The Age-Old Question of Circumcision

3rd Edition, Section: Science & Technology

Circumcision is the first surgery most American boys encounter. But the reason for doing it isn't usually medical; it's more likely a matter of habit, style or religion.

For years, the  American Academy of Pediatrics and  American College of Obstetricians and Gynecologists have said routine circumcision of newborn boys isn't medically warranted. As a result, the procedure now isn't covered routinely by many insurance plans, including Blue Cross and Blue Shield of Massachusetts.

While most newborn American boys still are circumcised, the number seems to be dropping. According to the National Center for Health Statistics, 59 percent of newborn boys, or 1,163,000 babies, were circumcised in 1985. The center doesn't have statistics for previous years, but specialists say the number has fallen significantly compared to 10 or 20 years ago; 20 years ago, they say, circumcision of newborns was routine.

In Boston, specialists say the numbers have declined, too. At  Brigham and Women's Hospital, the largest maternity service in the state (expecting close to 10,000 babies this year) 58 percent of boys born in 1986 were circumcised. At Beth Israel Hospital, second largest with 5,000 deliveries expected this year, roughly 70-80 percent of boys are circumcised.

Most circumcisions involve strapping the baby onto a board and inserting a bell-shaped plastic or metal device between the foreskin and the head of the penis. The foreskin is clamped against the bell and cut off with a scalpel. Usually, there is a little bleeding, and the wound heals in a week to 10 days. In some states, pediatricians do circumcisions; in Massachusetts and most other states, it's usually done by the obstetrician in the first three days of the baby's life.

Anesthesia seldom is used. General anesthesics are considered too risky for such a minor operation, although they're used if circumcision is done at a later age. Local anesthesics, sometimes used, may not work and carry some risk. Numbing sprays or creams don't penetrate far enough.

How painful is circumcision? Doctors say it seems to vary; some babies scream for 10 minutes, others cry but can be quieted easily, says Dr. William D. Cochran of the Joint Program in Neonatology at  Brigham and Women's,  Beth Israel and  Children's hospitals. Few babies appear to be in pain half an hour later.

Even if the pain isn't long-lasting, why perform any surgery without a good medical reason? Jewish and Moslem babies are circumcised for religious reasons; Jews to signify the covenant between God and the Jewish people, Moslems because it was instructed by Mohammed.

For decades, most non-Moslem, non-Jewish Americans chose circumcision out of custom or because of arguments that it improves hygiene, discourages masturbation or reduces the chance of cancer of the penis, or in sexual partners, cancer of the cervix. These arguments now are widely discarded. In a few cases, boys who don't get circumcised at birth need to be circumcised later for medical reasons; the surgery is more complicated and seemingly more painful then.

The prime reason for infant circumcision today, though, doctors say, is that parents want their sons to look like their father and like other boys. And, doctors say, since everyone seems to choose circumcision,it's easiest just to go along.

I think it's something that feeds on itself. Parents tell me when I try to talk them out of it that they don't want their child to look different in the locker room, says Dr. Ronald L. Poland, professor of pediatrics at  Wayne State University School of Medicine. Poland is chairman of an American Academy of Pediatrics committee that recently reaffirmed the academy's stand against routine circumcision. As more and more boys go without circumcision, the locker room argument may fade.

In the last two years, however, one new contention in favor of circumcision has surfaced. Studies published in 1985 and 1986 in the journal Pediatrics showed an increased risk of urinary tract infections in babies who weren't circumcised. These infections, which occur in about 4 percent of uncircumcised boys, usually aren't dangerous, but occasionally cause serious kidney damage, says Dr. Thomas E. Wiswell, chief of the newborn service at  Brooke Army Medical Center in San Antonio and author of the studies. He says his research shows that circumcised boys have only one-tenth to one-twentieth the rate of infections.

This connection hasn't been proven to the satisfaction of Poland's committee and many other specialists, but they agree the data are provocative.

Wiswell says that even if the connection is proved, he's not sure that means all boys should be circumcised.

Right now, I'm sort of in a quandary, he says. For years, Wiswell argued against routine, non-religious circumcision. I felt as most people did that there were really no medical indications, he says. Right now, I can't say that. I know of a valid medical reason, and the strongest statement I say right now is that every single parent who's considering the procedure has to be aware of the pros and cons…I frankly consider circumcision a barbaric kind of procedure because we do it without anesthesia. Is it worth it? I don't know.

The rate of complications following circumcision, usually infection, bleeding or removal or too much or too little tissue, is less than 2 percent, Wiswell says; his own study showed a complication rate of less than half a percent. But with so many circumcisions done each year, even a tiny complication rate means that children are harmed each year by the surgery.

In addition to cultural values and the desire to fit in, circumcision evokes another consideration—money.

I have some good friends who are obstetricians outside the military, and they look at a foreskin and almost see a $125 price tag on it, says Wiswell. Each one is that much money. Heck, if you do 10 a week, that's over $1,000 a week, and they don't take that much time.

For Jewish and Moslem couples, the decision often is not whether to circumcise their sons, but whether it should be done in a hospital operation or a religious ceremony. The options for Jewish families have just expanded. Earlier this month, 11 Boston-area physicians became certified mohelim, ritual circumcisers, after completing training through the Reform Jewish movement.

Whichever choice you make as parents, you should be sure your son's genitals, circumcised or not, get the proper care, mainly just washing. Penises don't need special hygiene; if the baby isn't circumcised, parents are advised to leave the foreskin alone and not forcibly retract it to clean underneath. In a few years, the foreskin probably will loosen on its own and be retractable for cleaning underneath. It also may be reassuring to know that newborns have particularly tight-looking foreskins; their penises will look more likegrown men's later.

Parents would do well to be on the lookout for signs of urinary infection, whether or not their child is circumcised, and call a doctor if symptoms, including fever, unusually bad-smelling urine, vomiting or diarrhea, appear.

For more information on how to care for a son's uncircumcised penis, send a stamped, self-addressed business-sized envelope to: Circumcision Brochure, Department C, American Academy of Pediatrics, Box 927, ElkGrove Village, Ill. 60009.

Copyright 1987, 1998 Globe Newspaper Company, Record Number: 00039111

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