Delicate decision

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Special to The Times

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.

Though these studies are significant, physicians warn that you can’t directly apply these findings in the U.S. In sub-Saharan Africa, the HIV epidemic is much greater, and the primary mode of HIV infection is through male-to-female sex, not male-to-male sex as it is in the United States.

Dr. Peter Kilmarx, chief of epidemiology in the CDC’s division of HIV/AIDS prevention, says the CDC is looking at how the findings apply here. “The early opinion from the consultants -- and not the position of the CDC, which involves a peer review process and public comment -- is that, given all the previous data on circumcision plus the recent HIV African studies, the medical benefits of male infant circumcision outweigh the risks and that any financial burden barring parents from making this decision should be lifted,” he said.

The American Academy of Pediatrics developed its current guidelines on circumcision in 1999 and reviewed and upheld them in 2005. Last year, the association formed a task force to study the matter further in light of the new data. Freedman and Diekema sit on that task force, and say the refreshed guidelines should be out next year.

“The HIV data is the most compelling to date that circumcision can help prevent the transmission of the virus in male-female sex,” Freedman says. “While this is important to sub-Saharan Africa, the question is how many infant boys need to be circumcised in the United States to prevent one case of HIV transmission 25 years from now? Factoring in even the rare complication that can occur with circumcision may render this study insignificant.”


The idea of performing circumcision for medical reasons is uniquely North American, Freedman adds. Worldwide, only 25% of males are circumcised, and that is mostly for religious or cultural reasons. In Jewish and Islamic faiths circumcision is customary.

“The procedure is so ancient, and steeped in cultures, I’m not surprised that the rate of adult circumcision in civilized countries doesn’t track with medical evidence,” Kilmarx says. “But as scientists, we don’t solely rely on what other countries do as a guideline.”


Strong family influence

In homes, the pivotal factor seems to be not science but what that family does. Says Freedman: “It’s a decision that for most people comes down to the question of: What tribe do I belong to?”

When Elisabeth Rettenwender, of Santa Cruz, had her son five years ago, the decision not to circumcise him was easy. The 38-year-old single mom weighed the possible pain and risk with the potential benefits, but ultimately decided to follow what her father and brother had done. Her family moved here from Germany when she was a girl. Neither her father nor her brother is circumcised. As a consequence, she said, she’s had to give her son a hygiene lesson. “I’ve had to teach him how to open up his foreskin and clean it. I’ve talked to him about the fact that some boys are circumcised and some aren’t, so he’ll understand when he starts noticing.”

Robert and Cara Moffat of Los Angeles, who are expecting their first child, a boy, in May, had no trouble deciding, and plan to have their son circumcised. Robert, who is 30 and circumcised, said, “I grew up with it, and my wife has a preference for it, so that’s what we’ll do. We’re doing what the family is comfortable doing.”

For the Mouallems, family tradition and religion were not factors. “We kept those separate and focused only on the scientific reasons,” says Tony Mouallem, who was against circumcising his son because he didn’t think it was necessary. Plus, he’s not circumcised. “You have to work a little harder to keep it clean, but that’s not a big deal.”


His wife, Nada, however, worried about the responsibility of keeping her newborn’s penis clean. She thought circumcision would help reduce the risk of infection and disease. “I wasn’t keen on my baby having a surgical procedure, but then I thought, why not if we can offer him more protection?”

In the end, Tony sided with his wife. Their son was born Feb. 10, and was circumcised the next day. Tony held him during the procedure. “There was no bleeding and he didn’t even cry,” he says. “I’m still not convinced it was medically necessary, but I didn’t want to burden my wife with the worry of cleaning it. And maybe it will be easier for him in the locker room.”

If parents do opt for the procedure, Freedman advises that they do it when the baby is a newborn, have someone trained and experienced perform the procedure, and use pain control. “The older a child gets, the less benefit there is, and the greater the risk,” he says. “I would ask parents of an older child to strongly reconsider if the only reason they’re doing this is cosmetic.”

Freedman faced the decision in his own home. He’s Jewish and his wife is not. She wasn’t for circumcision. In the end, they agreed to circumcise their son, and he performed the procedure. “I didn’t make any excuses that this was to avoid a UTI, or for medical reasons. My rationale was this: As a Jewish male in a long line of tradition, I didn’t want to be the link in a chain that broke.”

As parents and task forces sort through the variables surrounding this intimate decision, Freedman offers parents in turmoil this comforting advice: “Rest assured. No matter what decision parents make for their son, most men think whatever they have is just fine.”