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04-01-09, 09:35 PM #1
Should all males be circumcised? Dr. Wang thinks so
The day your wife gives birth to a baby boy, the kind, bespectacled face of Marvin L. Wang, M.D., is one that you want to see coming through the recovery-room door. Co-director of newborn nurseries at Massachusetts General Hospital in Boston, Dr. Wang has a perky, conversational bedside manner that puts everyone at ease. I have to hustle to keep up with him as he strides energetically between hospital rooms. Right now he's congratulating a pair of new parents. Larry is standing on wobbly legs, looking both ecstatic and shell-shocked, while Joy sits serenely, holding their newborn son to her breast.
Dr. Wang jokes with the new parents a bit and then says, "I understand you may want to have a circumcision for your baby."
Larry and Joy don't answer immediately. At last Larry says, "Well ... we don't know."
Dr. Wang smiles. He's familiar with the befuddled expression on Larry's face.
Circumcision, of course, is the surgical removal of the penile foreskin from the glans the fleshy crown of the penis. It is one of the most commonly performed procedures in American hospitals, and except for abortion, it may be the most controversial. The procedure has long been known to reduce the spread of a few rare, serious diseases, and to prevent a few annoying, uncomfortable ones. But in 1999, the American Academy of Pediatrics (AAP) determined that the risk of surgical complications, though small, nearly canceled out the benefits. They neither discouraged nor recommended the procedure. Since then, 16 states have eliminated Medicaid coverage for nearly all circumcisions.
But two years ago, a consortium of experts convened by the World Health Organization and UNAIDS (the United Nations' HIV program) announced that circumcision should indeed "be part of a comprehensive HIV prevention package." It did so because three separate, meticulous medical trials in Kenya, Uganda, and South Africa, involving more than 10,000 men, had proved that circumcision could reduce the risk of female-to-male HIV infection by approximately 60 percent. This discovery is one that, over the next two decades, could save three million lives in Africa alone.
Now, no one believes that the potential health benefits for American males are nearly as great, or as urgent, as they are for men in Africa, where HIV is spread mostly through heterosexual intercourse. Still, similar study results are turning up on this continent, as well. A team of researchers from the CDC, Johns Hopkins, and the Baltimore health department examined the records of more than 1,000 African American males all heterosexual who tested positive for HIV at Maryland clinics. Uncircumcised men were 50 percent more likely to be infected.
These results have caused many U.S. doctors to reconsider their positions. "I've always told families that the health benefits of circumcision are real, but not enough to warrant advocating that all boys be circumcised," says Lise Johnson, M.D., the director of healthy-newborn nurseries at Boston's Brigham and Women's Hospital. "But I find these HIV studies pretty striking. The weight of scientific evidence might be shifting in favor of circumcision."
Larry, the new dad, is circumcised himself but never thought much about circumcision until his wife became pregnant. "Joy kept saying, 'It's up to you,'" Larry tells Dr. Wang, "but when I finally said I wanted to do it, she said, 'Whoa! We have to talk.'"
After a few uneasy moments, the new father's feelings spill out.
"I guess I don't feel too strongly either way," he says, looking at his son tenderly. "But if there's a risk of hurting him ..."
Health benefits of circumcision
Pain, of course, is the first question that comes to mind whenever the words cut and penis are used in the same sentence. Ask Marilyn Fayre Milos about pain or better yet, don't. The founder of the National Organization of Circumcision Information Resource Centers (NOCIRC get it?) first witnessed the procedure in 1979 while training for her nurse's degree. The unlucky baby, she later wrote, was "strapped spread-eagle to a plastic board... struggling against his restraints tugging, whimpering, and then crying helplessly" while awaiting the knife. Then as the doctor, using no anesthesia, began cutting into the penis with a scalpel, "the baby began to gasp and choke, breathless from his shrill continuous screams..."
Is that what Dr. Wang is offering to do to Larry and Joy's innocent baby boy?
Not quite. Dr. Wang says the operation rarely hurts much anymore; since the 1990s, it's become routine in U.S. hospitals to anesthetize babies before the procedure. For every 1,500 circumcisions, there are maybe three complications, nearly all of which amount to a little unexpected bleeding or a treatable infection. In return, according to the AAP, circumcised boys have a lower risk of urinary-tract infections and penile cancer, and, indeed, "a slightly lower risk of getting sexually transmitted infections (STIs), including HIV, the virus that causes AIDS." But weighed against the potential risks, says the AAP, "these benefits are not sufficient ... to recommend that all infant boys be circumcised." (The AAP is now reviewing its guidelines, in light of recent scientific news.)
Larry seems to search the doctor's face for a hint of what to do, but Dr. Wang is as neutral as his white hospital coat. "You need more time to think about it," he says encouragingly. "I'll be back."
He heads off down the hall.
Circumcised or not, every man owes his foreskin a great debt of gratitude for its service in the womb. In the third month of gestation, when the nascent penis begins to bloom, the foreskin forms a little protective blanket under which the rest of the penis can safely grow. But once you and your penis are fully baked, the advantage of a foreskin is not clear. Some scientists speculate that it protected the prehistoric penis as it swung, naked, through thick forests and over tall grasses; and unless you take your penis on that sort of excursion, they argue, you don't need a foreskin.
That perceived uselessness may be one reason circumcision has such a long and varied history. Archeological evidence suggests that the practice may be at least 6,000 years old. Muslims and Jews, along with the aborigines of Australia, the Aztecs and Mayans of this hemisphere, and many other cultures all independently adopted this squirm-inducing practice, and it seems unlikely they'd have done so unless they were convinced that it conferred some earthly benefit.
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Here in the United States, foreskins were left mostly undisturbed until the second half of the nineteenth century. But it wasn't until the North Africa campaign of World War II that American doctors turned into enthusiastic circumcisers. More than 145,000 American GIs based there slacked off on their cleaning regimens and came down with foreskin-related ouches chiefly, balanoposthitis (inflammation of the foreskin and glans), phimosis (a foreskin that's too tight to retract over the glans), and paraphimosis (a foreskin stuck in the retracted position). After the war, doctors advanced a theory that circumcision reduces rates of cervical cancer a hypothesis now confirmed by scientific research.
Circumcision became routine, but anesthesia wasn't part of the plan. That, more than any other factor, may have provoked the fiery anti-circumcision movement that casts its long shadow over the Internet.
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 blasι 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."
04-01-09, 10:05 PM #2
Wang? That's pricelessBe kind, be courteous . . .
and have a plan to kill everyone you meet.
04-01-09, 10:44 PM #3
Someone is a little too obsessed with Dr. Wang......CHIRP! CHIRP!
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