Nursing student Diane Simard posted pink fliers all over Brigham and Women’s Hospital in Boston recently, advertising a talk titled “Another Look at Circumcision.”

The lecture was to be presented by Simard and Ronald Goldman, executive director of the Circumcision Resource Center, a Boston-based group that opposes the procedure. But a half-hour before the talk was scheduled to start, Simard was ordered to remove the signs by Dr. David Acker, chief of obstetrics at the Brigham.

“Oh, my God,” Simard said. “I was scared, he was so angry. He was in my face. He said it was too controversial and he didn’t want parents to see this.”

Acker said he merely thought a little more discretion was called for. “We did not stop her. We just suggested an alternative place,” he said. “It was a public area where people walking by could see in.”

The Brigham contretemps underscores how sensitive and controversial an issue circumcision remains in the United States, even more so since a March report by the American Academy of Pediatrics concluded that the medical benefits of circumcision no longer justify its use. Now, a no-cut consensus is starting to emerge.

And for the first time, the academy recommended that if circumcision is chosen, injections of lidocaine should be used to prevent “pain and physiologic stress.”

But the bigger issue, according to a vocal group of advocates, is why perform what has been called “the unkindest of cuts” at all.

“The United States is the only country in the world that circumcises most male infants for nonreligious reasons,” said Goldman, author of the 1997 book, “Circumcision: The Hidden Trauma.” A circumcision is performed every 25 seconds in the United States, making it the most common of all surgeries.

But in the rest of the world, 80 percent of males are uncircumcised, US parents are starting to follow suit. Circumcision rates in the country have dropped from nearly 90 percent in the late 1960s to about 60 percent today.

Still, the academy estimates that 1.2 million newborn males are circumcised in the United States each year at an estimated cost of $150 million to $270 million.

Dr. Edgar Schoen, who oversaw the 1989 report that said circumcision reduced the risks of urinary tract infections and sexually transmitted diseases, dismissed the new report as “a step backwards.”

“It’s highly biased,” said Schoen, director of the perinatal screening program at Kaiser Permanente Medical Center in Oakland, Calif. “The AAP report says it is not essential to current well-being. Well, 90 percent of what we do is not for well-being.”

Schoen also blamed a plethora of anti-circumcision Internet Web sites for putting pressure on the academy. “They stacked the deck,” he said. “The AAP should have told the parents, ‘Here are the advantages and disadvantages of circumcision,’ and let them make the decision.”

Dr. Thomas Wiswell, a professor of pediatrics at Thomas Jefferson University in Philadelphia, also criticized the report, calling it “very negative.”

“If you weigh all the potential benefits, which start immediately, they far outweigh the risks,” he says, noting that circumcision also acts as a preventative against sexually transmitted diseases. The report agrees that circumcised males have less chance of contracting sexually transmitted diseases, but it concludes that “behavioral patterns” are far more of a factor.

Fueling the circumcision controversy, Goldman thinks, is a lack of education among doctors about the procedure. “There’s a huge gap in medical education about this, and by avoiding the knowledge we avoid the anxiety,” he said. “To study it would raise a conflict, so this is the way we as a society avoid addressing that conflict.”

Goldman also said some consent forms, such as the ones used by Brigham and Women’s Hospital, are outdated and loaded with misinformation. For example, the Brigham’s information sheet says circumcision provides cleanliness benefits. But the report concludes that circumcision provides no cleanliness benefits.

“He’s entitled to his opinion,” Acker said. “Most of the consent is not in the written consent, it’s in the discussion with the nurse or doctors.”

One of the most controversial aspects of circumcision is that it is often performed without the use of an analgesic to lessen the pain.

“This is the only procedure done that involves a scalpel cutting skin that is done routinely without analgesia,” said Dr. Lisa Stellwagen, a pediatrician at Massachusetts General Hospital who said she always uses pain relief. “For decades, nurses have had to hold down these screaming babies, and it’s a horrible experience ... There’s really no excuse for not numbing up the baby anymore. The technology has been around for 20 years and is exceedingly safe.”

Although some obstetricians argued that there is also pain associated with giving a needle, most agreed that pain relief should be a no-brainer. “I was personally embarrassed,” said Acker, who began using analgesia after watching a demonstration last year by Stellwagen. “The difference is night and day.”

Brigham and Women’s Hospital now says that nine out of 10 circumcisions are performed with analgesia. But other hospitals are slower to change. Last year at Newton-Wellesley Hospital, the majority of circumcisions were performed without analgesia. Today, that number has dropped to half, said Dr. Thomas Beatty, chief of obstetrics and gynecology.

Although Stellwagen has performed about 3,000 circumcisions, all using analgesia, she is against the practice. “I think it’s not necessary,” she said. “It’s cosmetic. If parents ask me if I think it’s necessary, I often try to talk them out of it.”

One recent day, Stellwagen scheduled a circumcision for an 11-day-old boy. The father smiles broadly and tells her he wants his son to look like him, a common reason for circumcision. “It’s that Dad thing, that locker room thing,” Stellwagen says after the parents have left the room. The parents are not invited to the procedure but can attend if they insist. Most don’t.

Nurse Alexa Laurent places the baby on a plastic device called a Circumstraint. He begins to cry when his legs are strapped down. Laurent gives the baby a sugar-coated pacifier to calm him and holds his arms. “Babies don’t like to be restrained,” Stellwagen says.

Wearing gloves, Stellwagen gives the baby a series of four injections around the base of the penis. The baby cries again and there is a little blood. Stellwagen waits five minutes and begins separating the foreskin. The whole procedure takes four minutes during which the baby cries, but there is no blood-curdling scream. “He feels a little of that,” Stellwagen says. A little blood is wiped away, the baby is hugged, wrapped, and returned to the parents.

At Massachusetts General, a group of doctors and nurses on break who were polled about circumcision are overwhelmingly opposed to it. The nurses charge that some doctors do not take the time to discuss circumcision with parents. “For the great majority of Americans, circumcision is taken for granted,” said Dr. Marvin Wang, a pediatrician at the hospital. “I don’t know what this bond is that parents feel the need for the son to look like his father.”

Others think circumcision rates would tumble if parents had to pay for the procedure. “It’ll change when the insurance companies don’t cover it anymore,” said one nurse. In Britain that is exactly what happened. Once insurance stopped covering routine circumcisions in 1948, rates fell to below 1 percent.

Complication rates of circumcision are rare, but some procedures have to be redone. “I’ve heard circumcision redo rates as high as 10 percent. Parents aren’t aware of that,” Stellwagen said.

“I strongly disagree with the procedure. I think it’s totally unnecessary,” said Jane Burleson, a registered nurse at Mass. General. “It’s a big decision to make for someone who has no say in the matter. Would you make a choice to have it medically done unless there was a real compelling medical reason to do it? Why is it OK to do that?”

Nationwide, some nurses have come together against circumcision. “Why would you cut a healthy functional body part from somebody when you haven’t got their consent? It’s genital mutilation,” said Mary Conat, a registered nurse and cofounder of Nurses for the Rights of the Child, a Santa Fe advocacy group.

But human rights organizations do not see it as an issue. “Amnesty International doesn’t consider ordinary circumcision a human rights issue,” said Josh Rosenfeld, Amnesty’s northeast regional director. “There’s no comparison to female genital mutilation. It’s not castration. Should I be arrested for torture because I had a bris in my living room under Jewish law using a topical anesthesia?”

Jews and Muslims believe in circumcision, although Muslims circumcise later in childhood. Jews believe it is part of the sacred pact between Abraham and God to be performed by a specially trained mohel on the eighth day after birth. Usually the mohel uses a local analgesia cream or a wine-soaked cloth for the ceremony.

Earliest records show that circumcision began in Egypt about 4,500 years ago. It became popular in the United States in the late 19th century when doctors thought it would discourage masturbation. After World War II the procedure was sometimes automatically done without a consent form after birth.

Now, in addition to what some call the barbarism of the practice and its dubious medical benefit, many are questioning circumcision on the grounds that it can make sex less enjoyable for the male.

“We have a country of males who don’t get to choose whether they want their primary erogenous tissue,” said Dr. Christopher Cold, a clinical pathologist from Wisconsin. “It’s insane. You’re taking part of the sex organ and removing it. There’s nerve endings there. A man with a complete penis has more erogenous sensations. The normal response is they would have a greater sex life.”

But Cold acknowledged that the debate on the sexual effects of circumcision obscures the more fundamental issue of whether the practice should be carried out at all. “Do we automatically lump off a little girl’s breast as a protective measure because 47,000 women die each year of breast cancer? Do we pull out all the teeth and say now you can never get a cavity?”

Burleson said she now regrets that her son was circumcised. “I feel very badly about it,” she said. “I was clearly uninformed. At 4 years old, my son announced from the back seat of the car that he remembers when they cut his penis. I felt terrible. If I had the choice to make again I wouldn’t do that, even if my husband said yes. He wouldn’t have any say in the matter.”

This story ran on page A01 of the Boston Globe on 07/25/99. © Copyright 1999 Globe Newspaper Company.