The Great Foreskin Debate: Why the Midwest leads the world in infant circumcision and what the hell that says about us

Oct 1, 2014 at 1:00 am

On Friday, Sept. 12, NoCirc of Michigan, an anti-circumcision group, protested on the lawns of the state capitol. Eighty men and women gathered, some wearing white jumpsuits with giant red splotches painted on the crotch. They hoped to bring attention to what they feel is the needless cutting of healthy skin off infant males, attention they hoped might result in legislation that would prevent a procedure they feel is unwarranted in healthy baby boys by making it illegal for the government to pay for it.

The next day they took to Royal Oak, protesting in front of Beaumont Hospital. Circumcision, they say, does no good, and doctors and nurses would do well to remember their oath to first do no harm. Five infants a day are circumcised at Beaumont Royal Oak, a number that adds up to almost 2,000 children by year's end. Most, if not all, of these procedures are done with nothing more than a topical anesthetic that only penetrates the first layer of skin. Essentially, the baby feels everything. The nearly 51,000 procedures that are done in Michigan cost upward of $11 million annually, $4 million of which comes from taxpayers, via Medicaid.

Circ-ling The Issue

Norm Cohen heads NoCirc of Michigan, an organization he's been involved with for 20 years. He feels that all people, including infant males, have the right to an intact body and to make the decision whether to be circumcised for themselves. The facts he presents about circumcision are startling. For example, he says Michigan, along with a few other Midwest states, leads the world in non-religious circumcision. In fact, nearly 85 percent of the boys born in Michigan will be circumcised, mainly because that's what parents, without seeking information on the surgery, think they're supposed to do.

University of Michigan's C.S. Mott Children's Hospital conducted a study in March 2014 about where parents get their circumcision information. While 87 percent of parents said before their baby is born is the best time to review information on circumcision, the study also showed that many parents don't schedule a prenatal visit with their health care provider to receive and review that information, thus rendering themselves entirely uninformed on the surgery's pros and cons.

Furthermore, parents who participated in the study indicated that they wanted their health care provider to clarify the American Academy of Pediatrics' stance on circumcision, which isn't at all surprising. After all, the AAP essentially says they both condone and don't universally recommend the circumcision of infant males, saying that the benefits of the surgery outweigh the risks, but that it shouldn't be done routinely on all infant males.

Sarah Clark is a faculty member in pediatrics at Mott Children's Hospital; she was also the main researcher on the circumcision study.

"It's pretty nuanced," she says of the AAP's statement on circumcision. "The benefits aren't at the level where they would endorse a universal recommendation of it."

As for why it's so confusing, Clark sees a clear reason.

"I think the reason behind it is that first they recommended it, and then evidence came out that it wasn't necessary, so they didn't recommend it," Clark says. "Now they're saying it's not nothing. There is some data on benefits, but not enough to recommend it for all infant males."

"It's a parental decision," she says of the surgery. "It's an elective procedure."

Dr. Doug Diekema served on the AAP's task force that shaped the organization's statement on circumcision. He describes himself as a moderate on the issue, neither pro- nor anti-circumcision. The Seattle-based doctor is even-keeled, offering what seems like a level-headed reasoning behind the statement.

"Many people find it confusing or not as direct as they would like," he says, calling it a "murky recommendation." He says that's because the statement is derived for pediatricians who are assisting parents in making the decision for their child.

"The reason it's not as direct as people would like is because it's not an ideal world," he says. "You don't know what child is going to benefit from it and which child isn't."

In the end, Diekema says, it's all up to the parents. "It's a complex decision for parents to make."

To Cut or Not to Cut

While many parents give little thought to the surgery, or wait until it's too late to seek out information, advocates and critics of circumcision do battle over the Internet on a daily basis, and facts on both sides of the argument seem cloudy. On one hand, advocates say circumcision prevents everything from urinary-tract infections to the spread of HIV and sexually transmitted diseases, while critics point to the fact that the percentage of boys who get UTIs is so minuscule it's almost pointless to note. Plus, critics says that girls are much more likely to contract a UTI, at which point the infection is treated with an antibiotic that would be just as effective when used on a boy.

But to Diekema, downplaying the rate of UTIs in babies is thoughtless.

"People have irresponsibly minimized UTIs in infants," he says. "A UTI in a 6-week-old is a lot different than a UTI in an adult woman. For an infant, they're getting intravenous antibiotics in the hospital, and an extended work-up."

That "extended work-up" can include anything from spinal taps to catheterization. As for the rate of infant males who actually contract a UTI, Diekema asks what "rare" really means.

"This is not an uncommon thing for me to see working in the emergency room," he says of infant UTIs, noting that any malady in a baby is rare because most babies and children are generally healthy. In fact, he says aside from the common cold, a UTI is one of the more common illnesses he treats.

According to Central Michigan University's pediatrics team director Dr. Robert Van Howe, there are some drawbacks to the surgery. So-called "botched circumcisions" can range anywhere from a little too much skin being cut to whole parts of the penis accidentally being removed. Van Howe has testified as an expert witness in many cases that have gone "horribly wrong." He says most cases are brought by parents on behalf of their children.

"A lot of men have more skin taken off than should be," Van Howe says. "Nowadays, more and more skin is being taken off." That removal of too much skin leads to painful erections in adult men, and oftentimes a result of the practitioner not knowing what the size of the fully grown organ will be.

"There are a lot of botched circumcision victims out there," he says, "but they don't get reported because guys think it's normal."

Other complications include neonatal stenosis, the narrowing of the urethra, which decreases urine output. Van Howe says this occurs in anywhere from 5 to 20 percent of circumcised infants. To correct the issue, another painful procedure is required.