Washington Blade - January 4, 2008
Ryan Lee

He remembers every detail of the encounter, from the screen name of the guy he hooked up with, to the animal Rahim thought of when he first saw what was in his pants.

"The skin covered the head, and it reminded me of an elephant trunk," Rahim said.

More skin is almost a deal-breaker for D.J. Levi, 26, who has a "strong preference" for circumcised men.

"If it's big enough, I can overlook it," joked Levi, who added that "my reasons are dumb" for being biased against uncut penises.

"I think circumcised looks better, and it's more hygienic," Levi said. "Guys have to be taught the proper way to clean uncircumcised foreskin, and everyone isn't taught that.

"I've actually known guys to have to get circumcision done because they got an infection from improper cleaning," Levi said.

Despite their differing tastes when it comes to their partners' phallus, Rahim and Levi share the perception that uncircumcised men are more prone to hygiene-related infections and STDs.

"I've read about uncut men being more susceptible to STDs, but that's if they aren't being clean," said Rahim, who added that despite his preference for uncut men, he is glad to be circumcised.

Whether or not circumcision status plays a role in the spread or prevention of STDs is an ongoing topic debated by scientists, with several recent studies coming to dramatically conflicting conclusions. Two separate studies conducted by the Centers for Disease Control and Prevention appear to show that circumcision profoundly reduces the risk for heterosexual men in Africa to contract HIV, while having "absolutely no effect" on whether gay and bisexual men in the U.S. contract the disease.

While trying to figure out why black and Latino gay and bisexual men have higher rates of HIV even though they engage in less risky behavior than their white counterparts, CDC researchers looked at data from more than 2,000 black and Latino gay men to see if being uncircumcised increased their probability of being HIV-positive. About 74 percent of black men in the study - which was unveiled at the CDC's National HIV Prevention conference last month - were circumcised, compared to 33 percent of Latinos.

"We found no overall association between circumcision status and HIV-infection status among black or Latino [gay and bisexual men]," said CDC epidemiologist Greg Millet, the study's author. "We also found no protective benefit of circumcision among those men reporting recent unprotected sex with a male partner in which they were exclusively the insertive male partner."

Essentially, men who are sexual tops are not more at risk of contracting HIV if they are uncircumcised, nor are they safer if they are circumcised, Millet said. Circumcision offers gay men a "moderate protective factor, at most," Millet said.

When looking at a subset of black male participants who also engaged in sex with females, the researchers "also found no protective benefit" from circumcision.

Millet's data echoes other studies that have suggested circumcision has little effect on HIV transmission among gay and bisexual men. In the U.S., a recent study of STD clinics in San Francisco revealed that circumcision offered no protection from HIV for gay and bisexual men, while an Australian study of 68 HIV-positive gay men showed that uncircumcised men were no more likely to have contracted the disease through insertive anal sex.

"Two previous studies conducted in the United States, but primarily among white [gay and bisexual men], did show a possible protective benefit of circumcision," Millet said. "However, one of those studies also found that the protective effect for circumcision was moderate compared with other factors associated with HIV seroconversion.

"It is possible that the disproportionately high prevalence of HIV in black and Latino [gay and bisexual] communities may offset any moderate protective affect that circumcision might afford," Millet said.

The data relating to circumcision among gay and bisexual men is in stark contrast to a study of heterosexual men in three African countries that showed that circumcision had the potential to be one of the "landmark accomplishments in the history of HIV-prevention research," said CDC researcher Peter Kilmarx.

Uncircumcised men have two layers of foreskin - the external "fibrous protein keratin," and the reverse, or inner foreskin, known as the "intermucosal surface."

While the external layer of foreskin is thick and serves as a protective barrier, the intermucosal surface is thin, "more susceptible to HIV infection, and when the penis becomes erect, becomes highly exposed to the sex partner's body fluids," Kilmarx said.

In three randomized controlled clinical trials in Africa, participants were divided into two groups: men who were to be circumcised and those who were to be wait-listed for circumcision at the end of the study. All three studies were stopped early, and all participants were offered circumcision, when it became clear that the men in the circumcised group were about 60 percent less likely to contract HIV, Kilmarx said.

"It's an important, proven new HIV-prevention intervention," Kilmarx said of circumcision, which was recognized in 2007 by the World Health Organization and UNAIDS as an effective way to reduce heterosexually transmitted HIV infections.

Childhood circumcision rates in the U.S. peaked in the late 1970s and have been on a decline in recent years, Kilmarx said. The American Academy of Pediatrics has see-sawed between being indifferent about circumcision in the early '70s, to advocating its medical benefits in the late '80s, to "an explicit lack of recommendation in 1999," Kilmarx said.

In April 2007, a CDC consulting panel on circumcision recommended that HIV-prevention messages needed to indicate that "studies demonstrated only partial efficacy, and only for female-to-male transmission," Kilmarx said.

"For men who had sex with men, the consultants felt that there was insufficient data to recommend male circumcision, and that men should be informed that this procedure had not shown to be protective for HIV transmission during male-male sex," Kilmarx said.

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