Frequently writing on faith issues from my vantage as a co-founder of a Hindu advocacy group, my faith and family, interests and occupation overlap. A Hindu voice has long been absent in our nation’s dialogue on many contemporary issues, and I endeavor to add just one where I can. But in the circumcision debate, I check my religion at the door and take a seat inside. The doctor, a pediatric urologist, is in.
Nearly every day, I perform a circumcision. During my discussions with the family prior to the procedure, I discuss the position statement put forth by two organizations that have published evidence based policy statements on circumcision: the American Academy of Pediatrics and the American Urological Association. Both statements state clearly the facts: neonatal circumcision reduces the risk of urinary tract infection in the first year of life, eliminates the risk of penile cancer, and significantly reduces the risk of syphilis and HIV transmission. I tell the families in the same breath that these statements also caution that the urinary tract infection risk in uncircumcised boys is as low as 1%, and that access to good hygiene also prevents penile cancer. Of epidemiological interest, despite the fact that regions in China and Scandinavia do not practice circumcision for newborns, the incidence of penile cancer is exceedingly high in the former and very low in the latter, presumably due to excellent cradle to grave medical care in Scandinanvian countries. And while circumcision’s reduction of HIV risk by 60 percent has led the World Health Organization to embrace the procedure as a critical step, it can never substitute for safe sex practices.
I echo the ambivalence of the profession to which I belong when families ask about the procedure. I present the facts. And nearly 80 percent of the time in the United States, the parents will choose circumcision for their child. I will receive as much for doing the procedure as I would for seeing any patient in the office for fifteen minutes. It is not an income source. But I offer the service because families truly, deeply, and sometimes, desperately, want the procedure for their son. And if they decide to go forward, I will place an antibiotic cream on the penile skin and then inject an additional milliliter of lidocaine to provide enough anesthesia that most children barely whimper, though some will cry.
The data is mixed, there is no wrong or right answer. Families deal with the nebulous every day and make a decision that is right for their children. But to me, the inanity over the circumcision debate lies also in its ignorance of medical realities. If a child has had recurrent urinary tract infections or a lower urinary tract anomaly, circumcision can protect the child from the risk of renal damage by nearly 10 to 15 fold. If a child has a hypospadias, an anomaly where the urethral opening opens along the shaft of the penis rather than at the tip, then I will use the foreskin to reconstruct the urethra, and a circumcision results. And while my clinic is full of children, also, with partially done circumcisions, adhesions that have formed, and urethral openings that have narrowed after circumcision requiring additional surgery and health care dollars, my clinic is just as full of children with foreskin that is painfully infected, scarred with lichen sclerosis, ballooning, torn and tight that may necessitate a circumcision..
A circumcision in childhood is a rapid outpatient procedure; a circumcision after adulthood can be traumatic, painful, and substantially more expensive. A procedure costing $250 in the newborn period would cost $5000 in adulthood due to the need for anesthesia and perioperative care. Any type of blanket ban on a circumcision until the age of consent so ignores the real medical necessities of circumcision in some cases, that the concept is beyond contemplation; it is medically irresponsible and dangerous.
Circumcision rates will drop naturally if the medical data disproves putative benefits. There is no circumcision industry or lobby that influences or supports the medical profession, buying the procedure’s perpetuity. The procedure lives because there are some benefits and Americans have rendered the procedure a cultural norm. I am well aware that our colleagues in Canada, England, and France, to name a few, snicker at the American propensity to cut foreskin and believe that circumcisions are overdone in this country. Many pediatricians and pediatric urologists here in the States will even agree.
But the concept of banning the procedure does not enjoy credibility even overseas where they are not commonly done, simply because circumcision has been performed for five thousand years and is intertwined with faith, preference, and cultural realities. The current publicity given to the stunt in San Francisco frightens me not for its medical ignorance, but for its overt and retrograde anti-Semitism. The animated depictions of the Jewish ritual bris--the innuendo eliciting comparisons to genital mutilation--are overwrought and shocking.
There is room for a healthy debate on the medical necessity for circumcision and whether it should be performed as routine. Any answer lies in a robust review of properly performed population studies that control for confounding factors. Indeed, it was just such trials that confirmed the spectacular benefit of a circumcision for reducing the transmission of HIV. We doctors already do not encourage newborn circumcisions as opposed to a generation before us that mandated them. And we even talk families out of circumcisions if they are at all hesitant. But never could we support a comprehensive ban for a procedure that has established benefits for certain children. And because we must empower parents to make choices for their children--they are difficult decisions with long term implications--but decisions parents make everyday.
The industry dedicated to cirumcision’s end, seems more a misdirected passion, based on a medically dubious altruism at best, and anti-Semitism at its worst. And these voices will, undoubtedly, alienate reasoned, thoughtful voices that could begin an enlightened dialogue.
Aseem Shukla | Jun 10, 2011 9:21 AM