News You Can Use 6/15/98

HEALTH

Rethinking a custom
Circumcision is no longer an automatic decision for parents

BY SARA JOAN LOWEN

Even before their son, Emmet, was born in 1989, Philip and Penelope
McGuire knew how they felt about circumcision. Without much agonizing,
the East Lansing, Mich., couple decided that they would leave their
son's foreskin intact. Recalls Penelope, "Circumcision seemed
ridiculously unnecessary and painful."

A generation ago, Emmet would have been in the noticeable minority
of uncircumcised American males. Attitudes are changing and neonatal
circumcision rates have dropped steadily during the past three
decades from 90 percent to 64 percent. However, the United States
stands out as the only nation where circumcision for nonreligious
reasons is widespread. (Jews and Muslims circumcise boys as a part
of religious practice.) In Western Europe, only 5 percent to 8
percent of newborn boys are circumcised.

Circumcision remains the most commonly performed surgery on males
in this country--some 3,300 operations a day. The popularity of
the procedure in America is historically related to what some
scholars say was a national obsession with hygiene, heightened by
prudery. Edward Laumann, a University of Chicago sociologist, says
that nonreligious circumcision was introduced during the late 19th
century as a means of preventing sexually transmitted diseases;
the Victorians also thought that it curbed masturbation. In the
years after World War II, circumcision had become so ubiquitous
that many hospitals offered it as a routine part of birth-related
services.

Radical views. The trend away from circumcision has its roots in
the natural childbirth movement of the 1970s, which sought to make
birth as gentle as possible for the infant. Women who undergo a
drug-free labor for their baby's benefit hesitate to subject him
to surgery a few days later. But a more strident anticircumcision
movement, centered mainly in the San Francisco Bay area, is trying
to influence parents. These circumcision opponents, who include
some doctors, promote their views through pamphlets, books, videos,
and the Internet, arguing that the procedure violates medical ethics
and human rights by subjecting infants to what they see as disfiguring
surgery. They liken it to female genital mutilation, which was
outlawed in the United States in 1996. Despite little medical
research, the activists hold circumcision responsible for male
sexual dysfunction and psychological problems. Some have even staged
protests accompanied by recordings of babies screaming during
circumcision.

Parents in the mainstream who decide not to circumcise mainly want
to spare their sons the pain and risks of surgery. Oakland, Calif.,
resident Donald Bivin, the father of an uncircumcised son, says,
"Humans have been around for millions of years without being
circumcised, and it hasn't been a problem." While the risk of
complications from a circumcision (most often infection, not lopping
off the penis) is small--between 2 and 6 incidents per 1,000
procedures--credible research is showing that infants do feel pain.
Most doctors defend the surgery as low risk and point out that a
local anesthetic can eliminate the pain involved. (The American
Academy of Pediatrics, which is neutral on circumcision, is expected
to update its guidelines later this year, recommending the use of
a painkiller.)

There is reliable medical evidence that removing the foreskin
reduces the incidence of first-year urinary tract infections in
boys and ensures that they won't develop penile cancer, which does
affect uncircumcised men. But penile cancer is rare (occurring in
about 9 out of a million men), and first-year urinary tract infections
occur in only 1 percent of uncircumcised boys. There's no clear
evidence that circumcision reduces rates of sexually transmitted
diseases. All the same, some physicians acknowledge that the demand
for circumcision in the United States is based on religious or
cultural, rather than medical, needs. "There is no proven, documented
medical reason that says circumcision is better, as long as you
teach your child to pull back the foreskin and wash," says Dr.
Karin Blakemore, director of the maternal-fetal medicine division
at Johns Hopkins University School of Medicine.

Despite circumcision's slipping popularity, couples who decide
against the procedure often are left with the impression that
doctors and nurses expect the surgery nonetheless. Susan Flanigan
and Michael McDowell of Washington, D.C., decided shortly after
their son's birth not to have him circumcised. Then during Flanigan's
three-day hospital stay, nurses came by repeatedly and asked about
circumcising her baby--"as if to say, 'Are you really, really
sure?'" she recalls.