Correction National Post Dr. Khalid Aziz, a physician in Newfoundland and spokesman for the Canadian Paediatric Society's committee on newborns, does not perform circumcisions. Incorrect information appeared in a story on Jan. 22. The National Post regrets the error.

Dave Sidaway, The Gazette "Out of the many decisions new parents make, this is the one that fathers really want to have input on," says Karen Weinthal, a prenatal instructor at Toronto's Women's College Hospital.

When it is time for her prenatal class to discuss circumcision, Karen Weinthal always turns to the fathers first. She goes around the room, asking each of the men what they will do if the baby is a boy.

"Out of the many decisions new parents make, this is the one that fathers really want to have input on. They may not care about diapers or all the other stuff, but you can bet they have an opinion on this one," says Weinthal, who has been teaching prenatal classes at Toronto's Women's College Hospital for 18 years.

The discussions are never dull. British, French and South American parents are usually appalled at even contemplating an act they equate with female genital mutilation. For most of the Jewish and Muslim parents, it is an unavoidable cultural necessity.

"In the end, most of them decide according to 'Like father, like son.' After all the debate and conflicting information and accusations that it's mutilation or it's barbaric ... For most parents, it's a gut thing that they go with," says Weinthal.

Circumcision, which is usually done during the first few days of a baby boy's life, removes the inner and outer layers of the foreskin from around the head of the penis. The surgery is rooted in a medical tradition that once held that it reduced the chances of disease and infection.

Jews and some Christians have always justified the surgery with a passage in the book of Genesis declaring that every male shall be circumcised as a sign of the covenant between God and Abraham. Jesus is said to have been circumcised.

When Weinthal first started teaching prenatal classes, the decision was considerably less vexing than it is now. In 1970, it was estimated as many as 97% of all boys and men in the United States and anywhere from 50% to 75% of all Canadian males were circumcised. Recent statistics estimate that today only 25% of all newborn boys are circumcised. The change is a result of 20 years of studies on the procedure.

Many hospitals no longer offer circumcisions and most provinces refuse to pay for them. New parents are left to find a place that will circumcise their child, book an appointment in the baby's first few days of life, and pay about $150 for the procedure.

The debate over circumcision has become such an emotive subject that some doctors who believe in the medical benefits of circumcision have received threatening letters from a growing anti-circumcision lobby.

The medical community is divided. There have been hundreds of contradictory studies on the subject of circumcision. Some show that it reduces the risk of urinary tract infection, HIV and penile cancer. Others detail the impact of pain and the ineffectiveness of pain-relief methods commonly used in the procedure. In addition, the Internet is filled with testimonials from men claiming they were stripped of their full range of sexual feeling when their foreskin was removed. There is even a movement dedicated to those intent on rebuilding the lost folds of skin: National Organization of Restoring Men.

Last week, the Ontario Human Rights Commission entered the fray. Dr. Arif Bhimji, a Toronto-area physician, had asked the commission to denounce routine male circumcision in the same way it condemns female genital mutilation. Rather than do that, the commission simply revoked its existing policy, which had said that male circumcision caused no damage to the penis and presented minimal danger.

The move is being hailed as a victory by anti-circumcision advocates, such as Lawrence Barichello, executive director of an organization called Intact, which is organizing a class-action lawsuit on behalf of Canadian men circumcised as infants.

But others like Dr. Khalid Aziz, a physician in Newfoundland and spokesman for the Canadian Pediatric Society's committee on newborns, are more skeptical. He says the policy change is really just another example of an organization trying to be uncontroversial over an issue that is rife with passionate opinion but lacking in strong medical evidence.

In 1996, the Canadian Pediatric Society released its circumcision policy, which stated that routine circumcisions were not medically necessary. The American Academy of Pediatrics released a similar statement in 1999.

The Canadian statement, which was contained in a detailed report in the Canadian Medical Association Journal, came after an examination of nearly 700 published studies on circumcision.

Among its findings:

- Even though circumcision results in an approximately twelvefold reduction in the incidence of urinary-tract infection in infancy, more evidence is required on alternative methods of preventing these infections, including more information about the effect of simple hygienic interventions.

- The incidence of complications with circumcision is generally between 0.2% to 2%, mostly minor complications, but more epidemiological data are needed on the incidence of surgical complications, later complications and problems associated with being uncircumcised.

- There is evidence that circumcision results in a reduction in the incidence of penile cancer and of HIV transmission, but the evidence was inadequate for recommending circumcision as a public health measure to prevent these diseases.

The report concluded that "the overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns.

"When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms," the policy said.

The difficulty for most parents is that there continues to be a plethora of contradictory medical evidence out there.

Detailed studies from the U.S. Army have documented the increased incidence of urinary tract infections in uncircumcised boys. The studies by Dr. Ted Wiswell examined all infants born in U.S. Army hospitals around the world over a 10-year period and found that uncircumcised male infants had a higher incidence of urinary-tract infection than female infants, and a tenfold greater incidence of infection than circumcised male infants.

In 1998, researchers from Toronto's Hospital for Sick Children found that circumcising infant boys reduces the risk of bladder and kidney infections, but not as much as previously thought. Dr. Teresa To's study of 60,000 boys born in Ontario between 1993 and 1994 showed that the risk of urinary tract infection in the first three years was only 3.7 times higher in uncircumcised boys.

Last summer, the British Medical Journal reported that uncircumcised men are at much greater risk of becoming infected with HIV than circumcised men. Using information from over 40 previous studies, Australian researchers suggested that the virus targets specific cells found on the inner surface of the foreskin. These cells possess HIV receptors, making this area particularly susceptible to infection.

The most dramatic evidence of the possible protective effect of circumcision comes from a new study of couples in Uganda, where the woman was HIV positive and her male partner was not. Over a period of 30 months, no new infections occurred among 50 circumcised men, whereas 40 of 137 uncircumcised men became infected.

To further complicate the decision, researchers at the University of Washington recently conducted a series of tests on complications resulting from circumcisions. They came up with a trade-off analysis that for every case of a boy who has a complication from circumcision, six boys can be expected to have avoided urinary-tract infections, and for every two cases of circumcision complications, one case of penile cancer is prevented.

"Now, I can tell parents that one in 500 circumcised children may suffer a complication, and one in 100 children may derive a benefit," says Dr. Dimitri Christakis, an assistant professor of pediatrics at the university's school of medicine. "However, the vast majority of children will gain no medical benefit nor suffer any complication as a result of circumcision."

Aziz, of the Canadian Pediatric Society, says that because the medical evidence is so contradictory and because there are no properly randomized control trials with long-term follow-ups, "I doubt whether we will ever be unequivocally against male circumcision."

He says the critical thing for the medical community is that these operations should be done for the right reasons, "and as physicians, we should be doing things because they are medically indicated."

Aziz says the most difficult justification for circumcision is unfortunately the most common one, which is essentially cosmetic -- because of family tradition, because the father is circumcised, because it just looks better to the parents.

"At some point, society has to make a decision on this, but we are a long way from that," says Aziz. As a physician practising in Newfoundland, where it is very rare to have a baby circumcised, he performs maybe one circumcision a year. When he was practising in Alberta, where about half of the baby boys were circumcised, a circumcision was almost a daily thing.

One Hamilton, Ont., mother of six boys, aged 14 down through to four, says: "When I had the first boy, it was just assumed that it would be done and I would have been looked upon as a fanatic if I had questioned it. By the time I got to the later boys, when there was more questioning about it all, I made the decision cosmetically, in that I wanted the boys to all look the same.

"I did feel terrible when the procedure was being done and for a few days after the procedure, but I really felt it was important they all be the same," says the mother, who does not want her name used.

For those who agonize over the pain they are inflicting on their babies, some physicians can offer a quicker, relatively painless alternative to the traditional method.

Dr. Neil Pollock, a Vancouver-area physician who is also a trained mohel designated to perform ritual Jewish circumcisions, has pioneered a technique with Dr. Murray Katz of Montreal using a four-step approach to pain relief and a piece of equipment that allows for a much quicker operation.

Pollock's circumcision using a Mogen clamp can be done in less than a minute, compared to an average of about 15 minutes using the traditional Bell Gomco technique.

The Mogen clamp, which is seldom used except by mohels, draws the foreskin together over the tip of the penis, rather than stretching it away, before it is cut off.

Pollock's method, which was highlighted last summer in the Archives of Pediatric and Adolescent Medicine, also combines various methods of pain relief for the baby: brown sugar granules wrapped in gauze soaked in grape juice, Tylenol, a topical anesthetic cream, and a modified dorsal-penile nerve block injected into the soft tissue.

Daiva Ratavicius, a Toronto mother of a five-year-old boy, remembers when her son came back from his circumcision surgery "with his little bandage wrapped around it, and I cried and cried."

She and her husband had agonized over the decision and were tormented and confused by the contradictory material that abounds on the pros and cons of circumcising.

In the end, she said, what swayed them was the desire to reduce any risk of infection in case their son ever travelled to foreign countries: "It is agonizing, but it boils down to an emotional reaction."