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Circumcision on a Budget?

A visit to L.A.’s Gentle Circumcision, the clinic where tips are snipped for a fraction of a hospital’s fee

Dr. Jerome Pittman, founder of the Gentle Circumcision clinic in Culver City, CA, estimates that he gets through about 15 procedures a day. Newborns in the morning, older kids in the afternoon, adults on Fridays (so they have time to heal before work on Monday). School-age patients spike during summer break, with infants squeezed in between, but now that class is back in session, it’s “mostly all newborns,” Pittman says. “It’s a seasonal thing.”

When he opened the clinic in 2005, it was supposed to be his low-key gateway to retirement after 20 years as a general pediatrician, with just a handful of procedures scheduled each week. That didn’t last for long. “People found out that I was doing this exclusively, and it just snowballed from there,” Pittman says. “The next thing you know, we were in the circumcision business.”

And Pittman’s circumcisions are the best deals in town, ranging from $175 for newborns to $1,600 for adults, compared to a hospital’s range of anywhere from $800 to $3,000. “The whole idea was to make it affordable,” Pittman says. In his years as a general pediatrician, he saw how the hospital system puts parents in a tough spot, especially if their baby can’t be circumcised within the first few weeks because of complications during the birth or other health problems. In those situations, Pittman says, “traditionally the hospital would make you wait until the baby was one year old, then have it done by the urologist under general anesthesia,” which makes the cost skyrocket.

How does he keep prices so low? Two words: local anesthesia. “This is not a major procedure, you know what I mean?”

Most of the time they just numb the skin around the penis for the operation, avoiding the cost and complications that come with putting a patient under. “It’s like you’re going to the dentist,” Pittman says.

That’s except for the most involved adult circumcisions, which Pittman hands off to Gentle’s resident urologist and which can involve general anesthesia. The price increases for each age group mostly result from an increasing risk of complications and the attendant rise in malpractice insurance rates as the patients get older. Plus, at a certain age and size, Pittman has to operate “freehand” on the member in question — rather than using one of the devices that simplify the procedure for younger patients — which increases the difficulty and the amount of time required.

From his sixth-story corner office, Pittman points to some of the hospitals that regularly guide patients his way. “Some of my biggest referral centers are UCLA, Cedars, Centinela, and even Rady [Children’s Hospital] down in San Diego — they’ve got a trek coming up the 5 freeway now.”

If they’re referring foreskins his way, why not just cut costs themselves? “I think it’s a money issue, and when I say that, I mean profit motive.” The prices aren’t low just because Pittman keeps his overhead down — he opened Gentle Circumcision precisely to provide low-cost services.

“The mission was to take the cost part out of it,” Pittman says. “If you wanted your child to have a circumcision, it should be affordable — it’s as simple as that. My staff are always saying I’m crazy — I’m not gonna get rich off this, by any means.”

That cost-cutting model has proven popular to a wider base than Pittman anticipated. His client base reflects the diversity of Southern California, including everyone from Filipinos to African Americans. “We think Jews, and Muslims sometimes, but everybody has their thing,” he says. “When we opened, no Hispanics were circumcised, and now I’d probably say they make up a quarter of my patients.”

Though the CDC and the American Academy of Pediatrics have officially recommended the procedure in recent years—given the evidence that it reduces the risk of UTIs, penile cancer, and STIs—sometimes, Pittman counsels against circumcision, when a newborn needs to heal after a rough birth, or his penis needs to develop more fully before the procedure can proceed safely. Other times, it’s clear that the parents don’t agree on whether they want to send their child in for alterations.

“Parents will ask, ‘Why should I be doing this?’, and that throws up that red flag,” Pittman says. “By the time you get to me, you need to have done your homework and come to some decision — I’m going to send you home with some resources, and then let’s decide. Often though, they have done the research, and they really just want me to say ‘Yes, he should have a circumcision.’ But that decision is not my decision.”

Pittman generally recommends against operating on what he calls “school-age” kids. Physical pain isn’t the problem as much as the psychological impact. “Around four or five, or maybe before that, he’s discovering his penis, and his uniqueness, his difference between him and his sister, you know?” Pittman says. “And then all of a sudden you’re changing things.”

As we spoke, patients started filtering into the waiting room for afternoon follow-up appointments. Based on the crying, one patient was clearly none too thrilled with his first visit.

For the most part, based on Gentle Circumcision’s many online reviews, Pittman’s customers walk away happy. But he does have his vocal critics — the intactivists, who consider male circumcision to be a cruel and barbaric practice. Yelp and Google are both helpful in removing the one-star reviews of strangers who haven’t stepped foot in Pittman’s clinic, but Facebook has proven problematic. “Facebook allows opinions.”

Five years ago, in fact, Facebook shut down Gentle Circumcision’s page due to the intactivists’ overwhelming, coordinated review-bombing. “They come in groups, and call us all kinds of names and so forth,” Pittman says, “and Facebook counts their ratings whether they’ve ever seen us before or not.” An “unofficial” page for Gentle Circumcision, started by intactivists, is still up on Facebook, filled with articles criticizing the procedure as a “violation of human rights” and memes promoting “foreskin pride.”

Pittman knew that this would be waiting for him when he first decided to dedicate himself to the circumcision business, but he didn’t think that the ideologically opposed would be quite so vehement. Once, he says, a man stopped by, asked his receptionists hostile questions, and threatened to come back and sit in the waiting room to convince patients to leave their boys uncut. “We haven’t heard from him since,” Pittman says, “but I always tell my staff to be prepared.”

The crying from out front seemed to be getting louder. Pittman had to get back to work, and he got up to show me out. In the waiting room, he asked the patient’s father how old his son was: three. “Yeah, that’s a tough, tough age.”

He said that the intactivists had gotten under his skin at first. “I was kind of hiding before, just like, ‘Don’t bother me.’” But it was hard to picture him shaken — in the face of his patient’s full-blown snot-flying sob mode, Pittman seemed as calm and cheerful as he had all afternoon. With eleven years as L.A.’s only dedicated circumciser under his belt, and a growing practice, he’s back to being unflappable. “Now it’s like, hey, you know something? It is what it is — I can’t hide it. I guess I’m stuck.”