Circumcision debate cuts both ways

June 13, 2000

By Mike Falcon
With medical adviser Stephen A. Shoop, M.D.
A Doctor In Your

To cut or not to cut?

That's the question every parent of a newborn male must face. And today, more and more are saying no.

"Little wonder," comments San Francisco nurse Marilyn Milos, a leading voice in the anti-circumcision movement. "It's the most erogenous zone in the male body, rich with blood vessels and sensitive nerve endings. The foreskin that protects the head of the penis is there for good reason. Mother Nature didn't put it there by mistake."

More or less

In the '70s, more than 90% of male babies in the USA were circumcised. Today, although the data is still extrapolated from a small number of voluntarily reporting hospitals, the percentage has dropped to an estimated 64%.

"People are thinking it over now," observes Dr. Paul Fleiss, a Los Angeles pediatrician who no longer performs the procedure. "There's simply not a compelling medical reason to do it."

"Oh, yes there is," counters Dr. Thomas E. Wiswell, professor of pediatrics at Thomas Jefferson University in Philadelphia. "A higher incidence of infant urinary tract infections and penile cancer later in life are clearly present in the uncircumcised population. A host of studies also indicate that circumcised men appear to be more resistant to HIV."

Last week's issue of the British Medical Journal (BMJ) backs him up, pointing to more than 40 studies which seek to explain why circumcised men may be more protected from the HIV virus than their uncircumcised counterparts. The most recent, a 30-month Ugandan study, surveyed 50 circumcised and 137 uncircumcised HIV-negative men who had HIV-positive female partners. Of the uncircumcised men, 40 contracted the virus, while none of the circumcised men tested positive.

Only 11% of the participants used condoms, leading the study's Australian authors to theorize that sensitive cells found on the inner lining of the retractable foreskin may be a binding receptor site for HIV and could contribute to an increased possibility of viral infection.

Reaction from circumcision opponents has been strong and swift.

"Nowhere did they say that circumcision protects American men - who have been overwhelmingly circumcised - from contracting HIV," notes Milos. "It's abundantly clear from AIDS statistics in this country that circumcisions do absolutely nothing to protect men from the virus."

The other medical arguments are also under attack. "If it's a simple urinary tract infection, then treat it as one," urges Milos. "Use antibiotics, not a scalpel."

And penile cancer? "It's overwhelmingly seen in old men," says Fleiss. "Performing a circumcision on someone who doesn't have any say in what's happening to his body, ostensibly to reduce the risk of a type of cancer seen 70 years later, seems somewhat premature at best."

Only 1,500 men develop the disease each year in the USA, a group so small it's practically insignificant statistically - unless you're one of the victims.

But the issue appears even more questionable when you consider that Denmark, a country of overwhelmingly uncircumcised men, has the lowest penile cancer rate in the world. India, on the other hand, with a similarly large uncircumcised population, has one of the world's highest penile cancer rates.

What's the difference? Some proponents point to hygiene, the traditional argument for circumcision.

"But an intact penis is easily cleaned," says Milos. "In fact, it's easier to keep clean than female genitalia. The hygiene issue just doesn't stand up, unless there are environmental and cultural factors that fail to promote cleanliness."

Informed choice

All factors considered, last year's study by the American Association of Pediatricians concluded that the "potential medical benefits" of newborn male circumcision are "not sufficient to recommend routine neonatal circumcision." Urging that parents determine "what is in the best interest of the child," the AAP Task Force on Circumcision emphasized that "parents of all male infants should be given accurate and unbiased opportunity to discuss this decision." And if circumcision is performed, "procedural analgesia should be provided."

"This was a select group that came to a largely political decision," counters Wiswell, "and it ignores very real and very basic health risks." But the expert concurs when it comes to the issue of pain.

Wiswell estimates that half of all circumcisions are performed without anesthesia. Milos says the percentage is far greater than that. "Many hospitals routinely claim to use local anesthesia but don't. They simply figure - correctly - that the parents will never find out."

Both agree that unless pain control is employed, babies definitely feel significant pain. "To perform the procedure without anesthesia is unconscionable," says Wiswell, who uses a 90-minute three-part protocol to completely eliminate any discomfort for the newborn. "At the base of all of this is a profound concern for the well-being of the infant."

That concern should be foremost in the minds of parents faced with the circumcision dilemma. Careful consideration of the facts and a thorough understanding of the procedure itself are essential. Take the time to arrive at an informed choice before - not after - the baby is born.