Studies show that circumcision is on the decline

So much stress over a few inches of skin.

Arlene and Victor Bordinhao's son, Sebastian, was circumcised just over a month ago, and the experience was as traumatic for Mom and Dad as it must have been for Sebastian.

Even now, the memory of Sebastian's tears and cries is "still fresh," Arlene admits. "Now, he's fine. He's a healthy baby and I don't think he was traumatized by it."

Jenny and Ben Titus opted against circumcising their son, Griffin, now 4.

"I had a home birth, so I had natural childbirth for both of my children," Jenny says. "I read a lot about it when I found out I was having a boy, and I just could find no good medical reason to do it. So, I figured, why cause my son pain if there's not a good a medical reason for it?"

The stress is understandable.

Deciding whether to circumcise a newborn is the first elective medical decision most parents make for a son. It can be painful for the child. It's irreverisble. And the result is something the boy will live with every day for the rest of his life.

Nope, no pressure there.

DECLINE IN RECENT YEARS

Circumcision describes the surgical removal of the foreskin of the penis, and most newborns who have the procedure have it done within days of birth. For some parents, deciding to have a son circumcised is no decision at all. In Judaism, for example, circumcision is performed eight days after a boy's birth, as commanded in the Bible, as a sign of the covenant between God and Abraham.

"Generally, it's done in the home or synagogue and with family and friends around," notes Rabbi Shea Harlig of Chabad of Southern Nevada. "We bring in somebody called a mohel ... who was trained to do this ritual circumcision."

For other new parents, however, making the call hinges on an equation that may take into account such diverse factors as medical concerns or aesthetics.

Fewer parents today are choosing to have their sons circumcised. According to a 2011 review of three data sources by the U.S. Centers for Disease Control and Prevention, the percentage of newborn boys having circumcisions in hospitals fell from between 58 and 64 percent in the past 12 years to betweeen 55 and 57 percent in recent years.

Anti-circumcision sentiment met the voting booth this year when activists in San Francisco put on the city's November ballot a proposed ban on the circumcision of minors. However, in July, a judge removed the ballot issue, saying a ban would violate a California law that makes the regulation of medical procedures a state, rather than a municipal, matter.

Why has circumcision -- which for much of the latter half of the 20th century was a widespread and almost routine medical procedure -- reappeared on the public's radar? Dr. Andrew Eisen isn't sure, but figures that, "like a lot of things, it tends to come in cycles."

"I just think a lot of it has to do with shifting public opinion," adds Eisen, associate dean for clinical education at Touro University Nevada.

The procedure is "fairly simple," notes Dr. Kami Larsen, an assistant professor of pediatrics at the University of Nevada School of Medicine. "It takes anywhere from five to 15 minutes, depending on the patient, to perform it, and it's a very low-risk procedure that's easy to do in the office."

After administering an anesthetic, the physician separates the baby's foreskin from the penis. Then, one of several types of devices are used to protect the glans of the penis while cutting the foreskin free.

"The incision usually takes three to five days to heal," Larsen says, and there's usually "very little bleeding."

MEDICAL BENEFITS MINIMAL

Most parents "don't have a lengthy debate" about whether to have their sons circumcised, Eisen says. "Certainly, for Jews and Muslims, there is no discussion ... so the decision is really settled long in advance."

"We definitely have some families who come in with a very definite idea (that) yes, they want a circumcision or, no, they don't want a circumcision," Larsen says, as well as "maybe 10 to 15 percent" who haven't decided but wish to seek the physician's advice first.

As recently as a generation or two ago, many of the parents who chose circumcision did so with the belief that the procedure provided direct medical benefits to a child. And, Eisen notes, "the data that are out there demonstrate that there is some medical benefit to circumcision. It's not huge, but it is positive.

"There is some reduction in the rate of urinary tract infections, particularly (in children) under a year of age. There is some reduction in penile cancer, although that's a pretty rare cancer to begin with: It occurs in about 1 in 1,000 in circumcised and about 1 in 100 uncircumcised men, and that's really a sort of top-end estimate."

There also is evidence that there "appears to be a bit of a decrease in the risk for HIV" for circumcised men, Eisen adds, "but, again, that's small."

So while evidence is there, it's not "overwhelming," Eisen says. Consequently, the American Academy of Pediatrics' stance is that "there appears to be some medical benefit from circumcision, but not a tremendous benefit, and not enough to warrant a recommendation that every male child be circumcised," Eisen says.

"So, the issue is, I think parents need to be made aware that there is some medical benefit, but it's not a huge benefit, and the decision really is a family decision, it's not a medical decision," Eisen says. "And I would never push a family to circumcise a child if they didn't want to, but by the same token, I would not tell a family they should not circumcise a child."

ROLE OF FAMILY, CULTURE

For some families, the most important factor in the circumcise/don't circumcise equation is whether dad is circumcised.

"If dad is circumcised, most sons are circumcised, and if dad isn't circumcised, the son is less likely to, too," Eisen says.

This desire for familial conformity -- that dads and sons are to look alike -- is "a huge contributing factor," Larsen agrees.

Cultural forces also may play a part in the decision. Here, "the Hispanic population tends not to circumcise," Larsen says. "That's very standard for them, as opposed to the Caucasian population, where the percentage (of circumcision) is definitely higher."

Generational forces also could be at play, as health-aware, holistic-minded young people may choose to not circumcise "even if dad is," Larsen says.

In addtion, any parent would find it difficult to ignore the potential discomfort or pain the procedure will cause a newborn.

"Anyone who says the procedure does not cause pain is not paying attention, because it certainly does cause pain," Eisen says.

However, he continues, "we have gotten much better in terms of anesthetic techniques for circumcision -- things like penile nerve block. It's a very low-risk procedure."

But making circumcision less painful doesn't make it right, argues Georganne Chapin, executive director of Intact America, an anti-circumcision organization.

"There's no other modern country in the world with a high-quality health care system that does routine medical circumcision," Chapin says.

Chapin doesn't agree that infant circumcision is a parental choice -- laws already exist banning female circumcision, she notes, and male circumcision routinely is done despite the child's inability to offer informed consent -- and says circumcision is, itself, an unnecessary and unethical form of genital alteration.

Mothers already know that, Chapin adds.

"I get calls from mothers who are often in tears. They're very upset and say things like, "I couldn't believe it when they brought my baby back to me,' or, 'They took him away and I heard a shriek I never heard coming out of a human being.' They say, 'I feel so guilty. I'm supposed to protect my son.' "

Titus said that the more she read about circumcision, the more she wondered how it would benefit her son.

However, opting against circumcision "was a hard decision," she adds, "because my husband is circumcised and everyone I know is and everyone in my family is."

Not having Griffin circumcised was "something out of the normal," she says. "But I just couldn't see any good reason to do it, and I don't think it will be an issue" as he grows up.

Bordinhao says she and Victor had Sebastian circumcised primarily "because my husband is circumcised."

But, she says, "it was the hardest thing we have done so far. It was really heartbreaking. I probably shouldn't have even been in the room. You see your child in pain and it kind of made Victor and me think like maybe we shouldn't have done it."

Will she and Victor do it again if they have another son? "I don't know," she says. "We would really have to consider the factors, and I don't even know if we would do it."

Nonetheless, it is a decision every parent of a male child will face, and Larsen suggests that prospective parents begin thinking about it even before their son's birth.

"What we suggest is if a parent has a chance to interview with their pediatrician prior to delivery, which is always a good idea ... they can discuss it before the baby is even born."

"We have some families who decide six or nine months later that they wish they had chosen to circumcise at an earlier age," Larsen adds.

"It can be done on an older infant and a toddler, but at that point it becomes a true surgical procedure, and those patients are referred to either a pediatric surgeon or a pediatric urologist and done under general anesthetic. So it's not something we take lightly."

Contact reporter John Przybys at jprzybys@review
journal.com or 702-383-0280.