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Mens Health, pages 130-135,163 - July/August 1998
photographs by Bill Emory
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the typical American boy,
EVERY 30 seconds a baby boy is circumcised. It is the most common surgery performed in America. It is usually done without anesthesia, and often without the consent of the parents.
I never questioned it, says Kyle Joseph, the father of a circumcised boy. The doctor took him away, performed the operation and brought him back. Thats just the way it was done. I was circumcised; he was circumcised. I dont even remember signing a consent form.
Thats typical, according to Craig Shoemaker, M.D., a North Dakota pediatrician and member of the American Academy of Pediatrics (AAP) task force on circumcision. Many doctors do not adequately counsel parents regarding circumcisionwhat the risks are, what the potential benefits are, how much it costs. Performing a circumcision without such counseling is inappropriate. Some people would call it criminal assault.
Most parents dont know what circumcision really is, and yet 65 percent of them still allow doctors to do the surgery.
America is the only country in the Western world that routinely circumcises newborn boys. Eighty-five percent of the worlds men are uncircumcised.
The practice violates all seven principles of the American Medical Associations code of ethics, charges George Denniston, M.D., a Seattle physician and founder of Doctors Opposing Circumcision. By definition its not even surgery. Surgery is removal of diseased tissue, or a repair of some kind.
Nonsense, says Edgar Schoen, M.D., director of perinatal screening at Kaiser Permanente Medical Center in California, and an outspoken proponent of circumcision. There are numerous medical reasons for it. This pro and con argument has been raging in the medical community for almost three decades. Meanwhile, the circumcisions continue.
baby boy is strapped in a Circumstraint as shown.
If youre like most American men, youre circumcised. But you probably havent given it any thought since junior high school, when you first noticed that not every kid in the locker room looked the same. In fact, if youre single or childless now, you may think that its purely a father/son issue of little concern to you. Think again. Circumcision removes one-third to one-half of the skin on the penile shaft, says Ronald Goldman, Ph.D., executive director of the Circumcision Resource Center in Boston and author of Circumcision: The Hidden Trauma. The average circumcision cuts off what would grow into about 12 square inches of sexually sensitive skin.
According to Canadian pathologist John Taylor, M.B., the foreskin is one of the key erogenous zones of the male body. Its 240 feet of nerves and 1,000 nerve endings are similar to those on the fingers and lips.
The fact is, says Goldman, when it comes to sex, circumcised men dont know what theyre missing.
But a few do. Increasingly, men who were circumcised as adults (for various medical reasons) are speaking out against circumcision, providing firsthand accounts of sex before and after.
I had ample sexual experience, and I was quite happy as an intact male, says Rick Thomas, who was circumcised on advice of his doctor at age 26. After my circumcision, that pleasure was utterly gone. On a scale of 10, the uncircumcised penis experiences pleasure of at least 11 or 12; the circumcised penis is lucky to get to 3. If men who were circumcised at birth knew the loss of pleasure they would experience, they would storm the hospitals and not permit their sons to undergo this.
Douglas MacArthur, a 55-year-old locksmith from Pennsylvania who was also circumcised as an adult, reports similar problems. Sex before circumcision was like driving a luxury car with automatic transmission, he explains. I used to just glide along. Sex now is like driving a tiny, powerless compact with a manual transmission. It takes a lot of work to get anywhere. My penis has lost 90 percent of its sensitivity.
Only in the last decade have scientists devoted in-depth studies to the structure and function of the foreskin. The foreskin is a complex, two-layer organ similar to the eyelid; its designed to protect the head of the penis from abrasion and infection. Its surface represents 50 percent of all penile skin, and folds around the opening of the penis. Its inside surface is composed of a soft mucosa that secretes antibacterial and antiviral lubricants called smegma, which further protect the glans from friction and infection. Because the glans is sheathed in this moist envelope, it retains its sensitivity. During sex, the foreskin glides along the penile shaft, providing lubrication and stimulation.
Says one spouse of her uncircumcised husband: Theres a big industry in this country selling lubricants and jellies to enhance sex, but theyre unnecessary for those of us lucky enough to have married an uncircumcised man. An intact mans glans is naturally moist and juicy.
no anesthesia, the doctor grips the foreskin with a clamp
Outside of the Jewish community, where its a religious rite, circumcision was practically unheard of in America until 1870, when Lewis Sayre, M.D., claimed to have cured a 5-year-old boy of paralysis by stretching out his foreskin and snipping it off. For the next two decades, Dr. Sayre and his associates crusaded for circumcision, claiming it could cure hip-joint disease, epilepsy, hernia, convulsions, elephantiasis, poor eyesight, tuberculosis, and rectal prolapse, among other things. This was all disproved, of course, and circumcision would probably have vanished from the American medical scene had its backers not found a compelling new way to sell it: as a cure for masturbation.
To the publicly puritanical but privately lascivious Victorians, masturbation was the root of numerous social maladies and physical illnesses, including blindness and even insanity. Naturally, they believed, if circumcision could prevent masturbation, it would prevent other diseases as well.
Doctors of the time reported that removal of the protective covering of the glans tends to dull the sensibility of the penis and thereby diminishes sexual appetite. In 1888, John Harvey Kellogg, M.D., of cereal fame, summed up the medical professions opinion and gave justification for the next 60 years of foreskin removal. A remedy for masturbation which is almost always successful in small boys is circumcision. The operation should be performed by a surgeon without administering an anesthetic, as the pain attending the operation will have a salutary effect upon the mind.
By the end of World War II it was clear that circumcision was not stopping men from masturbating; but, by then, the procedure was institutionalized. It had become the norm for white, middle-class American men. The uncircumcised were often recent immigrants or African-Americans. Probably as a result of racial prejudice, the uncircumcised penis was viewed as unhygienic and unclean.
But this, too, turns out to be false.
The uncircumcised penis is self-cleaning, explains Robert Van Howe, M.D., a pediatrician from Wisconsin who has been studying the causes of circumcision for 20 Years. Every time you urinate, you flush out the preputial cavity. The hygiene issue was just another excuse. Since its inception, circumcision has been a surgery looking for a rationale. First it was disease, then masturbation, then hygiene; now its back to disease. In 1971 the American Academy of Pediatrics (AAP) stated that circumcision was medically unnecessary. At the time more than 80 percent of American baby boys were circumcised. Then in 1989, the AAP released a new position paper that equivocated: Newborn circumcision has potential medical benefits, as well as disadvantages and risks. Still, by the following year, the rate was down to 59 percent.
Dr. Schoen chaired the AAP task force that made that reversal. He still stands by the position, claiming that the foreskin is the genital equivalent of the appendix, and that newborn circumcision is a preventive health measure analogous to immunization.
The most important health benefit of circumcision is the decreased risk of urinary-tract infections, explains Dr. Schoen, citing a well-known 1985 study, which he says has since been overwhelmingly confirmed by other studies. But Martin Altschul, M.D., a pediatrician and M.I.T.-trained mathematician, has reexamined the evidence and finds it fraught with problems.
penis is secured with a Gomco clamp and a steel cone is slipped over its head.
The whole body of research on this issue is a how-to-lie-with-statistics classic, argues Dr. Altschul. Depending on how you collect the data, you can get almost any result you want. Dr. Altschuls own research also found that many of the urinary-tract infections in uncircumcised boys were attributable to congenital anomalies. Recently, several studies have suggested that neonatal circumcision may actually increase the infection rate.
Dr. Schoen cites two other medical benefits of circumcision, namely decreased risks of developing penile cancer and contracting sexually transmitted diseases, such as HIV and syphilis.
Youre more likely to be struck by lightning than to suffer from penile cancer, counters Dr. Van Howe. Japan, Norway, Finland, and Denmark all have lower rates than the United States, and they dont circumcise their boys.
In fact, in 1996, representatives of the American Cancer Society wrote a letter to the AAP in which they pointed out that fatalities caused by circumcision accidents may approximate the mortality rate from penile cancer. The letter also stated that perpetuating the mistaken belief that circumcision prevents cancer is inappropriate.
Penile cancer is extremely rare-less than one case for every 100,000 men, adds Dr. Altschul. Its preposterous to even suggest that because we have some minuscule risk of disease, we should cut off the foreskin of every little boy.
Breast cancer in women is common, says Dr. Denniston, more common than all the purported health risks of the foreskin combined. Does that justify cutting off all breasts at puberty?
What about circumcised men and STDs? A recent study published in the Journal of the American Medical Association found that circumcised men did have a lower incidence of syphilis and HIV. But they had a higher rate of infection with herpes, hepatitis, and chlamydia. Overall, the study authors wrote, We found no evidence of a prophylactic role for circumcision, and a slight tendency in the opposite direction.
The bottom line, says Dr. Denniston, is that the alleged benefits of circumcision dont approach the risks.
July 3,1991; Oakland, California: While circumcising a 12-hour-old baby, the doctor cuts off one-third of the glans.· The severed head is reattached, but the child is disfigured. A court awards the minor plaintiff $256,000.
September 12,1992; San Diego, California: During a circumcision, a doctor cuts off a boys glans. The doctor claims that since there is no apparent loss of function, he met the standard of care. A jury awards the minor plaintiff $36,400 in damages.
July 18, 1995; Houston, Texas: A 5-year-old boy goes into a coma while being circumcised. He dies a week later.
The complication rate for circumcision varies from 2 to 6 percent, says Dr. Van Howe. The average male will have more health problems from being circumcised than from being left alone.
Some medical professionals believe that circumcision for other than religious purposes would disappear from America if it werent covered by insurance. This is what happened in England, where the circumcision rate prior to World War II was roughly equivalent to that in the United States. After the war, British doctors could find no compelling evidence to continue the surgery, and it was dropped from the list of covered services. Within a decade, the circumcision rate dropped from 50 percent among the working class and 85 percent among the upper class to less than half a percent in both.
A dab of antiseptic, and the procedure is complete.
Why is this procedure still covered by HMOs and health-insurance companies? The simple answer is, because parents want it, says Patricia Wald, M.D., regional coordinating chief of pediatrics for Kaiser Permanente Medical Center in southern California. There, doctors counsel parents so theyre making an informed decision, and dont perform the operation unless asked. We cover it as a courtesy. But to me its cosmetic surgery, like ear piercing.
Circumcision is estimated to be a $400 million business in America. The average cost of the procedure ranges from $50 to $350, with $115 being the average. The usual insurance reimbursement to doctors is around $95. Dr. Van Howe claims that a busy doctor can generate $25,000 a year from circumcisions alone. But Dr. Shoemaker disputes the contention that money alone lies behind the practice.
After you counsel the parents appropriately and do the procedure, Dr. Shoemaker explains, its not a profitable use of time.
Circumcision is the only surgery in America routinely performed without anesthesia. Sixty-four to 96 percent of circumcised infants endure the procedure with nothing to deaden the pain. Until recently, doctors often told parents they didnt feel the same pain as adults.
I didnt know what circumcision really was when I consented to have my three sons circumcised, says Marilyn Milos, founder and executive director of the National Organization of Circumcision Information Resource Centers (NOCIRC). My doctor told me it was necessary, that it didnt hurt, and that it took only a moment to perform-like cutting the umbilical cord, I thought.
Ten years after her last son was born, Milos went back to school to become a registered nurse. As a student, she was asked to assist at a circumcision. To see a part of a babys penis being cut off without an anesthetic was devastating. Later, while working as a nurse, she made a videotape of the procedure and called it Informed Consent.
Parents had no idea what was happening to their baby boys, she explains. The point was to show them what circumcision really entailed. The hospital, Marin General in California, refused to allow expectant parents to view the tape. They said it was too much for parents to see. I said, Then perhaps its too much for babies to experience.
In 1985, Milos founded NOCIRC. Its all such an unspeakable cover-up. The doctors are in denial, so the hospitals are in denial, so the parents are intentionally, illegally uninformed. Circumcision is the worst fraud in American medical history. Recent studies support Milos gut reaction to unanesthetized circumcision. A recent issue of the Journal of the American Medical Association reported that newborns...who did not receive an anesthetic suffered great distress during and following the circumcision, and they were exposed to unnecessary risk (from choking or apnea). The report goes on to say that the skill of the surgeon did not reduce the pain, and that infantile amnesia (the he-won t-remember-it-anyway argument) cant justify it.
But even if doctors did use anesthesia, the reduction in pain would have to be measured against other concerns, such as the danger of using potent painkillers on day-old babies.
Then there is the question about how long the hurt lasts. Circumcision causes such traumatic pain in newborns that it may have damaging effects upon the developing brain, says James Prescott, Ph.D., director of the Institute of Humanistic Science in Long Beach, California. A psychologist who has written extensively on childhood trauma and its long-term effects, Prescott says the stress of circumcision damages the neural systems that mediate genital pleasure. In effect, he says, the babys brain is encoded to associate pain with pleasure. In fact, the pain is so severe that its not unusual for babies to go into a kind of shock, suddenly becoming silent and ceasing to struggle.
Ten years after Milos founded her organization, 24 nurses at the St. Vincent Hospital in Santa Fe, New Mexico, declared themselves conscientious objectors to infant circumcision. Later, several of them formed Nurses for the Rights of the Child. Our goal is to protect unconsenting infants and children from surgical alteration of their genitals, says co-founder Mary Conant.
Two years ago attorney J. Steven Svoboda, a former Human Rights Fellow at Harvard Law School, founded Attorneys for the Rights of the Child. Our position is that circumcision is medical malpractice, he explains. The medical profession, which has perpetuated this tragic disfigurement of baby boys genitals, will now be challenged by an organization of legal professionals.
The courts are already considering cases. On July 22, 1995, a jury in Montgomery, Alabama, found Jackson Hospital and Clinic guilty of negligence in a case where a newborn was mistakenly circumcised against his mothers wishes. The minor plaintiff was awarded $65,000.
Most of the worlds leading medical establishments have come out against this surgery. Circumcision of newborns should not be routinely performed, says the Canadian Paediatric Society. To circumcise...would be unethical and inappropriate, says the British Medical Association. The Australasian [Australia and New Zealand] Association of Paediatric Surgeons states: Neonatal male circumcision has no medical indication. It is a traumatic procedure performed without anesthesia to remove a normal, functional and protective prepuce.
The AAP is expected to publish its new position on circumcision sometime this year. This is just my opinion, says task-force member Dr. Shoemaker, but I think the Academy is going to say theres not enough medical evidence to recommend routine circumcision but that theres also not enough evidence to say it shouldnt be done at all. If this happens, the position paper will again be subject to interpretation, and it will be of little guidance.
Kent Kleppinger, M.D., a pediatrician who performs circumcisions, says, I tell parents circumcision is cosmetic surgery. It isnt difficult to dissuade the mothers, but the fathers generally override their decisions. They want their boys to look like other boys in the locker room. They want their boys to look like them.
Like father, like son. This may be one of the hidden reasons why infant boys are still circumcised in America. But Shell Thompson, an editor for a national outdoor magazine and father of two boys, finds the locker-room argument specious. I was a fat kid, a tub boat. I was teased unmercifully when I was a teenager. But so were the skinny kids and the kids with acne and the kids with red hair. At that age, boys will find something to pick on, no matter whats between their legs.
Thompson was circumcised as an infant but chose not to circumcise his boys, a decision that is becoming increasingly common. Rates for circumcision are dropping all over the country. On the West Coast theyre already down to 34 percent. By the time a baby born today takes his first junior-high shower, he may be in the minority if hes circumcised.
It may all come down to the basic human rights of the child. In 1996, the Canadian Medical Association approved a code of ethics that instructs doctors to refuse to participate in or support practices that violate basic human rights. This suggests that, in the case of circumcision, parental preference should not override the childs physical rights to his body.
Margaret Somerville, professor of law and medicine at McGill University in Montreal and founding director of the Centre for Medicine, Ethics and Law, recently raised the hair on the necks of all North American pediatricians by declaring circumcision technically criminal assault.
Once you decide that circumcision is not medically necessary, you take away the therapeutic intent. Take away therapeutic intent, and circumcision becomes an unjustified wounding, she says.
Leo Sorger, M.D., writing in ObGYN News, is even more explicit: Circumcision causes pain, trauma, and a permanent loss of protective and erogenous tissue. Removing normal, healthy, functioning tissue [for no medical reason]... violates the United Nations Universal Declaration of Human Rights (Article 5) and the United Nations Convention on the Rights of the Child (Article 13).
In September 1996, the United States Congress passed a law banning the mutilation of female genitalia. Americans are horrified by female genital mutilation, says attorney Svoboda, but they somehow dont recognize the routine torture going on in their own culture. He acknowledges that a clitoridectomy is a more serious and detrimental surgery than circumcision, but he argues that human-rights law doesnt say if you cut off four toes, its a human rights violation, but if you cut off only three, its okay. Thats not how human-rights law works. If its wrong, its wrong. Involuntary circumcision is wrong.
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