To Cut or Not to Cut?

Chris Macgowan was one of a dozen first-time dads enrolled in a class for expectant fathers. Topics ranged from breast-feeding to car-seat safety to daycare options, but there was one subject that brought the freewheeling conversation to a virtual standstill: circumcision.

Legs were crossed and the room grew quiet; Macgowan quickly realized he was the only soon-to-be dad who did not plan to circumcise his son. Even the class leader seemed to favor the procedure, in which the foreskin is trimmed from the penis of an infant boy, usually on the second day after birth. “It seemed like in Minnesota circumcision was just the expected thing to do,” says Macgowan, a software engineer who lives in St. Paul. “I remember feeling very alone.”

It wasn’t his imagination. While the rate of nonreligious neonatal circumcision has gone down nationwide, with recent estimates as low as 56 percent, the procedure remains enormously popular—critics say puzzlingly so—in the Upper Midwest. While only a third of infant boys are circumcised in the western United States, a little boy born in the Midwest still has about a seven in ten chance of leaving the hospital without his foreskin.

In the rest of the world, this ratio is almost reversed. It was Macgowan’s experience living (and visiting the occasional locker room) in Germany that first made him question whether circumcision was necessary. By the time he and his wife, Jennifer Hays, were expecting their first boy seven years ago, the circumcision rate in the United States had been trending down (from a high of between 85 and 90 percent in 1965) and public opinion seemed to be tipping against it. In 1999, the American Academy of Pediatrics issued a statement saying the potential medical benefits of neonatal circumcision weren’t sufficient to recommend the practice. The American Medical Association followed suit soon after, declaring neonatal circumcision a “nontherapeutic” procedure.

Then, last winter, the results of a National Institutes of Health study in Africa suggested that circumcision may reduce a man’s risk of contracting AIDS from heterosexual sex by more than half. The clinical trials of nearly 8,000 men in Kenya and Uganda were discontinued when health officials decided it would be unethical not to offer the procedure to all the men in the study. The NIH findings sparked a flurry of letters to The Lancet, the British medical journal that first published the data, and in New York City inspired discussion about offering circumcision to men at high risk of contracting AIDS. The findings also reignited the anxieties of new parents, who are burning up online message boards with heated arguments for or against the procedure. As the editors of the online parenting magazine babble.com noted, “broaching the topic of circumcision has become a sure-fire way to start a shouting match.”

The shouting may be somewhat muted in Minnesota, says Laurie Frattalone, a birth and family educator with Fairview Children’s Clinic in Minneapolis. “Parents might be afraid to reveal what they’re planning to do because it’s politically hot right now.”

“The history of circumcision goes back to Abraham,” says Carolyn McKay, a pediatrician at Fairview Children’s Clinic, noting that, historically, the procedure “marked the child as a member of the tribe of Israel.” McKay has been explaining circumcision to parents and performing the procedure since she left medical school in 1968. “Of course, when I’m being irreverent,” she adds, “I say I think Abraham may have spent too much time in the hot sun.”

Though circumcision has been performed as a religious ritual or a rite of puberty for thousands of years, it achieved a wider popularity during the Victorian era as a “cure” for everything from epilepsy to “self-abuse.” In the late 1800s, one doctor announced that genital irritation caused “an insanity of the muscles,” which could be relieved by removing the foreskin. And circumcision wasn’t promoted only for babies, but also for older boys and young men who masturbated. Not that it was ever proven effective. Great Britain eventually dropped circumcision from its national health care coverage in 1948, and now fewer than one in a hundred male infants there undergoes the procedure.

The story has been quite different on this side of the pond, where an estimated 77 percent of adult white and African American men in a 1992 national probability sample reported having been circumcised. (It’s worth noting that precise, up-to-date numbers are hard to come by. One study found that almost a third of adolescent males incorrectly identified their circumcision status before a physical exam.)

During the world wars, the armed services promoted the procedure as a hygiene measure. Many fathers of baby boomers expected their sons to “look like me”—still the most frequently expressed reason dads favor circumcision. In the Midwest, circumcision rates reached as high as 86 percent during the baby boom and in more recent years have hovered near 80 percent. The Minnesota Department of Health doesn’t track circumcisions, but local hospital claims submitted in 2005 showed the rate to be about 72  percent.

Why is circumcision still so common in our part of the country? It could be because the Midwest is relatively less ethnically diverse—until recently, whites favored circumcision at much higher rates than did African Americans, Hispanics, and several other groups. It could be because of our strong economy—circumcision is more common among infants born to families of higher socioeconomic status. It could even have to do with history. Coincidentally or not, the Midwest was the home of one of the nation’s leading circumcision promoters, John Harvey Kellogg, the Battle Creek, Michigan, doctor best remembered for inventing corn flakes. (He believed corn flakes reduced the human sex drive. He also administered yogurt enemas to his sanitarium patients.) In an infamous 1877 tract, Kellogg suggested that circumcision was the best “remedy” for masturbation. “The operation,” he insisted, “should be performed by a surgeon without administering an anaesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment, as it may well be in some cases.”

This unfortunate quote and the procedure’s promotion by quacks and sexually repressed religious fanatics is often cited as proof of its dubious provenance by members of the current anti-circumcision movement, which includes groups such as Mothers Against Circumcision and Doctors Opposing Circumcision. The critics’ rhetoric is frequently heated. “During the 20th century, more than 120 million foreskins were severed from American penises, more than in any other country in the world,” reads one broadside. “At the height of the circumcision frenzy, a foreskin was being sundered, and a penis crippled, every 17 seconds.” The photos can be even more unsettling.

Sometimes known as “intactivists,” circumcision opponents argue that the procedure is as abhorrent as the female genital mutilation practiced in some parts of the world, and they claim that it cuts male sexual response by almost half. They point to a recent study funded by an anti-circumcision group, during which 163 men each rigged with nineteen pressure-sensitive filaments watched erotic films; according to the study, the five most sensitive points of the penis are in the portions removed by circumcision. The study’s author, Michigan State University pediatrician Robert Van Howe, an outspoken critic of the procedure, says his results will be replicated by others. “It would be hard to fake,” he noted.

Critics of routine circumcision call it a “procedure in search of an indication.” But do the latest findings concerning HIV transmission provide that indication?

So far, the AAP and the AMA haven’t revised their statements on the procedure, while the Centers for Disease Control and Prevention in Atlanta is reportedly only beginning to design studies that might lead to a national policy. In the Twin Cities, Carolyn McKay notes that the recent AIDS–related headlines may seriously confuse the issue. “Cutting the HIV transmission rate by 50 percent is great, but what you really want is a zero rate of transmission,” she says, adding that the only way to prevent AIDS is to use condoms.

Interesting as the public health debate may be, studies have shown that it’s had almost no bearing on parents’ decision to cut or not to cut. “It’s so far down the road, most parents can’t even grasp that their kids are going to grow up and have sex,” says Laurie Frattalone. Few parents ask questions about sexually transmitted diseases and infection rates, she says. They wonder, instead, about other, more esoteric questions: Will our son be teased if he’s circumcised—or if he’s not? Will he be confused if he doesn’t look like his dad? What if he’s unhappy with the choice we’ve made for him? What will his grandparents say? Will the procedure go out of fashion, cosmetically or politically, or will it experience new popularity because of some new medical advance?

Maria Douglas Reeve, a newspaper editor in St. Paul, asked herself these questions when her first son was born, and then decided in favor of circumcision. “It just seemed like the accepted thing to do,” she says. “I didn’t want him getting dressed one day and wondering why he looks different from his dad.” Now expecting her third child, another boy, she says the recent headlines gave her new confidence about making the choice again.

The Macgowan–Hays family, expecting their newest addition this month, read the latest news about circumcision and came to the opposite conclusion. “The [new findings] may give us an opportunity to talk to our sons sometime in the future about safe sex and being responsible,” says Macgowan. “[But] we still feel we made a good decision, and we’ll definitely make it again.’’

Perhaps not surprisingly, McKay says that in her nearly forty years of pediatric practice, there seems to be only one constant in the debate about circumcision. “It’s a deeply personal decision,” she says. “And parents feel quite passionate about their choice.”