In a sunlit synagogue in Durham, North Carolina, everyone’s eyes are on an eight-day-old boy—my new nephew, bundled in his grandmother’s arms. While a rabbi speaks about new life and making the world a better place, a woman quietly sets out gauze, scissors and other tools on a table near the altar. The atmosphere is a little tense. We have all gathered to celebrate this brand-new baby. We have also come to witness the removal of his foreskin.
Ritual circumcision is a common practice for Jews and Muslims around the world. It is a legacy of God’s commandment to Abraham to circumcise his penis as a sign of their special bond, as chronicled in the Book of Genesis, and it persists as a kind of tribal marking.
In America, even irreligious Jews still embrace this initiation rite. Some blame peer pressure: “I didn’t want him to look weird,” my brother-in-law explained about his newborn son. Others take comfort in the fact that this tradition has also been blessed by the American medical establishment. Neonatal circumcision has been the most common surgery in America for over a century. Nearly six out of ten newborns are released from hospitals foreskin-free. The practice is so widespread, in fact, that one study of 90 active American medical textbooks and models found that less than a third featured a penis with foreskin intact.
Because male circumcision is so common in the states, few Americans realize how rare it is most everywhere else. The practice has fallen by the wayside in Australia, Canada, Britain and New Zealand, and fewer than one-fifth of all male Europeans are circumcised. In December, the Danish Medical Association recommended ending the practice for boys, arguing that because it permanently alters the body it should be “an informed, personal choice” that young men make for themselves.
In Germany, a district judge ruled in 2012 that ritual circumcision of juveniles is a crime that violates “the fundamental right of the child to bodily integrity.” South Korea is the only Asian country to embrace the procedure, as a kind of physiological souvenir of America’s occupation following World War II. But there, too, circumcision rates are declining fast, as the adolescent boys who would otherwise go under the knife (as per local custom) gain access to research about its purported benefits online.
Most Americans assume the practice is medically useful, like a vaccination. The medical community agrees: both the U.S. Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) claim the benefits of circumcision outweigh the risks, citing evidence that circumcision lowers a man’s risk for HIV, urinary-tract infections and penile cancer. But a closer look reveals that, at least in the industrialized world, the health benefits of circumcision may be negligible.
Circumcision, for example, does slightly lower the risk of a urinary-tract infection in male newborns. But UTIs affect fewer than 1% of uncircumcised infants and are easily treatable with antibiotics. For every six urinary-tract infections prevented through circumcision, at least one infant is likely to suffer a complication from surgery, such as hemorrhage.
Men without a foreskin do appear less likely to get penile cancer. But the disease is uncommon—affecting roughly one in 100,000 men in the US each year—and fairly treatable. (For a bit of perspective, women are 100 times more likely to get breast cancer.)
And while it is true that three randomized trials in Africa found that circumcision more than halved the risk of men getting HIV, it is harder to justify a prophylactic procedure in a place with considerably less HIV risk. In South Africa, for example, almost a quarter of the adult population is already infected, whereas in America, a little over one third of 1% (.37%) have HIV. In addition, the trials found that circumcision helped men who have sex with infected women. In America, however, HIV is transmitted primarily via nonsterile syringes or sex between men, and there is no evidence that a foreskin affects either mode.
“I have no qualms if it binds people to their God, but I think the data is pretty slim to support medical indications for circumcision,” says Timothy R.B. Johnson, a professor of obstetrics and gynecology at the University of Michigan who has authored several reports on the subject.
So what explains America’s fuss over foreskins? A closer look at how this religious rite became a national practice reveals some uncomfortable truths about health care in the US. Apparently, all it takes to popularize an elective preventative surgery with questionable health benefits is a mix of perverse incentives, personal bias, and ignorance.
First, it helps to know a bit of history. Although religious practitioners have been snipping foreskins for thousands of years, the medical practice dates from the late 19th century—a time when the causes of most diseases were poorly understood. Mystified by everything from epilepsy to madness, some physicians in both America and England began to suspect that the real trouble was phimosis, a condition when an overly tight foreskin hinders normal function. By removing the foreskin, surgeons believed they could heal all sorts of maladies, from hernias to lunacy.
Around the turn of the 20th century, American epidemiologists were also trying to explain why Jews lived longer than other groups of people. Jews tended to have lower rates of infectious diseases, such as syphilis and tuberculosis, in part because they had little sexual contact with non-Jews. But some scientists began to suspect their rude health was a product of circumcision.
At the time, surgical interventions of all kinds were becoming more popular, owing to better anesthesia and greater concern over cleanliness, which reduced hospital contagion. Doctors began recommending the operation as part of the neonatal routine. Not only did the procedure prevent phimosis, but it was also believed to make the penis more hygienic and less tempting for wayward masturbating boys (a notion that might have been quashed by something known as the scientific method). As David Gollaher explains in his book Circumcision: A History of the World’s Most Controversial Surgery, a circumcised penis swiftly became a mark of distinction, a sign of good breeding, sound hygiene and the best medicine money could buy.
In Britain, too, circumcision became a habit of the upper classes, including the royal family. Anyone who could afford to have a child delivered by a doctor rather than a midwife was keen to heed the latest scientific advice.
But this changed in the UK with the launch of the publicly funded National Health Service in 1948. Because British doctors could not agree that circumcision was necessary, the practice was not covered. At a time when most Brits were financially strapped, few cared to pay for something that suddenly seemed frivolous. Circumcision rates swiftly dropped.
In America, however, the postwar boom years created a glut of jobs, and employers often wooed workers with plush health benefits, which typically covered circumcision. A growing number of Americans could suddenly afford to give birth in hospitals, and routine infant circumcisions spiked.
This helped entrench an elective medical practice, creating generations of foreskinless fathers and doctors who were inclined to believe it was best for their sons, too. It is a trend that America’s unwieldy fee-for-service health-care handily reinforces, as doctors and hospitals have incentives for offering interventions deemed unnecessary most everywhere else.
Johnson, the University of Michigan professor of obstetrics and gynecology, observes that the procedure is “highly remunerative” for the pediatricians at his hospital.
“I think the professional charge in our state is somewhere between $150-200,” he says. “That’s real money if you can do four or five circumcisions in an hour.” In states where Medicaid does not cover the practice, rates have fallen fast.
This is not to say that official bodies such as the CDC and AAP are issuing health guidelines with an eye on the bottom line. But it is important to recognize some of the cultural biases informing America’s embrace of circumcision.
“When surgeries become the norm, the intuitive valuation of what’s at stake just shifts,” says Brian Earp, associate director of the Yale-Hastings Program in Ethics and Health Policy. He notes that because most American physicians are circumcised and work in places where the surgery is common, they are more likely to look for reasons to support the practice than question it.
As the procedure is both deeply personal and a bit taboo (no one really likes talking about genitals), few people even discuss it at all. Grown men who have never known life with a foreskin are disinclined to mourn it.
Elsewhere, however, uncircumcised physicians are better placed to appreciate this elastic, functional sleeve of tissue, which is not only tremendously sexually sensitive but also handy for protecting the head of the penis from abrasion. Government-financed health care also squeezes out costly discretionary practices, making it easier for doctors in other developed countries to see that a prophylactic surgery on healthy, non-consenting infants is not quite the most conservative, least harmful way of achieving certain results. Some uncircumcised boys will still run the risk of phimosis, but the risk is rare. A new population-based study from Denmark, where most boys are uncircumcised, found that medical necessity forced a foreskin intervention in a mere .5% of Danish boys.
Because there are less invasive ways to enjoy the negligible benefits of circumcision, some argue that the practice in America is unethical. They have a point—particularly as the surgery permanently alters those who have no say in the matter. Parents may still wish to go through with it, for religious or cultural reasons. But it would be better if more Americans questioned a medical establishment that encourages a surgery that every other country in the industrialized world recognizes as unnecessary.