SOUND BODY
"To cut or not to cut"
by Stephen Smith: October 16th, 2006 The Boston Globe

He's from Sweden. She's from China. They had their baby, a son, in America.
And so Jonas and Kathy Hellgren confronted a classic American choice: Should they leave their infant boy's foreskin intact or should they have him circumcised?

``If we were in Sweden, we wouldn't even be having the conversation" because circumcision is not routine there, said Jonas, whose son Erik was born Sept. 18. But ``here in the US, a lot of other people do it, so we thought maybe we should do it just because they do."

Circumcision is one of civilization's oldest acts of surgery, a practice tracing back to ancient Africa and Egypt, and freighted with symbolism and mythology. Today, the millenniums-old procedure is being studied in the developing world as a method for slowing the spread of a devastating modern disease, AIDS.

In the United States, where the profile of the HIV epidemic is different, the swirl of questions confronting parents about circumcision isn't framed by life-and-death considerations. It's more likely to be defined by familial heritage and social norms, and thus circumcision, which usually lasts less than a half-hour and costs under $500, still excites strong emotions.

``Anytime you put together medicine, religion, culture, and the penis, you're going to have strong feelings," said Dr. Lise Johnson , a pediatrician at Brigham and Women's Hospital . ``We would like to say we operate totally in a vacuum from our culture and our society and its priorities, but we don't. And we probably shouldn't."

In the past few years, medical associations and researchers have engaged in extensive risk-benefit analyses that, fundamentally, aim to answer this question: Are there sufficient health benefits to warrant subjecting a newborn to surgery and removal of his foreskin?

One influential answer came from the American Academy of Pediatrics, which found there isn't enough medical evidence to dictate that every baby boy be circumcised.

Still, an academy panel said as recently as last year that the decision to circumcise a newborn should be left to parents, whose cultural and religious background may strongly encourage the practice. Circumcision, for example, is standard among Muslims and Jews. Specialists estimate that 70 percent of adult men in the United States are circumcised, although the numbers appear to be declining.

``There are certainly plenty of people in the country who argue that circumcision should not be done on any boy, since we're not showing a major medical benefit and a boy can't give consent to having his body changed when he's an infant," said Dr. Jack Swanson , an Iowa pediatrician who participated in drafting the American Academy of Pediatrics policy.

``But we took the middle of the road stance that a parent had the right to decide based on their interpretation of the risks and benefits or other reasons, religious or social or familial."

When it comes to discussing the medical benefits of circumcision, the conversation typically turns to three issues: sexually transmitted diseases, urinary tract infections, and penile cancer.

Circumcision was put back in the spotlight by studies examining whether circumcising adult men can reduce the spread of HIV in Africa, where the epidemic is predominantly spread through heterosexual contact. Landmark research, reported last year, showed that circumcised men in South Africa were 61 percent less likely to contract the AIDS virus from their female partners.

Then earlier this year, a review of 26 medical studies found that circumcised men were less susceptible to two additional kinds of sexually transmitted diseases, syphilis and chancroid.

Foreskin is more subject to inflammation than a circumcised penis, making it easier for germs to enter. The sensitive skin also contains certain cells that link easily with the AIDS virus.

But public health officials are awaiting the results of more definitive studies now underway before recommending circumcision as a way to prevent sexually transmitted diseases, said Patrick Sullivan of the US Centers for Disease Control and Prevention. ``The evidence right now is insufficient for us to make such a recommendation," he said.

Repeated medical studies have demonstrated that circumcised infants have a significantly lower risk of contracting a urinary tract infection, with some reports estimating that uncircumcised boys are 10 times more likely to suffer a urinary tract infection before their first birthday.

``With the foreskin there, there's nothing really to rub the bacteria off, and so they have a nice environment for multiplication," said Dr. George Klauber , chief of pediatric urology at Tufts-New England Medical Center .

Still, even in uncircumcised infants, the incidence of urinary tract infections is low -- about 1 percent -- and usually they can be treated with antibiotics.

Similarly, penile cancer appears to be less common among men who have been circumcised than those who haven't. But even among uncircumcised men, the disease is uncommon and appears largely limited to the developing world, where conditions may be less sanitary.

Specialists theorize that secretions trapped in the foreskin may lead to penile cancer in those rare cases. But because the disease is almost unheard of in Scandinavia, where few men are circumcised, those specialists also believe that good hygiene may eliminate the threat in uncircumcised men.

Dr. David A. Diamond , a urologist at Children's Hospital Boston , said that if parents asked him whether their son should be circumcised to reduce his risk of penile cancer, ``I would say not unless you're a missionary or your family is going to spend significant time in a developing country. Otherwise, it does not seem like a compelling reason."

Like any surgery, circumcision comes with some risk, albeit slight. There can be bleeding and, in unusual cases, infections or secondary surgery needed. Still, doctors said, those episodes are infrequent.

Opponents of the practice, such as Boston psychologist Ronald Goldman -- who brands it a ``trauma" perpetrated on infants -- said that men can experience sexual dysfunction as a result of circumcision.

``It's not like trimming a fingernail," said Goldman.

In its review, the American Academy of Pediatrics was more equivocal, citing one study that actually found fewer sexual problems among the circumcised. But the academy also acknowledged anecdotal reports from circumcised men who say they have reduced penile sensation.

The Hellgrens had heard all of this -- and more -- before the birth of their first child. The day after Erik was born, Kathy said in an interview that she and her husband were ``right on the fence." She, too, came from a nation where circumcision is not routine.

They talked to doctors, they talked to friends.

``The bottom line is, we concluded, you'll either do it for religious reasons, which don't apply to us, or for social reasons -- `everybody else does it so we need to do it, too, so the poor kid doesn't look different when he grows up,' " Jonas said.

Ultimately, the Hellgrens, who live in Cambridge, decided not to have Erik circumcised.

``If we can't find a reason to do it, why do it?" Jonas said. ``Hopefully, he won't regret it."

Stephen Smith can be reached at stsmith@globe.com.


Arguments for circumcision

Fewer urinary tract infections
Studies have shown that circumcised infants are less likely to get these infections, although they’re usually easily treated with antibiotics.

Reduced risk of penile cancer
Circumcised men almost never get cancer of the penis, but even among uncircumcised men, rates of the disease are quite low.

Lower incidence of sexually transmitted diseases
Mounting evidence shows that circumcised men are not as likely to catch the AIDS virus, syphilis.

Hygiene
Men without foreskins generally have an easier time washing.

Cultural and religious values
Circumcision is standard practice in certain religions, including Judaism and Islam.


Arguments against circumcision

Risks of surgery
Although the procedure typically takes no more than 15 or 20 minutes, circumcision is surgery and comes with the standard risks of any operation, including infection.

Narrowing of urethral opening
In some babies, circumcision causes scarring in the urethra, resulting in deflection of the urinary stream and requiring followup surgery.

Sexual function
Opponents of circumcision argue that it can result in sexual performance problems in men and that female partners prefer uncircumcised men.

Heightened pain response
Researchers found that circumcised infants — especially those who did not receive a pain killer during the procedure — reacted more forcefully months later when receiving vaccinations.


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