Circumcision, the oldest known surgical procedure according to Greek historian Herodotus, is also among the least necessary and least understood.
The operation -- which originated some 6,000 years ago in matriarchal tribes where a piece of foreskin was demanded as a sacrificial offering -- is still imbued with religious, social and cultural significance. Yet circumcision is performed so routinely, physicians say, that many parents-to-be do not even view it as potentially risky surgery or seek guidance about whether to have their infant sons circumcised.
Area physicians estimate that between 80 and 90 percent of newborn American males continue to have their foreskins excised within hours of birth, despite policy statements adopted in 1971 by the American Academy of Pediatrics and affirmed in 1978 by the American College of Obstetricians and Gynecologists that say there is "no absolute medical indication for routine circumcision of the newborn."
But there is some risk.
Two infants in Georgia lost their penises in August when circumcision operations went awry.
In Atlanta, two families have filed malpractice suits against the physicians, the hospital and Valley Labs of Boulder, Colo., maker of an electrical cauterizing device used to perform the operations.
In one case, the parents claim that the "severe and progressive nature" of the baby's burn -- including the entire scrotum -- resulted in the need for a sex-change operation.
"Baby Doe is now a female person who has been rendered sterile and completely incapable of reproduction, and who will require medical monitoring and hormonal therapy for the remainder of her life," the suit says.
The second malpractice suit claims that 90 percent of the boy's penis was severely burned, causing the entire external shaft to fall off.
In a third case in Sylvester, Ga., an out-of-court settlement recently awarded $5 million to the parents of an infant burn victim after a plastic surgeon testified that he reconstructed a miniature penis for an infant who was severely deformed by circumcision several years ago.
Subsequent to those suits, Atlanta's Northside Hospital has banned the electric cautery instrument that was used.
Most circumcisions are still done with surgical knives, experts say.
"Electric cautery devices were used in a few cases with bad results. They're not a medically acceptable way to do circumcisions," says Dr. Joseph Greensher, a pediatrician and chairman of the the American Academy of Pediatrics accident and poison prevention committee.
"Circumcision is still a very controversial area," says Dr. Katherine Stone, a medical epidemiologist who works in the sexually transmitted disease division at the Centers for Disease Control in Atlanta. "The parents are the ones who want it . . . It's such an engrained social custom."
Arthur L. Caplan, associate director of the Hastings Center, which specializes in medical ethics issues, says "a lot of circumcisions happen because it is not usually presented as an option by physicians . . .
"It evolved from social and religious customs . . . and now often comes down to parents not wanting their children to look or feel different than they do. Like father, like son."
Caplan, who recently had his own son circumcized "more for personal than empirical reasons," says the subject never came up among the 15 couples who attended childbirth classes with him and his wife. "And this was a very urban, very educated, very Yuppie crowd . . . which indicates parents have to actively seek information and answers.
"Most people think of it as a very minor surgical procedure that was done to them and may be beneficial, so why not?"
Caplan adds that as long as insurance companies continue to pay between $80 and $200 for circumcisions, there will be an incentive to perform the surgery.
Several Washington area obstetricians say they have seen some change in public attitude toward circumcision in recent years.
"More people are opting not to have it done," says Montgomery General Hospital's chief of obstetrics, Dr. Charles Tuegel. "It's gone from almost 100 percent getting circumcisions to about 94 percent."
Susan L. Schick, former education director for Parent and Child, a group that holds childbirth classes for about 2,400 Washington area couples a year, says she's noticed a pronounced change in attitude.
"When I first started teaching nine years ago, parents just assumed circumcision was something you did to all baby boys . . . but now more parents are bringing it up in class," says Schick. "They want to know the pros and cons and seem to be making more informed decisions."
Some parents decide to go ahead with circumcision at birth, some physicians say, rather than take the slight risk that it might have to be done for medical reasons later in life when it could be more traumatic or painful.
For a long time, cervical cancer in women was thought to be linked to uncircumcized males, says CDC's Stone, adding to the pressure to circumcise. "But we really don't know if cervical cancer is a sexually transmitted disease."
Penile cancer in uncircumcized men has also been used as a medical reason for circumcision. But penile cancer in this country is extremely rare in both circumcized and uncircumcized men, accounting for about 0.2 percent -- or about 1 out of every 500 -- of all male cancers, according to Dr. Matthew Zack, chief of the cancer branch in CDC's division of chronic disease control.
In countries where routine circumcision is not the rule, cancer of the penis is higher. In India, for example, it accounts for about 16.7 percent of all male cancers.
Medical schools now teach that circumcision is unnecessary, says Dr. James A. Patterson, an obstetrician at the Georgetown University Medical School. But he says some doctors may neglect to pass that information on to their patients. "If mothers ask, then of course we lay out the alternatives, but only about 25 percent ask."
Dr. David A. Grimes of CDC said he assumed parents would begin to ask questions about circumcision as an outgrowth of the natural childbirth movement, but said he has seen very little change in the past 15 years.
"Most [parents] have no understanding that this is an operation normally done without anesthesia," he says, "and that it requires their informed consent." Studies have shown that some women mistakenly believe circumcision is necessary for admission into the Armed Services or that it is done to prevent masturbating or excessive crying, he says.
"There is great concern about minimizing birth trauma to the newborn, using subdued lighting, encouraging immediate trust and bonding . . . Yet parents don't seem to see it as inconsistent to strap a baby boy spread-eagle to a hard surface a day or so later, douse him with cold antiseptic and then use a crushing clamp to excise penile tissue."
Grimes says he has no objection to circumcizing men who later develop phimosis, a chronic inability to retract the foreskin, or any pathology where surgery is necessary.
"If it needs to be done at age 1 or 5 or 30, then it can be done with anesthesia . . . I object to it for newborns because it is so cruel. Yet we doctors get away with it because infants can't articulate their anguish."
For the nation's Jewish community, circumcision is a sacred, religious ritual, not a medical procedure.
Jews have circumcised infant males on the eighth day after birth to symbolize their blood covenant with God since 1713 B.C., when the Book of Genesis says the prophet Abraham first made ritual circumcision mandatory.
"Circumcision is not important medically, except in very few cases, but for we Jews, that fact does not matter. We do it because the Bible tells us to and because of our spiritual relationship with God," said Rabbi Samuel Weiss, who has performed "thousands and thousands" of ritual circumcision ceremonies -- called a bris -- in his 38 years as a rabbi and mohel in the Washington area.
"It's not painful. People are wrong when they say it is. If it was painful, then doctors wouldn't do it. Babies cry very little, and we mohels are very fast."