The Debate Over Circumcision


Should All Males Be Circumcised?





Some
call it genital mutilation. Others, a lifesaving STD stopper (for men
and women). Whether or not you still have your foreskin, you have a
stake in the battle over circumcision


By: Charles Hirshberg, Photographs by: Plamen Petkov











The day your wife gives birth to a baby boy, the kind, bespectacled
face of Marvin L. Wang, M.D., is one that you want to see coming
through the recovery-room door. Codirector of newborn nurseries at
Massachusetts General Hospital in Boston, Dr. Wang has a perky,
conversational bedside manner that puts everyone at ease.

I have to hustle to keep up with him as he strides energetically
between hospital rooms. Right now he's congratulating a pair of new
parents. Larry is standing on wobbly legs, looking both ecstatic and
shell-shocked, while Joy sits serenely, holding their newborn son to
her breast.


Dr. Wang jokes with the new parents a bit and then says, "I understand you may want to have a circumcision for your baby."


Larry and Joy don't answer immediately. At last Larry says, "Well...we don't know."


Dr. Wang smiles. He's familiar with the befuddled expression on Larry's face.


Circumcision, of course, is the surgical removal of the penile foreskin from the glans -- the fleshy crown of the penis.
It is one of the most commonly performed procedures in American
hospitals, and except for abortion, it may be the most controversial.
The procedure has long been known to reduce the spread of a few rare,
serious diseases, and to prevent a few annoying, uncomfortable ones.
But in 1999, the American Academy of Pediatrics (AAP) determined that
the risk of surgical complications, though small, nearly canceled out
the benefits. They neither discouraged nor recommended the procedure. Since then, 16 states have eliminated Medicaid coverage for nearly all circumcisions.

But 2 years ago, a consortium of experts convened by the World Health
Organization and UNAIDS (the United Nations' HIV program) announced
that circumcision should indeed "be part of a comprehensive HIV
prevention package." It did so because three separate, meticulous
medical trials in Kenya, Uganda, and South Africa, involving more than
10,000 men, had proved that circumcision could reduce the risk of
female-to-male HIV infection by approximately 60 percent. This
discovery is one that, over the next two decades, could save three million lives in Africa alone.

Now, no one believes that the potential health benefits for American
males are nearly as great, or as urgent, as they are for men in Africa,
where HIV is spread mostly through heterosexual intercourse. Still,
similar study results are turning up on this continent, as well. A team
of researchers from the CDC, Johns Hopkins, and the Baltimore health
department examined the records of more than 1,000 African American
males -- all heterosexual -- who tested positive for HIV at Maryland
clinics. Uncircumcised men were 50 percent more likely to be infected.


These results have caused many U.S. doctors to reconsider their positions. "I've always told families that the health benefits of circumcision
are real, but not enough to warrant advocating that all boys be
circumcised," says Lise Johnson, M.D., the director of healthy-newborn
nurseries at Boston's Brigham and Women's Hospital. "But I find these
HIV studies pretty striking. The weight of scientific evidence might be
shifting in favor of circumcision."

Larry, the new dad, is circumcised himself but never thought much about
circumcision until his wife became pregnant. "Joy kept saying, 'It's up
to you,'" Larry tells Dr. Wang, "but when I finally said I wanted to do
it, she said, 'Whoa! We have to talk.'"


After a few uneasy moments, the new father's feelings spill out.


"I guess I don't feel too strongly either way," he says, looking at his son tenderly. "But if there's a risk of hurting him..."


Pain, of course, is the first question that comes to mind whenever the words cut and penis
are used in the same sentence. Ask Marilyn Fayre Milos about pain -- or
better yet, don't. The founder of the National Organization of
Circumcision Information Resource Centers (NOCIRC -- get it?) first
witnessed the procedure in 1979 while training for her nurse's degree.
The unlucky baby, she later wrote, was "strapped spread-eagle to a
plastic board... struggling against his restraints -- tugging,
whimpering, and then crying helplessly" while awaiting the knife. Then
as the doctor, using no anesthesia, began cutting into the
penis with a scalpel, "the baby began to gasp and choke, breathless
from his shrill continuous screams..."


Is that what Dr. Wang is offering to do to Larry and Joy's innocent baby boy?

Not quite. Dr. Wang says the operation rarely hurts much anymore; since
the 1990s, it's become routine in U.S. hospitals to anesthetize babies
before the procedure. For every 1,500 circumcisions, there are maybe
three complications, nearly all of which amount to a little unexpected
bleeding or a treatable infection. In return, according to the AAP,
circumcised boys have a lower risk of urinary-tract infections and
penile cancer, and, indeed, "a slightly lower risk of getting sexually
transmitted infections (STIs), including HIV, the virus that causes
AIDS." But weighed against the potential risks, says the AAP, "these
benefits are not sufficient... to recommend that all infant boys be
circumcised." (The AAP is now reviewing its guidelines, in light of
recent scientific news.)

Larry seems to search the doctor's face for a hint of what to do, but
Dr. Wang is as neutral as his white hospital coat. "You need more time
to think about it," he says encouragingly. "I'll be back."


He heads off down the hall.


Go on to the next page for more on the dilemma of circumcision...














Circumcised or not, every man owes his foreskin a great debt of
gratitude for its service in the womb. In the third month of gestation,
when the nascent penis begins to bloom, the foreskin forms a little
protective blanket under which the rest of the penis can safely grow.
But once you and your penis are fully baked, the advantage of a
foreskin is not clear. Some scientists speculate that it protected the
prehistoric penis as it swung, naked, through thick forests and over
tall grasses; and unless you take your penis on that sort of excursion,
they argue, you don't need a foreskin.

That perceived uselessness may be one reason circumcision has such a
long and varied history. Archeological evidence suggests that the
practice may be at least 6,000 years old. Muslims and Jews, along with
the aborigines of Australia, the Aztecs and Mayans of this hemisphere,
and many other cultures all independently adopted this squirm-inducing
practice, and it seems unlikely they'd have done so unless they were
convinced that it conferred some earthly benefit.

Here in the United States, foreskins were left mostly undisturbed until
the second half of the nineteenth century. But it wasn't until the
North Africa campaign of World War II that American doctors turned into
enthusiastic circumcisers. More than 145,000 American GIs based there
slacked off on their cleaning regimens and came down with
foreskin-related ouches -- chiefly, balanoposthitis (inflammation of
the foreskin and glans), phimosis (a foreskin that's too tight to
retract over the glans), and paraphimosis (a foreskin stuck in the
retracted position). After the war, doctors advanced a theory that
circumcision reduces rates of cervical cancer -- a hypothesis now
confirmed by scientific research.

Circumcision became routine, but anesthesia wasn't part of the plan.
That, more than any other factor, may have provoked the fiery
anti-circumcision movement that casts its long shadow over the Internet.

Isaac is a newborn whose mother, months before she gave birth, made the
decision to circumcise him. He awaits Dr. Wang atop a small operating
table. His expression is blasé until a nurse standing over him slides a
sugar-coated pacifier into his mouth. His eyes open wide and he
commences sucking with gusto. Sugar, Dr. Wang says, is known to send a
rush of endorphins to certain parts of the brain, dulling sensitivity
to pain.

Dr. Wang gently wraps Isaac's legs in a soft harness. Until fairly
recently, he remarks, it was standard practice to restrain babies'
arms, too. "But it's distressing to them to be tied down like that, and
it's really not necessary."

Fortunately, Dr. Wang says, circumcision is no longer performed in
American hospitals without anesthesia, as Milos described it. After a
quick examination of Isaac's manhood (if that's the right word for it),
Dr. Wang administers four evenly spaced injections of lidocaine around
the base of the baby's penis; Isaac shows no distress. At that point,
Dr. Wang waits 5 minutes for the anesthetic to take effect, then swabs
Isaac's privates with sterilizing iodine and gets down to business. He
arranges a clamp that pulls the foreskin forward, off the penis, where
it can be safely cut off with surgical scissors in one snip. Isaac
became agitated only once -- when his sugary pacifier fell from his
mouth. "Usually," says Dr. Wang, "the part they hate most is being
washed off afterward. They don't like to feel the cold."



A few weeks later, I call Larry to find out what he's decided to do.

"We opted not to do it," he says. "When you go on the Internet and read
about this," he says, "you find out that there's really no reason for
doing it. People try to think up new justifications for it, and when
one doesn't work, they come up with another."


If you go on the Internet, you'll "find out" precisely what Larry found out. The problem is, it's not true.



Go on to the next page for more on the dilemma of circumcision...