CircumcisionThe fate of the foreskin has a curious place in the lore of American medicine. Around the turn of the previous century physicians here began to hold the opinion that there were measurable medical benefits to circumcision including basic hygiene, prevention of venereal diseases, and the avoidance of cervical cancer in females who were so unwise as to mate with a man who had an intact foreskin. Parents were thus informed of these beliefs with, one may presume, considerable gravity. Moreover they were given a gruesome set of instructions regarding the care of the uncircumcised penis should they opt to go against medical advice, the mom being required to make sure she tore the adhesions binding the foreskin to the glans free each and every day, yanked the foreskin down to the base, and then attempted to pull it back up over the head, a bloody, painful, tears-inducing ritual for both mother and infant. Actually the care of the uncircumcised foreskin is roughly the same as that of the right thumb – simply clean the outside and otherwise leave it alone. That’s basically all there is to it; the adhesions will break naturally on their own with time.

The rest of civilization outside our borders, the British in particular, never really bought into the belief that circumcision was medically necessary. Nonetheless the practice took hold on this side of the Atlantic and thus three to four generations of American males were ritually circumcised. Finally in the seventies and eighties a second look was taken at these sacred beliefs. Applying appropriate control groups and modern scientific methods newer studies arrived at an entirely different set of conclusions. Simply put, all previous rationalizations for the procedure to turn to dust. It turns out that the exposed head of the penis is more susceptible to skin infections than keeping the natural covering intact, the acquisition of a gynecological cancer has nothing to do with the circumcision status of the woman’s partner, and the likelihood of a male acquiring a venereal disease is far more dependent upon the sexual history of his lady friend than the length of his foreskin.

There do exist a few theoretical benefits. Circumcision is relatively protective against both uncomplicated bladder infections in the first year of life and cancer of the penis, a very rare disease exclusively limited to extremely elderly men. Furthermore, should a male choose to practice unprotected sex recent studies indicate his risk of acquiring a venereal disease may indeed be somewhat higher if he still has an intact foreskin, although abstinence, good judgment, and proper application of a condom remain far more beneficial. Risk/benefit analysis of these factors (the holy grail of determining the validity of a medical intervention) still falls short of tilting the scale in favor of a recommendation supporting routine newborn circumcision. However, the Academy of Pediatrics is currently in the process of considering a reversal of its long-standing opposition in light of African studies which do indicate some modest protective effect in the transmission of AIDS. If at some time in the future the panel does come forward with a statement supporting the procedure a veritable firestorm of protest will surely be forthcoming from the highly opinionated and emotional pro-foreskin lobby.

Given the medical opinion over the past three decades that there was no longer a valid reason for circumcision one would have assumed the custom would have quietly disappeared. Why would parents subject their newborn son to a surgery which is not only painful but carries the risks of bleeding and infection if there is no measurable medical benefit? The simple truth is that old habits are slow to die and the removal of the foreskin in this country thus remains quite the fashion. There are significant geographic differences, the west coast being the quickest to adapt to the new recommendations, the southern states maintaining the highest rate, and the midwest somewhere in between – the typical blue state, red state, confused state distribution – but everywhere you go there continues to this day to be a great number of circumcisions being performed.

There are several reasons parents continue to sign the consent even in this age where circumcision is considered entirely elective. First of all is religion, of course, the Jewish faith most predominantly in America along with a host of others. Beyond that all the other rationales fall under the general category of cosmetic. A key factor for many families is whether or not the father is circumcised. Apparently it is critical to have the sons resemble their fathers in this important aspect. But more than that circumcisions have become a tradition in this country, kind of like Super Bowl parties. Dad, Grandpa, and Great-Grandpa had their foreskin trimmed, so it would be a form of heresy not to do the same to little Timmy. Even though some young hotshot pediatrician may try to tell the kids it isn’t necessary, that the head of the penis is every bit as easy to clean uncircumcised as otherwise, Grandma knows far, far better. She’ll set the new parents straight as soon as the doctor leaves the room. Elective? Huh! Who ever heard such nonsense?

The other major cosmetic reason is what I refer to as “The Eighth Grade Locker Room Argument.” The key concern here is the makeup of their son’s gym class fourteen years hence, and the answer to that query is that the overwhelming majority of his peers will be circumcised. Oftentimes this fact alone seals the fate of the newly born male infant.

Generally the father is allotted fifty-one percent of the vote on this subject, his spouse acquiescing quietly to his superior judgment. (For many of us this will be the one and only occasion we ever get majority say about ANYTHING involving our children, although none of us realize it at the time….) The new dad, taking ownership and bearing the weight of responsibility for the procedure squarely on his shoulders, will on occasion feel compelled to give rather specific instructions regarding precisely how he would like to have the procedure performed, offering precious kernels of advice such as, “Now, make sure you take off enough, doc. But hey, be careful, don’t remove too much!” A note to you prospective fathers out there – these well-intentioned tips of yours are not particularly helpful.

A circumcision is actually not nearly as dangerous and brutal as many would have one believe. The risks of the procedure are those universal with any surgery and in practice are remarkably rare. Trimming a hangnail probably carries roughly the same potential of bleeding and infection as a circumcision. Pain is certainly an issue but physicians have become much more sophisticated and skilled regarding this in recent years. It wasn’t very long ago the baby boy was simply strapped on a papoose board and cut without any anesthesia at all based upon the discarded theory that “newborns don’t feel pain,” one of the greatest lies ever perpetrated on humanity. Nowadays by injecting lidocaine underneath the skin at the base of the penis for a digital block in combination with the sedative effect achieved by having the infant suck on a sugar-containing substance the procedure is relatively benign. Some babies really do immediately go into a zone once they get that first taste of the sucrose making one speculate as to whether this could be a possible future predictor of a sweet tooth. Time will tell….

In case you’re wondering about what we did with our own son that is a bit of a funny story. During the latter stages of my wife’s second pregnancy she spent much of her time haggling with me over the choosing of a boy’s name (I holding out for monosyllabic, masculine, appropriate; her list of acceptables seemingly inspired by the names of baby dragons in fantasy novels) and reading anti-circ literature. Armed with information gleaned from “The Rape of the Foreskin” and the like she asked me at dinner one night if I had strong feelings about circumcision. I assured her I did not, honestly feeling the whole topic is much ado about nothing. She said she just didn’t see any legitimate justification in favor of having it done and unless I had a significant argument to the contrary she would prefer we pass on the option. I told her no problem and she smiled with relief, gave me a hug, and expressed her gratitude at my open-mindedness.

Sensing an opportunity I decided to press my luck.
“John?” I suggested.
“No!” she replied in horror.
“Forget it.”
A couple of weeks later, more or less right on schedule, our baby boy arrived. On the second hospital day the two of us were sitting in our hospital room with Keith and a familiar smell wafted up from the bassinet. My wife volunteered to do the change and paused midway, staring down in confusion at the newest addition to our family.
“Is there a problem?” I inquired.
“Well,” she said hesitantly, “I don’t know.”
“What is it?”
“I’m not sure.”
I rose from my chair and strolled over to join her.
“Yes, dear?”
“I was just wondering…what is that?”
“What is what?”
“That,” she said, waving her hand vaguely in the general direction of our son’s genitalia.
“Yeah. That…”
“That,” I pronounced in my most authoritative pediatric intern voice, “is an uncircumcised male penis.” (At least I knew something.)
“Hmm,” she said thoughtfully.
“What is it, dear?”
“Well,” she replied, shaking her head slowly as she arrived at a decision, “that’s simply not going to do.”
The following morning my son got whacked. And thus I have added, “What is that?” to my list of reasons for parents having their newborn boy circumcised.
The title of this chapter, circumcisions being forgiving, refers to an expression we have amongst ourselves in the pediatric community. The truth is pediatricians will never be mistaken for plastic surgeons and not uncommonly at the completion of the procedure the end product sometimes appears a bit gnarly. But a circumcision is amazingly resilient and by the two-week checkup inevitably it appears just fine. There is a parallel saying which goes, “Nothing on the planet looks worse than a circumcision two to three days later.” Typically there is a red, swollen head, thick, yellow adhesions, seeping drainage, and worse. However this is nothing more than an unsightly but natural phase of the healing process.

So in the final analysis what should one do? Even today, centuries later, it remains a valid question. In the end it’s not all that critical because whatever is decided the odds are overwhelming everything is going to turn out just fine. There will be much more critical decisions to make as a parent later on down the line, believe me.

Sometimes I do wonder how all of this got started. I mean, there had to be a beginning, didn’t there? That’s what I am curious about, the very first one. In my imagination it probably went something like this…

Thousands of years ago a mother and father are seated side by side, proudly holding their newborn son. The local priest comes up to them and inquires, “What have you got there?”
“It’s a boy,” states the dad.
“Congratulations,” says the priest. “What are you going to call him?”
“Arganon,” the mom announces with a contented smile.
The father grimaces.
“Arganon…I like it,” lies the priest. “Say, I have an idea of something I’d like to do to your baby. Now bear with me on this for a moment while I explain. I know it’s going to sound a bit crazy at first, but what I have in mind is…”
The new parents listen patiently to his description of the procedure. When he is finished the father glances at his beloved, an inquisitive expression on his face. She gazes off in the distance considering for a time before slowly nodding her head in assent. The dad turns back to the priest and says, “What the heck – I say go for it.”
“Great!” grins the priest, clapping his hands together in delight. “Let me go find a sharp rock and I’ll be right back.”

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