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

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.

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."

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.

"In the 19th century this was so common, the Jewish community referred to it as 'second circumcision,'" Van Howe says.

As for HIV and STDs, advocates can only point to studies done in Africa on consenting adult men who've been paid for their participation. The World Health Organization now advocates the procedure be done on adults because of these studies, even though regular condom usage gets the same results. In fact, even circumcised men must wear condoms to keep from contracting or spreading the disease.

Diekema says the WHO's stance on circumcision is much different than the AAP's for one big reason.

"The World Health Organization is a public health organization that is looking for implications for large groups rather than singular people," he says. "It's more complicated when you're looking at individuals."

Still, Diekema notes that circumcision helps reduce the spread of diseases like the human papillomavirus (HPV), which is known to cause cervical cancer in women and penile cancer in men.

"Most of the benefits are preventative," he says. "You don't know which kids will suffer either way."

Some critics have gone so far as to attempt to link circumcision to autism.

To that, Diekema almost chuckles. "It's difficult to know where to put all the little girls with autism, then," he says. "There is absolutely no data to support that."

Other arguments for circumcision include that women prefer circumcised men, that boys who aren't circumcised will be made fun of, and that it's harder to clean an uncut penis.

All of these points can be argued either way. Critics say that the foreskin provides a layer of lubrication during sex that is absent in a circumcised penis. That lubrication makes sex more comfortable for both the woman and uncircumcised man. Advocates say women like the look of a circumcised penis, and the increased penile-vaginal contact, stimulation, and marginally better staying power during sex make circumcision advantageous, according to literature by circumcision proponent Brian Morris, professor emeritus of molecular medical sciences at the University of Sydney, Australia.

Hygiene might be the biggest issue, though, as advocates assert that an uncut penis will be smegma-filled and odorous, while critics say nothing more than warm water is necessary to keep the organ clean. Critics say that even doctors are misinformed on this issue and that they often misadvise parents that the foreskin should be pushed back and cleaned at every diaper change and during every bath.

But the foreskin doesn't actually retract until the child hits puberty, and retracting it before it does so on its own is painful, can tear the skin, and lead to infection.

Jennifer Rice is the mother of two sons. She had her oldest circumcised, but decided she didn't want to circumcise her second son.

"With my oldest, after he came back from the surgery he wouldn't take the binky, he wouldn't nurse, he was very irritable," says Rice. "With my second son, everything was very peaceful for him." She also notes that her second was also much easier to keep clean.

"With my first, you had to make sure his penis was Vaseline'd at every diaper change so that things wouldn't get stuck to it and it wouldn't get infected," she says. "You had to touch it a lot. With my second son, we don't touch it at all. We'd just give him a bath and he's fine. We don't even clean it with soap; I just dunk him in warm water. He doesn't smell at all."

Like many parents who choose to leave their sons uncircumcised, Rice experienced some backlash from her family, though she says that's all dissipated now. She even found that most doctors and nurses were receptive to her decision, and many of them congratulated her.

"I feel really proud of the decision that I made," she says. She'll likely have some questions to answer when her sons get older, about why she chose to circumcise one and not the other. She says it's important that both her husband, who is circumcised, and her oldest son know there isn't anything wrong with their penises.

Lillian Cannon isn't a doctor, a nurse, or a psychologist. Much like Rice, she's a stay-at-home mom with a 10-year-old son. It was her pregnancy with her oldest boy that led her to explore reasons for circumcision. On a quest for information about the procedure, she fell down an Internet rabbit hole and stumbled across the image of an infant being circumcised.

"You couldn't see any blood, the body was covered up with a robe, but you can see that baby screaming in pain," she says. That image convinced her she wouldn't be circumcising her son, but she needed to convince her circumcised husband that the surgery wasn't necessary, an uphill battle for many women who don't want to circumcise their sons. So she gathered up some literature and left it in the bathroom for her husband to peruse at his leisure.

"A couple months later, he came out and said, 'We don't have to do it.'" she says. "Since then, he's become vehemently against it."

Not all women find it so easy to sway their mate. Cannon says many men need to feel that what was done to them as infants must be justifiable in some way, so they can have a hard time seeing why the procedure is pointless.

But what makes Cannon an expert? Well, since her son was born and left uncircumcised, Cannon has continued to educate herself. She followed Dr. Darcia Narvaez, a professor of psychology at Notre Dame and executive editor of the Journal of Moral Education, and when Narvaez came under fire for a post on circumcision, Cannon volunteered some of her own findings to be published on PsychologyToday.com. You can read her work on the website, where it's published under Dr. Narvaez's blog.

Cannon represents a growing number of parents who are educating themselves rather than waiting for information from their doctors. Oftentimes, parents now are more informed about how to care for an uncircumcised child than the health care provider is, a total reverse from decades past.

Marilyn Milos is the mother of three sons, all of whom are circumcised. She went to nursing school when her boys were older, only to experience the traumatic effects of the procedure first-hand.

"My doctor had told me that there was no pain for the baby, that it only took a minute, and that it would be helpful to the baby," she says.

But during clinicals, she was exposed to an infant circumcision first-hand. She says the baby was strapped down to a table, fighting against its bonds like any adult would, and screaming in protest. She attempted to soothe the baby, letting it suck on her finger, stroking his head, and speaking gently. She says the baby settled down, until the doctor performed the circumcision without anesthetic. After that, there was no calming the child.

"The doctor looked at me and said, 'There is no medical reason for doing this,'" Milos says.

Shortly after, in 1986, she founded NoCirc and since then she's spent her time as a nurse refuting claims made by doctors, health organizations, and circumcision proponents. When she speaks, it's with passion and intensity.

"It's a hoax," she says of the WHO's studies. "They'll never end circumcision here because doctors love money too much."

Norm Cohen, head of NoCirc Michigan, hopes that as Medicaid slowly stops paying for the procedure in order to curb budgets and save money, rates will drop dramatically. He feels that when uninformed, uneducated, poor mothers are presented with the idea that the surgery is free and will help the child, they're much more likely to have it done to their sons. As soon as they're told they'll be paying for the procedure, then they start doing some research.

It's a worthy point, considering how rates are dramatically dropping out west, a region where many states have stopped paying for circumcision through Medicaid in order to help curb costs.

Still, parents, doctors, health organizations, and even insurance providers search for reasons to cut or not to cut. Tradition might be one reason that the surgery is so prevalent in the Midwest, despite declining rates of circumcision in the United States overall. Another, Cannon notes, is that the Midwest isn't always the most trendy of regions.

"The Midwest isn't as culturally on top of things as the rest of the country," says the Pittsburgh native. She cites the procedure as being a "manly" tradition that parents consider to be the right thing to do, since their sons might be made fun during gym class or scorned by potential mates.

NoCirc of Michigan's Cohen says the tradition really took hold during the Victorian age. Doctors recommended it as a way to curb the maladies they thought resulted from too much masturbation.

"The disease of the decade is always curbed by circumcision," Cohen says.

While the tradition remains strong in the Midwest, across the country rates of newborn circumcision have been steadily declining since the late 1970s, with a few upswings in the '80s. The Center for Disease Control released a report in 2013 that shows the spikes and drops in infant circumcision over the last 40 years, and while circumcision was at an all-time high in the mid-'80s, by 2007 its prevalence dropped to a little more than half the population, with the Midwest keeping the average up and the West showing serious declines in the procedure. In fact, circumcisions in the West decreased to less than 35 percent of newborn males in 2007, while the Midwest spiked to nearly 85 percent.

Several other factors go into a region's newborn circumcision rate, including ethnicity, insurance, and Medicaid. With a large Hispanic population and several states that have stopped paying for circumcision through state-funded insurance, it's no wonder their rates are dropping so rapidly, making the difference between the Midwest and the West around 50 percent.

According to Diekema, it's also important to keep in mind that circumcision rates are never 100 percent accurate. Because they're calculated based on procedures that are done in-hospital, essentially zero Jewish circumcisions are counted toward the rate. All Jewish circumcisions are performed as ceremonies outside of the hospital; therefore they're not counted in the state circumcision rate. Muslims boys are circumcised in-hospital, contributing to Michigan's 85 percent circumcision rate.

Around the world, circumcision ranges in popularity. According to a report by the WHO, while most men are circumcised in the Middle East, it's rare that a mother will circumcise her son in South or Central America. Studies show that around 11 percent of men are circumcised in Costa Rica, Mexico, and Panama and as few as 7 percent of men are circumcised in Brazil and Colombia. The surgery is also on the decline in the United Kingdom, where a study done in 2000 found that less than 16 percent of men between the ages of 16 and 44 were circumcised, and the majority of those were Muslim or Jewish. In Korea, the practice has been on the upswing since the United States established a trusteeship with the Republic of Korea in 1945. Before that, circumcision was also unheard of there. In Indonesia, Pakistan, and Bangladesh, it's done almost universally. Most Africans circumcise, but it's typically done during adulthood and has been since long before the WHO recommended it. There, many tribes consider it to be a rite of passage from childhood to manhood. Some see the foreskin as feminine, and cutting it off signifies that a boy is ready to take on his manly duties.

The Jewish faith requires all infant males be circumcised by their eighth day of life to show their covenant with God. Rabbi Doniel Neustadt serves the Orthodox Jewish community in metro Detroit and says he hasn't seen a decline in religious circumcisions, despite nationwide trends.

"It is possible that there is a decline in the secular community, and that is unfortunate," he says. "The lack of proper Jewish education in the secular community is at the root of this problem."

The rabbi also notes that circumcision done in a hospital has no religious meaning, and as for health reasons, that's up to a physician to decipher.

According to Father Jim King of St. Mary's Antiochian Basilica in Livonia, the practice of circumcision isn't something that's regularly talked about in his church, though he believes that a chapter in Acts essentially states that it's not necessary for Christians to circumcise.

"It's a personal preference, I think," he says.

For Muslims, however, circumcision is required. The practice is similar, but not identical to, the Jewish ritual.

"My mother told me when I was younger that [having sex] with an uncircumcised man is like eating pork," says Lina Hammad*. "It's not halal."

For religious, cultural, or cosmetic reasons, humans have been circumcising men since the beginning of recorded history. The WHO displays an ancient Egyptian drawing depicting circumcision on the cover of its packet on the surgery's global trends, determinants of prevalence, safety, and acceptability.

Jacquelyn Williamson, an Egyptologist and research associate at the Harvard Semitic Museum, describes the image attached to the WHO's packet on circumcisions as "a stone relief from the tomb of the Official Akh-ma-hor in Saqqara, dating to Dynasty VI." She says it's one of the few representations we have of what is likely a circumcision procedure and that the Egyptians probably practiced male circumcision, as statues and relief of nude men demonstrate circumcised penises."

But what did circumcision mean to these people?

"We do not know very much about the practice in Ancient Egypt, although if it did happen it appears men were circumcised at puberty," says Williamson.

That statement seems to apply to the circumcision of many infants in the Midwest, the United States, and the world today. Parents circumcise following the tradition of their grandfathers, fathers, and brothers, but what does it really mean? With no clear recommendation from the Center for Disease Control, the American Academy of Pediatrics, or the World Health Organization, is there really enough thoughtful evidence available to condone violating a child's inherent right to an intact body?

"Our reptilian brains want to belong," says Van Howe. "It's more psychological than anything." — mt