Circumcision rates are down amid controversy

Gilroy obstetrician Dr. Jumnah Thanapathy recalls seeing a botch, one of the tiny percentage of procedures that go wrong, when she was still working at Kaiser Medical Center years ago.

During the elective circumcision of an infant, the doctor performing the procedure accidentally cut too far down, slicing off the glans and much of the head of the infant’s penis.

It was sewn back on like a re-attached finger, said Thanapathy, but the damage was done. Its extent would be impossible to calculate until the wound healed.

“We live in a society that looks at the statistics of a situation,” said Thanapathy. “People see a 99 percent success rate, and they never think that they’ll be part of that one percent, but I just don’t see taking that risk for an elective procedure.”

Thanapathy is one voice in a growing number of physicians and parents questioning the practice of circumcision, a surgical procedure to remove the penis’ foreskin.

Nationwide, the circumcision debate has raged in chat rooms and through medical journals for more than a decade, but the procedure, practiced since ancient times in many Middle Eastern cultures and commonly in the United States since the end of World War II, has fallen precipitously in popularity among inhabitants of the Western United States - down from 62 to 37 percent between 1980 and 1999, according to the Centers for Disease Control.

Conversely, the number of infants receiving circumcisions in Midwestern and Southern states has risen, despite an increasing number of insurance companies and state programs unwilling to cover the procedure anymore.

In the Midwest, circumcision rates are as high as 81 percent, according to the CDC. At the heart of this disparity are deep and conflicting emotional ties both to religion and social precedent.

Most circumcisions in the United States after WWII were recommended for hygienic reasons.

Soldiers from allied forces had experienced b[a]lanitis, an infection between the foreskin and penile shaft caused by a buildup of urine or foreign material, in “epidemic proportions” during actions in sandy North Africa, according to an article by Dr. J. M. Hudson published in the June 2004 issue of the Journal of Medical Ethics.

It would be easier to circumcise infant males, who are less likely to experience serious side effects from the procedure, than treat blanitis later in life military physicians concluded, and this logic worked its way into medical practice back home as doctors who had been serving in the war transitioned back into civilian practice, he wrote.

Along the way, other medical reasons for the procedure were attached. It could reduce the risk of frequent urinary tract infections in boys, provide minor protection against the transmission of sexually transmitted diseases and prevent congestion of the penis, studies found. Thus, circumcision became a common practice in the United States.

But the evidence never quite stacked up in the minds of many physicians and critics. In 1999, the American Academy of Pediatrics issued a statement from its second task force on circumcision stating that, while the procedure did offer some benefits in terms of hygiene, there was insufficient evidence to suggest the procedure be performed routinely. The group warned that it could have dangerous side effects - botched procedures could lead to excessive bleeding, infection and damage to the penis, including decreased ability to experience sexual sensation later in life.

“(The foreskin) provides a different kind of stimulation for both partners, it keeps secretions in place, and it protects the head of the penis from exposure when rubbing up against clothes,” said circumcision opponent Ronald Goldman, Ph.D., author of “Questioning Circumcision: A Jewish Perspective” and “Circumcision: The Hidden Trauma.” “(Circumcision) removes a significant portion of the sensitive, erogenous tissue of the penis that compromises up to half of the shaft skin.”

However, the issue is sensitive not only in terms of circumcision’s relationship to sexual function, but to cultural beliefs. Jewish baby boys are routinely circumcised on their eighth day of life as part of a celebratory ceremony called the Brit Millah, or more commonly known as a bris. A special rabbi, trained and medically qualified to perform circumcision, snips the foreskin of the infant without anesthesia as part of the ceremony meant to celebrate the boy’s acceptance into the Jewish community, which traditionally traces descent through maternal lines.

The tradition arises from a story in the Torah in which God made a covenant with Abraham naming him the father of nations in exchange for his vow to be circumcised along with all the men of his house and all of his descendants. Many Christian sects also have adopted the rite of circumcision as part of their religious experience as well. The majority of both these groups reject the idea of circumcision as an unnecessary or dangerous procedure.

“I understand that circumcision is a hot topic right now, but extremist groups advocating against circumcision and seeking to change religious traditions to match their personal feelings often fail to recognize this important procedure in Jewish tradition has been performed successfully for over 3,500 years,” said Rabbi Yitzhak Miller, leader of Congregation Emeth Reform Synagogue, which serves the South Valley area.

The origin of these beliefs may have its roots in a more practical purpose, however. In “Circumcision: A Surgeon’s Perspective,” Hutson postulated that the ritual cuttings arose as a common practice of early Jews, Christians and Muslims as a means to combat the problem of b[a]lanitis among adult males, but noted that the practice had never attained popularity in less-sandy areas such as Europe or Asia.

Circumcision for any reason other than medical necessity is uncommon in Hispanic culture, rare in Europe and nearly unheard of in Australia, a country whose medical establishment actually recommends against the process.

In the United States, the majority of infants circumcised are white or black, but policy on the procedure has changed markedly in the last 20 years, according to Thanapathy.

“When I was having my own children, the doctor didn’t even ask me,” said Thanapathy, who does not perform circumcisions. “They just gave me the consent form to sign. I had to say, ‘Hey! Wait a minute.’ I think now it’s gotten to the point where most parents who are going to get the procedure ask for it instead of the doctor offering.”

In her own practice, about 50 percent of parents ask about the procedure, but only about 30 percent end up following through with circumcision.

Even among Jewish families, some of circumcision’s staunchest supporters, a few members have split with the norm.

Gillian Flato, a San Jose-based technical writer, formed the group Jews Against Circumcision nearly five years ago after a conversation with a friend from India shifted her perspective on the subject.

“In Judaism, the ritual is considered routine, but Indians don’t generally circumcise,” said Flato. “He said, ‘Any religion that says you have to cut off part of your penis in order to join is not one I’m interested in.’ I thought, ‘Wow! When you say it like that, it seems like a really screwed up thing to do.’ We’re raised with all kinds of lies and myths that it doesn’t hurt, and it’s quick and heals well, but (after researching it) I came to the conclusion that it was painful and barbaric and a gross violation of human rights.”

Flato has found kindred spirits in the 125 or so members of her online group, but she has also faced some resistance from her family and community, some of whom don’t believe she can support Judaism with the view.

“In the Talmud it says we are not to inflict pain on others or harm others,” said Flato. “How can we turn around and torture infants? Religion is in your heart, not in your penis. If you believe in Judaism and you go to synagogue and you believe, I believe you’re a Jew.”