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TWENTY-FIVE years ago, a penis without a foreskin was not so much the mark of being Jewish or Muslim as the mark of being a modern American. Circumcision had reached the peak of its popularity in the United States. Although only 25 percent of the world's men were circumcised, 90 percent of American newborn boys were.
In 1971, though, the tide began to turn when the Committee on the Fetus and Newborn of the American Academy of Pediatrics decided for the first time not to recommend routine circumcision of infants. Circumcision rates began to tumble.
The trend continues. Circumcision of newborns has now dropped to between 60 and 70 percent nationwide, though rates vary from 80 percent in the Midwest to 50 percent in California, where there are large numbers of Asian and Hispanic immigrants (who traditionally do not circumcise), a preponderance of energetic anti-circumcision groups, and a trendy, affluent middle class for whom the possession of a foreskin is now chic, according to Dr. Edgar Schoen, a senior consultant in pediatrics at Kaiser Permanente Medical Center in Oakland.
The decline in the number of American circumcisions has had a curious consequence: circumcision once again has a tribal meaning, though that meaning is not as unambiguous as it once was.
These days, perplexed parents deciding whether to circumcise their infant sons must consider conflicting medical advice, the fashion of their socioeconomic group and their own ethnic traditions. They can even consult British royalty. While Queen Victoria, who believed her family descended from King David, sanctioned circumcision, and Prince Charles was circumcised by a mohel (a rabbi who specializes in circumcision), Princess Diana decided that Princes William and Harry would go uncircumcised.
Doctors themselves are divided. As with any surgical procedure, there are dangers. Complications, estimated at 1 in 500, usually involve local infection and bleeding. And there are rare cases of damage to the penis.
"There are risks," says Dr. Terry W. Hensle, director of pediatric urology at Columbia College of Physicians and Surgeons, "but they are low." He adds, "Given the choice, most rational folks would choose to have their infant sons circumcised." Removal of the foreskin virtually precludes penile cancer, and eliminates balanoposthitis (infection of the foreskin) and phimosis (inability to retract the foreskin).
Dr. Schoen, who chaired the American Academy of Pediatrics' task force on circumcision in 1989, thinks that several recent studies support routine circumcision. Dr. James Roberts, of Tulane University, found that the underside of the foreskin is a favorite hiding place for the bacteria called P-fimbriated E coli. The bacteria like to cling to the underside of the foreskin, where they colonize, and then climb up the urethra, causing urinary tract and kidney infections.
The second set of studies concerns H.I.V. infection. A March Scientific American article showed that "only one factor" seemed to correlate with susceptibility to H.I.V. infection in Africa: lack of circumcision. A 1994 study by Dr. Stephen Moses in the International Journal of Epidemiology showed that around the world uncircumcised men were three to four times likelier to be infected with H.I.V. than circumcised men. (The virus may be transmitted through tears in the foreskin during intercourse.)
In spite of these findings, many doctors don't recommend circumcision. Dr. David Kaufman, an assistant professor of clinical urology at Columbia College of Physicians and Surgeons, says, "If proper hygiene is practiced, all of the potential medical problems can be avoided."
Unfortunately, studies show that even in developed countries, good hygiene can be elusive. A study of uncircumcised British schoolboys in 1964 showed that 70 percent had poor genital hygiene. And 63 percent of 6-year-olds in Denmark had unclean foreskins. Even Dr. Kaufman, who doesn't support routine circumcision, says he performs circumcisions on adults once or twice a week, many as a result of infections caused by bad hygiene, the rest because the delicate foreskin sometimes tears during intercourse.
Opponents, nonetheless, say that routine circumcision is not warranted to avoid urinary tract infections that occur in 1 percent of boys, nor the rarer cases of penile cancer (2.2 per 100,000 for uncircumcised men), nor phimosis, which affects one-half to 1 percent of infants. (Louis XVI of France, a famous phimosis sufferer, was unable to have sex with his wife, Marie Antoinette, until he was circumcised at age 21.)
There are risks in hospital circumcision that are new. While skilled pediatricians used to circumcise babies, now growing insurance costs have forced many to abandon the procedure, which often falls to the lowest qualified person in the delivery room. Some doctors think mohels do a better job. "They're probably the best," says Columbia's Dr. Hensle.
The most vigorous objection to circumcision is that the baby has no say in the matter. Hanny Lightfoot-Klein, the author of "Prisoners of Ritual," goes so far as to compare male cirumcision to clitoridectomy in Africa, an operation that causes infections and renders sex and childbirth painful. She says: "A cut is a cut. And it's the first cut that cuts the trust between a child and its mother."
Some opponents suggest that cutting an infant imprints violence on the baby's brain. James Prescott, a psychologist, says: "You're now encoding that primitive, immature, developing brain with pain when it was designed to be encoded with pleasure. This is one of the beginning stages of establishing the sadomasochistic personality."
Whereas resentment of patriarchal domination colors the language of some opponents, the language of the men's movement can be found in others. Marilyn Milos, founder of Nocirc, an anti-circumcision clearinghouse, says, "What man wants to hear the best part of his penis was thrown into the wastebasket?" She cites the work of researchers who claim the tissue of the foreskin is more sexually responsive than the tissue beneath it.
"How do they know that?" asks Dr. Hensle. "The neuroreceptors are in the glans, not in the hood."
James Bigelow, the author of "The Joy of Uncircumcising!" says that many men are traumatized by the loss of their foreskins. He says of himself, "When I first saw the scar on my penis, I felt someone had taken something." Mourning the lost body part is a necessary step to getting well, he says, and for some men, so is stretching a new foreskin. He says one man who had stretched his skin over the glans told him, "It's at home."
Dr. Yehuda Nir, a psychoanalyst who was formerly head of child psychiatry at Memorial Sloan-Kettering Hospital, says he hasn't observed circumcision trauma. "The only thing men are concerned about with regard to the penis is its size."
Circumcision was part of religious rites in Egypt and Greece dating back to 4,000 B.C., and is now practiced for religious reasons by Jews, Muslims and Africans, among others.
Dr. Nir, who is Jewish, survived in Poland during World War II with his mother and sister by posing as a Catholic. He knew that had someone discovered he was circumcised, he and his family would have been sent to the gas chamber. "Circumcision was very much a part of my four years of struggle," he says, "but it's a matter of identity."
Like Dr. Nir, most parents are influenced more by religious belief or ethnic custom than by the medical evidence. Dr. Kusum Khanna, a pediatrician in New York City, says most mothers want their sons to look like their fathers. But among those who are undecided, the more educated opt to go without circumcision because of uncertainty about its medical benefits. Dr. Khanna says, "The chances of it being done for the son of a blue-collar worker is higher than for a professor at Columbia."
Anti-circumcision groups are now turning up the volume, and being heard. Blue Shield of Pennsylvania, the Prudential Insurance Company and some welfare programs have stopped paying for the circumcision. The anticircumcisionists are also using lawsuits to intimidate doctors. One California doctor who circumcised an infant without mishap after getting a signed consent from the mother was sued in 1985 for "battery, cruelty, infliction of pain, child abuse, false imprisonment, kidnapping and mayhem." The suit was thrown out by an appeals court.
Sigmund Freud wouldn't be shocked by the passion of the debate over the foreskin, as he believed that circumcision was unconsciously associated with castration. The modern-day debate about circumcision seems to support his belief. Only 25 years ago, circumcision was a simple medical procedure. Now it is a tribal mark of a different nature.