December 22, 2000

By Leah Shafer

Skipper Chong Warson

hen Shay Fitzgerrell's son Jacob was born in 1992, she would no sooner let doctors cut off the end of his penis than one of his fingers. "God made us this way, and it didn't make sense to me that he needed to be changed -- we are perfect when we are born," she says. "I believe that the foreskin is there for a reason."

The biological functions of the foreskin are debated, but seem related to sexual pleasure and protection of the urinary tract. Still, until recent years, cutting the foreskin of a baby boy in this country was almost as common as cutting his umbilical cord -- it was a ritual that few parents and pediatricians questioned. But today more and more people are choosing to leave their newborns uncircumcised. It is an ongoing debate, often passionately argued, with no easy answers.

An emerging body of evidence has been reinforcing the American belief that circumcision provides real medical benefits, such as protection against infant urinary tract infections and sexually transmitted diseases, including HIV, later in life.

But for many like Fitzgerrell, the idea of amputating healthy, erogenous tissue is akin to barbarism, especially since babies often have less-than-adequate pain relief during the procedure. "Birth is a traumatic thing for a child anyway," she says. "They've already gone through quite a trip just getting here. They shouldn't have to go through that unneeded, painful surgery."

The medical community, for its part, offers mixed messages on the topic. The American Academy of Pediatrics (AAP) won't endorse or denounce the practice. Their position on circumcision affirms its potential medical benefits but also says that the data are "not sufficient to recommend routine neonatal circumcision." This leaves new parents with a perplexing dilemma: Should they follow the norm and circumcise, or break away and protect their son's foreskin?

The times, they are a changin'

For Laura and Jeff Embree, the question of whether or not to circumcise their infant son, Brandon, was answered early during her pregnancy. After considering the pros and cons, the decision came down to family tradition. "I wanted my son to be like my husband," Laura says. "I also thought about Brandon in the locker room in high school; I don't want him to feel different or self-conscious."

The Embrees are pretty typical in the United States, where 60 percent of infant boys are circumcised every year and many parents follow family tradition. The circumcision rate varies greatly by geographical location, from 81 percent in the Midwest to 38 percent in the Western states.

The roots of circumcision

The practice of amputating the foreskin began thousands of years ago, in ancient Africa or Egypt, depending on who you ask. It was eventually picked up by the Jews, who have preserved the ritual over the centuries.

A few theories exist to explain the possible impetus behind the first circumcisions. One theory holds that it was adopted as a way to purify individuals by discouraging the "unclean" side of human nature, that is, sexual pleasure. Because the foreskin is the most sexually sensitive part of the male body, cutting it off would naturally make sex less enjoyable and thus less attractive. This logic seems to have blossomed around 1865-1870 in the United States and England, when Victorian morality frowned coldly upon masturbation. It was around this time that circumcision became an accepted medical practice.

During the two world wars, doctors noticed that unhygienic conditions led to problems for uncircumcised men. "We found that dough boys in trench warfare had a good deal more infections of the penis and foreskin," says Craig Shoemaker, M.D., director of children's services at Meritcare Children's Hospital in Fargo, North Dakota. "In World War II, uncircumcised soldiers in North Africa, jungles in Asia, and at sea, men who bathed in salt water had much more irritation [than circumcised soldiers]." Circumcision came to be viewed by the public more as a hygienic, rather than moral or religious, option.

Health benefits

"There is fairly well documented evidence that baby boys who are circumcised have a lower rate of urinary tract infections early on," says Dr. Shoemaker. Indeed, circumcision lowers the risk of UTIs in infant boys by a factor of ten. To put this in perspective, however, only about 1 percent of uncircumcised boys will suffer from a UTI before their first birthday, according to the AAP.

For many parents, the idea of amputating healthy, erogenous tissue is akin to barbarism, especially since babies often have less-than-adequate pain relief during the procedure.

Another potential health benefit of circumcision has taken the medical community by surprise. "Adult men who are circumcised appear to have lower rates of HIV and other STDs," Dr. Shoemaker says, though he's quick to point out that "a healthy lifestyle is more important in preventing STDs than circumcision."

Specifically, it's circumcision's potential role in preventing the spread of female-to-male HIV infection that really raises eyebrows.

A secret weapon against HIV?

The foreskin is indicated in the spread of HIV from females to males for three reasons. First, the foreskin is rich in Langerhans cells, portals of entry for HIV. Second, an uncircumcised penis is more vulnerable to scratches and tears during intercourse, providing another entry for pathogens. And third, these Langerhans cells and scratches raise the risk of other lesion-forming STDs, like syphilis and herpes, which in turn make men more likely to contract HIV.

For parents in the United States, this should factor in to their decision about whether or not to circumcise but should not play the starring role, says Daniel Halperin, Ph.D., of the University of California San Francisco's AIDS Research Institute and medical anthropology program. "If you're having sex with an infected female partner, it does matter if you are circumcised or not," he explains. "We don't have a lot of heterosexual transmissions here, but it's still a factor, and you have to add up all the factors."

Circumcision may be a key to curbing the spread of AIDS in Africa, where most infections are from heterosexual encounters. Preliminary evidence suggests that circumcised African men contract HIV at a significantly lower rate than do uncircumcised African men. The research is still somewhat sketchy, but it's promising.

Weighing the risk

Circumcision is not without risks. While major surgical mishaps are very rare, minor complications like bleeding and bruising do sometimes occur. Parents can minimize these risks by making sure that whatever type of doctor they choose to perform the operation -- urologist, pediatrician, obstetrician or family practitioner -- has performed the operation often and has been specifically trained to circumcise.

The pain associated with circumcision is often what makes parents think twice about the procedure. Traditionally, the operation was performed (and often still is) without anesthesia, based on the mistaken belief that newborn babies cannot feel pain. This theory has been discounted, though. Circumcision without any pain relief appears to cause intense short-term pain for the baby and disturbances in sleeping and eating patterns for several days following the operation. Interestingly, it also appears to increase sensitivity to pain later in infancy and possibly even later in life.

The AAP now recommends the routine use of anesthetic in circumcisions. This could come in the form of an anesthetizing cream, a local anesthetic, or a dorsal penile nerve block.

So how to decide?

With compelling arguments on both sides of the debate, new parents undoubtedly feel confused and unsure about the fate of their infant's foreskin. With unbiased information from the child's pediatrician, parents can weigh the lifelong implications of circumcision. Some of the best advice comes from Jack Swanson, M.D., a pediatrician and member of the AAP's task force on circumcision.

"I think parents should discuss the reasons both for and against circumcision with their physician and understand the possible benefits and the possible risks," he says. "Then they should decide for themselves what they would like for their boy."