Male circumcision, the surgical removal of foreskin from the penis, is falling out of practice in the United States. It’s usually conducted within 10 days of a newborn’s birth, and is usually done for religious and traditional reasons. It may also be done for medical reasons during adulthood.

According to The National Hospital Discharge Survey, 65 percent of male babies went under the knife in 1999, while only 55 percent did so in 2007. This procedure isn’t common in other countries around the world. Throughout Europe, circumcision rates are less than 5 percent, while rates are higher in Jewish and Muslim nations.

Throughout America, the instances of circumcision vary. The CDC has found an overall decrease in the practice in the West and Midwest. The Western United States sees the lowest instances of neonatal circumcision at a little less than 45 percent, while the Midwest boasts the highest rate, at around 70 percent.

What might be the reason for this decline? Turns out that insurance coverage for the procedure has decreased. In western states—namely Washington, California, Oregon, and Arizona—Medicaid doesn’t cover the procedure, despite the American Academy of Pediatrics’ (AAP) insistence that the benefits outweigh the costs. They cite decreased STI transmission, decreased UTIs, and increased hygiene as compelling reasons for the surgery. The AAP, though, doesn’t suggest routine newborn circumcision. They ask that parents weigh cultural reasons, the pros, and the cons, prior to making a decision. The cons include pain, chances of botched surgery, and regret in the male’s life later on.

In Europe, where there are low rate of circumcision, doctors claim that the AAP’s stance on neonatal circumcision is culturally biased. Europeans countered that the research on the correlation between sexual transmission and circumcision is weak and doesn’t “represent compelling reasons for surgery before boys are old enough to decide for themselves.” In Scandinavian nations, political parties decry circumcision as child abuse.

In the U.S., there is a growing population of people against neonatal circumcision. One such group is Intact America. They argue that it’s fundamentally wrong to remove a part of a newborn’s body that cannot—and will not—grow back in adulthood, thus taking away the person’s right to their own body.

Despite the procedure’s wavering popularity, it does appear to have some real benefits. This procedure has been used on adult male volunteers in African nations to deter HIV transmission. The President’s Emergency Plan for AIDS Relief has enacted a policy of volunteer circumcision on male adolescents and adults in nations with high rates of HIV and low rates of circumcision. Studies have shown that circumcision decreases the risk of heterosexual HIV transmission by 60 percent. Unfortunately, there was an unforeseen negative consequence. Patients in Kenya, Rwanda, Tanzania, and Uganda had contracted tetanus as a result of the procedure, with some of the cases being fatal.

While it’s true that tetanus wouldn’t be a health consequence for most Americans, circumcision as a primary means of STI protection is a poor choice. Despite the U.S.’s relatively high rates of circumcision, HIV/AIDS are still prevalent. Condoms, on the other hand, are effective at reducing STIs, whether one is circumcised or not.

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