The Case Against the Case Against Circumcision

Photo: Hannah Whitaker/New York Magazine

Anyone with a heart would agree that the Jewish bris is a barbaric event. Grown-ups sit chatting politely, wiping the cream cheese off their lips, while some religious guy with minimal medical training prepares to slice up a newborn’s penis. The helpless thing wakes up from a womb-slumber howling with pain. I felt near hysterical at both of my sons’ brisses. Pumped up with new-mother hormones, I dug my nails into my palms to keep from clawing the rabbi. For a few days afterward, I cursed my God and everyone else for creating the bloody mess in the diaper. But then the penis healed and assumed its familiar heart shape and I promptly forgot about the whole trauma. Apparently some people never do.

I am Jewish enough that I never considered not circumcising my sons. I did not search the web or call a panel of doctors to fact-check the health benefits, as a growing number of wary Americans now do. Despite my momentary panic, the words “genital mutilation” did not enter my head. But now that I have done my homework, I’m sure I would do it again—even if I were not Jewish, didn’t believe in ritual, and judged only by cold, secular science.

Every year, it seems, a new study confirms that the foreskin is pretty much like the appendix or the wisdom tooth—it is an evolutionary footnote that serves no purpose other than to incubate infections. There’s no single overwhelming health reason to remove it, but there are a lot of smaller health reasons that add up. It’s not critical that any individual boy get circumcised. For the growing number of people who feel hysterical at the thought, just don’t do it. But don’t ruin it for the rest of us. It’s perfectly clear that on a grand public-health level, the more boys who get circumcised, the better it is for everyone.

Twenty years ago, this would have been a boring, obvious thing to say, like feed your baby rice cereal before bananas, or don’t smoke while pregnant. These days, in certain newly enlightened circles on the East and West Coasts, it puts you in league with Josef Mengele. Late this summer, when the New York Times reported that the U.S. Centers for Disease Control might consider promoting routine circumcision as a tool in the fight against AIDS, the vicious comments that ensued included references to mass genocide.

There’s no use arguing with the anti-circ activists, who only got through the headline of this story before hunting down my e-mail and offering to pay for me to be genitally mutilated. But for those in the nervous middle, here is my best case for why you should do it. Biologists think the foreskin plays a critical role in the womb, protecting the penis as it is growing during the third month of gestation. Outside the womb, the best guess is that it once kept the penis safe from, say, low-hanging thorny branches. Nowadays, we have pants for that.

Circumcision dates back some 6,000 years and was mostly associated with religious rituals, especially for Jews and Muslims. In the nineteenth century, moralists concocted some unfortunate theories about the connection between the foreskin and masturbation and other such degenerate impulses. The genuinely useful medical rationales came later. During the World War II campaign in North Africa, tens of thousands of American GIs fell short on their hygiene routines. Many of them came down with a host of painful and annoying infections, such as phimosis, where the foreskin gets too tight to retract over the glans. Doctors already knew about the connection to sexually transmitted diseases and began recommending routine circumcision.

In the late eighties, researchers began to suspect a relationship between circumcision and transmission of HIV, the virus that causes AIDS. One researcher wondered why certain Kenyan men who see prostitutes get infected and others don’t. The answer, it turned out, was that the ones who don’t were circumcised. Three separate trials in Uganda, Kenya, and South Africa involving over 10,000 men turned up the same finding again and again. Circumcision, it turns out, could reduce the risk of HIV transmission by at least 60 percent, which, in Africa, adds up to 3 million lives saved over the next twenty years. The governments of Uganda and Kenya recently started mass-circumcision campaigns.

These studies are not entirely relevant to the U.S. They apply only to female-to-male transmission, which is relatively rare here. But the results are so dramatic that people who work in AIDS prevention can’t ignore them. Daniel Halperin, an AIDS expert at the Harvard School of Public Health, has compared various countries, and the patterns are obvious. In a study of 28 nations, he found that low circumcision rates (fewer than 20 percent) match up with high HIV rates, and vice versa. Similar patterns are turning up in the U.S. as well. A team of researchers from the CDC and Johns Hopkins analyzed records of over 26,000 heterosexual African-American men who showed up at a Baltimore clinic for HIV testing and denied any drug use or homosexual contact. Among those with known HIV exposure, the ones who did turn out to be HIV-positive were twice as likely to be uncircumcised. There’s no causal relationship here; foreskin does not cause HIV transmission. But researchers guess that foreskins are more susceptible to sores, and also have a high concentration of certain immune cells that are the main portals for HIV infection.

Then there are a host of other diseases that range from rare and deadly to ruin your life to annoying. Australian physicians give a decent summary: “STIs such as carcinogenic types of human papillomavirus (HPV), genital herpes, HIV, syphilis and chancroid, thrush, cancer of the penis, and most likely cancer of the prostate, phimosis, paraphimosis, inflammatory skin conditions such as balanoposthitis, inferior hygiene, sexual problems, especially with age and diabetes, and, in the female partners, HPV, cervical cancer, HSV-2, and chlamydia, which is an important cause of infertility.” The percentages vary in each case, but it’s clear that the foreskin is a public-health menace.

Edgar Schoen, now a professor emeritus of pediatrics at the University of California San Francisco, has been pushing the pro-circumcision case since 1989, when he chaired an American Academy of Pediatrics Task Force on the practice. The committee later found insufficient evidence to recommend routine circumcision, but to Schoen, this is the “narrow thinking of neonatologists” who sit on the panels. All they see is a screaming baby, not a lifetime of complications. In the meantime, sixteen states have eliminated Medicaid coverage for circumcision, causing the rates among Hispanics, for one, to plummet. For Schoen and Halperin and others, this issue has become primarily a question of “health-care parity for the poor.” The people whom circumcision could help the most are now the least likely to get it.

This mundane march of health statistics has a hard time competing with the opposite side, which is fighting for something they see as fundamental: a right not to be messed with, a freedom from control, and a general sense of wholeness. For many circumcision opponents, preventive surgery is a bizarre, dystopian disruption. I can only say that in public health, preventive surgery is pretty common—appendix and wisdom teeth, for example. “If we could remove the appendix in a three- or four-minute operation without cutting into the abdomen, we would,” says Schoen. Anesthesia is routine now, so the infants don’t suffer the way they used to. My babies didn’t seem to howl more than they did in their early vaccines, particularly the one where they “milk” the heel for blood.

Sexual pleasure comes up a lot. Opponents of circumcision often mention studies of “penile sensitivity regions,” showing the foreskin to be the most sensitive. But erotic experience is a rich and complicated affair, and surely can’t be summed up by nerve endings or friction or “sensitivity regions.” More-nuanced studies have shown that men who were circumcised as adults report a decrease in sexual satisfaction when they were forced into it, because of an illness, and an increase when they did it of their own will. In a study of Kenyan men who volunteered for circumcision, 64 percent reported their penis to be “much more sensitive” and their ease of reaching orgasm much greater two years after the operation. In a similar study, Ugandan women reported a 40 percent increase in sexual satisfaction after their partners were circumcised. Go figure. Surely this is more psychology than science.

People who oppose circumcision are animated by a kind of rage and longing that seems larger than the thing itself. Websites are filled with testimonies from men who believe their lives were ruined by the operation they had as an infant. I can only conclude that it wasn’t the cutting alone that did the ruining. An East Bay doctor who came out for circumcision recently wrote about having visions of tiny foreskins rising up in revenge at him, clogging the freeways. I see what he means. The foreskin is the new fetus—the object that has been imbued with magical powers to halt a merciless, violent world—a world that is particularly callous to children. The notion resonates in a moment when parents are especially overprotective, and fantasy death panels loom. It’s all very visual and compelling—like the sight of your own newborn son with the scalpel looming over him. But it isn’t the whole truth.

The Case Against the Case Against Circumcision