ICON Magazine, April, 1998.

Joshua was born a healthy six pound, nine ounce baby boy. Shortly after his birth, the baby's mother signed a consent form permitting her son's circumcision. During the procedure, the obstetrician used a device commonly called the Gomco clamp. The tool has two parts: a small cone that slides between the foreskin and head of the penis, and a clamp that cuts off the circulation of blood to the base of the foreskin. With the clamp in place and the foreskin sufficiently desensitized, the doctor ripped it from the shaft of Joshua's penis.

Immediately after the procedure, the doctor wrapped the wound in sterile, Vaseline soaked gauze, and Joshua went home with his mother the following day. At four the next morning, she noticed a reddening on her baby's scrotum and raced back to the hospital. The physician removed Joshua's clothing and found that most of the infant's skin appeared severely burned. He diagnosed the condition as Scalded Skin Syndrome, the result of a staph infection that had entered the body through the circumcision wound. Despite the hospital's round-the- clock care, Joshua died three days later. He was eight days old.

Each day, more than 3,400 baby boys are circumcised in hospitals across the United States. Though the majority of these operations are performed without incident, between 2 and 10 percent of circumcisions result in complications such as excessive bleeding, infection, or even death.

In what seems a bizarre twist, some botched circumcisions have been corrected by surgically altering the remaining tissue into female genitalia. One such procedure, widely known as the case of John/Joan, was recently reported in the Archives of Pediatrics and Adolescent Medicine. Based on the theory that the absence of an adequate penis would be psychosexually devastating, surgeons removed the child's remaining male tissue and constructed a vagina. But despite the parents' best efforts at feminization - having the child wear dresses and makeup, and letting her receive estrogen treatments at age 1 - the child rebelled. At 14, she learned the truth about her past and demanded to have her manhood restored. Now in his mid twenties, "John" is married and has adopted children. He's able to ejaculate, but he must urinate while sitting down (through a tube at the base of his penis).

Though the rate of circumcision in the United States has fallen from a peak of 90 percent in the 1970s to just over 60 percent today, certain religions, including Islam and Judaism, consider it essential. The B'rit Milah, which is performed eight days after birth, has been a Jewish custom for nearly 4,000 years. According to Rabbi Marty Pasternak of Congregation Agudas Achim in Austin, Texas, "It's very simple. Circumcision is a basic commandment directly spoken by God to Abraham in the Old Testament. The b'rit is the first ceremony sanctifying the child into the Jewish tradition." Every b'rit must be performed by a mohel, or ritual circumciser, who is formally trained in both circumcision techniques and Jewish law. There's a definite link between circumcision and sacrifice," says Rabbi Daniel Silberman Brenner of the National Center for Learning and Leadership in New York City. It's a covenant of blood, and contact with blood instills a sense that our bodies are a sacred thing."

In the United States, circumcision crossed into the secular community in the late 18th century. In 1870, Dr. Lewis A. Sayre, the first American surgeon to advocate circumcision, found that "relieving the imprisoned glans penis" cured many of his patients who suffered from paralysis and hip-joint disease. Circumcision became even more fashionable toward the turn of the century, when personal cleanliness grew to be associated with "good morals, sound health, and upright character," according to David L. Gollaher, Ph.D., president of the California Health Care Institute.

Physicians also began using circumcision to desensitize the penis and thus discourage masturbation, which many people believed led to blindness, nervousness, insanity, venereal disease, tuberculosis, and death. The Journal of Orificial Surgery reported in 1898: "Clarence B. was addicted to the secret vice practiced amongst boys. I per- formed circumcision. He needed the rightful punishment of cutting pains after his illicit pleasures. Realizing his error, his eyes grew bright, his gait became elastic, his intellect widened, and his memory returned."

Many immigrants to America at the turn of the century looked upon cir- cumcision as something of a status symbol - the first sign of a baby's birthright in a new land. During the two world wars, the military took to circumcising its soldiers - unsuccessfully - in an attempt to halt the spread of sexualIy transmitted diseases. Meanwhile, this country's medical field became increasingly standardized, and women started giving birth in hospitals in greater numbers. Following World War II, the economic boom resulted in more jobs that offered health insurance. By 1960, 85 percent of American males were routinely circumcised. It wasn't until the late '60's that the first studies to probe the link between circumcision and mental and physical health were published.

The medical community's conclusions regarding circumcision are "controversial, to say the least," says Dr. Hans Kersten, a pediatrician at St. Christopher's Hospital for Children in Philadelphia. "For parents who are undecided, the medical evidence just isn't strong enough to say you definitely need this." Evidence that supports circumcision generally cites reduced rates of penile cancer and sexually transmitted diseases, including AIDS. Studies in Kenya suggest that HIV infection is more common in men with foreskins. These results, however, don't account for cultural, economic, or religious differences between the two groups. Another study, conducted by Dr. Thomas Wiswell, a pediatrician and professor at Thomas Jefferson University Hospital in Philadelphia, followed 200,000 boys born in U.S. Army hospitals from January 1985 to December 1990. A subsequent report found that circumcision reduced the rate of urinary tract infections (UTIs) almost tenfold.

Urinary tract infections, however, occur in only one percent of all males. "How do you go from a one percent risk of UTI to to 0 percent amputation of foreskins?" asks Dr. George Denniston, president of Doctors Opposing Circumcision (DOC). "The relative risks don't justify the act."

The American Academy of Pediatrics has reported that penile cancer in the United States is found almost exclusively in uncircumcised men. However, in Denmark and Japan - two countries where circumcision is not routine - the rate of penile cancer is the same as it is in America. According to the Circumcision Consent Form, which every parent is required to sign, "It is known that most cases of penile cancer are caused by human papillomavirus, which is acquired through sexual intercourse. More baby boys die each year from circumcision than men die of penile cancer."

With all the studies being done on the effects of circumcision, relatively few address the pain of the newborn child. Only recently have doctors started administering local anesthetics, such as lidocaine, to ease the pain of the procedure. But the use of painkillers is still left to the physician's discretion. Researchers at the Hospital for Sick Children in Toronto found in 1997 that circumcision pain can continue to affect an infant several months after the operation. Some circumcised newborns were found to be particularly sensitive to the pain from their first vaccination shots. Infants have even been known to rupture their stomachs, sometimes fatally, as a result of hysterical crying following circumcision.

Mohels attribute the need for anesthetics to the technique that's followed by hospitals: It requires the baby to be strapped to a board for 50 minutes or more and is often performed by a doctor not experienced in the procedure. Says Canter Philip L. Sherman, a New York City based mohel who has performed 8,000 circumcisions, "A traditional b'rit takes only no seconds - and that's with the baby lying on a double pillow. There is significantly less pain - no anesthetic is necessary."

With annual revenues estimated at $1 billion, circumcision is an industry that involves medical equipment manufacturers, insurance companies, physicians, and biotech firms.

Olympic Medical and Allied Healthcare Products are both in the business of supplying hospitals with tools for circumcision - such as the Circumstraint Board, which immobilizes the infant during the procedure, and the aforementioned Gomco clamp.

Insurance companies are doing their part to defend the status quo. According to Dr. W. Knox Fitzpatrick, vice president of Medical Affairs for Blue Cross/Blue Shield of Utah, "It has been known for decades that circumcision has no demonstrable, medically necessary purpose. It is rooted in our culture, however, and efforts to the contrary have done little to abolish the habit. The public demands that this service be included in their insurance policy."

Without coverage, circumcision's future could be bleak. When MediCal, a state sponsored healthcare program in California, stopped covering circumcision, the circumcision rate in one hospital fell from 35 percent to 6.1 percent. Availability of health insurance may also be a reason that circumcision rates vary among whites (81 percent), blacks (65 percent), and Hispanics (54 percent). In the Midwest, the circumcision rate exceeds 80 percent, while in the West, it stands at only 34 percent.

The cost of a circumcision varies according to the physician and the location. The national average in 1994 was $137, but fees ranged from $98 to $400. Multiplying the average cost of a procedure by the 1 million operations performed per year reveals that doctors are generating $164.4 million annually from routine infant circumcision.

The scientific community has found uses for infant foreskin that defy the imagination. According to Frederick Hodges, Ph.D., a medical historian at Oxford University, "The after market for human foreskin is where the real money is made. Foreskins are sold to biomedical companies, which use them in the manufacture of insulin. They're also sold to middlemen, who package them for sale to research companies that in turn use them for biochemical analysis." Corporations such as Advanced Tissue Sciences (ATS), Organogenesis, BioSurface Technology, Genzyme, and Ortec International are taking cells from amputated foreskins and experimenting with artificial skin. Products like DermagraftTC, which sells for about 33,000 per square foot, are grown from the cells in infant foreskins and used as a temporary wound covering for burn patients. One foreskin contains enough genetic material to grow 250,000 square feet of skin.

For burn patients and diabetics with foot ulcers, foreskin grafting can be a more sterile choice than what was available just a few years ago. "The advances in this field have been astounding," says Janet Wall of Advanced Tissue Sciences. "It used to be that when burn patients didn't have enough of their own skin to cover wounds, the only alternative was to use skin from a cadaver, which raised concerns about the transmission of disease." The patient's body would often reject the cadaver skin in a matter of days or weeks.

Parents' decisions about circumcision are often based on little that resembles science. Fear of a son's alienation is a haunting thought to an expectant father - even if he didn't take part in the ridicule as an adolescent, he was probably a witness to a scenario like, "Hey Robby, what's wrong with your ding a ling? You're weird" And that stigma is nothing compared to the scorn of the girl next door. "Nothing prepared me for the first time I actually saw one uncircumcised penis - I wasn't sure what to make of it," says Sarah M., a student at the University of Texas at Austin. A study published in 1988 in The Journal of Sex Education Therapy concluded that women actually prefer circumcised men.

The United States is. the only country in the Western Hemisphere that routinely practices nonreligious male circumcision. As DOC's Dr. Denniston points out, circumcision violates one of the basic tenets of medicine: primum non nocere (first do no harm). And since the choice is made for them so early in life, most men have no idea what they're missing. With more than three feet of veins, arteries, and capil- laries, 240 feet of nerve fibers, and more than 1,000 nerve endings, the foreskin is one of the most erotically sensitive parts of the penis. Removing it leaves the exposed glans, which reacts best to intense pressure or pain. "Sex was always much better with a fore- skin," laments Matthew R., who was circumcised at age 21 for medical reasons. "After it was removed, it was like going from technicolor to black and white."

Not only do the glans and foreskin act as a tag team of stimulation, but the foreskin also produces a natural moisturizer called smegma. Just as the eyelid and tears protect the eye, the foreskin and smegma keep the reproductive package in top condition. But smegma is a pungent, grayish, cheese like substance that can be a nuisance if the penis is not properly cleaned. In any case, children are quick to learn how to maintain proper hygiene. Says Matthew R., "It becomes second nature, like washing your armpits."

Michael Deacher is a writer whose work has appeared in "Texas Monthly" and "Hoover's Online."

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• Deacher M. Ego: Circumcision. Icon Magazine, April 1998.

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