Circumcision, long in decline in the U.S., may get a boost from a doctors’ group
When Tamar Jacobs became pregnant, she found herself hoping for a girl, mainly because she was dreading a difficult rite of passage that often comes with the birth of a boy — circumcision.
Growing up Jewish in Baltimore, “I never really questioned it,” she said, but the more she read and thought about it, the more “unnecessary and even cruel” circumcision seemed. By the time the grainy 20-week sonogram showed the outward sign of an XY chromosome, she knew she could not go through with it.
“It seemed like such a severe, out-of-this-time thing to do,” she said.
The 32-year-old fiction writer and community college professor is part of a new wave of parents who are questioning not just an ancient Jewish tradition but a long-entrenched American one.
More than 1.2 million infant boys undergo the surgery each year, making the United States one of the industrialized world’s leading producers of circumcised men. But the once ubiquitous practice, in which the foreskin is removed from the penis, is waning.
From a high of about 80 percent in the 1960s, the portion of baby boys leaving hospitals with petroleum-jelly-covered wounds in their diapers dropped to 56 percent in 2008, according to the Centers for Disease Control and Prevention. (The figures do not include those circumcised in outside clinics or by religious providers.)
The downward trend is probably fueled by Medicaid laws in many states that have stopped paying for the surgery, increased immigration from Latin America and other areas were circumcision is less common, and a growingly vocal cadre of so-called “intactivists” who argue that the practice is a human rights violation.
It also reflects a generation that’s more likely to trust nature and second-guess their medical treatment. For these parents, circumcision has become less of an assumption and more of a choice, and not always an easy one.
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An expectant parent wading into the debate around circumcision is likely to discover a maze of medical research, white-hot rhetoric pitting children’s rights against religious freedom, and a choir of bathroom humor.
In interviews for this article, the untrimmed foreskin was alternately derided as an HIV-spreading “wrinkled elephant trunk” or heralded for its “elegant function” and thousands of pleasure-inducing nerve endings.
An uncircumcised California native described the embarrassed feeling of being the kid who looked different in the locker room, and an anti-circumcision activist explained how he spent the past decade trying to re-stretch his shorn foreskin and increase sensitivity in his penis by using a commercially available plastic cone that applies tension to the remaining skin.
Given the prevalence of circumcision, perhaps the most surprising perspective is one offered by American doctors, many of whom summarize the procedure as a “cosmetic” or “aesthetic” choice.
The American Academy of Pediatrics, which advises children’s doctors on research-based practices, has been officially neutral on the issue for more than a decade.
According to its 2005 position statement, which reaffirmed its 1999 stance, “existing scientific evidence demonstrates potential medical benefits” of newborn circumcision but not enough to “recommend routine neonatal circumcision.”
That position is poised to change, though, as the AAP is expected to release an updated statement and report reflecting recent research later this month.
While details are not yet available, the new position concludes that the health benefits of circumcision outweigh the risks, said Michael Brady, a pediatric expert at Nationwide Children’s Hospital in Columbus, Ohio, and a member of the AAP’s task force on circumcision.
Three large-scale trials in Africa within the past decade found that circumcised heterosexual men were up to 60 percent less likely to become infected with HIV than uncircumcised men. The men were also less likely to contract herpes and human papillomavirus, which, if spread to female partners, can lead to cervical cancer.
Ronald H. Gray, a professor of reproductive epidemiology at Johns Hopkins University, who led two of the recent studies, attributed the results to the fact that the cells of the foreskin and the low-oxygen, moist environment it creates are more receptive to viruses.
Responding to these studies, the World Health Organization and the Joint United Nations Programme on HIV/AIDS (better known as UNAIDS) in 2007 recommended more voluntary circumcisions in 14 African countries where HIV is epidemic and circumcision is uncommon.
The AAP’s new position falls short of a routine recommendation, Brady said, adding that parents should continue to take into account their own cultural, religious or social views. “But from a public health perspective, I think it’s a good decision and a lot of children will benefit.”
‘A human right’
Many people, however, question the safety and ethics of using surgery to prevent disease. Some opponents liken it to using mastectomy to prevent, rather than treat, breast cancer.
At last month’s AIDS conference in Washington, protesters displayed signs outside the Walter E. Washington Convention Center that read “Circumcision is torture” and “Intact genitals are a human right.”
Activists traveled from Norfolk, Boston and New York to hand out condoms as a safer way to contain the virus. They challenge the relevance of the African studies in the United States. And they argue that men, not their parents, should be able to choose what to do with their genitals.
Recently, they have scored some victories. The German Medical Association this summer advised doctors to stop performing elective circumcisions after a regional court in Cologne ruled that the rights of “bodily integrity” outweighed the rights of parents or religious freedom in a case involving a Muslim boy who suffered medical complications after his circumcision.
In San Francisco, activists gathered 12,000 signatures last year, enough to put a measure on the ballot to criminalize the circumcision of anyone under 18. The measure was withdrawn before election day following intense protest from the Jewish community and a court ruling that such medical regulations could be enacted only by the state.
“Things are starting to happen,” said Matthew Hess, president of San Diego-based MGMbill.org, a group working to outlaw what he calls “male genital mutilation” around the country. Hess, the activist who is trying to restore his foreskin, also has attracted attention with his controversial Foreskin Man cartoons, which depict a Jewish “Monster Mohel” as a circumcising villain.
Hess and other activists say a key challenge in their fight is countering denial among circumcised men who don’t want to acknowledge they have been victimized and among the parents and medical practitioners who have gone along with the status quo.
“To cut a body part off a little tiny baby in cold blood, you have to [suppress] a lot of your natural instincts,” said Georganne Chapin, executive director of Intact America, a four-year-old organization opposing infant circumcision.
Like asking about religion
Another obstacle, of course, is millennia of tradition. Circumcision is one of the oldest known surgical procedures. Egyptian wall paintings dating to 2300 B.C. depict adult circumcision ceremonies. Aboriginal Australians, Aztecs and Mayans practiced some form of genital cutting. Such traditions have uncertain origins or meanings, but at times appeared to be a rite of passage, test of bravery or sign of endurance, according to a 2007 report by the World Health Organization and UNAIDS.
“It’s like asking the question ‘Where does religion come from?’ . . . There are a lot of different myths around it,” said David L. Gollaher, a medical historian and author of “Circumcision: A History of the World’s Most Controversial Surgery.”
An estimated 30 percent of men are circumcised around the globe today, according to the report. That includes North Sudanese boys circumcised at age 8 (using a cord and a knife) before they can enter school as well as 2-day-old American-born boys clipped at the hospital using a clamp — sometimes compared to a “cigar cutter” — and some local anesthetic.
Though most Americans are aware of circumcision’s Jewish roots, worldwide fewer than 1 percent of circumcised men are Jews. Muslims, who make up more than a fifth of the world’s population, account for two-thirds of circumcisions. Islamic circumcision rituals vary widely by region and sect, but Jews adhere to a specific tradition, whereby a boy is circumcised by a specially trained mohel on the eighth day of life.
The practice is rooted in a deal struck between God and Abraham described in the Book of Genesis: “This is my covenant, which ye shall keep, between me and you and thy seed after thee: Every man child among you shall be circumcised.”
The Baby Jesus’s circumcision is recorded in the Bible and depicted in medieval and Renaissance art. And although Christianity did not widely embrace the practice, some European churches have claimed to possess the “Holy Foreskin,” a relic credited with miraculous powers. Pilgrims traveled to the northern Italian town of Calcata to pay tribute to one of these relics as recently as 1983, when it was reportedly stolen.
Circumcision took hold in the United States in the late 19th century, spread by a different evangelical force: modernizing medicine. A few prominent doctors advocated the surgery as a cure for paralysis, epilepsy, venereal disease, even mental illness. Throughout the Victorian era, it was extolled for its virtue of cleanliness and as a cure for masturbation.
Along the way, it became a sign of class status. As medicine moved into hospitals, it was a marker of state-of-the-art medical care and, by extension, good parenting.
Despite its long medical roots in the United States, research remained thin on the actual benefits.
Starting in 1971, the American Academy of Pediatrics ruled and then periodically reaffirmed that there was no medical imperative for routine circumcision for babies.
Medical ambivalence curbed the practice of nonreligious circumcision in some Western countries, including Canada, New Zealand and Australia, over the past half-century. In Britain, national health insurance after World War II opted not to cover it, and the circumcision rate plummeted.
The practice remains common throughout the Middle East and North and West Africa; it’s more rare in Latin American and East Asia, with the exception of South Korea and the Philippines, where it’s become a social norm.
Within the United States, in-hospital circumcision rates vary regionally. In 2005, they ranged from 75 percent in the Midwest to 31 percent in the West, according to government data.
Locally, 58 percent of the boys born at Inova Hospitals in 2011 were circumcised. At George Washington University Hospital, the rate was 68 percent. And at Sibley Memorial Hospital, 66 percent of parents during the first six months of 2012 said they intended to circumcise. (About 10 percent did not respond or were undecided.)
Risks increase with age
Joy Gresham, a 32-year-old mother of three from Prince William County, said it was an “easy choice” to circumcise her two sons, because she thinks it’s healthier and because her husband is circumcised. She is also planning to have her third son, due this month, circumcised. Because of a gap in medical insurance, the couple expect to cover the cost — expected to be close to $1,000 — themselves.
She does not want to wait, though. The surgery gets more dangerous and more memorable the older you get, she said.
Complications, most often bleeding or infection, are rare for neonatal circumcision in clinical settings — occurring between between 0.2 and 0.6 percent of the time. Non-clinical circumcisions can be more risky. The Centers for Disease Control and Prevention reported this summer that 11 baby boys in New York contracted herpes between 2000 and 2011 because of an ancient procedure occasionally still used in some ultra-Orthodox ceremonies in which the circumciser uses his mouth to suck blood from the fresh wound.
A cultural alternative
Tamar Jacobs and her husband, Raymond Anthony Scott Lloyd II, who is not Jewish and is not circumcised, opted for a different path entirely.
They planned what they called an “alterna-bris,” or what some call a bris shalom (covenant of peace), with a secular rabbi. There was a traditional ha-motzi (blessing for the bread) and a kiddush (blessing of the wine) and a naming ceremony, where their new son, Ray, was given a Jewish name, Reuven, but there was no traditional cutting.
The hardest part was telling her parents. They were at first “a little taken aback,” she said, “worried that somehow that would mean Ray would not be Jewish.’’
But they soon embraced the idea. They hosted the ceremony in their living room and baked challah and hundreds of cookies with their grandson’s name written on them.
“It was really cathartic to talk about some of these things. I think it got all of us thinking in a bigger way,” Jacobs said. “I feel like we are at the beginning of something exciting.”