Spirited Debate Over the Question of Circumcision

Times Staff Writer

Dr. Loraine Stern, a Newhall pediatrician, recalls the incident as if it were yesterday--even though it occurred in the early 1970s when she was finishing her residency.

She was delegated to perform a circumcision on a newborn baby boy who was about to be discharged from the hospital. So, dutifully, the young doctor prepared the baby and began cutting away his foreskin.

In the process, though, the scalpel inflicted a slight cut and, after she applied pressure to stem the blood flow, Stern realized her heart was pounding because she had nearly inflicted a serious injury on what many would argue is, psychologically, the most important part of the male anatomy.

"I thought," Stern said as she recalled the incident a few days ago, " 'Why am I putting myself and this baby through this?' " The bleeding quickly stopped, but Stern's reaction stayed with her.

She had no idea then that circumcision would become a quasi-political issue and even figure--as it now has--in the nation's preoccupation with acquired immune deficiency syndrome (AIDS).

Spirited Debated

Stern's doubts about circumcision inadvertently had coincided with a trend just taking root at that time--and still gaining speed today. In the intervening years, this movement has begotten an ongoing and spirited debate in medicine, the formation of at least one strident national anti-circumcision organization, books, magazine articles and hours of conversation on television and radio talk shows.

But questions remain about whether circumcision is or is not good medicine. The extremes of the debate range from the assertion that circumcision is no better than a procedure where "children die or are mutilated" to a view by a small number of physicians that circumcision may very well prove to prevent such diverse problems as urinary tract infections in infants, kidney infection in adult men, the spread of herpes and other sexually transmitted diseases and penile cancer.

Moreover, there is the prospect--introduced just last week in a letter to the editor of a major medical journal--that circumcision may be instrumental in impairing the rate of heterosexual transmission of AIDS. This speculative view is held by Dr. Aaron Fink, a Mountain View, Calif., urologist who has emerged as the most prominent defender of circumcision on the national scene today. He bases his beliefs about circumcision and AIDS in part on a review of tribal and religious circumcision practices in Africa, where AIDS is more common among heterosexuals than it has been, so far, in the United States.

To Fink, circumcision may be an area of health care in which parents should be asked to sign a statement of "informed refusal," as opposed to the traditional informed consent, in which they attest to having been told of the potential benefits of circumcision but decline to have the procedure done on their son.

He Recommends It

"I would encourage circumcision to be done," Fink said in an interview. "I would recommend it."

Fink is most frequently at odds with the National Organization of Circumcision Information Resource Centers, based in the San Francisco Bay-area suburb of Corte Madera, which has sponsored a national campaign against circumcision that includes three malpractice suits filed in California that seek to make circumcision such a potential liability that physicians will no longer offer it.

In the most recent court action, filed last July, the parents of an Oakland infant sued the doctor who circumcised their son. The suit argues that though the parents authorized the circumcision, the doctor is liable because he offered to perform a surgery with no legitimate purpose. It could be five years or more before the action is resolved.

The circumcision resource center's head, Marilyn Milos, a nurse, contends that circumcision is "an important issue and, for me as a mother, extremely urgent. Surgery is being performed on babies that can be dangerous and is unnecessary," she contends. "It should be stopped now."

There is even a debate over terminology focusing on whether a male who still has his foreskin should be called "intact" or "uncircumcised." Such an emotional overlay has been introduced to the question that even physicians like Stern, who has acted as a national spokesperson counseling against circumcision for the American Academy of Pediatrics, find a regrettable intrusion of rhetoric into what ought to be, she contends, a private decision for parents.

In 1975, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists--the two leading professional associations in their respective fields--issued a carefully worded statement concluding there is "no absolute medical indication" for routine circumcision.

Since then, though the United States still has the highest circumcision rate in the world, the proportion of infant boys who undergo the procedure has declined from an estimated more than 93% to slightly less than 60% in 1985--only the third year the federal government has tried to tally such matters.

In many ways paralleling the movement toward natural childbirth, the decline in circumcision has been most pronounced in the West, where the regional rate has dropped to 49%, according to an analysis of figures gathered by the federal government's National Center for Health Statistics. As in many aspects of health care, there are substantial geographical variations in circumcision, with the Midwest recording the highest rate--70.5%--followed by 65% in the East and 56% in the South.

Circumcision has been practiced for at least 2,000 years and had its roots in early attempts to avoid transmission of infection and disease and to promote improved personal hygiene. These objectives were initially proposed as part of religious practices and circumcision still has a uniquely religious aspect to it. It has long been the subject of cyclic debates within the medical profession over whether it actually achieves the objectives attributed to it.

By the late 1960s, however, American doctors had clearly begun to gravitate to the view that circumcision's medical benefits had historically been overstated and that circumcision accomplished little except to perpetuate cultural norms that dictate how a penis should look.

In 1971, the American Academy of Pediatrics formed a committee that concluded that circumcision does, indeed, make hygienic care of the penis easier. But the organization held that the slight risk present in circumcision--of infection, penile trauma and other complications--could not continue to justify its routine use in light of other conclusions reached at the time that circumcision is unrelated to such diverse problems as cancer of the prostate, development of cervical cancer in female sexual partners and transmission of a variety of venereal diseases.

The position was reiterated in 1975 by the two national groups and remains their official policy.

In the years since, research has continued, with the most significant findings coming from studies suggesting circumcision may prevent the spread of some sexually transmitted diseases and, more recently, in two studies that found circumcised boys may have a lower incidence of urinary tract infections during their first six months of life than those who are not circumcised.

Some studies have concluded that having a severe urinary tract infection in infancy may increase the chance of suffering from chronic kidney problems.

But Dr. Thomas Wiswell, of Brooke Army Medical Center in San Antonio, Tex., and the principal researcher in the urinary tract infection studies, said he has some reservations about the statistical validity of the studies because only 41 baby boys of the 5,261 whose records were scrutinized actually developed the infections. None of the youngsters is yet old enough to assess long-term health consequences. A larger study is being planned.

Wiswell said that, while he would not have his own male child circumcised, he believes strongly in making sure parents are aware of all aspects of the circumcision debate so they can make the best decision for their own sons.

"I think that we now have to mention that there may be at least one valid medical indication" for circumcision, Wiswell said. He said Fink's suggestion--published last week in the New England Journal of Medicine--that there may be a link between AIDS and circumcision, is an "intriguing possibility."

"For years," he said, "people have tried to show that the presence of a foreskin is associated with sexually transmitted diseases. And (if there is an interrelationship) with AIDS, that would be fascinating."

Health insurance plans have made different decisions on circumcision coverage. Earlier this year, the Pennsylvania Blue Shield program drew national attention when it discontinued payments for circumcision, saying it would save $1 million a year. But California's Blue Shield plan had stopped circumcision reimbursement in 1972, though spokesman said the program is aware that many parents simply negotiate inclusion of circumcision in an obstetrician's overall fee for delivering a baby.

California Blue Cross still pays for circumcisions but the Prudential Insurance Co. of America, one of the state's largest health-care underwriters, halted circumcision reimbursements last April 1.

Both Stern and Dr. Martin Gershman, a top official of the American Academy of Pediatrics' California district, agreed that though they both are still persuaded by the organization's existing circumcision position, the question has, unfortunately, become the subject of unnecessarily strident debate.

"I don't think that a rhetorical battle is appropriate," said Gershman. "I don't think this is a big issue. We could spend a lot of time arguing about whether circumcision is medically indicated but that any of the research is questionable. A kid, as he grows up, wants to be like his dad (and his friends).

Gershman noted, however, that there can be cases in which an uncircumcised man eventually develops a genital organ problem that requires circumcision when he is an adult. In fact, at Hollywood Presbyterian Medical Center in Los Angeles, a spokesperson said surgeons have recently noticed a small but steadily increasing number of men in their 20s who are requesting adult circumcision.

Circumcising a boy when he is a newborn--with either no or a local anesthetic and very simple instruments--costs between $90 and $125, doctors interviewed agreed. If the procedure is done as an adult, however, it can be a comparatively serious operation requiring a general anesthetic, costing $1,500 and requiring a week's recuperation.

To Stern, the question of circumcision of newborns is not unlike debates that have seen the essential demise of nearly routine tonsillectomy in young children. And though circumcision still is the single most common surgery performed in the U.S., Stern said, "millions of dollars are being spent in this country on an unnecessary procedure.

"Doing surgery for convenience (as opposed to better training in personal hygiene) is not a valid medical argument."

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