The day your wife gives birth to a baby boy, the kind, bespectacled face of Marvin L. Wang, M.D., is one that you want to see coming through the recovery-room door. Co-director of newborn nurseries at Massachusetts General Hospital in Boston, Dr. Wang has a perky, conversational bedside manner that puts everyone at ease.
I have to hustle to keep up with him as he strides energetically between hospital rooms. Right now he's congratulating a pair of new parents. Larry is standing on wobbly legs, looking both ecstatic and shell-shocked, while Joy sits serenely, holding their newborn son to her breast.
Dr. Wang jokes with the new parents a bit and then says, "I understand you may want to have a circumcision for your baby."
Larry and Joy don't answer immediately. At last Larry says, "Well ... we don't know."
Dr. Wang smiles. He's familiar with the befuddled expression on Larry's face.
Circumcision, of course, is the surgical removal of the penile foreskin from the glans — the fleshy crown of the penis. It is one of the most commonly performed procedures in American hospitals, and except for abortion, it may be the most controversial. The procedure has long been known to reduce the spread of a few rare, serious diseases, and to prevent a few annoying, uncomfortable ones. But in 1999, the American Academy of Pediatrics (AAP) determined that the risk of surgical complications, though small, nearly canceled out the benefits. They neither discouraged nor recommended the procedure. Since then, 16 states have eliminated Medicaid coverage for nearly all circumcisions.
But two years ago, a consortium of experts convened by the World Health Organization and UNAIDS (the United Nations' HIV program) announced that circumcision should indeed "be part of a comprehensive HIV prevention package." It did so because three separate, meticulous medical trials in Kenya, Uganda, and South Africa, involving more than 10,000 men, had proved that circumcision could reduce the risk of female-to-male HIV infection by approximately 60 percent. This discovery is one that, over the next two decades, could save three million lives in Africa alone.
Now, no one believes that the potential health benefits for American males are nearly as great, or as urgent, as they are for men in Africa, where HIV is spread mostly through heterosexual intercourse. Still, similar study results are turning up on this continent, as well. A team of researchers from the CDC, Johns Hopkins, and the Baltimore health department examined the records of more than 1,000 African American males — all heterosexual — who tested positive for HIV at Maryland clinics. Uncircumcised men were 50 percent more likely to be infected.
These results have caused many U.S. doctors to reconsider their positions. "I've always told families that the health benefits of circumcision are real, but not enough to warrant advocating that all boys be circumcised," says Lise Johnson, M.D., the director of healthy-newborn nurseries at Boston's Brigham and Women's Hospital. "But I find these HIV studies pretty striking. The weight of scientific evidence might be shifting in favor of circumcision."
Larry, the new dad, is circumcised himself but never thought much about circumcision until his wife became pregnant. "Joy kept saying, 'It's up to you,'" Larry tells Dr. Wang, "but when I finally said I wanted to do it, she said, 'Whoa! We have to talk.'"
After a few uneasy moments, the new father's feelings spill out.
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"I guess I don't feel too strongly either way," he says, looking at his son tenderly. "But if there's a risk of hurting him ..."
Health benefits of circumcision
Pain, of course, is the first question that comes to mind whenever the words cut and penis are used in the same sentence. Ask Marilyn Fayre Milos about pain — or better yet, don't. The founder of the National Organization of Circumcision Information Resource Centers (NOCIRC — get it?) first witnessed the procedure in 1979 while training for her nurse's degree. The unlucky baby, she later wrote, was "strapped spread-eagle to a plastic board... struggling against his restraints — tugging, whimpering, and then crying helplessly" while awaiting the knife. Then as the doctor, using no anesthesia, began cutting into the penis with a scalpel, "the baby began to gasp and choke, breathless from his shrill continuous screams..."
Is that what Dr. Wang is offering to do to Larry and Joy's innocent baby boy?
Not quite. Dr. Wang says the operation rarely hurts much anymore; since the 1990s, it's become routine in U.S. hospitals to anesthetize babies before the procedure. For every 1,500 circumcisions, there are maybe three complications, nearly all of which amount to a little unexpected bleeding or a treatable infection. In return, according to the AAP, circumcised boys have a lower risk of urinary-tract infections and penile cancer, and, indeed, "a slightly lower risk of getting sexually transmitted infections (STIs), including HIV, the virus that causes AIDS." But weighed against the potential risks, says the AAP, "these benefits are not sufficient ... to recommend that all infant boys be circumcised." (The AAP is now reviewing its guidelines, in light of recent scientific news.)
Larry seems to search the doctor's face for a hint of what to do, but Dr. Wang is as neutral as his white hospital coat. "You need more time to think about it," he says encouragingly. "I'll be back."
He heads off down the hall.
Circumcised or not, every man owes his foreskin a great debt of gratitude for its service in the womb. In the third month of gestation, when the nascent penis begins to bloom, the foreskin forms a little protective blanket under which the rest of the penis can safely grow. But once you and your penis are fully baked, the advantage of a foreskin is not clear. Some scientists speculate that it protected the prehistoric penis as it swung, naked, through thick forests and over tall grasses; and unless you take your penis on that sort of excursion, they argue, you don't need a foreskin.
That perceived uselessness may be one reason circumcision has such a long and varied history. Archeological evidence suggests that the practice may be at least 6,000 years old. Muslims and Jews, along with the aborigines of Australia, the Aztecs and Mayans of this hemisphere, and many other cultures all independently adopted this squirm-inducing practice, and it seems unlikely they'd have done so unless they were convinced that it conferred some earthly benefit.
Here in the United States, foreskins were left mostly undisturbed until the second half of the nineteenth century. But it wasn't until the North Africa campaign of World War II that American doctors turned into enthusiastic circumcisers. More than 145,000 American GIs based there slacked off on their cleaning regimens and came down with foreskin-related ouches — chiefly, balanoposthitis (inflammation of the foreskin and glans), phimosis (a foreskin that's too tight to retract over the glans), and paraphimosis (a foreskin stuck in the retracted position). After the war, doctors advanced a theory that circumcision reduces rates of cervical cancer — a hypothesis now confirmed by scientific research.
Circumcision became routine, but anesthesia wasn't part of the plan. That, more than any other factor, may have provoked the fiery anti-circumcision movement that casts its long shadow over the Internet.
Anesthesia now used during procedure
Isaac is a newborn whose mother, months before she gave birth, made the decision to circumcise him. He awaits Dr. Wang atop a small operating table. His expression is blasé until a nurse standing over him slides a sugar-coated pacifier into his mouth. His eyes open wide and he commences sucking with gusto. Sugar, Dr. Wang says, is known to send a rush of endorphins to certain parts of the brain, dulling sensitivity to pain.
Dr. Wang gently wraps Isaac's legs in a soft harness. Until fairly recently, he remarks, it was standard practice to restrain babies' arms, too. "But it's distressing to them to be tied down like that, and it's really not necessary."
Fortunately, Dr. Wang says, circumcision is no longer performed in American hospitals without anesthesia, as Milos described it. After a quick examination of Isaac's manhood (if that's the right word for it), Dr. Wang administers four evenly spaced injections of lidocaine around the base of the baby's penis; Isaac shows no distress. At that point, Dr. Wang waits 5 minutes for the anesthetic to take effect, then swabs Isaac's privates with sterilizing iodine and gets down to business. He arranges a clamp that pulls the foreskin forward, off the penis, where it can be safely cut off with surgical scissors in one snip. Isaac became agitated only once — when his sugary pacifier fell from his mouth. "Usually," says Dr. Wang, "the part they hate most is being washed off afterward. They don't like to feel the cold."
A few weeks later, I call Larry to find out what he's decided to do.
"We opted not to do it," he says. "When you go on the Internet and read about this," he says, "you find out that there's really no reason for doing it. People try to think up new justifications for it, and when one doesn't work, they come up with another."
If you go on the Internet, you'll "find out" precisely what Larry found out. The problem is, it's not true.
I Googled the word "circumcision," and two of the first three sites that popped up were the Circumcision Research Center and the Circumcision Information and Resource Pages — titles that suggest unbiased collections of data. In fact, both sites are run by anti-circumcision crusaders. A seemingly unending list of similar sites followed: Mothers Against Circumcision, Doctors Opposing Circumcision, Stop Infant Circumcision Society, and Milos' NOCIRC. Many of these activists have spent decades arguing that circumcision has no medical value, and recent scientific revelations have left them red-faced — not with embarrassment, but anger. According to Milos, for instance, all three of the Africa trials were part of what she calls an "ill-fated plot to circumcise everyone regardless of AIDS status!" She and others often demonize the scientists whose research has produced facts that contradict their extremist views.
Daniel Halperin, Ph.D., spent much of the 1990s poring over epidemiological studies of AIDS, looking for places in Africa and Asia where HIV rates were relatively low and then trying to figure out why. Halperin, a senior research scientist at Harvard's school of public health, concluded that circumcision played a role and he paid a high price for saying so — many people thought he was nuts. In some ways, since he's been proved right, the price has become steeper. To get a flavor of it, look at his inbox.
"F**K OFF," begins one e-mail, "with your PRO-CIRCUMCISION BIASED BULLS**T .... [forcing] genital surgery on young boys who haven't done anything wrong." Another e-mail calls him "a Super Racist" devoted to the murder of Black Africans under the guise of helping them.
"It's been quite a struggle," Halperin sighs, shaking his head.
But it's not without its rewards. The Africa trials add substantial weight to a mounting pile of evidence that circumcision also reduces the spread of other sexually transmitted illnesses, including several types of cancer and venereal disease. The journal BMC Infectious Diseases published a study (co-authored by Halperin and four others) that compared rates of cervical cancer — caused by the sexually transmitted human papillomavirus, or HPV — in more than 100 countries in Asia, Africa, and Latin America. In countries where fewer than 20 percent of men were circumcised, cervical-cancer rates were about 70 percent higher than in countries where more than 80 percent were circumcised.
All of this makes many public-health experts in the United States lament the decision of some states to withdraw Medicaid coverage for routine circumcision. "Because uncircumcised males face greater risk of HIV and other sexually transmitted infections," a different study concludes, "lack of Medicaid coverage for circumcision may translate into future health disparities for children born to poor families."
Verdict still out on circumcision
So what's the verdict? Should all males be circumcised? Not one doctor or scientist interviewed for this article expressed that opinion. Robert Bailey, Ph.D., a professor of epidemiology at the University of Illinois at Chicago, feels that "American parents should definitely factor all of this in, but it's not an automatic. Most of the diseases [circumcision] is known to prevent are pretty rare in the United States."
But, Halperin notes, "those illnesses may be rare at least partly because circumcision has been so widespread here."
But whatever you decide for you and yours, do not let anyone tell you circumcision can't slow the march of HIV. At a time when billions of American tax dollars are pouring into Africa to fight AIDS, it is extremely important that money is spent on methods that have been proved to help.
Elliot Jones (not his real name) underwent circumcision at age 35. He had a painful case of phimosis, a condition in which the foreskin tightens around the head of the penis, and surgery was the solution. "I heard you lose a lot of sensitivity, but at that point I was in enough pain that I didn't care," says Jones.
"It's a simple surgery, but people think it's painful because it has to do with the penis," says Larry Lipshultz, M.D., chief of the division of male reproductive medicine at Baylor College of Medicine. Most patients choose general anesthesia for the hour-long surgery and go back to work the next day, says Dr. Lipshultz.
For a week after the surgery, Jones would wake up in pain from a morning erection pulling at the dissolvable stitches. But after 2 weeks, his wife was more than ready to test out his newly shorn package. The sensation? "This is better than before," says Jones, now 7 years post-op. "The skin under the foreskin used to be very sensitive — sometimes too sensitive. Now that it's aired out, it's a nonissue."
"My wife and I joke that she's the only one who's had the new penis," says Jones. "It's like I was a virgin again."
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