Should all males be circumcised?

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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