News & Issues

CIRCUMCISION PERSISTS DESPITE DOCTORS' DISAPPROVAL

By Sharon Bass
Deputy Editor

[See also: Editorial]

The newborn boy is typically 24 hours old when he is brought into a hospital treatment room and placed on a molded, plastic table where his arms and legs are held down by Velcro straps. A doctor then tightens a clamp around the tip of the baby's penis, squeezing the foreskin up and over. Then with a scalpel, a one-inch high tubular piece of tissue is severed. The clamp is left on for five to six minutes afterwards to keep the arteries constricted and stop the bleeding. All the while, the baby cries, screams, turns red and his heart races.

Because of the pain and trauma associated with this procedure, called circumcision, and the alleged health benefits have been found questionable, more and more physicians are reluctant to perform it. And some will not do it at all.

"I think the history of it in itself is pretty appalling," said Burtt Richardson, a pediatrician in Winthrop, who did circumcisions during medical training but refuses to do them now. "Performing a painful procedure on a newborn is assaultive and inhumane."

While many doctors today either share Richardson's attitude, or say that circumcision is not medically called for, the majority of parents in Maine and nationally still opt to have their sons snipped. The number one reason, according to both doctors and parents, is so son will look like father and his male peers.

Bangor pediatrician John Farquhar tries to explain the ongoing popularity of circumcision by saying: "Old traditions die hard. If everybody cut off their left ear, then that's something that would probably continue," too - even though in this country, the only one where circumcision is routinely performed for non-religious reasons, the custom is barely two generations old.

The last time Norridgewock family practitioner Kenneth Baker excised a newborn's - or anyone's - prepuce was 18 years ago. "In my mind, I knew this wasn't right; the pain I was causing. I was removing healthy tissue," he said. When Baker's son was born 11 years ago, the foreskin was left intact.

Bethany Hays, a Yarmouth obstetrician-gynecologist, who had done the surgery since 1974 but stopped last year, calls circumcision "the most common, unnecessary surgical procedure done in the United States. God put that skin there for a reason. Why the heck are we taking it off?"

Hays and most other physicians are skeptical that there are any substantial health benefits. While there is evidence that uncircumcised males have a higher risk of urinary tract infections, those infections themselves are pretty rare and benign in men. And penile cancer, which does show some statistical correlation, is even rarer leading doctors to believe it's not worth the risk of circumcision.

Baker said studies have shown that in Europe, where newborn circumcision is rarely performed, only one in 1,000 adult males requires the procedure, often due to infection brought on by diabetes. The penile cancer rate is about one in 100,000 - lower than for male breast cancer.

In the United States, amputating babies' foreskins became routine after World War II, after many prospective soldiers flunked physicals and interest in public health techniques grew. Both Jews and Muslims perform circumcision as part of religious beliefs. But in this country cosmetic reasons predominate.

"Our feelings was," said Stephen Harris, of Cumberland, a father of a circumcised son, "we'd rather have him look like dad and the boys in the locker room." But he made that decision eight years ago. Today, Harris maintains, "If I knew then what I know now, I never would have done it. I mean, why don't we just remove their appendix?"

Nationally, the growing consensus against the procedure has had some effect. As recently as the 1980s, roughly 90 percent of baby boys were circumcised; by last year it dropped to 60 percent. Maine numbers seem to have risen slightly, from 64 percent in 1985 to 69 percent last year, according to the Maine Health Care Finance Commission. The figures may be affected by a larger number of hospitals reporting. Still, no one questions that circumcision is more the rule than the exception in Maine.

Just the Facts
Maine circumcision rate
Hospital, town                                1985       1990       1995

Southern Maine Medical Center, Biddeford      89.2       85.2       89.5
Kennebec Valley, Augusta                      72.3       78.4       83.7
Maine Medical Center, Portland                58.2       72.8       76.4
Mid-Maine Medical Center, Waterville         ------      71.2       76.3
Mercy Hospital, Portland                      70.3       81.6       75.9
Central Maine Medical Center, Lewiston       ------     ------      75.2
Houlton                                       58.4       70.5       71.9
Mt. Desert, Bar Harbor                        31.9       50.8       61.5
Eastern Maine Medical Center, Bangor         ------     ------      46.8
York Hospital, York                          ------      42.1       45.5
Rumford                                       85.4      ------      43.2
Northern Maine, Fort Kent                     20.0       36.8       40.4

The Preference of parents for circumcision persists even though doctors rarely recommend it and the procedure is usually paid for out-of-pocket; few private health insurers cover it. Even doctors who continue to circumcise doubt its medical necessity. Portland obstetrician Tom Sunshine said that while penile cancer only occurs in uncircumcised men - some disagree - he also said, "I don't think we can make a strong case" for circumcision for health reasons.

[photo of Dr. Kenneth Baker: Norridgewock doctor Kenneth Baker is among a growing group of physicians who opposes circumcision. / Martha Mickles photo]

Francis Kleeman, a urologist in Biddeford who's been circumcising boys of all ages for 30 years, agrees. "A lot of it is personal choice. I don't feel strongly that every male [has] to be circumcised." The number one reason his patients choose to do so, he said, is to make son look like father.

Ponee Roberts' son was circumcised when he was born last month, even though the Gorham mother said she was against it: "Why do it? I figured the foreskin was there for some reason. But the main reason [for not doing it] was the pain." However, Roberts lost out as her husband insisted on having it done.

Since circumcision is classified as a cosmetic procedure, most insurers will not cover the $100-$150 cost. In an interesting twist, however, Medicaid - the federal-state program for low-income Mainers - does pay at $88 per baby. Dr. Timothy Clifford, Medicaid's medical director, said "It's always been a controversial issue." But Medicaid has always reimbursed, despite growing doubts about the procedure's usefulness.

When Greg Thompson, a Falmouth family practitioner, had his first son he had him circumcised. But then he said he developed some "social concerns" and withheld the scalpel with his next three sons. He's also withholding it in his practice; he last did the surgery in 1987 when he was an intern. "They're not medically necessary," he said. "Kids scream when you do it. I don't think it damages their psyches, but..."

Others are more vehement. Falmouth obstetrician Bethany Hays subscribes to William Reich's theory, saying the "trauma stays in the body," and even goes so far as to equate the emotional effects of the penile surgery with the effects of childhood sexual abuse. Reich, an early follower of Freud who summered in the Rangely area, was an outspoken opponent of circumcision. Though many experts in psychology find Reich's theories of "orgone energy" half-baked, he continues to have followers.

In addition to the lack of apparent health benefits, circumcision opponents argue that it sharply decreases sexual pleasure. Dr. Kenneth Baker says that circumcision removes nerve endings, and that the foreskin provides a gliding, "very pleasurable" action during intercourse. And he cites reports of males circumcised as adults indicating a "tremendous loss of pleasurable sensation."

Suzanne Cook, founder of the Maine chapter of the Circumcision Information Resource Centers, a national anti-circumcision group, agrees. The 24-year-old woman has two sons; neither are circumcised. "It's not just a little snip of skin," said Cook. "Studies show that the baby is traumatized for 48 hours." She talks about men who go through primal therapy, where the unconscious is untapped, and say they recall the "terror" of their circumcisions.

While doctors may not buy into the theory that circumcision leaves emotional scars, they agree that it hurts, contrary to earlier theories that newborns can't feel pain. Most physicians use an anesthetic. Portland pediatrician Steven Blumenthal said he suggests it to obstetricians who circumcise his prospective patients: "The babies seem less stressed when anesthetized."

The anesthetic of choice is lidocain, similar to the dentist's Novacaine. It doesn't always work, however; the problem is in reaching all of the millions of nerve cells.

Dr. John Farquhar of Bangor said that while he does perform circumcisions on request, he feels "there's no medical necessity" for them. "To me, the only valid, strong feeling for doing it is a religious one." Adverse reactions can include excessive bleeding and infection. Twice, in 25 years, he's had to put a newly circumcised baby on intravenous antibiotics.

Complications, though rare, can be serious. The now-abandoned practice of using electro-cautery - an electrical instrument that stops bleeding during surgery - with circumcision resulted in a few cases where serious infections developed requiring amputation of the entire penis and a sex-change operation, said obstetrician Hays. "We forget," she said, "that every kind of surgical procedure has risks."

Risks and pain coupled with what most agree is an unnecessary operation drove Kenneth Baker years ago to require parents to watch a circumcision, either videotaped or live, before he'd agree to perform one on their son. No one ever did. Baker, who has joined the advisory board of Cook's anti-circumcision group, said "That tells us something if they're not willing to watch."

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