Snip it or skip it? San Francisco debates circumcision 

Circumcision was once so routine that it was barely discussed — much less voted on.

As recently as the 1980s, American parents seldom received a choice. Infant boys were circumcised shortly after birth, recalls Dr. Carol Miller, the medical director of the Well Baby Nursery at UC San Francisco’s Benioff Children’s Hospital.

The procedure often was performed without anesthesia.

“The first time I remember it becoming controversial is in the ’70s, and after that the issue of consent came in,” Miller said. “Before that, it was just automatically done on the boys, and parents didn’t get upset.”

Yet anesthesia is now common, and whether to circumcise is largely decided by parents. Authorities provide a great deal of information but no firm recommendation — at least officially.

“We consider this an elective procedure in most instances and we will support the parents as they make the decision,” Miller said.

The American Academy of Pediatrics outlines circumcision’s benefits and risks, but holds back from endorsing it. That has led some insurers and many state Medicaid programs to drop insurance coverage.

“Because the procedure is not essential to a child’s current well-being, we recommend that the decision to circumcise is one best made by parents in consultation with their pediatrician,” the academy said recently.

Apparent benefits include reduced risk of sexually transmitted diseases, reduced rates of penile and cervical cancers for men and their partners, fewer urinary tract infections in the first year of life and reduced risk of foreskin issues such as phimosis, which can force circumcision in later years.

Risks include infection, bleeding and surgical mishaps. Opponents also say men missing foreskins suffer from reduced sexual function, but Cooper said no evidence supports that.

Based on the academy’s stance, parents might conclude that circumcision’s benefits are slight. But Dr. Edgar Schoen, a clinical professor of pediatrics emeritus at UCSF, said the lack of endorsement is due more to internal politics and lobbying by anti-circumcision groups. He said the academy has considered endorsing circumcision in recent years.

Schoen, who served on the academy’s 1999 committee on circumcision and contributed to its legal brief in a lawsuit seeking to block the proposed San Francisco circumcision ban, said strong evidence supports circumcision. Infancy is the best time for the procedure, he says, because such circumcisions are easier, heal better and require less anesthesia.

Yet other doctors are less emphatic. Miller notes that the cancers circumcision reduces are fairly rare, as are foreskin problems and urinary tract infections in boys.

And for opponents, the evidence remains unconvincing.

San Francisco parent Rochelle Torke, 36, read the studies about HIV transmission and found them less than compelling. She didn’t circumcise her sons.

“I just didn’t feel like there was a compelling reason for me to be making this decision on behalf of someone who’s a few days old,” Torke said. “It’s basically a cosmetic procedure. There’s really no other cosmetic procedure we can perform without someone’s consent.”

Lloyd Schofield, author of the San Francisco measure on the November ballot that would ban the procedure in The City, said circumcision’s medical benefits are overstated, and that the HIV studies are seriously flawed. He noted that routine circumcision was touted in the 1800s as a cure for masturbation.

“For a hundred years, circumcision has been a cure in search of a disease,” Schofield said. “All the medical findings have been debunked, but everybody keeps trying to come up with new reasons to do this.”

He notes that medical authorities in the Netherlands condemn the practice, which he and other opponents call “genital mutilation.”

For many parents, the decision isn’t medical. One local father who decided to circumcise said the decision was about letting his son fit in with peers.

“Everybody says ‘I don’t want to impose something on my child,’ but I think that’s an issue that lives in the mind of the parent, not the child,” said the 42-year-old freelance editor, who asked not be identified. “By not imposing something on them, you’ve imposed something on them, by making them different.”

Regarding his own circumcision, he noted that he hasn’t ever experienced the “feelings of loss” that some opponents describe. “I’m not sure where that feeling comes from,” he said, “but I’m pretty sure it’s not from that flap of skin.”

Cultural expectations play a role, as do family pressures. Schoen said circumcision rates tend to increase among children of immigrants, suggesting it is part of the adopted American culture.

And, of course, religion is a factor for Jews and Muslims. Samantha, a 34-year-old speech pathologist, struggled with the decision, but ultimately decided to circumcise because it is part of her faith.

“I grew up in a fairly conservative Jewish community and I wanted my son to be accepted into any Jewish community,” Samantha said. “It was a hard decision, because my husband and I are both of the opinion that under the age of 6 months, we don’t ever want to make our child cry. But this was ultimately the exception.”

For Jewish and Islamic groups, the issue is about religious choice and freedom.

“This isn’t about circumcision or about the merits of circumcision,” said Abby Porth of the Jewish Community Relations Council. “We don’t want the government involved in how we practice our religion.”

Even among opponents, government prohibition seems to be a tough sell. Parents interviewed for this article said they did not want to see their choices restricted, and some felt the proposal was anti-Semitic.

Manae Ross, a Jew who didn’t circumcise her sons, said more education is necessary before a ban would make sense.

“So many people believe this is normal and not a big deal,” Ross said. “Even though I personally believe it’s best not to do that, and not that far different from any other form of genital mutilation, I think we’re not quite ready for that. Maybe eventually.”

Schofield said it should be the choice of the child.

“That is where the choice lies, with the owner of the body that is going to undergo the surgery to the genitals,” Schofield said.

 

Demographics driving circumcision rates

With a progressive reputation and a proposal to prohibit circumcision on the ballot, one might assume that more San Franciscans are choosing to skip the snip. Yet local circumcision rates, while below the national average, are higher than California’s and appear to be rising.

Anti-circumcision activists point to the steady decline in circumcision as proof their message is getting out. “There’s huge increasing awareness,” said Lloyd Schofield, sponsor of the proposed ban on the November ballot.

But experts say demographics are the biggest factor.

The largest decline has occurred in the western United States, where the circumcision rate has dropped from 64 percent in 1979 to 41 percent in 2008, according to the Centers for Disease Control and Prevention. The Midwest, for instance, only declined from 74 to 71 percent.

That difference largely stems from the West’s higher proportion of Latinos and Asians. Typically, whites and blacks are most likely to circumcise, with Latinos and Asians least likely to do so.

Nationally, circumcision rates among whites fell only from 66 percent in 1979 to 63 percent in 2008. The rate for blacks climbed in the 1990s but then returned to its 1979 level of about 58 percent. It’s in the rate for the “all other races” category that the largest decline has been seen, from 50 percent in 1979 to 41 percent in 2008.

Dr. Edgar Schoen, a clinical professor of pediatrics at UC San Francisco, said that while Hispanic and Asian immigrants are less likely to circumcise their sons, rates appear to increase among second and third generation immigrants. “It’s a form of Americanization,” he said.

In California, which has large Hispanic and Asian populations, circumcision rates have hovered between 20 and 22 percent since 1995, according to the Office of Statewide Health Planning and Development.

But in San Francisco, circumcision rates have remained comparably high over the past 15 years, according to state figures. While the 1995 rate was 31 percent, it largely hovered in the low 40s over the past decade. In 2009, it even jumped to 46 percent. And the true rate may be higher, since circumcisions tend to be underreported.

Comparing hospitals demonstrates the extent to which ethnicity and economics matter. At San Francisco General Hospital, where mothers are often poor or minority, the circumcision rate was only 27 percent in 2010.

At California Pacific Medical Center’s California Street campus, where the ethnic mix is more white and Asian, 66 percent of the boys born between January and May were circumcised.

And California Pacific Medical Center’s St. Luke’s campus, in the more heavily Latino Mission district, reported a circumcision rate of only 11 percent in 2009.

 

Medical benefits and risks

Benefits

  • Reduced risk of urinary tract infections in the first year of life
  • Reduced risk of some sexually transmitted diseases including the human papilloma virus.
  • Studies have found that female partners of circumcised men have a lower risk of cervical cancer.
  • Studies have shown a reduced risk for HIV infection.
  • Reduced risk of foreskin problems including phimosis.

Risks

  • The complication rates for infant circumcision range from .2 percent to 2 percent in various studies.
  • The most common complications are bleeding and infection. More serious complications, such as partial amputation or even death, can occur but are extremely rare.
  • There is some evidence for reduced sensitivity.

Sources: Centers for Disease Control and Prevention, American Association of Pediatrics

 

How San Francisco compares in state

The City’s circumcision rates have hovered between 37 and 42 percent in the past decade, while California’s have remained between 20 and 22 percent.

Normal male births with circumcision, by percent

Year San Francisco California
1995 31 22
2000 40 22
2005 41 20
2009 46 22

Source: Office of Statewide Health Planning and Development

 

Circumcision rates for male newborns during birth hospitalizations, by percent

U.S. circumcision rates have declined over the past 30 years, driven largely by immigration and demographics.

Year White Black All other races
1979 65.8 57.9 50.1*
2008 62.9 57.6 41.2

*Percentage in 1980; data not available for 1979

Source: National Hospital Discharge Survey, Centers for Disease Control and Prevention

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Sara Gaiser

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