to cut or not to cut

Circumcision: What used to be a routine decision is now a big quandary for many parents-–to-–be.

New controversy has arisen over the ancient practice of circumcision. Depending on the source, the procedure is either much ado about nothing or the unkindest cut of all, and parents are taking another look at the procedure to determine whether it's right — or necessary — for their sons.

At birth, a boy's penis is protected by a sheath of skin called the foreskin. As he grows, the foreskin naturally loosens and slides easily back and forth over the head of the penis. Circumcision entails removing the foreskin surgically so the tip of the penis, or glans, and the opening of the urethra (through which urine passes) are exposed to air. People circumcise their babies for assorted reasons, including religious, health, societal and aesthetic.

Circumcisions have been performed for thousands of years; what began as an Egyptian religious rite eventually was adopted by Jews and Muslims, for whom circumcision remains an important ritual today. "For Jewish and Muslim parents, circumcision is a religious decision," says Mary L. Brandt, M.D., a pediatric surgeon at Baylor College of Medicine in Houston. "But in other cases, it is a matter of choice, and many of my patients' parents are deciding to decline the procedure."

Indeed, in most of the world, circumcision is not routine. According to the National Center for Health Statistics, more than 60 percent of American men are circumcised, compared with 20 percent of men worldwide. Rates vary by ethnicity and geography. In the Midwest, 80 percent of infant boys are circumcised, while the rate is closer to 42 percent in the Western United States and about 68 percent in the Northeast. About 81 percent of non-Hispanic whites nationwide are circumcised vs. 54 percent of Hispanic males and 65 percent of black males, according to "The National Health and Social Life Survey," which was reported in the April 2, 1997, issue of the Journal of the American Medical Association.

For most parents, the decision may be influenced by tradition — fathers wanting their sons to "look like them" — or aesthetics. But what are the medical implications of circumcision? The 53,000-member American Academy of Pediatrics remains firmly neutral. Although it has convened a special circumcision task force to pursue the matter, the AAP's position statement simply says, "Circumcision has potential medical benefits and advantages, as well as inherent disadvantages and risks."

Medical pros and cons

Scientific evidence gives circumcision a slight advantage in terms of long-term health benefits. Studies have shown that uncircumcised males are six to 10 times more likely to develop urinary-tract infections (UTIs) in their first year of life. Also, cancer of the penis, though rare, is almost exclusively a disease of uncircumcised men. This cancer is thought to be hygiene-related, because viruses and bacteria can thrive in a cheesy substance called smegma that collects underneath the foreskin.

But Marilyn Milos, R.N., founder of The National Organization of Circumcision Information Resource Centers in San Anselmo, Calif., says the argument that circumcision may have medical benefits carries little weight with her. "Penile cancer is extremely rare," she says. The American Cancer Society estimates that 1,500 new cases will be diagnosed in the United States in 1998, with 200 deaths projected. "Penile cancer affects one in 100,000 men," Milos adds. "But one in nine women [will] get breast cancer. It would make more sense to cut off the breasts of baby girls." As for UTIs, Milos concedes that intact males are at greater risk but maintains that the condition is still relatively benign. "Most males never get one, and besides, UTIs are easily treated with antibiotics," she says.

Milos' argument doesn't end there. "Circumcision is surgery, with all the inherent risks, such as hemorrhaging, infection and surgical mishap," she says. (The complication rate is less than .1 percent, according to the December 1994 issue of Clinical Pediatrics.) Finally, Milos' organization objects to circumcision for ethical reasons: "Doesn't every human being have the right to his own body?"

And then there's the pain

For many years, babies were thought to be incapable of experiencing pain because their nervous systems aren't fully mature immediately after birth. But today, we know better: Researchers believe circumcision does involve pain for the baby. According to a 1991 study published in American Family Physician, "Behavioral, cardiorespiratory and hormonal changes caused by the stress of circumcision have been documented." The AAP also supports the contention that infants do feel pain during surgery.

How much that pain affects babies still is a matter of debate. Some doctors maintain that the pain is no greater than that of drawing blood, while others suggest that circumcision may alter a baby's general response level for months after surgery. In fact, one recent study conducted by Gideon Koren, M.D., at the Hospital for Sick Children in Toronto, observed that circumcised infants cried longer during vaccinations than did uncircumcised babies.

In any case, pain-management options are available. They include the use of a nerve-blocking injection at the base of the penis and a topical cream to numb the skin, as well as doses of acetaminophen before and after surgery; these choices should be discussed with your pediatrician. "I want to say emphatically that under no circumstances should any child have a circumcision without anesthetic — that is barbaric and unconscionable," Brandt says.

An informed decision

However you weigh the evidence for and against the procedure, circumcision remains a highly personal issue that parents should discuss with their pediatrician.

"My bias is that if I had a son, I would not circumcise him," Brandt says. "It's medically unnecessary, and there are some risks associated with it. However, there's nothing wrong with it — in our society right now, it's acceptable. It's a cosmetic procedure, like ear piercing."