San Francisco: back to the Gold Rush days…

Despite living here for 15 years, San Francisco continues to surprise me. In this city renowned for being progressive and open-minded, there ballot item for November 2011 that has the entire world abuzz.

The Male Genital Mutilation Bill

What’s in the ballot box for this fall is called the “Male Genital Mutilation Bill.” It seeks to make it “unlawful to circumcise, excise, cut, or mutilate the whole or any part of the foreskin, testicles, or penis” of anyone 17 or younger in San Francisco.”  A person who violates the proposed ban could be jailed (for <1 year) or fined (< $1,000). Exemptions for religious reasons would not be allowed. This Bill is on the ballot because, in this fair city, if 7,168 people sign on, then it can be added as an election item.

Circumcision: The Cultural Context

It is likely that this bill was inspired by the worldwide movement to ban the cultural practice of female genital mutilation or female circumcision. This is a common procedure in Africa and Southeast Asia performed on 2 million girls annually. A female circumcision is not the same as the male variety however. With female circumcision, the clitoris is removed (clitoridectomy). In a boy, this would be the equivalent to removing the entire visible penis and not just the hood of skin covering the penis.

For a bit more context, please note:

• Virtually all Jews, most Muslims, as well as an estimated 55% of the American population are circumcised.
• Overall, it is estimated that 16% of the world’s population is circumcised.
• Most medical societies worldwide do not recommend routine circumcision on boys.
• Abortion has been legal since 1973.

For more medical context, please note the following demonstrated benefits of male circumcision:

• Prevention of urinary tract infections in boys
• Prevention of spread of HIV, Herpes, HPV (warts) and possibly other sexually transmitted diseases
• Prevention of penile cancer

As I have stated before in this forum regarding the medical issues with circumcision: “A clean penis and a clean life may be all that’s needed to replace the knife.” Clearly the issue of whether or not to ban medical, cultural or religious circumcision in boys is a very personal matter. What fascinates me is that, as a urologist who performs adult circumcisions, depending on how the vote goes in November, I could become an outlaw in my own city. The Wild West all over again. Guess I’ll have to follow the advice of Will Rogers: “Don’t squat with your spurs on.”

Related posts:

1. For the Good of the Hood

Do you agree with the Ancients on the good of the hood?

To circumcise or not. A loaded subject to be sure. The practice of male circumcision is ancient, likely far older than the biblical account of Abraham in Genesis. The Jewish faith, but not that of the Greeks or Romans, routinely recommended circumcision of newborn males. In the past century, it became “medicalized” as a preventative procedure only to be debunked in the last decade. Well, it may be now a procedure on the rise once again.

Circumcision is the removal of some or all of the foreskin or prepuce from the penis. The august American Academy of Pediatrics continues to recommend that circumcision is medically unnecessary, that it lacks any proven benefit, and that it should not be performed routinely in neonates. Maybe that is why the incidence of neonatal circumcision in the U.S. has continued to decline, from 80% in the 1960’s to 60% in 1996, to 55% of boys in 2001.

Why should circumcision be avoided? Issues of neonatal pain, behavioral changes and the potential for loss of sexual sensitivity from removal of the prepuce are age-old arguments for its discontinuation. However, a military study showing that there is a higher rate of urinary tract infections (UTIs) in non-circumcised boys and the fact that penile cancer tends to occur almost exclusively in uncircumcised men has kept the procedure alive and well.

In a somewhat radical departure from earlier recommendations, public health officials are now arguing that circumcision of men is a key weapon in the fight against human immunodeficiency virus (HIV) in Africa. Three recent, large, controlled studies have shown that circumcision reduces infection rates by 50 to 60% among heterosexual African. These studies stem from 3 different parts of the continent: South Africa, Uganda, and Kenya. In fact, two of the three clinical trials were stopped early because of overwhelmingly positive results. Experts now estimate that more than 3 million lives could be saved in sub-Saharan Africa alone if the procedure becomes widely used. And there is more recent data showing that the incidence of Herpes virus and HPV (Human Papilloma Virus) may also be reduced in circumcised men.

How circumcision prevents HIV transmission is not completely understood, but it is believed that the foreskin acts as a reservoir for HIV-containing secretions, increasing the contact time between the virus and target cells in the foreskin.

The problem with HIV and circumcision is that it is much more than a simple “behavior-based” intervention and this may ultimately be its biggest obstacle to wide acceptance. Changing social mores and behavior is one thing, but the “cold, hard steel” aspect of this public health initiative may not survive in the long run. If you don’t live in Africa, a clean penis and a clean life may be all that’s needed to replace the knife.

Related posts:

1. You Are The Pill That You Eat
2. Pop Quiz on Men’s Sexual Health
3. Sexual Health Pop Quiz #2
4. What Comes After the Pill?
5. Getting There Early or On Time: Which is Better?