Delicate decision: To circumcise or not?

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FOR nearly all of Nada Mouallem's pregnancy, she and her husband, Tony, had a running argument. She wanted to have their son circumcised. He didn't. "Many days, I'd go off and research all the pros. He'd go and research all the cons. Then we'd get together at night and fight," she says.

Arguments about circumcision often polarize today's parents. The procedure, dating to ancient Egypt, is -- in simple terms -- the removal of the foreskin, the piece of skin that surrounds the tip of the penis. But imbued in that small piece of skin are passionate opinions on sex, money, religion, tradition, health, hygiene, human rights and locker room pressure.

Parents of baby boys have to weigh all those factors.

Forty years ago, when almost every male born in this country was circumcised, the decision was easier. In 1965, 85% of boys born in the United States were circumcised, so parents followed the crowd.

But as of 2005, 56% of newborn boys were circumcised, according to the Agency for Healthcare Research and Quality, which analyzed hospital-based circumcisions that year. That figure varies by region: In the report, 75% of boys born in the Midwest were circumcised, 65% in the Northeast, 56% in the South and only 31% in the West. Factors influencing the decline, experts say, include immigration from Latin America and other countries where circumcision is less common, declining insurance coverage and a tendency for parents to choose less medical intervention.

Dr. Doug Diekema, pediatrician at Seattle Children's Hospital, where he's chairman of the academic committee on bioethics, says today's climate makes parents think harder about this decision.

"The fact that circumcision is an even split these days is not a bad thing," he says. "If there are not religious beliefs, then parents really are left with the primary question of whether circumcision offers another benefit. The data are not compelling in either direction.

"The social pressure parents faced before to circumcise their sons was not the best reason to do it."

Tandy Parks, childbirth education specialist at Santa Monica-UCLA Medical Center and Orthopaedic Hospital, has seen the numbers of parents electing to have sons circumcised drop dramatically since she began teaching these classes in the 1970s. "Before, everyone did the procedure. There was no discussion." Now, she estimates, out of every six West L.A. couples she teaches, three plan to circumcise; two will not, and one is on the fence.

"I hear from parents who don't feel it's right to remove a piece of someone's body, and who believe it might be there for a good reason, and from those who want their son to match Daddy, who worry about cleaning the penis properly, and who acknowledge the slight medical advantage. I've even had adult men arguing with each other in class over which one feels sex better."

Medical considerations

Those crunching the numbers consider the benefits and risks of newborn circumcision to be slight. Medical benefits include a reduced risk of urinary tract infections, penile cancer, sexually transmitted diseases and phimosis (closure of the foreskin over the tip of the penis). Risks include a chance of excessive bleeding or infection. Even rarer are surgical mishaps that may require a later surgical repair.

In the first year of life, 1 in 100 uncircumcised boys will develop a urinary tract infection. Only 1 in 1,000 circumcised boys will. "While that's a tenfold reduction, you have to keep in mind that the risk was only 1% to begin with," says Dr. Andrew Freedman, pediatric urologist at Cedars-Sinai Medical Center. Proper hygiene can prevent most infections.

In noncircumcised populations, phimosis occurs in 4% of males. Of those who develop this problem, half get circumcised. The other half use stretching creams and noninvasive treatments, Freedman says. Penile cancer affects only 1 in 100,000 men, but circumcised men are three times less likely to get that disease.

Those who strongly oppose infant circumcision believe the procedure violates a child's human rights. Some call it "male genital mutilation" and rather than cite circumcision rates, they track "genital integrity rates." Others argue that this is a decision sons should make for themselves when older. Internet support groups give voice to men who lament the loss of their foreskin and help to those seeking to restore it.

The downside of letting the child make the decision later is that adult circumcision is more expensive, painful and extensive. During an infant circumcision, practitioners numb the site with local anesthesia, then attach a bell-shaped clamp to the foreskin and excise the skin over the clamp. The clamp helps prevent bleeding. In adults, the procedure involves two incisions, above and below the glans (tip of the penis), stitches and a longer recovery. The cost is about 10 times that of a newborn procedure.

The American Academy of Pediatrics and the American Urological Assn. offer little guidance. The AAP policy states, "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision." The statement goes on to advise parents to determine what's in the best interest of the child and adds that it's legitimate to take cultural, religious and ethnic traditions into account along with medical factors.

The urological association's policy is equally noncommittal: "Neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks. . . . Medical benefits and risks, and ethnic, cultural, religious and individual preference should be considered."

New studies on HIV

However, both medical associations, as well as the Centers for Disease Control and Prevention, are reevaluating their positions based on new findings out of Africa. Three randomized controlled studies conducted in South Africa, Uganda and Kenya over the last several years, found that circumcised male adults were 51% to 60% less likely to acquire HIV from heterosexual vaginal sex with an infected woman.