Essays

News Review
March 11, 2010

The controversial cut

Medical experts say circumcision is unnecessary, but the longstanding debate over the issue roils on

By Stacey Kennelly

Circumcision isn’t reversible, so it’s a big decision for parents to make. Obviously, it’s most important for the child, who will have to live with the outcome.

By the numbers: Statistics show that circumcision is in decline in all English-speaking countries. For a closer look at the data collected by the National Hospital Discharge Survey and the National Inpatient Survey, visit www.cirp.org/library/statistics.

As a parent, Angelica Dilts has a lot of important decisions to make. And as the mother of a baby boy, her first boy, there is one big, irreversible decision she needed to make within the first few days of his life: whether to have him circumcised. She chose not to.

“It’s a painful, unnecessary and traumatic procedure,” she said. “For me, it’s not my right to be cutting off parts of my baby’s body when there’s nothing wrong with him.”

Dilts made that decision at the end of her pregnancy, when she was gathering information about the procedure from midwives, doctors and other experts in the Chico area. The knowledge she acquired through her research, coupled with the free-thinking values her parents taught her as a child, led to her conclusion.

It was a choice that alarmed the baby’s father, who Dilts said expressed social and cosmetic reasons for wanting to have his son circumcised.

“We both had very strong reactions,” she said. “But as a parent, it’s your job to make decisions based on the information you gather. It’s about what’s best for the child. It’s about being a critical thinker.”

The disagreement between Dilts and the baby’s father is representative of the growing fundamental split American society is facing regarding the issue of circumcision, which has been called one of the world’s oldest and most controversial surgical procedures. More and more parents are deciding to keep their newborn sons intact, for reasons ranging from changing recommendations by medical authorities to the growing trend of parents not wanting to blindly follow social norms.

On the other side, more-traditional individuals continue to seek the procedure for social and cosmetic reasons. Some have concerns about their infant’s hygiene and future experiences in social and romantic situations. Then there are the cultural and religious reasons many parents have for circumcising their sons—especially those who come from Jewish and Muslim backgrounds.

This split in values has widened in the past decade, said Dr. John Asarian, a pediatrician who has been practicing in Chico for almost 13 years.

Asarian said that 20 years ago “most” infant boys in the United States were circumcised for a combination of social, cosmetic and cultural reasons. However, he has noticed more of a 50-50 split in the number of parents who are choosing to have their sons circumcised today. And with more and more parents choosing to keep their sons intact, the social and cosmetic arguments—which often concern the infant boys’ “looking” like their fathers and peers—are losing ground.

The practice of circumcising infant males became widespread in the United States during the “hygiene era” of the late 1800s, when natural processes such as reproduction became increasingly medicalized, said Lyndall Ellingson, a professor in Chico State’s Health and Community Services Department who focuses on multicultural health. The procedure of removing the foreskin was believed to cure myriad conditions, including masturbation, whooping cough and a variety of other ailments.

Since then, the medical reasons for circumcision have largely been debunked. In 1999, the American Medical Association released a statement discouraging routine circumcision, and that same year the American Academy of Pediatrics released a circumcision policy statement relaying that, while there are possible medical benefits to having the procedure performed, the data are not sufficient to prove the procedure is necessary to ensure the well-being of a normal infant boy. The academy reaffirmed its findings in 2005.

Ellingson said the shift in attitude by medical authorities likely has been influenced by a shift in social attitudes that’s been taking place since the 1960s and ’70s, when many individuals began questioning authority and challenging the dominant social paradigm. Changing attitudes about circumcision, she said, were a part of that “constellation” of societal changes.

“It was based on grassroots change and then incorporated into the system,” Ellingson offered. “And now you have the system itself changing its attitude. It’s just kind of this wave of moving forward.”

Asarian stopped performing circumcisions four years ago when he decided that the risk of the surgery did not outweigh the medical benefits, which are mostly related to hygiene.

The circumcision procedure is uncomfortable for the infant boys, who are laid on a molded plastic instrument and restrained by their arms and legs. The procedure is usually performed on the second or third day of life, and cannot be performed within the first eight hours because a newborn’s midsection cannot be exposed to the cold.

“There are a lot of physiologic changes at birth, so the baby has enough to do just to get used to breathing, for example,” Asarian said. “So it’s not the time to do surgery unless it’s needed for a real medical emergency.”

Asarian also noted that, while many parents choose circumcision to prevent infection, the risk is not as great as many think, and most infections intact boys develop can easily be treated with topical or systemic antibiotics.

“I tell [the parents] it’s more of a social decision than a medical decision, because the evidence is not very clear-cut in the U.S.,” he said. “There is a small decrease in the number of infections in male babies who are circumcised compared to non-circumcised. You’d have to perform circumcisions on 300 to 400 babies to prevent one infection.”

And while the Center for Disease Control has warned Americans about the risk of increased incidences of HIV and other sexually transmitted infections for intact adult males, Asarian said it is important to understand that simple hygiene, preventative behaviors and increased education may be more appropriate ways of dealing with those risks.

Dilts said that while she always had an idea of how she would handle the decision whether to circumcise her son, the process of defending her decision has been more challenging than she expected.

“Until you are put in the actual situation, you’re not personally affected. I’ve become more of an advocate [against circumcision] since I’ve had a boy,” she said. “And you need to make decisions for yourself and your baby despite whether that’s the social norm. If we all wanted to stay with what the norms are, people would never change. Society would never move forward.”

Zimdiaspora
March 6, 2010

Circumcision has positive benefits in HIV infection

By Dr Timothy Stamps

I must confess, at the outset, my initial reservations about the enthusiastic, and sometimes irrational, adoption of adult male circumcision as a strategy against the worldwide threat, especially the threat in our country, Zimbabwe, posed by HIV infection.

For a start, it confuses some of the messages we have painfully and intensely propagated over many years. The "ABC" of abstinence, being faithful, and using a condom is somehow muddied, because young men, in particular, go for circumcision in order to avoid the messy business of having to use a condom.

Secondly, the widely publicised experiments at Orange Farm in Gauteng, South Africa, Rakai in Uganda and Kisumu in Kenya were not, by any ordinary definition, "gold standard" randomised controlled trials. In fact, they were not random controlled trials at all, and even the experiment was uncompleted.

The only thing which was randomised, and this was not fully blinded, was the allocation of the volunteers to the two groups (circumcision or delayed circumcision). It is obvious to anyone that both the volunteer and the researcher knew immediately to which group the volunteer belonged, raising the strong probability of [the Hawthorne effect], i.e. the bias introduced by multiple changes occurring at the same time, only one of which is recorded as being responsible for the effect seen. This, of course, was the effect that the funders of the experiment wanted to see. A moment’s thought will impress the objective observer that circumcision with enforced abstinence for 42 days is probably the most dramatic "behaviour change" a sexually active young man can ever experience as an individual!

Thirdly, if money for health initiatives is available, there are many more urgent and beneficial initiatives which cry out for funding in this region, in particular. One has only to see the disastrous effects, and, indeed, downstream consequences on both the family and the health worker of the deteriorating statistics and causes of maternal mortality and perinatal death and disability in our country. This quantum of money could have been more profitably used in preventing and treating cervical cancer, from which almost nobody now dies in rich countries. And I’ve only touched on reproductive health. Many initiatives in the broad spectrum of health could produce better and more permanent improvements in our social setting.

Fourthly, the question of gender balance has to be raised. Even the most ardent enthusiast will admit that this initiative will benefit men, exclusively, in the initial phase at least, though I’ve seen some fanciful medical modelling claiming that it will lead to benefits for women (on the HIV incidence) eventually. It is, however, an initiative totally targeted at benefiting young men.

Fifthly, there is the thorny problem of discrimination. Some can still remember the fact that in the Nazi regime the mere fact of being circumcised was likely to end you up in a death camp. Similar discrimination, either for or against circumcision, has been with us throughout the ages. It is not as well known that the British civil service, especially those who were to serve in the East India Company, were required to be circumcised, because the Moghul empire in the 16th and 17th centuries would not negotiate with the uncircumcised heathen!

And the medical services of the 19th century on both sides of the Atlantic advocated adult male circumcision as a "cure" for all kinds of illnesses, including paralysis, hip-joint disease, and, more frequently, psychiatric disease brought on by various environmental conditions — "exhausting climate, work, worry, tobacco and alcohol". Some, such as Remondino, even associated the prepuce with "a malign influence . . . striking the patient down unawares in the most unaccountable manner …"

In 1894, Merrill Ricketts listed a whole series of illnesses that could be cured by male circumcision, including eczema, elephantiasis epilepsy, gangrene, TB, bed-wetting, convulsions, "hystero-epilepsy" and impotence. If only the manufacturers of Viagra had known!

No wonder that the British Royal family circumcised all their male heirs, and, by the start of the Second World War an estimated 80 percent of "upper class" males were circumcised in the UK.

Some civilisations, such as those in the earlier part of the Islamic religion, made it a condition of rising in rank in the armed forces that the number of trophies — prepuces of unbelievers — removed personally counted in the superiority. I suppose that was analogous to the scalps in a "Red Indian’s" pouch demonstrating him to be a mighty warrior. And in the years leading up to the Turkish occupation of Armenia in 1915, large numbers of male indigenous Armenians were forcibly circumcised (and died, because circumcision was done in primitive, unhygienic conditions, and without anaesthetics) although I suppose it also helped in the process of annexing the land, because so many fighting people were disabled.

Lastly, the scenario of the international debates was deeply divisive. Both in Toronto, (which to some of us is more associated with a charismatic event — the "Toronto blessing") and in Montreux, (which has staged some brilliant jazz festivals) both sides accused the other of "irrationality", and created some curious alliances, which served only to deepen the stigma associated with the disease when we have put in so much to promote the normality of those affected by HIV. Some of the claims of the effectiveness (against Aids) do need to be assessed in the light of experience, rather than the enthusiasm demonstrated by zealots that this procedure alone can replace appropriate behaviour education and practice.

In Kenya, scene of one of the highly publicised experiments, Professor P. Aggleton was told that it would be unthinkable for that nation to have an uncircumcised President, and Dr. R. Darby reports that boys have been excluded from some schools if they aren’t circumcised.

I’ve gone into some of the history of the procedure because, in some circumstances male circumcision, especially adult male circumcision, can be a deeply political activity. Its connexion with a whole range of non-clinical beliefs, mores, and the process of colonising the mindset of a nation such as Zimbabwe, is very broad and needs to involve all aspects of our emerging society. The advocacy, and indeed the policy, for upscaling adult male circumcision in Zimbabwe comes largely from rich countries in the North, and the money for the procedure almost exclusively from international organisations and NGOs who call themselves "donors". The danger of attracting sexually deviant persons and "voyeurs" who have a twisted pleasure in seeing young, male, black penises has been underplayed, too.

So, we have to be careful on several points:

(a) That the policy shall be ours, and in particular, not compulsory or enforced, even by monetary or other non-medical inducements, and

(b) That the policy we craft, or adopt, shall be unbiased and not affect the already significant gains we have already achieved against the disease, especially on the field of prevention.

(c) That the process shall accord with our culture (several traditional groups already promote the concept) and, conversely, the resons for adult male circumcision shall be purely a public health initiative, not an imposed programme by well-wishers with hidden agenda.

[Dr Stamps' statement of the caveats against circumcision to prevent HIV is excellent. As he says, even if is as effective as its advocates claim, circumcision should take a low priority behind more effective and generalised health measures. And it is good to see his warnings against the exaggerated claims of effectiveness, and that he has taken on board the lack of blinding, placebo etc. within the trials, which are serious concerns.

He should also consider "attrition bias" - differential loss from the trials of men of different circumcision and HIV status. 327 circumcised men, and a comparable number of intact men, left the trials, their HIV status unknown to researchers, but not necessarily to themselves, since they were encouraged to get tested at nearby clinics. Finding you had HIV after a painful and marking operation to prevent it would be a powerful inducement not to go back. Quite a small difference here could easily undo the claimed outcome of the trials. (Since everyone wanted the trials to succeed, men might even have felt encouraged to leave if they had the "wrong" test result.)

In the three trials, less than two years after circumcising 5,400 men, 64 of them had HIV, compared to 132 of the non-circumcised control groups - the difference, 73 circumcised men without HIV, is the total "protection" that has been infated into "miillions could be saved". Meanwhile, a Ugandan study found 18% of the partners of circumcised HIV+ men contracted HIV while only 12% of the partners of the non-circumcised HIV+ control group - but the study was called off before it could reach statistical significance. If circumcising men does indeed increase the risk to women, that could easily undo any benefit, because women are at greater risk already.]

With all the opinions I’ve expressed, it will no doubt come as surprise that I support the programme so far, and I believe readers have a right to know the positive benefits of male circumcision.

They are not limited to the narrow prevention of HIV infection, but they are, of course, related.

Firstly, Holy Scripture endorses it:

1. Abraham and his household were circumcised as a bodily sign of God’s covenant (Genesis 16). In fact, he was 99 years old when he got circumcised, and lived on a good few years after that. My interpretation of that recorded fact is that age is no barrier, and it doesn’t affect one’s future health. (Ishmael, by the way, was 13,and his half-brother, Isaac was a baby.)

[Many scholars agree Abraham was not a historical character, and in any case that covenent was only with him and his descendents.]

2. Our Lord, Jesus Christ, was circumcised, according to the customs of that time, on the 8th day — i.e. the 1st of January, A.D.1. Yes, I mean, 01.01.0001. That was the first day of our present era.

[Jesus was also reportedly scourged and crucified. We are not expected to imitate him in every detail. Orthodox teaching is that those were done to him so that worse would not happen to us, and several of Paul's epistles spend time arguing that circumcision is not necessary for Christians - most strongly Gal. 5: 2 "...if you become circumcised, Christ will profit you nothing."]

3. My namesake, Timothy, was circumcised as a young adult by Paul (Acts 15,3). Just in case the analogy is taken too far, I’m not advocating that (Dr.) Paul (Chimedza) should repeat that procedure now!

[Paul reportedly circumcised Timothy because his mother was Jewish and he was to go among Jews. It was tactical. He did not circumcise Titus, who was Greek. (Gal. 2:3)]

Secondly, male circumcision, done with optimal hygiene and expert skill is a very different proposition than even 100 years ago in civilised societies.

Modern surgical procedures, done in specially designated units in Zimbabwe, are safe, and the surrounding physical and professional environment ensures maximum security and success, and the counselling, both before and after the procedure, is of a very high standard. Especially the difficult 42-day period subsequently is handled with great attention to personal needs.

Thirdly, and to me, most importantly, it can serve to reinforce the "B" of our acronym — ABC.

Being faithful to one’s faithful spouse (and I suppose it can apply to traditional polygamy as well) has tended to be overshadowed in recent advocacy promotions by the "A" (Abstinence) and the "C"(Condoms) parts of prevention methods, both because they are simpler to propagate and, especially in the case of condom use, quantifiable. But if the two prevention policies succeed it takes little thought to see that eventually we shall end up with a childless Zimbabwe, and we shall have no posterity to thank us for our effort!

So, I was very impressed to see that over 25 percent of clients are accompanied to the procedure, and we should strongly advocate that adult male circumcision should involve women as well — not as clients, but as active participants in a life long decision.

That way we shall promote the "B" part of the fight against Aids, and promote the development of our country and region. I recall one of my patients telling me that her husband’s (circumcised) penis was the "only lolly that got bigger when she sucked it". And the joy of marital intimacy has been discounted for too long in our current society where relationships that go wrong seem to be the target for all sorts of publicity.

Confucius said the family is the most important part of any nation. And we would do well to emulate his wise counsel by being active contributors to the family.

Uxorial fidelity is not a well promoted concept. I hope that the current programme of adult male circumcision can enhance this joint adventure, and I anticipate a greater number of female partners being involved in what should be an inclusive programme.

[This argument is mysterious. If a couple is faithful to each other, circumcision is of no benefit to either of them. On the contrary it reduces pleasure for both.]

MOTHER JONES | MARCH/APRIL 2010, p 96

Much Ado
   About Cutting

Why the big flap over circumcision?

[by Nikhil Swaminathan
Practical Values]

LAST NOVEMBER, Christopher Mims, a 30-year-old expecting dad, updated his Facebook status: "Those of you who had boys, did you circumcise him? If not, why? KTHANKS." The question elicited a flurry of responses: "We think it's genital mutilation," replied one-half of a lesbian couple in Atlanta. "I'd say it bothered him for a few days afterwards," responded a new mom in Texas, "but I would not say he was in excruciating pain." A New Jersey mother noted that the only intact boy she knew needed surgery- due to chronic infections, warning, "You have to be extra vigilant about keeping the cheese outta there."

"The volume of discussion we've had about this is really incredible," Mims told me. Circumcision has become the expecting-parent-obsession du jour, gaining ground fast on classic yuppie conundrums like cribs vs. cos-leeping. Authors and parents Michael Chabon and Neal Pollack have written about agonizing over the decision. (Chabon calls circumcision "the first of many betrayals that you will subject your kids to.") Pundits Andrew Sullivan and Christopher Hitchens call the practice "mutilation." The vociferous anti-circumcision movement includes men trying to restore their foreskins (by attaching small weights to what's left of the flap). Julie Adler, a California rabbi who trains mohels to perform circumcisions, says Jewish parents are questioning the practice, even though their religion mandates it.

Just a few decades ago, circumcision was a virtual nondecision for new parents in the US. In the late 19th century, doctors believed snipping foreskin could cure a laundry list of ailments, including hernia, epilepsy, and indigestion. Early studies on the topic in the '30s indicated that circumcision decreased a man's susceptibility to penile cancer, and by the late 70s, 64 percent of newborn American males were cut. By 2006, that number had dwindled to 56 percent. Immigration trends may be partially responsible for the drop-oft: Worldwide, only a third of men are circumcised. Few modern doctors consider the procedure medically necessary: The rate of penile cancer in the US is vanishingly small to begin with. But Armin Brott, the author of a series of parenting books, says another factor was the natural childbirth movement that began in the 70s, which advocated "less medical intervention, fewer procedures, having your baby your way."

But the medical community may be poised to change its mind yet again. Recent studies have found that circumcised adult men in Africa have lower rates of HIV and other STDs - as much as 35 percent lower in the case of HIV. Researchers say this is because uncircumcised men are more vulnerable to infection - foreskin can tear and contains mucosal cells that easily pick up viruses. [These cells are supposed to pick up viruses and destroy them - with the exception of HIV, since that's it's modus operandi.] In light of these studies, the Centers for Disease Control and Prevention is weighing recommending the surgery as part of its HIV/AIDS-prevention strategy. But University of Michigan epidemiologist Divya Patel believes that because of differences in health care systems, modes of transmission of HIV, and age of sexual debut, the new data is not directly applicable to the US.

Sexual debut. Right. It's never too early to start thinking about your newborn's romantic career. A 1997 study reported that circumcised men were 33 percent more likely to receive oral sex than their uncut counterparts. [Actually, it was only some races, and more of the circumcised men reported ever having received oral sex. It's not saying that being circumcised improves your chances, but more likely that the races and classes to which non-circumcised men belong are those with stricter attitudes toward sexual practices.] But Debby Herbenick, author of Because It Feels Good: A Woman's Guide to Sexual Pleasure and Satisfaction, says her research shows only a minority of college coeds are skeeved by a hooded penis. Anti-circ groups routinely claim that cut men feel less pleasure, since they lack about 15 square inches of sensitive tissue. Adult film star Rocco Sitfredi (nom de guerre: Italian Stallion) says he found that out the hard way when he was circumcised at 31 for hygiene reasons. Siffredi, who calls his decision "catastrophic," says that with a foreskin, "you can feel much more fun."

Some recent parenting books suggest parents go with what dad looks like. But Georganne Chapin, director of the anti-circ group Intact America, calls that advice "freaking ridiculous": "If your husband was missing an eye, would you poke his [son's] eye out?"

Which is one reason Mims and his wife left their new son's foreskin intact, even though Mims is circumcised. "You've made all this preparation for your child's health and safety, and now you're thinking about amputating some part of his body," says Mims. "We had a visceral and emotional reaction against it." The Italian Stallion would be pleased. "The people who were circumcised since they were a baby," he warns, "they can never understand."