CDC proposes stronger endorsement of male circumcision

BMJ 2014; 349 doi: (Published 05 December 2014) Cite this as: BMJ 2014;349:g7494
  1. Michael McCarthy
  1. 1Seattle

Health providers should advise adolescents and adult men and the parents of male infants and boys that circumcision substantially reduces the risk of contracting several sexually transmitted infections, such as HIV, herpes, and human papillomavirus, say new recommendations proposed by the US Centers for Disease Control and Prevention on 2 December.1

Although the CDC tempers its proposed guidance by noting that the decision to undergo circumcision is “made in the context of not only health considerations, but also other social, cultural, ethical, and religious factors,” the statement is the CDC’s strongest endorsement of the procedure so far.

“Although data have been accumulating about infant male circumcision for many years,” the CDC officials wrote, “clinical trials conducted between 2005 and 2010 have demonstrated safety and significant efficacy of voluntary adult male circumcision performed by clinicians for reducing the risk of acquisition of human immunodeficiency virus (HIV) by a male during penile-vaginal sex.”

The three clinical trials cited by the CDC officials showed that adult male circumcision reduced the risk of HIV infection by 50-60% and the risk of contracting herpes simplex virus type 2 and types of human papillomavirus that can cause penile and other anogenital cancers by 30%.2 3 4

The trials, however, were conducted in sub-Saharan Africa, where HIV is spread primarily through heterosexual transmission. In a background document accompanying the proposed recommendation,5 the CDC officials acknowledged that the prevalence and lifetime risk of HIV in the United States was generally much lower than that seen in African countries and that most HIV transmission in the US was the result of male to male sex, a population where circumcision has not been proved to reduce the risk of HIV acquisition. “Despite these overall differences, the results of the African trials are likely to have application to HIV prevention efforts in the United States,” the CDC officials wrote.

Opponents of circumcision have challenged the CDC’s reliance on trials conducted in sub-Saharan Africa. “These studies have never been replicated elsewhere—let alone in the United States—and have no relevance to children or men in the developed world,” said Georganne Chapin, an attorney and executive director of Intact America, an anti-circumcision group.

“As a public health organization the CDC should be calling for a study of the true risks and complications from circumcision that occur over the lifetime of boys and men, before it promotes its evidence free claim that the benefits of newborn circumcision outweigh its harms,” Chapin said.

The CDC officials wrote that the risk of complications from circumcision was low, running at about 0.2%, with the most common being bleeding and infection, which are “usually minor and easily managed.”

Circumcision is common in the US, where the overall prevalence among adult males is 79%. But it is unclear whether the CDC’s new recommendations will convince uncircumcised men to undergo the procedure. A recent consumer survey of heterosexual uncircumcised men found that, when asked whether they would be likely to be circumcised if their healthcare provider told them it would reduce their risk of HIV infection, only 12% reported that they would be likely or very likely to undergo the procedure, while 83% reported that they would be unlikely or very unlikely to get circumcised.

The draft of the recommendations, which have been posted on the Federal Register, will undergo peer review and be subject to public comment for 45 days before being finalized. The comment period ends on 16 January 2015.


Cite this as: BMJ 2014;349:g7494


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