In Last Four Decades, Circumcision Has Lost Popularity in United States

Cutting the Procedure

Amanda Mann doesn't claim to be a perfect mother. Like any other parent, she has her momentary lapses, including the occasional loss of her temper, which are understandable for the mother of four boys.

Mann doesn't castigate herself for such episodes. But one moment from her first days as a parent does cause her continuing remorse.

The circumcision of my first son is the only thing I regret as a parent, said Mann, a Bartow resident.

Mann represents a growing segment of the American populace, parents who have turned against the previously routine practice of having their sons circumcised in their first days of life. Circumcision rates in the United States have declined from a high of nearly 90 percent in the early 1960s to about 57 percent in 2004, according to the National Health and Social Life Survey. The recently issued report found rates below 50 percent in some states.

Health experts say immigration from Latin American and Asian countries, where circumcision is not a cultural custom, has contributed to the decline. But the statistics suggest a rise in the number of white, native-born parents, like Mann and her husband, Curtis Romey, who have decided to go against the norm.

Circumcision - the surgical removal of the foreskin from the penis - has ancient origins. In the book of Genesis, it is described as a symbol of the covenant between God and the Hebrews, and a passage in Leviticus mandates circumcision on the eighth day of a boy's life. Observant modern Jews regard the procedure as a religious obligation, and circumcision is also common in Islam.

Some historians say circumcision gained wide acceptance because it was believed that removal of the sensitive foreskin would make boys less likely to masturbate or pursue sex. The practice, long shunned by Christians, became prevalent among Western countries in the early 20th century and was routine in American hospitals by the 1950s. It remains the default choice for many Americans.

Though official rates are not available for Polk County, Dr. Jeffrey Puretz, a Lakeland obstetrician/gynecologist, said he has noticed no decline in circumcisions during his 19 years in practice.

Every parent is counseled during pregnancy and given information on circumcision, Puretz said. They ultimately make the decision, but I haven't noticed that most are not having their sons circumcised.

Mann, 32, hadn't given much thought to circumcision before the birth of her first son, Zain, 11 years ago. She recalled giving written permission for the surgery as she signed a stack of papers in a local hospital.

When I changed his diaper the first time and saw the wound he'd been given, it made me horribly regretful and I couldn't believe I'd allowed something so mutilating to happen to one of my children, which I'd been given to protect, Mann said. At that point, it became clear to me with any future son there was not a chance it would happen.

Mann, a childbirth educator at Labor of Love, a natural birthing center in Lakeland, said Zain seemed to be in pain for more than a week after the circumcision and had difficulty nursing and sleeping as a result. Zain also developed adhesions - bits of leftover foreskin stuck to the glans - that Mann said caused the newborn boy additional pain.

Mann said she went to almost comical extremes after the birth of Asher, her second son.

I was worried about him being accidentally circumcised, so I was maybe a little overvigilant, she said. Anyone who walked in the room, I was making sure (they knew) he's not going to be circumcised, even if they were delivering a newspaper.

Nancy Moses, a friend of Mann's, arrived at the same outlook while pregnant with her first child, who turned out to be a girl. Four years later, Moses gave birth to a son, John, who is now 2 and, as Moses proudly states, not circumcised.

I think I always knew that I found circumcision odd, creepy and cruel, even, said Moses, 31. But it wasn't until I was pregnant that I knew how horrible it would be if someone hurt my baby. And imagine if I was the one to allow that.

Though some gentiles cite biblical passages as a reason for circumcision, Mann and Moses - both professed Christians - said their spiritual covenant obviates the need for the physical symbol of the Jewish covenant.

Moses, 31, a stay-at-home mom, said her husband, Rob, was at first inclined toward circumcision, but as soon as he learned about how it happens and how pointless it is, he was protective of our son's foreskin.

Leading medical organizations, such as the American Academy of Pediatrics, are neutral on circumcision. The AAP on its Web site mentions possible health benefits of the surgery, including a decreased risk of urinary tract infections and sexually transmitted diseases and the prevention of foreskin infections, but says the data are not sufficient to recommend routine neonatal circumcision.

When patients ask Puretz for his advice on circumcision, he lists the pros and cons without making a recommendation either way on what he called an elective procedure. Puretz, who is Jewish, regularly performs circumcisions for Jewish parents as part of the brit milah ceremony.

Dr. William Ray, a Lakeland pediatrician, said he tells parents the practice is based on cultural rather than clear-cut medical factors.

Most people have made their minds up without the aid of a physician, said Ray, a hospitalist in pediatrics for Watson Clinic.

Ray said the most influential factor, aside from cultural and family traditions, is insurance coverage. In 2003, Florida joined more than a dozen other states in dropping circumcision from the list of procedures covered under Medicaid, the program for low-income families. Ray said he noticed fewer requests for the surgery after the change in coverage, though some parents choose circumcision even if they have to pay for it themselves.

Tabatha Richardson of Winter Haven is one of those parents. She chose circumcision for her 10-month-old son, Tyler, even though her health plan didn't cover the procedure.

Richardson, who made the same decision for an older son, said she carefully researched the issue and concluded that circumcision made sense.

There were just so many pros for not just the immediate but the lifelong (health) that I decided to do it with my second son as well, Richardson said. Even as infants it's easier to keep that general area clean and free from infections with them being circumcised.

Parents such as Mann and Moses quail at the notion of having elective surgery performed on a newborn boy. Mann equates circumcision with breast augmentation, and Moses calls it optional cosmetic surgery.

There are three prevalent methods of circumcision. Two involve placing a clamp over the penis so the foreskin can be excised with a scalpel, and the third uses a thread that causes the foreskin to wither and fall off in a few days. The newborn usually receives a local anesthetic, either in a topical cream or an injection.

Opponents of circumcision say the procedure is doubly harmful, inflicting pain at the time of surgery and reducing sexual pleasure later through the removal of the nerve-rich foreskin. Puretz, the obstetrician, said it isn't clear the procedure has negative physical or emotional effects.

When I first trained, there were a lot of physicians who weren't using any anesthetic at all, and I felt a little disconcerted about that, Puretz said. Local anesthetics ... have virtually eliminated pain from the procedure. A lot of babies don't even know it's going on while it's happening.

I don't know one way or the other how babies feel about it later in life, subconsciously or consciously, if they remember it, he added. For me personally, it's not something I remember.

Mann and Moses would rather err on the side of caution. The two mothers also question the validity of studies finding lower rates of HIV among circumcised men, and they say foreskin hygiene is no more of a challenge than keeping ears or noses clean.

Mann, whose sons clustered affectionately around her at the family's Bartow home on a recent morning, said she's unconcerned that Asher, Atticus or Ivan might feel self-conscious or face ridicule for having a different penis from other boys.

The locker-room argument never really held a lot water with me, Mann said. I kind of liken it to, well, if I had a daughter who wasn't chesty would I consider breast augmentation for her? And the answer to that is absolutely, unequivocally not.

Mann and Moses use such words as amputation and mutilation in describing circumcision, they don't align themselves with militant intactivists who would like to see the procedure banned. Both said they respect the decisions of any parents who consider the matter carefully.

Mann said she hopes more and more parents will arrive at the same choice she did.

I'm proud to have three more intact boys in the world, she said.

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