Circumcision decision

By Katherine Nichols
Advertiser Staff Writer

Editor's note: This story contains sensitive material.

The 1-day-old baby boy lies strapped in a restraint, blankets warming his tiny body. With practiced efficiency, the nurse removes the diaper, then unwraps a sterilized clamp for the washed and gloved pediatrician. The doctor then places the penis – numbed with a local anaesthetic – in the clamp designed to protect the glans, or head of the penis.

Very carefully, the pediatrician removes the foreskin with a scalpel, wiping away blood as she cuts. The infant's cries are by turns feeble and shrill, but do not last the entire time. It's over in 10 minutes. The baby is whisked back into the neonatal unit 15 feet away, where nurses and volunteers at Kapi'olani Medical Center for Women and Children once again swaddle him until he is reunited with his parents.

For some families, circumcision is a given, a decision on which both parents agree with minimal discussion. For others, it's an excruciating dilemma. New research indicates the practice is no longer considered a medical necessity.

Although circumcision is a topic too difficult for some people to discuss, more parents today are giving new attention to the surrounding issues. Should parents circumcise their newborn son? What are the benefits? What are the risks?

"It (circumcision) just doesn't seem natural," said Lynn Kenton, a Kahala resident who now regrets having her 1-year-old son, Luke, circumcised when he was born.

"The human body is perfect, and the foreskin is there for some reason. . . . (For me) there was not a religious or cultural reason. I went back and forth. It's a personal decision, and I think I probably gave in to societal issues."

The Random House dictionary defines circumcision as follows: to remove the prepuce (the fold of the skin that covers the head of the penis) of a male, especially as a religious rite. It's also described as a spiritual purification.

In the Jewish tradition, a bris or brit milah is a ritual performed eight days after birth (usually in the home), "provided the child is healthy," said Rabbi Itchel Krasnjansky from Chabad of Hawai'i. Circumcision was a biblical commandment, he said, an ancient covenant between God and the Jewish people. Therefore, the claim by some – including anti-circumcision Web sites – that circumcision was brought to America to curb masturbation has little or no validity.

In many northern European cultures (in France, for instance), leaving the newborn uncircumcised remains the preference. "(Circumcision) is a very American thing to do," said Dr. Melinda Ashton, a pediatrician at Kapi'olani. "The great majority of men in the world are not circumcised."

In 1994 the National Center for Health Statistics in Washington, D.C., reported that 62 percent of men in the United States are circumcised. Though Hawai'i statistics were unavailable, physicians estimate a much higher percentage here.

Dr. Amy Harpstrite, a pediatrician with the Ohana Medical Group on the Windward side, said that it's "closer to 95 or 98 percent" in the Islands.

Dr. Michael Sia, department chairman of pediatrics at Kapi'olani, estimated that he performs circumcisions on 80 to 90 percent of the male infants in his practice. In Ashton's experience, it's about 75 percent.

"It's not a decision to take lightly," said Harpstrite. If parents choose not to circumcise and plan to raise the boy here, he "will need a lot of support. Nobody – especially adolescents – wants to be different, and they really have to prepare the (uncircumcised) child emotionally. It's definitely something they're going to need to address through the child's life."

Sia placed less importance on this issue. "I don't think it's that big of a deal," he said, recalling his own locker room days in high school, when they viewed the uncircumcised classmate as little more than a novelty.

Ashton said she has seen it become an issue only for kids who also struggle to fit into our society in other ways, like those who arrive from another country and must overcome language barriers and other cultural differences.

Still, parents should be aware of possible emotional ramifications when the son is different from his father or friends. Most of the remaining concerns are medical.

Sia said that in 1989 the American Academy of Pediatrics issued a statement citing the medical benefits of circumcision. At the time, the advantages were considered substantial enough for physicians to recommend that all children get circumcised.

Now, after 40 years of research, "The benefits are not significant enough for the American Academy of Pediatrics to recommend circumcision as a routine procedure," Sia said of the academy's official position on the subject.

Harpstrite confirmed this: "We no longer say circumcision is something medically recommended. It is easier to keep clean, and you are less likely to get a urinary tract infection, and it's true that only uncircumcised men get penile cancer." But the prevalence of urinary tract infections (maybe 2 percent of men) and penile cancer (less than 1 percent) is extremely low. Therefore, she said, "for most people these are not reasons to circumcise."

However, cleanliness can be an issue. "They do need to do a once-a-day cleaning with warm water and soap," said Harpstrite. "It's a task that has to be taught, because boys tend not to clean very well."

Ashton said it's important for parents to realize that they do not have to do anything special to clean the glans before it's ready, such as forcibly retracting the foreskin, which initially adheres to the glans. Natural separation usually happens around age 5. "You're going to teach him to wash that part of his body just like you would teach him to brush his teeth."

Treatment after circumcision is brief and simple: Apply an ointment (petroleum jelly) for four to five days to keep the head of the penis from sticking to the diaper.

A Web site called "Mothers Against Circumcision" (www.mothersagainstcirc.org) has multiple links and expounds on the benefits of leaving a child "intact," as they call the uncircumcised penis. Their reasons? Parents should allow the boy to remain in his natural state, and the potential pain and injuries associated with the procedure are not worth the risks.

Nevertheless, most doctors agree that the rate of injury is minimal. "I think circumcision is generally a safe procedure," said Sia. "Complications can occur in, at most, one in 500. And most are very minor." These complications may include some bleeding or local infections.

Ashton said, "In careful hands, there shouldn't be a concern. It's not a difficult procedure."

How much pain?

But some would still argue that the process itself is barbaric.

Kenton remembered how well she had taken care of herself during her pregnancy, shielding the fetus from harm for nine months, only to subject him to this trauma immediately after birth. "I didn't think you should put this newborn through this surgery," she said. "I don't care what anybody says, it has to be traumatic. And my little guy did scream and cry. Most baby boys I see at the beach are not circumcised; that's when I think, I just wish I wouldn't have put him through that."

Harpstrite tries to assure parents who choose circumcision that the procedure takes only about 10 minutes. "It's over quickly, and if all goes well, there isn't a lot of pain associated with it," she said. Indeed, some infants might even sleep through the procedure. Though she uses a local anaesthetic, she said that "most babies fuss during that time because they'd rather be cuddled than strapped onto a board."

Sia noted that the academy strongly recommends doctors provide pain relief. Relief comes in the form of lidocaine injections that numb the nerves of the penis, or from a cream called EMLA that goes on the penis about 30 minutes to an hour before the procedure and renders the same effect.

How much pain does the baby actually suffer? "It can be substantial if you don't have good pain relief," said Sia. But he believes modern methods eliminate much of this concern.

While modern devices like the Gomco (a kind of clamp) do protect the glans, and it is generally a controlled procedure, Sia said that some doctors may "take off too much or too little" foreskin. This can be tremendously upsetting to parents. If too much is taken off, almost nothing can be done. If too little has been cut, the circumcision in some cases must be redone. But again, this is extremely rare.

It gets especially tricky on very small penises, a phenomenon that is not uncommon with the number of premature babies who are able to leave the hospital at a mere 4 pounds. If Sia does not think he can perform a circumcision that will look good cosmetically, he is careful to discuss it with the parents and allow them time to change their minds.

Consequences of delay

Expectant parents should make this decision before they get to the hospital, where they're likely to be emotional and tired, because, said Harpstrite, "it's not reversible."

Parents who believe they are doing their baby a favor by waiting a few months, or even letting him decide when he's old enough, should rethink this philosophy. "It's more difficult to do a circumcision after the baby's been discharged," she said.

Later on, general anaesthesia might be needed, which is always more dangerous because there is the slight risk that a patient could stop breathing or have an allergic reaction. Waiting for the child to decide also means turning the operation into a ordeal that may cost thousands of dollars because it has to be performed by a general surgeon or a urologist and requires an entire surgical team.

Compared with the typical newborn fee of about $120 that is often covered by insurance, a procedure on an older child will not be covered (because it's always considered an elective operation). In addition, the Gomco (the clamp that guides the physician and protects the penis in a newborn's circumcision) would not fit, and the child or adolescent could suffer far more pain in the aftermath because the penis is larger and the surgery more intense.

"I see parts of both sides of the story," said Ashton. "I think we've been a little cavalier about circumcision. I'd like to see a cultural shift."

Sia said, "It boils down to a choice issue with parents," taking into account cultural, religious and ethnic traditions.

He stressed the importance of parents talking about the topic with their medical provider; in fact, it's an excellent point of discussion when expectant parents are interviewing pediatricians. "I lay out the facts and discuss the benefits and risks," he said, "and I really want parents to make an informed decision and do what's in the best interest of the child."