News You Can Use 6/15/98 HEALTH Rethinking a custom Circumcision is no longer an automatic decision for parents BY SARA JOAN LOWEN Even before their son, Emmet, was born in 1989, Philip and Penelope McGuire knew how they felt about circumcision. Without much agonizing, the East Lansing, Mich., couple decided that they would leave their son's foreskin intact. Recalls Penelope, "Circumcision seemed ridiculously unnecessary and painful." A generation ago, Emmet would have been in the noticeable minority of uncircumcised American males. Attitudes are changing and neonatal circumcision rates have dropped steadily during the past three decades from 90 percent to 64 percent. However, the United States stands out as the only nation where circumcision for nonreligious reasons is widespread. (Jews and Muslims circumcise boys as a part of religious practice.) In Western Europe, only 5 percent to 8 percent of newborn boys are circumcised. Circumcision remains the most commonly performed surgery on males in this country--some 3,300 operations a day. The popularity of the procedure in America is historically related to what some scholars say was a national obsession with hygiene, heightened by prudery. Edward Laumann, a University of Chicago sociologist, says that nonreligious circumcision was introduced during the late 19th century as a means of preventing sexually transmitted diseases; the Victorians also thought that it curbed masturbation. In the years after World War II, circumcision had become so ubiquitous that many hospitals offered it as a routine part of birth-related services. Radical views. The trend away from circumcision has its roots in the natural childbirth movement of the 1970s, which sought to make birth as gentle as possible for the infant. Women who undergo a drug-free labor for their baby's benefit hesitate to subject him to surgery a few days later. But a more strident anticircumcision movement, centered mainly in the San Francisco Bay area, is trying to influence parents. These circumcision opponents, who include some doctors, promote their views through pamphlets, books, videos, and the Internet, arguing that the procedure violates medical ethics and human rights by subjecting infants to what they see as disfiguring surgery. They liken it to female genital mutilation, which was outlawed in the United States in 1996. Despite little medical research, the activists hold circumcision responsible for male sexual dysfunction and psychological problems. Some have even staged protests accompanied by recordings of babies screaming during circumcision. Parents in the mainstream who decide not to circumcise mainly want to spare their sons the pain and risks of surgery. Oakland, Calif., resident Donald Bivin, the father of an uncircumcised son, says, "Humans have been around for millions of years without being circumcised, and it hasn't been a problem." While the risk of complications from a circumcision (most often infection, not lopping off the penis) is small--between 2 and 6 incidents per 1,000 procedures--credible research is showing that infants do feel pain. Most doctors defend the surgery as low risk and point out that a local anesthetic can eliminate the pain involved. (The American Academy of Pediatrics, which is neutral on circumcision, is expected to update its guidelines later this year, recommending the use of a painkiller.) There is reliable medical evidence that removing the foreskin reduces the incidence of first-year urinary tract infections in boys and ensures that they won't develop penile cancer, which does affect uncircumcised men. But penile cancer is rare (occurring in about 9 out of a million men), and first-year urinary tract infections occur in only 1 percent of uncircumcised boys. There's no clear evidence that circumcision reduces rates of sexually transmitted diseases. All the same, some physicians acknowledge that the demand for circumcision in the United States is based on religious or cultural, rather than medical, needs. "There is no proven, documented medical reason that says circumcision is better, as long as you teach your child to pull back the foreskin and wash," says Dr. Karin Blakemore, director of the maternal-fetal medicine division at Johns Hopkins University School of Medicine. Despite circumcision's slipping popularity, couples who decide against the procedure often are left with the impression that doctors and nurses expect the surgery nonetheless. Susan Flanigan and Michael McDowell of Washington, D.C., decided shortly after their son's birth not to have him circumcised. Then during Flanigan's three-day hospital stay, nurses came by repeatedly and asked about circumcising her baby--"as if to say, 'Are you really, really sure?'" she recalls.