauci presented no new strategies for preventing the spread of the disease.1 He made no mention of male circumcision, yet there is now compelling epidemiological evidence from over 40 studies which shows that male circumcision provides significant protection against HIV infection; circumcised males are two to eight times less likely to become infected with HIV.2 Furthermore, circumcision also protects against other sexually transmitted infections, such as syphilis and gonorrhoea, 3 4 and since people who have a sexually transmitted infection are two to five times more likely to become infected with HIV,5 circumcision may be even more protective. The most dramatic evidence of the protective effect of circumcision comes from a new study of couples in Uganda who had discordant HIV status; in this study the woman was HIV positive and her male partner was not.6 No new infections occurred among any of the 50 circumcised men over 30 months, whereas 40 of 137 uncircumcised men became infected during this time. Both groups had been given free access to HIV testing, intensive instruction about preventing infection, and free condoms (which were continuously available), but 89% of the men never used condoms, and condom use did not seem to influence the rate of transmission of HIV. These findings should focus the spotlight of scientific attention onto the foreskin. Why does its removal reduce a man's susceptibility to HIV infection?




Summary points


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The majority of men who are HIV positive have been infected through the penis

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There is conclusive epidemiological evidence to show that uncircumcised men are at a much greater risk of becoming infected with HIV than circumcised men

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The inner surface of the foreskin contains Langerhans' cells with HIV receptors; these cells are likely to be the primary point of viral entry into the penis of an uncircumcised man

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Male circumcision should be seriously considered as an additional means of preventing HIV in all countries with a high prevalence of infection

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The development of HIV receptor blockers, which could be applied to the penis or vagina before intercourse, might provide a new form of HIV prevention




Methods

To compile the information for this review a Medline search was done using the terms circumcision, HIV, Langerhans' cells, penis, foreskin, and prepuce, and extensive email correspondence with other researchers was also undertaken. Histological observations were carried out on samples of penile tissue obtained from 13 perfusion fixed cadavers of men aged 60-96 years, seven of whom had been circumcised.

The pathogenesis of sexually acquired HIV infection


Between 75% and 85% of cases of HIV infection worldwide have probably occurred during sexual activity.7 Most cases of primary HIV infection are thought to involve HIV binding initially to the CD4 and CCR5 receptors found on antigen presenting cellswhich include macrophages, Langerhans' cells, and dendritic cellsin the genital and rectal mucosa.

The most widely accepted model for the sexual transmission of HIV is based on infection of the genital tract of rhesus macaques with simian immunodeficiency virus. 8 9 After female macaques are inoculated intravaginally with simian immunodeficiency virus, the virus targets the Langerhans' cells located in the vaginal mucosa. Once infected, these cells fuse with adjacent CD4 lymphocytes and migrate to deeper tissues. Within two days of infection, the virus can be detected in the internal iliac lymph nodes and shortly thereafter in systemic lymph nodes. This ultimately leads to a fatal infection.

Similarly, infection in male macaques occurs when simian immunodeficiency virus is inoculated into the penile urethra or onto the foreskin; the same sequence of cellular events involving the infection of Langerhans' cells is then likely to occur.9 Infected Langerhans' cells have also been detected in the penile mucosa of male rhesus macaques that have chronic simian immunodeficiency virus infection.9 In humans, histological studies have identified antigen presenting cells in the mucosa of the inner foreskin and urethra.10 Therefore it seems likely that antigen presenting cells at these mucosal sites are the primary target for HIV in men.

In vitro studies have shown that the CD4 receptor is generally necessary, although insufficient on its own, to permit HIV-1 to enter host cells.11 The entry of HIV-1 into cells requires an additional chemokine receptor, usually CCR5, although CXCR4 is used by cells that become infected during the later stages of the disease.12 After primary infection occurs, the virus mutates, which allows it to utilise other chemokine receptors, such as CXCR4, and thus spread to a variety of cell types. However, more than 99% of HIV-1 isolates from acutely infected patients are homologous, indicating that one specific variant is likely to be responsible for most cases of primary HIV infection.13 HIV variants that are transmitted to other individuals almost invariably use CCR5 as a coreceptor and are therefore named R5 viruses, to reflect their specific requirement for a coreceptor.14





(Credit: WELLCOME TRUST)

Circumcision in ancient Egypt shown on a relief from Saqqara (c 2200 BC). Used with the permission of the Wellcome Institute for the History of Medicine, London





How HIV enters the penis

About 70% of men infected with HIV have acquired the virus through vaginal sex, and a smaller number have acquired it from insertive anal intercourse.7 Thus, on a global scale most men who are HIV positive have acquired the virus via the penis. This raises questions of how HIV enters the penis and why men who are uncircumcised are potentially more susceptible to becoming infected with HIV.

The uncircumcised penis consists of the penile shaft, glans, urethral meatus, inner and outer surface of the foreskin, and the frenulum, the thin band connecting the inner foreskin to the ventral aspect of the glans. A keratinised, stratified squamous epithelium covers the penile shaft and outer surface of the foreskin. This provides a protective barrier against HIV infection. In contrast, the inner mucosal surface of the foreskin is not keratinised15 and is rich in Langerhans' cells,10 making it particularly susceptible to the virus. This is particularly important because during heterosexual intercourse the foreskin is pulled back down the shaft of the penis, and the whole inner surface of the foreskin is exposed to vaginal secretions, providing a large area where HIV transmission could take place.

There is controversy about whether the epithelium of the glans in uncircumcised men is keratinised; some authors claim that it is not,15 but we have examined the glans of seven circumcised and six uncircumcised men, and found the epithelia to be equally keratinised. In circumcised males only the distal penile urethra is lined with a mucosal epithelium. However, this is unlikely to be a common site of infection because it contains comparatively few Langerhans' cells.10

Ulcerative or inflammatory lesions of the penile urethra, foreskin, frenulum, or glans that are caused by other sexually transmitted infections may provide additional potential routes for HIV transmission. In uncircumcised males, the highly vascular frenulum is particularly susceptible to trauma during intercourse, and lesions produced by other sexually transmitted infections commonly occur there. Thus, male circumcision further reduces the risk of infection by reducing the synergy that normally exists between HIV and other sexually transmitted infections.5

Conclusions


Of the estimated 50 million people infected with HIV worldwide, about half are men, most of whom have become infected through their penises. The inner surface of the foreskin, which is rich in HIV receptors, and the frenulum, a common site for trauma and other sexually transmitted infections, must be regarded as the most probable sites for viral entry in primary HIV infection in men. Although condoms must remain the first choice for preventing the sexual transmission of HIV, they are often not used consistently or correctly, they may break during use, and there may be strong cultural and aesthetic objections to using them. Cultural and religious attitudes towards male circumcision are even more deeply held, but in the light of the evidence presented here circumcising males seems highly desirable, especially in countries with a high prevalence of HIV infection. Although neonatal circumcision is easy to perform, and has a low incidence of complications,16 it would be 15-20 years before a programme of circumcision had any effect on HIV transmission rates. Circumcision at puberty, as practised by many Muslim communities, would be the most immediately effective intervention for reducing HIV transmission since it would be done before young men are likely to become sexually active.

It may also be time to re-think the definition of "safe sex." Since the penis is the probable site of viral entry, neither infected semen nor vaginal secretions should be allowed to come in contact with the penis, particularly in uncircumcised males. Thus, mutual male masturbation during which a penis is exposed to the potentially infected semen of another male should be regarded as risky sexual behaviour.

New preventive strategies are needed that could be used by men or women before the onset of intercourse. The disadvantage of topical virucides, such as nonoxinol 9, is that they may cause local irritation and thus increase susceptibility to HIV infection. The development of topically active agents that could block HIV binding sites, such as CCR5, and which could be applied to the penis or vagina to create a "chemical condom," might be more effective and acceptable than any mechanical barrier or surgical intervention.

Acknowledgments


We thank Professor John Mills for helpful comments on an early draft of the manuscript and Professor Daine Alcorn and the staff of the Department of Anatomy, University of Melbourne, for supplying and processing the specimens from human cadavers.


Contributors: RS reviewed all the relevant literature, carried out the histological examination of the specimens, and wrote the first draft of the manuscript. RVS initiated the study and participated in redrafting of the paper. Both authors will act as guarantors.

Footnotes


Funding: None.


Competing interests: None declared.

References

1. Fauci AS. The AIDS epidemic: considerations for the 21st century. N Engl J Med 1999; 341: 1046-1050[Full Text].
2. Halperin DT, Bailey RC. Male circumcision and HIV infection: 10 years and counting. Lancet 1999; 354: 1813-1815[Medline].
3. Cook LS, Koutsky LA, Holmes KK. Circumcision and sexually transmitted diseases. Am J Public Health 1994; 84: 197-201[Abstract].
4. Moses S, Bailey RC, Ronald AR. Male circumcision: assessment of health benefits and risks. Sex Transm Infect 1998; 74: 368-373[Abstract].
5. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect 1999; 75: 3-17[Abstract].
6. Quinn TC, Wawer MJ, Se****ambo N, Serwadda D, Li C, Wabwire-Mangen F, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med 2000; 342: 921-929[Abstract/Full Text].
7. Joint United Nations Programme on HIV/AIDS. The HIV/AIDS situation in mid 1996: global and regional highlights. Geneva: United Nations, 1996. (UNAIDS fact sheet 1 July 1996.)
8. Spira AI, Marx PA, Patterson BK, Mahoney J, Koup RA, Wolinsky SM, et al. Cellular targets of infection and route of viral dissemination after an intravaginal inoculation of simian immunodeficiency virus into rhesus macaques. J Exp Med 1996; 183: 215-225[Abstract].
9. Miller CJ. Localization of simian immunodeficiency virus-infected cells in the genital tract of male and female rhesus macaques. J Reprod Immunol 1998; 41: 331-339[Medline].
10. Hussain LA, Lehner T. Comparative investigation of Langerhans cells and potential receptors for HIV in oral, genitourinary and rectal epithelia. Immunology 1995; 85: 475-484[Medline].
11. Zaitseva M, Blauvelt A, Lee S, Lapham CK, Klaus-Kovtun V, Mostowski H, et al. Expression and function of CCR5 and CXCR4 on human Langerhans cells and macrophages: implications for HIV primary infection. Nature Med 1997; 3: 1369-1375[Medline].
12. Dragic T, Litwin V, Allaway GP, Martin SR, Huang Y, Nagashima KA, et al. HIV-1 entry into CD4+ cells is mediated by the chemokine receptor CC-CKR-5. Nature 1996; 381: 667-673[Medline].
13. Zhu T, Mo H, Wang N, Nam DS, Cao Y, Koup RA, et al. Genotypic and phenotypic characterization of HIV-1 patients with primary infection. Science 1993; 261: 1179-1181[Medline].
14. Kahn JO, Walker BD. Acute human immunodeficiency virus type 1 infection. N Engl J Med 1998; 339: 33-39[Full Text].
15. Barreto J, Caballero C, Cubilla A. Penis. In: Sternberg SS, ed. Histology for pathologists. 2nd ed. Philadelphia: Lippincott-Raven, 1997.
16. Morris B. In favour of circumcision. Sydney: University of New South Wales Press, 1999.


(Accepted 11 May 2000)

[Asher]

tandeetaylor: I saw that too, I think it was on Dateline a long time ago.

[Asher]

Sneak...I don't think you get it.
There are many studies that go both ways (28 total at last count). When these studies are combined, the net result is still a higher percentage chance of circumcised men from being infected.

It's a controversial subject still. You're not being cautious by cutting off his foreskin, you're increasing the chance of infection in the operation, have a chance of the operation being botched, and at the same time may also be increasing his chances of getting HIV.

[tandeetaylor]

Originally posted by SuperSneak
Hate to break it to you guys, but the last person I'm going to entrust my son's future penile health to is a gay man.

Woah... I don't think that has any place in a discussion.

I don't mean to take sides or make a fight bigger, but in most issues, there is a right and a wrong answer. You can't blame someone for taking a side, and not yielding it when incompetent and incomplete arguments are presented.

[DanS]

"I know this sounds bad, but my when husband and I can't agree, I get my way. I'd prefer it the other way. I'm sure that I can convince him in three months, considering the progress I already made in one night."

Don't know from what culture your husband's family is from, but in some muslim cultures the mother is expected to have more influence over the females while the father is expected to have more influence over the males. They might see this as meddling or you acting outside your sphere unnecessarily.

Anyway, not all things that are bound up in religion are strictly religious. A lot of what supports religion is tradition, ceremony, family and way of life, rather. I find it helpful to distinguish among all of these.

Good luck!

[SuperSneak]

No, I base my statement on the fact that I would prefer a medical professional, who has made her life's work the care of children and invested a lot of time and money in that pursuit, to advise me on the safety of my child, over two men who do not have children and belong to a group of people whose mortality rates do not reflect a true understanding or adherance to sexual safety.

[Boris Godunov]

Originally posted by SuperSneak
Hmmmm....you must be the exception and not the rule, otherwise, all your preaching about penile health, condoms, etc, would be universally accepted and the evidence of a massive plague among gay men wouldn't be there to confront us...out of all the sexual subgroups, I certainly wouldn't take the advice of a representative of a community that is dying in droves due to irresponsible prevention of sexual diseases.

Most persons infected with HIV are heterosexual, so by your logic, you should listen to gay men first. Also, transmission rates of HIV are highest in heterosexual women. And "massive plague among gay men" is certainly hyperbole. Saying I'm the exception is not true--the VAST majority of gay men are not infected with HIV. And it is exactly because HIV is a significant issue in the gay community that responsible gay men such as myself are well-versed on the subject.

I'm not surprised at your erroneous thinking, though--such thought seems to be what guided you into lopping off your son's foreskin, too.

[Eroberer]

About the pain, I'm almost positive the babies just don't feel it. I remember this from the Discovery channel show about operations on babies a long time ago, because it was particularly interesting. The pain just doesn't register as anything bad to them at that point, is my guess, but I do remember the show saying that there is no evidence that it disturbs them.

I imagine if it were so bad, then there would be some baby anesthesia out on the market (just a guess). I don't really want to do research on the internet for this, though, so do forgive me if I am wrong.

[Asher]

Originally posted by SuperSneak
No, I base my statement on the fact that I would prefer a medical professional, who has made her life's work the care of children and invested a lot of time and money in that pursuit, to advise me on the safety of my child

Make up your mind, Sneak, is she an OB/GYN or a Pediatrician? Surely you'd know they're not the same thing, right?

over two men who do not have children and belong to a group of people whose mortality rates do not reflect a true understanding or adherance to sexual safety.

You're such a moron. Unbelievable. Hopefully your wife has the brains in the family.

[Boris Godunov]

Good thing there aren't any black men here, I'd hate to see what SS would say to them, considering they have the highest HIV infection rate.

[SuperSneak]

The per capita infection rate of heteros to homosexuals is what is important, not the "total" number infected.

In any case, the deed is done and I'm perfectly fine with it. If my son does turn out to be gay, that's not a problem either.
I will continue to defer to medical professional's opinions on these and other subjects as long as there is not definitive evidence to the contrary. There is currently a groundswell of anti-vaccination sentiment as well...and I'm not about to stop having my son vaccinated. As there is no strong evidence either way, I asked a professional (and the Pediatrician agreed, BTW) and went with her opinion.
I agonized over the decision and was present when the procedure took place...I did not dodge a thing.
As I've said before, you cannot know until it is a real concern, in the meantime, feel free to sit in lofty judgement about something that will most likely never have any sort of personal impact on you personally.

When he's old enough, we can have my son post here and tell you all about his horrific trauma and deep feelings of marginalization at what his cruel and thoughtless Cro-mag of a father did to him.