THE SALT LAKE TRIBUNE, Salt Lake City, Utah,
Thursday, 17 April 2003.

More Parents Questioning Routine Infant Circumcision

There are roughly 25,000 baby boys being born a year in Utah and in the first few days of life, most go through the same painful experience.

You know what we are talking about. Yeah, ouch. Circumcision.

For Utah's Jews and Muslims, circumcision is a matter of religious faith. But for most new parents, the practice is part of a Western medicine and cultural tradition that has deemed the foreskin useless and expendable. (See box, D3.)

And that's a big mistake, according to anti-circumcision advocates, whose view is gaining momentum as the slim flap of skin is increasingly the focus of welfare reform, legal challenges and preference for holistic health practices.

In February, Utah joined 10 other states in eliminating Medicaid funding for circumcision, saving more than $350,000 annually, according to the Utah Health Department. Other states are said to be lining up to adopt similar measures and if they do, the savings to Medicaid would be about $35 million annually, according to the Circumcision Information and Resource Pages Web site.

Such policy reform has the backing of individuals and groups opposed to circumcision, though they say the debate is more about human rights than about public funds.

"The time has come to stop mutilating babies and to treat babies for what they are—beings that are extremely precious and that should be treated with the same respect we give any person," said Paul Fleiss, a clinical professor of pediatrics at the University of Southern California Medical Center and co-author with Frederick Hodges of the new book What Your Doctor May Not Tell You About Circumcision.

Fleiss came to the cause by what he described as an epiphany. His early training taught him babies didn't see, hear or feel pain. Through hundreds of circumcisions, he focused on the procedure and screened out the "agonizing, horrifying cry" from the baby.

"When I finally did hear the cry, I knew nothing good was coming out of it," he said.

The American Academy of Pediatrics, which until the 1970s was a proponent of circumcision, reiterated in 1999 there is no medical reason to make the surgery routine for all infant boys. The academy said, however, parents should be allowed to take cultural, religious and ethnic traditions into account when deciding whether to circumcise a son. And for the first time, the academy recommended that pain relief be provided during the surgery.

Circumcision is required to treat some physical conditions, such as phimosis in which the foreskin is so tight it won't retract from the penis, and some research shows uncircumcised males are at more risk of urinary-tract infections, sexually transmitted disease and penile cancer. But the academy concluded that all those risks are extremely low and do not warrant making circumcision standard practice.

Still, scientific fact is up against cultural conformity when it comes to circumcision.

Roughly 80 percent of adult American men are circumcised and the preference has been for "like father, like son"—with much thought given to what a boy may face later in the school locker room. Even so, circumcision rates have fallen to somewhere between 55 percent and 65 percent nationally, according to information groups.

That decline is due in part to public education efforts by groups such as the National Organization of Circumcision Information Resource Center (NOCIRC), founded in 1986 by Marilyn Milos to protect the rights of male, female and intersex children until they are old enough to decide for themselves how they want their genitals to be treated.

Utah may be behind the national curve.

"I don't think there is any appreciable decrease in the number of circumcisions done, but people are definitely thinking about it and asking questions about it more often than they did 10 years ago," said Louis Borgenicht, a Salt Lake City pediatrician and co-author with son Joe of the just-published The Baby Owner's Manual.

Heidi and Bob Varechok of Park City are typical of the couples showing up in local doctors offices. The Varechoks are expecting their second child in August and learned last Friday they will have their first son.

"It's one of those things we didn't have to deal with [when we had] our little girl," Bob Varechok said.

The couple plan to discuss circumcision with Heidi's obstetrician and their pediatrician and will be guided by what they say, but right now "we have no preconceived ideas one way or the other going into this," Bob Varechok said.

Based on his experience, Borgenicht said parents who opt against having their baby boys circumcised are "at peace with the fact that they really don't have to from a medical standpoint" and tend to be "new age people who are more into counterculture medicine."

Fleiss said a small number of physicians cling to the idea there are medical reasons to do a circumcision, but most "do what parents want them to do."

It's more than a matter of cultural preference for Jews and Muslims, who consider circumcision part of a covenant God made with Abraham.

"My denomination in general on these issues is pro-individual choice," said Rabbi Joshua Aaronson of Temple Har Shalom in Park City. "We certainly support circumcision as a rite of passage for male infants in the Jewish tradition. It's been going on for thousands of years and has a tremendous ritual and tremendous emotional significance."

Shuaib Uddin, imam at the Khadeeja Islamic Center in West Valley City, said Muslims are unanimous about male circumcision being a requirement of their tradition.

That said, some within those faiths, such as Jews Against Circumcision, have spoken out against the practice.

Religious issues aside, cultural preference for circumcision is strong.

That's partly because few Americans understand what is lost when the foreskin is removed, said Steve Scott of Salt Lake City, a director of NOCIRC of Utah and expert on the issue.

Circumcision removes skin that is loaded with sensory nerves, protective and sexual functions, Scott said. Like an eyelid, the foreskin keeps the penis moist and warm, provides immunological protection and acts as a rolling mechanism during sexual intercourse. The specialized skin is "all obliterated in circumcision," said Scott.

An infant circumcision, which takes place days after birth in either a hospital or clinic, takes about 5 minutes and costs $175 to $200. Parents typically are not present when the surgery is performed.

Complications occur in 1 in 200 to 1 in 500 circumcised newborn males, according to the American Academy of Pediatrics—most often bleeding and local infection.

Occasionally, circumcisions go horribly wrong and the penis is damaged or excised. In rare cases, infants have died.

Some parents have sued after the procedure was performed on their sons, saying they gave consent while indisposed or weren't properly informed of the risks and benefits of circumcision.

Zenas Baer, an attorney in Hawley, Minn., represented a client who made such allegations in a case against MeritCare Hospital in Fargo, N.D. The hospital was exonerated in February, but Baer, who considers circumcision "barbaric," has vowed to seek a retrial.

In 1995, David J. Llewellyn, an Atlanta-area attorney, won a $65,000 verdict in Montgomery County, Ala., on behalf of a child who was circumcised against his mother's wishes.

Since then, Llewellyn has taken on about 17 wrongful circumcision or circumcision damage cases, most involving infants or young boys but also several men with diabetes who underwent circumcisions recommended by urologists—with horrendous results.

"Parents are told virtually nothing except that it is cleaner and supposedly reduces the incidence of certain things," Llewellyn said.

He believes there are three reasons parents continue to seek circumcision: They want their sons to look like Dad; it is a big business—he estimates it generates at least $250 million a year; and there is a cultural psychosexual phenomenon that promotes genital conformity.

Once genital cutting becomes embedded in a society, "there is a deep-seated need to continue that conformity," Llewellyn said.

"Can a doctor as a doctor put tribal marks on the face of a child to look like Mom and Dad?" he asks. "We assault the penis and for some reason, we assume that's all right."

Tribune reader panel participants contributed to this story

A brief history of circumcision in the United States

In America, circumcision is "this coat rack we keep hanging myths on," according to Marilyn Milos, director of the National Organization of Circumcision Information Resource Centers.

Justification for the surgery has ranged over time from a treatment for paralysis to not wanting to look different, Milos said. That evolution was outlined by medical historian David Gollahar in a 1994 article in the Journal of Social History. Here is a look at circumcision over time:

*1870s: A New York doctor uses circumcision to treat paralysis and mental disorders in young boys. Until now, circumcision was done for religious reasons or to treat cancer and an overly tight foreskin.

1880s: Doctors advocate circumcision for infants, citing hygienic reasons as well as prevention of masturbation and venereal diseases.

1890s: Germ theory and cancer fears boost circumcision acceptance. One doctor credits circumcision as a cure for alcoholism, epilepsy, hernias, headaches and a host of other conditions. A popular baby book advocates the procedure in most cases, particularly to prevent "the vile habit of masturbation."

Early 1900s: Infant circumcision is becoming standard practice and is viewed as an indicator of rank and social order since only babies delivered by private physicians in hospitals receive the surgery.

Mid-1900s: Fears of penile cancer continue to be used as reason for circumcision. It also is seen as helping to prevent cervical cancer in women.

1960s: In the midst of the sexual revolution, the belief in circumcision's ability to prevent spread of sexually transmitted diseases resurfaces even as more people question common medical wisdom.

1970s: Up to 90 percent of American baby boys are circumcised, even as leading medical groups—and baby guru Benjamin Spock—say there is no medical reason to continue routine practice of the procedure. Cultural acceptance outweighs medical knowledge.

1980s: A flawed study gives circumcision new momentum when it indicates higher risk of urinary-tract infections in uncircumcised males.

1990s: With the spread of HIV and AIDS, circumcision is touted as way to avoid the disease.

—Sources: Medical historian David Gollaher; Marilyn Milos

Resources for more information on circumcision:

  • On the Web:

    Circumcision Information and Resource Pages,

    National Organization of Circumcision Information Resource Centers,

    Doctors Opposing Circumcision,

    National Organization to Halt the Abuse & Routine Mutilation of Males,

  • Books:

    What Your Doctor May Not Tell You About Circumcision (Warner Books) by Paul Fleiss and Frederick Hodges

    Doctors Re-examine Circumcision (Third Millennium Publishing) by Thomas Ritter and George Denniston

    Circumcision, The Hidden Trauma (Circumcision Resource Center) by Ronald Goldman

    Circumcision: A History of the World's Most Controversial Surgery (Basic Books) by David Gollaher

(File revised 30 April 2003)