While researching the multitude of questions that come with being a new mother, Tina Overton encountered one that made her dizzy: whether to circumcise her newborn son.
She never had reason to think about it before, let alone consider an alternative. But quickly, Overton became familiar with a small but vocal minority of parents and researchers arguing against circumcision. After months of scouring books, articles and the Internet, she reasoned the procedure was unnecessary, painful - and a violation of her son's human rights.
"It became clear, it was not my body to alter," said Overton, who teaches childbirth classes with her husband in their Sykesville home. "A generation ago, it was just done and nobody spoke of it or questioned it. People didn't know the issues, the complications, the discomfort, the pain. Now, thankfully, people are getting the information and choosing not to do this."
Dating back centuries, circumcision has been done for cultural, religious and medical reasons. But what was once considered standard American practice is now controversial. A debate over circumcision emerged quietly in the United States in the 1970s and, since then, the discussion has intensified and the rates of circumcision have declined.
In 2006, about 56 percent of infant boys were circumcised, a drop from 66 percent nearly a decade earlier in 1997. In at least 17 states - Maryland not included - Medicaid has stopped paying for the procedure.
The debate is fueled, in part, by conflicting medical research. Parents and advocates - or inactivists, as the no-circumcision camp is known - are battling in Internet chat rooms about culture, sex, morality, health and what to say to a boy when he asks why he doesn't look like Dad.
At issue is a surgical procedure in which topical anesthesia is given and the foreskin over the tip of the penis is removed. For centuries, circumcision has been an important rite of the Jewish and Muslim religions and, until recently, it was routinely done among American babies of all backgrounds.
On one hand, some research points to medical benefits of circumcision, including decreased incidence of urinary tract infections in infants, and a reduction in the transmission of cancer-causing human papillomavirus, HIV and other sexually transmitted diseases. Some men who have not been circumcised as infants may have to do so for medical reasons such as phimosis, a condition in which the foreskin becomes so tight that it cannot retract from the head of the penis.
Opponents point to other studies that indicate few medical benefits of circumcision. They argue it leads to decreased sexual sensitivity and say the procedure is risky, painful and cruel.
Parents wondering what to make of all this won't get a yes or no from their pediatricians. The American Academy of Pediatrics does not recommend the practice, but doesn't discourage it either. In a 1999 policy statement that reviewed data, the organization said: "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision."
Dr. Timothy Doran, chief of pediatrics at Greater Baltimore Medical Center in Towson, says he is often peppered with questions on the issue from soon-to-be parents. "I tell them that this is their own personal, religious and ethical decision, and I will support them either way," he said.
Making the decision is not always easy.
Gary and Kazuyo Kegan were uncertain what to do upon learning that they were expecting twins - a girl and a boy. Kazuyo Kegan, an assistant researcher at the Johns Hopkins Medical Center, began asking her colleagues questions. A native of Japan, she knew circumcision is rare in her home country, but wanted the latest medical answers. Meanwhile, Gary Kegan, who assumed his son would be circumcised just as he had been, began reading everything he could on the Web. Finally, the couple chose to circumcise their son, Alex, now 3 months old.
"It was a health-related choice, if nothing else," Gary Kegan said. "We noted the health benefits. There is a little less risk of urinary tract infections and some types of cancers involved. And that alone was enough."
Pediatricians tend to agree about studies concerning urinary tract infections, which have found that uncircumcised infants are about 10 times more likely to get an infection in their first year. But the findings about the impact on sexual sensitivity and contracting sexually transmitted diseases are less clear.
Opponents of circumcision note that when the foreskin is removed from the penis, an infant has lost the most sensitive area of the genitalia. "You're taking an infant's procreative organs and causing extreme pain," said Dr. Mark D. Reiss, a radiologist and executive vice president of Doctors Opposing Circumcision.
Last year, a study in the British Journal of Urology showed uncircumcised men reported a slight decrease in sensitivity. But research published in the Journal of Sexual Medicine noted that few men report sexual functioning problems or decreased sensitivity. The American Academy of Family Physicians has concluded: "The effect of circumcision on penile sensation or sexual satisfaction is unknown."
Regarding the surgical procedure, however, studies agree: It is painful for infants and should always be done with anesthesia.
Studies concerning circumcision and sexually transmitted diseases have made headlines worldwide. Last year, three studies on circumcision's relationship with HIV in three African countries prompted the United Nations and the World Health Organization to recommend that adult men in Africa get circumcised to reduce the rate of HIV transmission.
Dr. Ronald Gray, professor of reproductive epidemiology at the Johns Hopkins Bloomberg School of Public Health, the lead researcher in one of the studies, found that circumcision reduced the rate of HIV infection by nearly 60 percent. The reason is complex, but has to do with the area beneath the foreskin having a higher density for target cells for HIV infection.
But is data a world away relevant to moms and dads here deciding whether to circumcise their sons? Gray says that while few comparisons can be made with Africa, given the AIDS epidemic there, parents may want to consider the data taken together with other information.
Ryan McCallister, the founder of NotJustSkin, an anti-circumcision and parent resource group in Takoma Park, fears parents may be influenced by such studies and little else.
"People are frightened of HIV, and parents want the best for their children," said McCallister, whose group is a local chapter of the National Organization of Circumcision Information Resource Centers, or NOCIRC. "If they get a set of information that doesn't discuss the risk and complications, and they are hearing it can prevent the spread of HIV, then it probably sounds like a no-brainer to them to circumcise."
Gray said opponents to circumcision have attacked his research as inaccurate, but maintains that their arguments "are not scientific."
"I think you present parents with all the information, benefits and potential risks - and you say what do you want to do," he said. "But I don't think you should prevent parents from taking that position, on the basis of anti-circumcision propaganda."
Reiss said his group focuses on highlighting the risks of circumcision. While some of the most common complications include bleeding and infection, other problems include inflammation of the urinary opening and a narrowing of the urethra.
"Circumcision is surgery, and any time there is surgery there can be complications," he said. "Just because it is the most common surgical procedure done in the U.S. does not mean it should be done."
For that reason, he and others ask: If there is little medical basis for the surgery, why bother?
Reiss thinks most parents choose circumcision for tradition's sake.
Reiss, who is Jewish, said he counsels Jewish couples who are seeking an alternative to the Jewish bris and offers a Web site with names of rabbis who preside over the sacred ceremony minus the cutting.
"It is no longer a taboo subject," he said. "I think people are talking about it more and more and people are questioning it."
Overton, whose son Sam is now 5, offers a brief discussion on circumcision to the parents in her birthing classes. But she stays away from the polarized debate on the topic. Instead, she says she offers her opinion only if asked and tries to foster polite discussion.
During one class, a group of future fathers discussed the issue for a full hour.
"Sometimes moms get on these message boards, and it can be heated, and it doesn't need to be," Overton said. "But these men were able to share their thoughts in a safe place without being judged and I thought, 'What a wonderful thing.' "