CIRCUMCISION CONTROVERSY

Doctors Debate The Benefits And Risks of This Common Procedure, but For Most Parents The Decision Is Personal

By Randi Hutter Epstein

The Washington Post, Tuesday, October 7, 1997; Page Z14

Thomas Wiswell is no celebrity and he's not on the run from the law. Yet the pediatrician from Philadelphia insisted on using an alias at a San Francisco hotel earlier this year. He was attending a medical meeting and reporting data about the benefits of circumcision. Wiswell feared harassment by anti-circumcision activists. Indeed, said Wiswell, a professor at Thomas Jefferson University in Philadelphia, security was beefed up and his talk was saved for the last day.

"Northern California is the hotbed for anti-circumcision groups," said Wiswell. "They've disrupted our meetings before. Several years ago when I worked in Washington, D.C., one of the groups had a police detective come to the hospital after me because they claimed I was mutilating genitalia. When the police realized it was circumcision, they backed off."

In 30 years of investigating the health effects of circumcision, Wiswell has heard from a variety of the nation's foreskin preservationists. There is NOCIRC, a national group against male and female circumcision; BUFF, Brothers United for Future Foreskin; RECAP, Recovery of a Penis; and NOHARMM, National Organization for Halting Abuse and Ritual Mutilation of Males. There is a magazine called "Foreskin Quarterly." And there are foreskin restorationists, promoting reversal techniques.

The anti-circumcision extremists are a small but vocal group of men and women fighting against an ambivalent medical profession. Though a few groups have been around for decades, many have formed in the past few years -- perhaps as a reaction to the medical community's greater acceptance recently of routine circumcision. For the most part, doctors still say the procedure is a parent's decision, often based not on health issues but religious and cultural values. Yet those who oppose the procedure believe they are on a crusade, fighting against an ignorant establishment to protect the rights of the newborn.

As George C. Denniston, a physician and president of DOC, Doctors Opposing Circumcision, based in Seattle, Wash., put it: "Circumcision violates every major tenet of medical practice, which is, `First, do no harm.' And secondly, modern medical ethics say parents do not have the right to ask for a medical procedure that is not in the best interest of their children."

Circumcision, the removal of the fold of skin covering the tip of the penis (called the foreskin, or prepuce), has not always been embroiled in controversy. For decades in this country, it was considered a routine step in the birthing process, much like cutting the umbilical cord. But now doctors are debating whether the benefits, such as reducing the likelihood of urinary tract infections, outweigh the risks, such as the possibility of inflicting pain or the rare chance of an infection near the incision.

There is little medical consensus. The American Academy of Pediatrics met last summer on the issue and is still considering whether to issue new guidelines.

"We are really trying to de-emotionalize this and make this an evidence-based decision," said Carole Lannon, an epidemiologist who chairs the task force on circumcision for the academy. "I wasn't aware of the strong feelings on both sides," added Lannon, who has been receiving e-mail from advocates and foes of circumcision.

Proponents point to studies showing that circumcision reduces the rate of urinary tract infections and drops the risk of penile cancer, which strikes about 1,000 men annually. "I don't tell people what to do, I tell them the facts, and the evidence is there are medical benefits," said Edgar Schoen, a clinical professor of pediatrics at the University of California, San Francisco.

Foes of foreskin removal believe that the procedure inflicts pain (see sidebar) and induces psychological and sexual trauma. "The effects of circumcision are not over when the cutting is done. There is the anger, shame, grief, feelings of being less than whole, of being violated," said Ron Goldman, a psychologist and author of "Circumcision: The Hidden Trauma" (Vanguard Publications, Boston) and the forthcoming "Questioning Circumcision: A Jewish Perspective," (Vanguard). He is the director of the Circumcision Resource Center in Boston.

Between these views are many authorities who believe that circumcising newborn males is neither a medical necessity nor a health hazard. "I don't advocate routine circumcision of the newborn," said John Gearhart, director of pediatric urology at the Johns Hopkins Children's Center in Baltimore. But he does not believe parents who choose to do it are inflicting life-long damage on their offspring.

Historical Trend

Despite conflicting evidence and confusing advice, more than 60 percent of American parents opt for the procedure, a drop from its peak in 1965 when 85 percent of newborns were circumcised, according to the American Academy of Pediatrics.

In 1971 and again in 1975, the academy's guidelines stated there was "no absolute medical indication for circumcision." Subsequent studies in the 1980s, linking uncircumcised men with an increased incidence of urinary tract infections, prompted a revision in that position.

The 1989 guidelines stated that circumcision has "potential medical benefits and advantages as well as disadvantages and risks . . . that should be explained to the parents and informed consent obtained." Since then, due to more data, "the academy felt it was time to revisit and reconsider the issues," said Lannon, an assistant professor of pediatrics and internal medicine at the University of North Carolina in Chapel Hill.

The main medical benefit associated with circumcision is a reduced risk of infections. Wiswell conducted a study that showed circumcision reduced the incidence of urinary tract infections by twentyfold. The study followed 200,000 boys born in U.S. Army hospitals from January 1985 to December 1990. By combining the results with the findings of other investigations, researchers concluded that the procedure reduced the rate of urinary tract infections from about 1 percent among uncircumcised men to 0.1 percent among the circumcised.

Similar results were found in a study of 899 newborns with fevers, said the investigator, Thomas Newman, associate professor of pediatrics and epidemiology, at University of California, San Francisco. The data, collected from pediatricians in 40 states, showed that uncircumcised babies with fevers were more likely to have urinary tract infections.

At the same time, the rate of urinary tract infections is generally very low. "Most babies who are uncircumcised don't get [urinary tract infections] and don't have trouble with their foreskin," said Newman, who reported his findings at the May meeting of the American Academy of Pediatrics meeting in Washington. "So I don't think we, as doctors, can say this is a procedure we should do because of the medical benefits. There is a medical benefit, but it is not very compelling. My experience is that, more often than not, parents want the kid to look like the dad so if the dad is circumcised he thinks that is what a penis should look like."

Some physicians recommend the procedure only for certain newborns. Robert Weiss, for example, chief of urology at Yale University, does not advise routine circumcision for medical reasons. But he does recommend it for newborns who may be at increased risk of urinary tract infections, such as those with a dilated urinary tract, which is apparent on fetal ultrasound.

The rate of complications associated with this procedure is also very low. Risks include bleeding, infection and, most uncommonly, injury to or removal of the penis. One practicing physician said he has seen two cases of amputation in the past 12 years.

"There are complications but they are very rare," said San Francisco's Schoen. "I think over the past 40 years there have been three deaths from bleeding disorders, such as hemophilia," he said. About one baby in 300 to 600 gets an infection or has excess bleeding, but these conditions rarely require a stitch. Infections can be effectively treated with topical antibiotics, he said.

Until the 19th century, circumcision was a religious practice among Jews and Muslims. It was introduced into secular society in the United States and Britain in the 1870s for two reasons: to prevent sexually transmitted diseases (physicians noted fewer STDs among Jews and attributed it to circumcision) and to prevent sexual desire and masturbation (during the Victorian era, circumcision was thought to quash libido), said Edward Laumann, chairman of the department of sociology at the University of Chicago.

"During World War II, it was Army policy to encourage circumcision as a prophylaxis against sexually transmitted diseases," said Laumann.

But new research dispels these notions about circumcision's effect on sexual behavior. Laumann's study of 1,410 American men, between the ages of 18 and 60, found that circumsised men are just as sexually active as uncircumcised men. The study, published in the April issue of the Journal of the American Medical Association, found no differences in the rate of sexually transmitted diseases between those with or without a foreskin.

Personal Choice

Regardless of accruing scientific information, the decision, for most parents, is not based on a checklist of health pros and cons. It is a decision based on tradition, religion and aesthetics. "A lot of factors go into the decision of a young family," said Gearhart. "For instance, whether the father is circumcised. It's a societal thing, a religious thing; it has to do with mores. It has nothing to do with medicine."

Most of the mothers interviewed for this story worried about the pain of the procedure. "Am I inflicting needless pain on my newborn?" was a common refrain. Fathers were concerned about aesthetics, such as will the boy be poked fun of in the locker room should he be the only one with a foreskin?

"The maddest parents, those who are ready to sue," said Gearhart, "are angry because their son doesn't look circumcised," because not enough skin was removed. These babies can be recircumcised, he said.

Ruth Dukoff, 34, a psychiatrist at the National Institute of Mental Health in Bethesda, said she grappled with the decision. She and her husband are Jewish, but "because I'm not religious, religious reasons weren't enough for me," she said. "And the medical reasons seemed bogus. European men don't get circumcised," said Dukoff. "But we ended up doing it for social reasons and we decided since we were going to do it, we might as well have the party (the Jewish naming ceremony, Brith Milah or bris, that accompanies circumcisions) and make the family happy."

Same for Tracy Springer, a 40-year-old Manhattan lawyer, who is also Jewish. "I read the studies and really thought about it," said Springer. "We have showers. We bathe. We're not wandering around Egypt any more. But we did it out of religious pressure and because of parental pressure, we did the party."

Sometimes parents opt not to circumcise and then change their minds. Tracy DiIorio, 32, an executive assistant at St. Barnabas Medical Center in West Orange, N.J., did not circumcise her son when he was born six years ago. "My husband and I thought the procedure was barbaric. My sister circumcised her two sons and I was so angry."

But when DiIorio's son was 4, his foreskin became infected and required circumcision. "I was embarrassed to tell people. It was like `I told you so,' " said DiIorio. "I was okay with it, though, because it was done under general [anesthesia] for medical reasons. I'm still opposed to what they do to healthy babies for no reason. I have lots of friends with uncircumcised sons who have never had infections."

The United States is the only industrialized nation that continues to circumcise newborns for nonreligious reasons, according to the University of Chicago's Laumann. The procedure generally is covered by insurance, including Medicaid. In Britain, circumcision rates were about the same as in the United States until 1948, when the newly created National Health Service stopped paying for it and rates dropped to about 5 percent, what they are today. The Canadian Pediatric Society does not advocate routine circumcision.

In this country, however, there is still a belief that circumcision leads to better health, said Laumann. "What's certainly clear is that in the U.S., with its fascination with health and controlling sexual things, the way circumcision was packaged [to prevent illness and quash sexual appetites] met our needs and concerns."

How a Circumcision Is Done

Prior to having a circumcision, most babies get an injection or topical cream to numb the pain. They may also get a sugar solution thought to provide pain relief.

Although there are several ways to perform a circumcision, the clamp is the fastest and used by most mohels, who perform Jewish circumcisions. The clamp has two small knives that can remove the foreskin within 30 seconds. The baby is placed on his back, legs apart. A blunt instrument is used to peel the foreskin away from the glans of the penis, said Edgar Schoen, a clinical professor of pediatrics at the University of California, San Francisco. The doctor or mohel then pushes the glans back and places the thin sliver of foreskin into the clamp, much like a guillotine that quickly amputates it. The clamp also squeezes the two ends of the foreskin together to staunch bleeding and promote healing.

Other doctors may use a plastic device that is shaped like a small bell and has a handle and a string. This is slower but simpler for those with less experience in doing a circumcision, according to Schoen. The device is placed on the penis and after separating the glans and foreskin, the string is used to shut off the blood supply. The excess foreskin is cut with a scissor and the patient is sent home with the bell covering the penis until the bell falls off on its own, like an umbilical cord.

Typically the tip of the penis appears very raw for about a week. A topical antibiotic is rubbed onto the penis and a gauze pad wrapped around it. Bandages must be changed daily. It is not uncommon for parents to fear that their newborn is suffering from an infection because of the very red look of the penis. Pediatricians are used to late-night phone calls from distraught parents about this.

Excess bleeding may signal a rare infection, but tiny bits of oozing blood or redness is common and the expected reaction to the removal of a layer of skin. The healing is usually completed within a week. JUMP INFORMATION APPENDED

The Question of Pain

Nowadays the question is not only whether to circumcise, but if so, whether the newborn needs anesthesia. Traditionally, physicians believed newborns did not feel pain. But mounting evidence shows just the opposite. Two recent studies by the same team of Canadian scientists found that babies who got pain relief showed fewer signs of discomfort. One study showed that they suffered less pain during subsequent vaccinations.

"Babies can perceive pain. They may not know it consciously, but they have all of the equipment to perceive it," said Anna Taddio, clinical pharmacologist at the Hospital for Sick Children in Toronto. "Our two studies that analgesia is effective and safe."

One study, in the April 24 issue of the New England Journal of Medicine, included 38 babies who got topical analgesia and 30 babies who got nothing prior to circumcision. The medicated group cried half as much and had heart-rate increases of 10 beats per minute less than those who got nothing, according to Taddio.

The second study of 87 newborns found that circumcised infants showed stronger pain responses to routine vaccination during the first six months of infancy. Infants who received analgesia during circumcision suffered less pain when they were vaccinated than those who were circumcised without painkillers. The study was published in the March 1 issue of the Lancet, a British medical journal.

Researchers say the results lend support to speculation that pain during infancy leaves a lasting imprint. In other words, the nervous system has a sort of memory, which affects subsequent behavioral responses to pain.

"People feel that because the babies don't remember the pain, it can't hurt. They may not remember, but their bodies remember," said Taddio.

One of the most controversial issues in neonatalogy is whether early experiences of pain have a significant impact years later. No one knows. Indeed very little is known about infant pain at all. Researchers can track pain pathways -- they are fully developed at birth -- but no one truly knows what the baby is feeling. The perception of pain has to do with both physiology and emotional responses. Some investigators believe that newborns do indeed feel the hurt but they do not know where the source of the pain is. For the most part, doctors believe the fleeting pain of circumcision does not have a life-long impact on children. And given the various sources of pain during childhood, such as vaccinations and accidents, it would be difficult if not impossible to blame one incident. To be sure, adults who are circumcised get anesthesia, and most doctors say that newborns deserve pain relief also.

As Thomas Wiswell, a pediatrician at Thomas Jefferson University in Philadelphia and a proponent of circumcision, put it in an editorial in the March 1 Lancet,"Circumcision carries a low risk and provides protective benefits. . . . Analgesia should be provided in all cases. Parents should demand no less."