Circumcision Unjustified

America's most popular surgery for males is usually done without medical justification, according to the official policy of the doctors who perform the operation.

Despite agreement that the surgery is seldom needed, few doctors expect the number of routine circumcisions to decline. About 1,494,000 circumcision were performed last year, according to the Commission on Professional and Hospital Activities in Ann Arbor, Mich., and the number has stayed fairly steady for years.

The removal of the foreskin from an infant's penis has its origins in antiquity. It has been a means of paying respect to tribal leaders, a way to differentiate slaves from free men and a religious ceremony. It still is required by Jewish law and is performed by a mohel, usually eight days after birth.

Scientists don't challenge the act as a religious ceremony. However, doctors' routine application of the operation for patients for whom it holds no religious significance is an example of medicine used as an unscientific ritual.

It is estimated that routine, nonreligious circumcisions cost Americans as much as $200 million a year and that the death rate from complications is at least as high as two per million. Some doctors suggest that deaths are under-reported and the rate could be many times greater.

As older medical justifications have proved inadequate, American physicians have found new justifications to circumcise baby boys.

Dr. Karen Ericksen Paige, a psychologist at the University of California in Davis, compared circumcision to the lengthening of ear lobes popular with some primitive tribes.

Paige's studies of the origin of circumcision in modern medicine have convinced her that it has become a ritual.

When a custom persists after its original functions have died, she said it may be accorded the status of ritual.

At the turn of the century, medical texts advocated cutting away a portion of the foreskin as a means of preventing the insanity thought to stem from masturbation.

When it became evident that masturbation didn't cause insanity and the circumcision didn't prevent masturbation, doctors began advocating the procedure to promote cleanliness and to prevent cancer.

Some doctors still use those arguments, but most admit that soap and water are better means to genital hygiene than surgery.

The latest argument is that uncircumcised boys may be damaged psychologically because they will look different from their fathers and from other boys.

I would guess that 80 percent of newborn boys are still getting circumcised, said Dr. Ervin Nichols, director of practice activities for the American College of Obstetricians and Gynecologists.

In 1978 that group adopted an official policy that there is no absolute medical indication for routine circumcision of the newborn.

That action followed the lead of the American Academy of Pediatrics but it has had little effect on the obstetricians who do most circumcisions, Nichols said.

Some obstetricians argue that the lack of absolute medical indication for routine circumcision doesn't mean the operation shouldn't be done routinely.

Dr. Ralph Wynn, a former Chicago physician who became head of the University of Arkansas Medical Center's obstetrics department instigated a policy of routine circumcision at the center.

The private hospitals were always doing them, he said, but the indigents coming to our hospital weren't getting them, and they need this the most to promote hygiene. We were seeing kids two and three years old who had trouble urinating.

Wynn said circumcision is needed to prevent a condition called phimosis, a constriction that makes it difficult to retract the foreskin over the head of the penis and to keep the penis clean. Phimosis occurs in two or three percent of males, and they usually outgrow it by puberty.

Most studies have concluded that the minimal medical benefits of circumcision are outweighed by the costs and complications. Wynn summarily dismissed such studies as quite biased.

The official position of his professional college didn't say circumcision is without benefit, Wynn said, but only that there is no absolute medical indication. We do a lot of things with no absolute medical indication. Circumcision is like nose surgery. There's no medical indication for that, but a lot of people want it done.

Another advocate of routine circumcision is Dr. Julian R. Taplin, a psychologist at the University of Oregon, who argues that to have a penis that looks different from the penises of age-mates is a psychologically crucial issue for a boy.

Younger children have asked Taplin why they are different, have said they don't like having to spend so much time washing their penises and have said their parents may scold them for spending too much time with the washing, he said.

Also, one must consider the response of women, Taplin said. Lots are disappointed to find they have an uncircumcised partner. They are concerned about cleanliness, cancer and a greater chance of getting venereal disease.

The connection between circumcision and cancer prevention can be traced to some studies done nearly 40 years ago that found Jewish women had less cervical cancer than women of other backgrounds.

There was a presumed causal relationship involving intercourse with men having had circumcision, said Dr. David Grimes, an epidemiologist at the federal Center for Disease Control in Atlanta. It was just a case of bad epidemiology. The tradition of cleanliness in the Jewish culture could just as well be responsible.

Many researchers have presumed that the material that accumulates underneath an uncircumcised foreskin--smegma--causes cancer. Laboratory tests have failed to find any scientific backing for that belief.

Arguing that circumcision prevents penile cancer is simply a case of medical overkill, Grimes said, because such cancer is rare.

Breast cancer in males kills more people each year than does cancer of the penis, so it would make more sense to surgically remove a male baby's breasts than his foreskin, since they serve no anatomical function, Grimes said, but I don't hear anyone advocating that.

While it is commonly done without anesthesia, circumcision carries medical risks to the baby in addition to the stress of pain.

A study of 5,521 circumcisions at the University of Washington Hospital in Seattle from 1963 to 1972 found that serious complications occurred in one of every 400 procedures.

Dr. Julian Ansell, chairman of urology at that hospital, described five complications in his study as life threatening. These included four infections and one case of hemorrhaging. Another nine complications were serious enough to require additional surgery.

Medical literature as well as malpractice lawsuits attest to instances where baby boys were surgically converted into girls after circumcisions were botched so severely that the child's entire penis had to be removed.

Physicians frequently overlook the anguish an infant is subjected to during circumcision, Grimes said. The common contention that the patient is too young to feel the pain is absurd, he said.

Infants cry, turn red and frequently vomit from the stress of the procedure. Studies have detected changes in sleep patterns of circumcised babies as well as increased wakefulness and crying.

Increases levels of natural cortisone in the blood stream of newborns 20 to 40 minutes after circumcision support behavioral indications that the cutting is stressful.

Estimates of the cost of circumcision vary. Grimes found that the 1.2 million done a decade ago probably cost between $50 million and $200 million, depending upon how much individual physicians charged and whether a complication developed.

At that time, the fee was around $25, but fees of $50 to $75 are more common today. Those fees have been cited as one reason doctors continue to circumcise babies despite the lack of medical need.

Assuming a fairly busy obstetrical practice, the extra fees collected for performing circumcisions amount to several thousand dollars a year, said Dr. Thomas Ritter of Pottsville, Pa., a vocal opponent of the procedure.

Many mothers often give permission for the operation without seeking a reason for it.

Studies have found that mothers had sons circumcised for such irrational reasons as to prevent excessive crying, masturbation or rupture. Some believed it was necessary for admission to the armed forces; others believed it was required by law or hospital policy.

One study found that when the physician opposed circumcision, only one mother in five still asked that it be done. When the physician supported the procedure, nearly all patients asked for it.

Social tradition and misinformation about circumcision are so prevalent that even facts cannot dissuade many mothers from seeking the surgery for their sons, said Dr. Theodore King, director of obstetrics at the Johns Hopkins School of Medicine.

I wouldn't choose circumcision, King said, It's a waste of money. I would hope that as people become more educated, they would stop utilizing the procedure.

Hopkins tries to assure that all mothers know the possible consequences of circumcision, King said.

Parents receive a written explanation that while two to three percent of males will ultimately require circumcision; clearly, the vast majority of newborn circumcisions appear to be done unnecessarily. However, circumcision in the newborn probably carries less risk than when it is done for an older child or adult.

Despite the warnings of complications, King said that every month hundreds of mothers still opt for the operation.

We emphasize that this isn't needed, he said. On our surgical consent form, we have a line that gives the reason for the procedure. With circumcision, we just tell the parents to 'fill in any reason you want' to underscore the lack of medical reasons. Still they keep asking for it, despite our efforts. It is really ingrained in our society.

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