Medical community, parents debate the necessity of circumcision

In the 1960s, when pediatrician Francesco Beuf's sons were born, the routine circumcision of newborn male infants in the United States was so prevalent that parents often weren't even included in the discussion.

My boys were born 36 and 37 years ago, and back then, we weren't even asked if we wanted the procedure or not, says Beuf, of Boulder's Pediatric Center. It was just done.

Circumcision, the removal of the foreskin of the penis by various methods, remains common among Jews and Muslims worldwide for religious reasons. However, with the notable exceptions of the United States and Australia, the ancient procedure is not widely done elsewhere.

But increasingly, routine neonatal circumcision is being questioned by parents and doctors in the United States. According to the National Center for Health Statistics, about 62.8 percent of newborn males were circumcised in 1997, the last year for which complete data have been analyzed. That number varies significantly from region to region, and even from hospital to hospital, according to local custom. In the Western states, only 38 percent of boys born in 1997 were circumcised, compared to 81 percent in the Midwest.

If anything, it seems likely that those numbers will decrease in the wake of a 1999 Policy Statement from the American Academy of Pediatrics' Task Force on Circumcision. Although the academy has never recommended routine circumcision, the latest policy went further than ever in casting doubts on its medical benefits.

Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however these data are not sufficient to recommend routine neonatal circumcision, the policy states. In the case of circumcision; in which there are potential benefits, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interests of the child.

The potential medical benefits can be summed up succinctly: Circumcision reduces the incidence of urinary tract infections (UTIs) in infant males, reduces the risk of a rare penile cancer (though only when performed in infancy), and recent studies indicate that circumcised men appear to be at a lower risk of contracting HIV, the virus believed to cause AIDS.

As far as genital hygiene—keeping the prepuce clean and bacteria free—the policy indicates that those issues can be easily mitigated with proper care.

Because there are sensitive religious and cultural issues at stake in the circumcision debate, the policy makes clear that it is legitimate for the parents to take into account cultural, religious and ethnic traditions, in addition to medical factors, when making this choice. The policy also recommends that circumcision should only be performed when the infant has received adequate local analgesia, which wasn't the case even 20 years ago. There is considerable evidence that newborns who are circumcised without analgesia experience pain and physiologic stress.

For the most part, pediatricians (who, along with religious practitioners, do most circumcisions locally; in some areas of the country, obstetricians do the procedure) seem willing to go along with the AAP recommendations and leave the decision up to parents, even those like Beuf, who generally oppose it.

I try to hand (parents) as much information as possible and say it's their choice, Beuf says. But I don't like to change a machine that works as beautifully as a human baby does.

Carolyn Terman, a spokeswoman for Boulder Community Hospital says that more than 50 percent of newborn boys born there are circumcised. Centennial Valley Pediatrics in Louisville reports that about 75 percent of their male patients undergo the procedure, and Beuf says about 60 percent do at the Pediatric Center. While religious practitioners do not necessarily use analgesia, local pediatricians do. We generally tell the parents that it boils down to a social decision, says Dr. Scott Zimbelman of Centennial Valley. What do you want your son to look like?

Anti-circumcision organizations—and there are many highly opinionated activist groups—hailed the 1999 AAP report as a victory. They argue that circumcision is not only traumatic for baby boys in the moment, but may cause lingering stress, even into adult life. (Studies have indicated that babies who were circumcised respond with more stress to later procedures, such as inoculation, but none has confirmed this continues into adulthood.)

Opponents also say there is an ethical issue at stake: Parents and doctors, they say, are removing healthy, normal tissue that later in life can heighten sexual pleasure and provide protection for the glans of the penis.

I'm for intact penises all the way, says Darcy Kamin, a Boulder registered nurse in private practice who had her own sons circumcised years ago, but changed her mind after assisting with circumcisions at  Boulder Community Hospital. I watched with horror as these kids were strapped down and had their genitals carved on. It was really clear to me that it was terrifying to them. It was brutal, not an OK way to treat a baby, or anybody.

Beth Engel of Estes Park said she chose not to circumcise her two sons, 10-months-old and 4-years-old, simply because she considers the procedure to be primarily cosmetic. I think it's an unnecessary procedure, and I felt that the hygiene reasoning was not accurate, she says. Basically, I'm not into unnecessary intervention.

Despite the most recent AAP policy—which essentially counsels informed consent, parental rights and the use of anesthesia—some doctors still argue the procedure's benefits outweigh the risks, which include the potential for bleeding and infection in newborns. Complications develop in about one of every 476 cases, according to one study published in Pediatrics magazine.

Dr. Edgar J. Schoen, former chairman of the AAP's circumcision task force, has been especially vocal in support of circumcision. In March, he and two colleagues wrote a rebuttal to the policy, which ran in AAP's Pediatrics magazine. He accused the Task Force of narrow, biased and inadequate data analysis.

By ignoring important medical evidence and discouraging newborn circumcision, the AAP Task Force is placing infant boys at increased risk for appreciable illness throughout life, they wrote. Circumcision advocates also say that beyond infection and hygiene issues, the procedure can eliminate phimosis—a condition in which the foreskin is too tight. The medical benefits of circumcision are proven by peer-reviewed, evidence-based studies and are not just 'potential' as claimed by the Task Force, Schoen and his colleagues wrote. In fact, the new AAP policy included substantial data about potential benefits of circumcision, butargued that they were small, statistically speaking:

Uncircumcised infants contract urinary tract infections at an estimated rate of 7 to 14 cases per 100,000 babies, compared to one to two cases for circumcised baby boys, a sevenfold difference.

An estimated .9 to 1 percent of men will develop penile cancer in their lives—nine to 10 men in a million—and uncircumcised men have a threefold greater risk.

Studies about the relationship between circumcision and sexually transmitted diseases, including HIV, are complex and conflicting, but there is a substantial body of evidence that links non-circumcision in men with (greater) risk for HIV infection. However, the policy concludes, behavioral factors appear to be far more important than circumcision status.

Marilyn Milos, a California nurse who lost her job because of her opposition to routine circumcision and now heads NOCIRC—the National Organization of Circumcision Information Resource Centers—says those small risks are not enough reason to traumatize a baby.

Milos says the American obsession with circumcision arose in the late 1800s, when the procedure was touted as a way to prevent masturbation in boys. When they realized that nothing short of death was going to prevent masturbation, she says, circumcision advocates next touted hygiene, and later, the issue of conformity — looking the same in the lockerroom — and most recently, the danger of AIDS.

This circumcision experiment has not worked for any of the reasons put forth, Milos says. And, says Kamin, removing healthy tissue is a heavy-handed way to prevent statistically rare problems.

We don't cut off girls' breasts at birth because they might get cancer, she says. And girls get more urinary tract infections than boys—but that's easily covered by antibiotics.

Complicating the debate is the fact that Jews and Muslims believe that circumcision is prescribed, based on the same passage in the Book of Genesis in the Old Testament, when God made his covenant with Abraham: Every male among you shall be circumcised. (For Christians, the procedure is optional, according to the writings of Paul in the New Testament.)

We knew that it was a purely ritual act, and that's how we treated it, says Alex Wolf of Lafayette, a Jewish man whose 2-year-son was circumcised as an infant. As a ritual, it was very powerful. To go through something that traumatic as parents and for him as a newborn, it clarified our bond in a certain way.

Wolf says he and his wife felt that there wouldn't be any longterm emotional effects, noting that birth itself is traumatic, and that they wanted to raise their child according to Jewish tradition.

I just felt the tug of the covenant, and if I decided not to, it would be going against something so core in the Bible, he says. But if we were Christians, no way would we have done it.

August 21, 2000

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