On a recent Saturday morning, Craig Adams stood outside the Robert Wood Johnson University Hospital in New Brunswick, New Jersey. It was sunny but cold. Adams, who had turned 40 the day before, wore white sneakers and a black T-shirt over a long-sleeve shirt. A fuzz of thinning hair capped his still-youthful face. His appearance would have been unremarkable if not for the red splotch of fake blood on the crotch of his white trousers. The stain had the intended effect: drivers rounding the corner were slowing down just enough to see the sign he was holding, which read “No Medical Excuse for Genital Abuse”.
Next to him, Lauren Meyer, a 33-year-old mother of two boys, held another sign, a white poster adorned only with the words: “Don’t Cut His Penis”. She had on a white hoodie with a big red heart and three red droplets, and a pair of leopard-print slipper-boots to keep her feet warm for the several hours she would be outside. Meyer’s first son is circumcised; she sometimes refers to herself as a “regret mother” for having allowed the procedure to take place.
It was two days after Christmas. Adams and Meyer had each driven about an hour to stand by the side of a road holding up signs about penises. On that same day, a woman stood alone at what qualifies as a busy intersection in the small town of Show Low, Arizona. She also wore white trousers with a red crotch, and held aloft anti-circumcision signs. A few people more people did the same in the San Francisco Bay area.
The protests were triggered by a recent event, but the issue at stake was an ancient one. Circumcision has been practised for millennia. Right now, in America, it is so common that foreskins are somewhat rare, and may become more so. A few weeks before the protests, the Centers for Disease Control and Prevention had suggested that healthcare professionals talk to men and parents about the benefits of the procedure, which include protection from some sexually transmitted diseases, and the risks, which the CDC describes as low. But as the protesters wanted drivers to know, there is no medical consensus on this issue. Circumcision isn’t advised for health reasons in Europe, for instance, because the benefits remain unclear. Meanwhile, Western organisations are paying for the circumcision of millions of African men in an attempt to rein in HIV – a campaign that critics say is also based on questionable evidence.
Men have been circumcised for thousands of years, yet our thinking about the foreskin seems as muddled as ever. And a close examination of this muddle raises disturbing questions. Is this American exceptionalism justified? Should we really be funding mass circumcision in Africa? Or by removing the foreskins of men, boys and newborns, are we actually committing a violation of human rights?
The tomb of Ankhmahor, a high-ranking official in ancient Egypt, is situated in a vast burial ground just outside Cairo. A picture of a man standing upright is carved into one of the walls. His hands are restrained, and another figure kneels in front of him, holding a tool to his penis. Though there is no definitive explanation of why circumcision began, many historians believe this relief, carved more than four thousand years ago, is the oldest known record of the procedure.
The best-known circumcision ritual, the Jewish ceremony of brit milah, is also thousands of years old. It survives to this day, as do others practised by Muslims and some African tribes. But American attitudes to circumcision have a much more recent origin. As medical historian David Gollaher recounts in his book Circumcision: A History of the World’s Most Controversial Surgery, early Christian leaders abandoned the practice, realising perhaps that their religion would be more attractive to converts if surgery wasn’t required. Circumcision disappeared from Christianity, and the secular Western cultures that descended from it, for almost two thousand years.
Then came the Victorians. One day in 1870, a New York orthopaedic surgeon named Lewis Sayre was asked to examine a five-year-old boy suffering from paralysis of both legs. Sayre was the picture of a Victorian gentleman: three-piece suit, bow tie, mutton chops. He was also highly respected, a renowned physician at Bellevue Hospital, New York’s oldest public hospital, and an early member of the American Medical Association.
After the boy’s sore genitals were pointed out by his nanny, Sayre removed the foreskin. The boy recovered. Believing he was on to something big, Sayre conducted more procedures. His reputation was such that when he praised the benefits of circumcision – which he did in the Transactions of the American Medical Association and elsewhere until he died in 1900 – surgeons elsewhere followed suit. Among other ailments, Sayre discussed patients whose foreskins were tightened and could not retract, a condition known as phimosis. Sayre declared that the condition caused a general state of nervous irritation, and that circumcision was the cure.
His ideas found a receptive audience. To Victorian minds many mental health issues originated with the sexual organs and masturbation. The connection had its roots in a widely read 18th-century treatise entitled Onania, or the Heinous Sin of Self-Pollution, and All Its Frightful Consequences, in Both Sexes, Considered. With Spiritual and Physical Advice to Those Who Have Already Injur’d Themselves By This Abominable Practice. The anonymous author warned that masturbation could cause epilepsy, infertility, “a wounded conscience” and other problems. By 1765 the book was in its 80th printing.
Later puritans took a similar view. Sylvester Graham associated any pleasure with immorality. He was a preacher, health reformer and creator of the graham cracker. Masturbation turned one into “a confirmed and degraded idiot”, he declared in 1834. Men and women suffering from otherwise unlabelled psychiatric issues were diagnosed with masturbatory insanity; treatments included clitoridectomies for women, circumcision for men.
Graham’s views were later taken up by another eccentric but prominent thinker on health matters: John Harvey Kellogg, who promoted abstinence and advocated foreskin removal as a cure. (He also worked with his brother to invent the cornflake.) “The operation should be performed by a surgeon without administering anesthetic,” instructed Kellogg, “as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment.”
Counter-examples to Sayre’s supposed breakthrough could be found in operating theatres across America. Attempts to cure children of paralysis failed. Men, one can assume, continued to masturbate. It mattered not. The circumcised penis came to be seen as more hygienic, and cleanliness was a sign of moral standards. An 1890 journal identified smegma as “infectious material”. A few years later, a book for mothers – Confidential Talks on Home and Child Life, by a member of the National Temperance Society – described the foreskin as a “mark of Satan”. Another author described parents who did not circumcise their sons at an early age as “almost criminally negligent”.
By now, the circumcision torch had passed from Sayre to Peter Charles Remondino, a popular San Diego physician descended from a line of doctors that stretched back to 14th-century Europe. In an influential 1891 book about circumcision, Remondino described the foreskin as a “malign influence” that could weaken a man “physically, mentally and morally; to land him, perchance, in jail or even in a lunatic asylum”. Insurance companies, he advised, should classify uncircumcised men as “hazardous risks”.
Further data came from studies of the “Hebrew penis”, which showed a “superior cleanliness” that had protective benefits, according to John Hutchinson, an influential surgeon at the Metropolitan Free Hospital of London. Hutchinson and others noted that Jews had lower rates of syphilis, cancer and mental illness, greater longevity, and fewer stillbirths – all of which they attributed to circumcision. Remondino agreed, calling circumcision “the real cause of differences in longevity and faculty for enjoyment of life that the Hebrew enjoys”.
By the turn of the 20th century the Victorian fear of masturbation had waned, but by then circumcision become a prudent precaution, and one increasingly implemented soon after birth. A desire to prevent phimosis, STDs and cancer had turned the procedure into medical dogma. Antiseptic surgical practices had rendered it relatively safe, and anaesthesia made it painless. Once a procedure for the relatively wealthy, circumcision had become mainstream. By 1940, around 70 per cent of male babies in the United States were circumcised.
In the decades since, medical practice has come to rely increasingly on evidence from large research studies, which, as many American doctors see it, have supported the existing rationale. When the CDC made its recent statement, for example, it cited studies showing that circumcision reduces the risk of urinary tract infection, several STDs, penile cancer, phimosis, balanitis (inflammation of the foreskin and head of the penis) and HIV. The CDC even noted benefits for women with circumcised partners, namely a lower risk of cervical cancer linked to human papillomavirus.
The mechanism behind these benefits is simple: the warm and moist region under the foreskin can house the bacteria and viruses that cause disease. A circumcised penis can’t be colonised so easily; without the blanket, it’s harder to hide. Circumcision also removes a large quantity of Langerhans cells, a component of the immune system that, according to some research, is targeted by HIV.
During the second half of the last century, an accumulation of studies demonstrated the beneficial impacts of these mechanisms. At times the research helped all but end the debate over circumcision. By the 1970s, for instance, more than 90 per cent of US men were circumcised, according to one study. The American foreskin had become a thing of the past.
Today circumcision is among the most common surgeries in the US: an estimated 1.2 million infants are circumcised each year, at a cost of up to $270 million. Its popularity has fluctuated since the peak of the 1970s; the CDC’s most recent estimate puts the current rate at 60 per cent of newborns. This may in part be because the American Association of Pediatrics (AAP) for a time equivocated over the issue. But in 2012 the AAP announced that benefits of circumcision outweighed the risks, suggesting that rates may rise again.
Yet whether it’s 60 or 90 per cent of American men who are circumcised, what’s more remarkable is that American parents are almost alone in the Western world in their desire to separate boys from their foreskins for reasons other than religion. This difference of opinion is decades old. It began in 1949, when a British paediatrician and scientist named Douglas Gairdner published the first investigation of the rationale for circumcision in English-speaking countries. He found the procedure to be unwarranted.
Phimosis, the condition Sayre held responsible for so many neuroses, was essentially a non-issue, said Gairdner. He discovered something that had somehow gone undocumented before: that most foreskins remain unretracted well into the toddler years. Phimosis is the natural state of the penis, Gairdner concluded. (Later work would confirm that the foreskin sometimes does not fully retract until the teenage years.) This was just the beginning. Gairdner showed that balanitis and posthitis, forms of inflammation that were considered cause for circumcision, were uncommon. He found no data to show that circumcision could prevent venereal diseases and little evidence for a lesser risk of cervical cancer. Cleaning the intact foreskin would do as much to thwart penile cancer as would removing it, he added.
At the National Health Service, which was founded a year before Gairdner’s paper appeared, officials heeded his advice and refused to cover circumcision unless it was medically necessary. By 1958, the circumcision rate in the United Kingdom had fallen to close to 10 per cent. Excluding British men who are circumcised for religious reasons, the rate is now 6 per cent or lower.
The situation is much the same elsewhere in Europe. The Victorian focus on circumcision was concentrated in English-speaking countries, and its popularity never spread. When European experts examine the evidence, they generally see no reason that it should. In 2010, for instance, the Royal Dutch Medical Association reviewed the same studies the AAP looked at. Aside from preventing urinary tract infections, which can be treated with antibiotics, it concluded that the health benefits of circumcision are “questionable, weak, and likely to have little public health relevance in a Western context”.
How can experts who have undergone similar training evaluate the same studies and come to opposing conclusions? I’ve spent months scrutinising the medical literature in an attempt to decide which side is right. The task turned out to be nearly impossible. That’s partly because there is so much confused thinking around the risks and benefits of circumcision, even among trained practitioners. But it’s also because, after reading enough studies, I realised that the debate doesn’t have a scientific conclusion. It is impossible to get to the bottom of this issue because there is no bottom.
Assessing the true risks of circumcision is the first challenge. Immediate complications are usually easily treatable, and also relatively rare – the AAP report states that problems like bleeding and infection occur in up to 1 in 100 circumcisions. But the frequency of later problems is less well understood. Some studies find few; others conclude that as many as one in four patients suffer some kind of complication after the surgery and subsequent wound healing. The possible late problems are many. The remaining foreskin tissue can adhere to the penis. The opening of the urethra may narrow, making urination painful and preventing the bladder from fully emptying, which in turn can lead to kidney problems. Craig Adams, the New Jersey protester, had to have surgery to correct such a problem when he was five years old. Lauren Meyer’s first son had surgery for the same reason when he was three. Other late complications include a second surgery to correct an incomplete circumcision, a rotated penis, recurrent phimosis, and concealment of the penis by scar tissue, a condition commonly known as buried penis.
The AAP acknowledges some uncertainty surrounding the data on risks, but not in a way that a parent looking for advice is likely to fully grasp. “The true incidence of complications after newborn circumcision is unknown,” the AAP’s recent report states. But complications are risks. “They’re saying, ‘The benefits outweigh the risks but we don’t know what the risks are,’” says Brian Earp, research fellow at Oxford University’s Uehiro Centre for Practical Ethics. “This is basically an unscientific document.”
The debate about the effectiveness of circumcision can be just as convoluted. One way of thinking about this is the number needed to treat (NNT), a figure that answers the question: how many people need to be treated with this approach in order to prevent one illness? For the ideal treatment the answer is one. But penile cancer is rare and circumcision doesn’t provide complete protection against it, so around 900 circumcisions are needed to prevent a single case. That’s a very high NNT. By comparison, 50 people need to take aspirin to prevent one cardiovascular problem.
It’s also worth noting that other preventive methods can have a greater impact on penile cancer. The American Cancer Society suggests avoiding smoking, for example. The same logic applies to sexually transmitted diseases. Studies show that circumcision reduces the chances of a man contracting herpes, for example. But the risk of this and every known STD can be stopped or at least dramatically reduced by correct and consistent condom use. “The benefits can all be obtained in other ways,” says Adrienne Carmack, a Texas-based urologist who opposes routine infant circumcision.
Even the premise behind this debate – that the usefulness of circumcision can be determined by weighing the risks and benefits – is questionable. A drug for a deadly disease has a lot of leeway in terms of side-effects. Cancer patients are willing to endure chemotherapy if it means they get to live, for example. But when the person is healthy and too young to weigh the risks and benefits themselves, the maths changes. “Your tolerance for risk should go way down because it’s done without consent and it’s done without the presence of disease,” says Earp.
These uncertainties undermine the case for circumcision. They don’t completely destroy it though. Even after the criticisms are factored in, circumcision does bring some benefits, such as reducing the risk of urinary tract infections in young boys. What the uncertainties do is raise questions about whether those benefits justify the procedure. And this is where an evidence-based approach breaks down. Because the procedure results in the loss of something whose value cannot be quantified: the foreskin. If you view the foreskin as disposable, circumcision might be worth it. For those who see the act as the removal of a valuable body part, the reverse is likely true.
More than the medical data, it’s these unquantifiable feelings about the foreskin that shape doctors’ thinking about circumcision, or at least that of male doctors. Because when it comes to medical opinions on circumcision, the foreskin status of the opiner matters. A 2010 survey in the Journal of Men’s Health found that close to 70 per cent of circumcised male physicians supported the procedure. An almost identical fraction of uncircumcised physicians were opposed. The AAP Task Force behind the 2012 statement was made up mainly of men, all of whom were circumcised and from the US, where newborn circumcision is the norm. “Seen from the outside, cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious,” wrote a group of European physicians in response to the AAP.
It’s also likely that most of these critics were not circumcised. “We never deny that we are from a non-circumcising culture,” said Morten Frisch, lead author of the response and an epidemiologist who studies sexual health at Statens Serum Institut in Denmark. “While we claim that the US view is culturally biased, the opposing view from the AAP was that it’s us who are culturally biased, and to an extent they are right.”
These cultural divisions make it nearly impossible to sort through the medical literature. Rather than clarifying, the debate gets bogged down in accusations of poor research and bias. Brian Morris, a molecular biologist at the University of Sydney who is an outspoken proponent of circumcision, recently circulated a 23-page critique of a study by Frisch. The Danish researcher’s work was “an ideological rant against male circumcision”, said Morris, who asked colleagues to complain to the journal that published it. In response, Frisch called out Morris for citing his own “pro-circumcision manifesto” as source material for his critique and, in a video response on YouTube, said that Morris had accused “us of racism and dishonesty and all sorts of things… in order to have the editors reject the paper”.
“Both sides tend to be highly selective on which bits of evidence they want to quote,” says Basil Donovan, an epidemiologist focused on sexual health at the University of New South Wales and a community-based infectious disease physician. Professional discussions have become so heated that Donovan rarely participates. “I stay out of the area,” he said. “I want to have a life, I don’t want people bombing the front door.”
None of this is much help to a circumcised man who is wondering about a body part he never knew. Then again, many circumcised men want to know something besides the health benefits. They want to know whether removal of the foreskin negatively impacts sex.
Some of the most compelling data in this area came from a pathologist named John Taylor, who in 1996 published the first description of the cells that make up the foreskin. An uncircumcised Englishman, Taylor was initially motivated by the prospect of his Canada-born children being circumcised. That’s what led him to examine the foreskins of 22 uncircumcised corpses. He wanted to know whether the tissue had any functional value – if foreskin cells are specialised and serve some particular purpose, Taylor reasoned, that should be weighed when considering circumcision.
Specialised cells were exactly what Taylor found. Measuring about 6.5 centimetres long when fully grown, the foreskin is a mucosal membrane that contains copious amounts of Meissner’s corpuscles, touch-sensitive cells that are also present in our lips and fingertips. “We only find this sort of tissue in areas where it has to perform specialised function,” Taylor later told an interviewer from Intact Canada, an organisation seeking to end circumcision. The mucosal inner surface is kept wet by a natural lubricant, and the tip contains elastic fibres that allow it to stretch without becoming slack. “This is sexual tissue, and there’s no way you can avoid the issue.”
One of Taylor’s most noteworthy discoveries was the “ridged band”, an accordion-like strip of flesh about 10 to 15 millimetres long that is as sensitive as the fingertips. During an erection, the band is turned inside out, placing highly sensitive cells at the base of the penis. In later work, Taylor and a colleague described the band as far more sensitive than the glans, the part of the penis left exposed after circumcision. “The only portion of the body with less fine-touch discrimination than the glans penis is the heel of the foot,” they wrote. The penis still works without a foreskin, of course. But the foreskin is erogenous tissue. It also keeps the penis protected and moist. Without it the exposed surface is smoother, drier, more sensitive to changes in temperature and more easily irritated by clothing. A thickening of the surface of the glans, known as keratinisation, can also decrease sensitivity.
Foreskin cells don’t grow back. Efforts to restore the foreskin by pulling the flesh downwards – a practice attempted by some men who’ve experienced sexual problems or who simply dislike having had their foreskin removed without their say – can create an overhang of skin, but can’t replace the sensitive cells. Taylor, who died in 2010, believed that the foreskin is as important as the glans to sexual function. “Doctors doing this procedure don’t know what they’re removing,” he told Intact Canada.
If Taylor is right, circumcised men should have less sensitive penises. One way to test that idea is to touch a lot of penises, circumcised and not, in a laboratory setting. At least one group has done so. In 2006, a team of US scientists and anti-circumcision activists used stiff nylon thread to measure the sensitivity of 19 points on the foreskin (when present) and glans of almost 160 men. The most sensitive spot on circumcised men was the circumcision scar; in uncircumcised men, it was the foreskin.
Many men also wonder if circumcision leads to sexual problems. Again there’s tentative evidence that it does. In 2011, Morten Frisch published data on the sexual experiences of more than 5,500 men and women. (This was the study disputed by Brian Morris.) Few people reported problems, but of those who did – trouble achieving orgasm, for instance, or, for women, pain during sex – most were circumcised men or their female partners.
Another opportunity to study the question arose when widescale circumcision was introduced in South Korea around 1950, largely as a result of the US presence there in the years after World War II. Researchers at Seoul National University asked recently circumcised men about sexual function before and after the procedure. Of the approximately 140 men who were sexually active before and after the surgery, nearly half said masturbation was now less pleasurable. Of the 28 men from this group who said sex was also now less enjoyable, most attributed the difference to a decrease in sensation.
Still, these data are far from conclusive, and other researchers have reached the opposite conclusion. Morris, the circumcision advocate, reviewed 36 studies, encompassing a total of around 40,000 men, and found no impairment in sensitivity, orgasm achievement, erectile function or any other measure of sexual function connected to circumcision. And so the debate goes on, offering little clarity to the people who need it most: parents wondering if they should circumcise their newborn sons.
All of this – the benefits, the harms, the bias, the anger – could justify a randomised clinical trial of circumcision. These experiments are the surest way to judge the usefulness of a treatment, and could eliminate the angst over the decision. Yet circumcision has never been the subject of one. It’s hard to see that changing. American parents would presumably be happy to have such a study to inform their thinking, but few would want their babies take part in it.
Actually, that point about trials isn’t entirely accurate: there have been randomised controlled trials of circumcision – three, to be exact. Just not in America. The studies took place in Uganda, Kenya and South Africa between 2002 and 2006. Their primary purpose was to determine whether circumcision reduces the risk of HIV transmission from women to men during sex. Each was large, involving around 3,000 subjects, and lasted around two years. Adult volunteers were randomly assigned to be circumcised or not, and the circumcised men ended up with fewer cases of HIV. Follow-up analyses have confirmed that the protective benefits persist.
This was big news in a region living through some of the worst of the AIDS epidemic. In South Africa, for example, around 6 million people are HIV-positive. The studies suggested that circumcision could reduce the risk of a man in the region acquiring HIV from heterosexual sex by 60 per cent. Based on this, a 2007 analysis estimated that if every man in sub-Saharan Africa were circumcised over a five-year period, countries in the region could cut their HIV rates from 12 per cent to 6 per cent by 2020.
Once the potential became clear donors decided to attempt something almost as ambitious. In 2007, the United States Agency for International Development and the Bill & Melinda Gates Foundation, together with other donor organisations, launched a $1.5 billion campaign to circumcise 80 per cent of boys and men across and southern Africa by the end of this year, a total of about 20 million people.
One afternoon last July I watched the final stages of this extraordinary campaign play out in Iringa, a city in the southern highlands of Tanzania. A pick-up loaded with a DJ and booming sound system was parked at a dirt crossroad bordered by concrete shops and lean-tos covered in corrugated metal. A young woman – peer promoter was her job title – spoke through a microphone. She wore a black T-shirt with “tohara”, the Swahili word for circumcision, across the front. A crowd gathered, and she asked circumcised onlookers to give testimonials about the importance of the procedure. Barefoot children sat listening on fence posts and danced to the music when the peer promoter took a break.
This was a demand-creation activity – an outreach effort designed to generate interest in circumcision. Iringans had good reason to be interested. Sixteen per cent of the local population have HIV, partly because truckers overnight there, and prostitution near the truck stops is common. Jhpiego, a nonprofit health organisation affiliated with Johns Hopkins University that was running the event, has placed circumcision clinics at health facilities in the area, advertised on the radio and posted giant billboards at heavy-traffic intersections.
In the crowd listening to the lessons on tohara I met Violet Msuya, a 21-year-old student holding her niece on her hip. “I want my man to be clean,” she said through a translator when I asked about her interest. “If that man is clean, it will help me avoid cervical cancer and HIV.” She told me that she hadn’t had sex with an uncircumcised man, but had heard from friends that a foreskin makes sex less pleasant.
Later that day, at one of Iringa’s larger hospitals, I talked with Gabriel, a 20-year-old who was about to be circumcised. “Circumcision will reduce my chance of being infected with HIV by 60 per cent,” he told me. He added that it would be easier for him to stay clean without a foreskin, and said he’d heard through the media that circumcision could reduce his risk of cancer.
It was his second visit to the hospital. Gabriel had chickened out the first time, but mustered the courage to return after discovering he could be circumcised with a device known as PrePex, a circular clamp that is applied to the penis. He sat on an operating table as Dennis Fischer, the clinic’s physician, demonstrated the health benefits of circumcision for me using a wooden dildo covered with a brown felt foreskin. Gabriel was still sitting on the table when I left, his thin, jean-clad legs dangling over the side, awaiting the PrePex. In a few days, he would return to have the clamp removed and the dead flesh cut off.
Before the campaign, Tanzania, which is home to over 100 ethnic groups, had a mixed prevalence of circumcision. Some groups, like the Maasai, practised traditional circumcision. So did the country’s Muslims. Others, including the Christian population, had rarely done so. Changing that required millions of dollars in infrastructure and salaries, and a collision with a variety of beliefs. Men feared circumcision would leave them impotent, or automatically convert them to Islam. Parents worried that their son’s penises would not grow. When the programme first began, there were rumours about discarded foreskins being ground up for use in meat stock in America, or being sent to Europe to make cosmetics. Even the country’s administration was resistant. “It took two years to convince government officials,” says Sifuni Raphael Koshuma, a surgeon from Dar es Salaam who leads the PrePex research.
Since then, organisations like Jhpiego have been so successful that circumcision is now fashionable. Even married couples embrace it. After visiting Iringa I drove out to Usokami, a rural clinic where the mud houses have no electricity or running water and bicycles are more common than cars. At the clinic I met Meshak Msigwa, 42, who told me his wife had encouraged him to get circumcised. He spoke to me from behind a blue hospital curtain, and his sentences were punctuated by the metallic click of scissors as a doctor snipped off his foreskin. I asked him if having the surgery implied that he or his wife – both are HIV-negative – would cheat. He told me that won’t happen. “I swore in church I would be faithful to my wife,” he said.
The goal of circumcising 80 per cent of men and boys over the age of ten in Iringa is nearly accomplished. Jhpiego is now conducting what the programme administrators refer to as a “mop-up”, targeting specific clinics where the total number of circumcisions has been low. The organisation is also promoting routine early infant medical circumcision. In Tanzania and other countries in Africa, as in America, the foreskin is becoming a thing of the past.
There is another similarity between the situation in Africa and that in America: in both cases, the scientific evidence for circumcision is less certain than advocates make out. A 60 per cent risk reduction is a long way from total protection, for one thing. Michel Garenne, an epidemiologist at the Pasteur Institute in Paris, notes that many interventions with that kind of efficacy – an early version of the cholera vaccine, the rhythm method as contraception – have not been recommended as wide-scale public health measures because the benefits don’t translate to a broad population that is repeatedly exposed to infection. The same is true of HIV: a man who repeatedly has sex without a condom runs a high risk of contracting the virus, regardless of his circumcision status. “If the randomised controlled trials had shown 99 per cent efficacy, that would be one thing,” says Garenne. “But they haven’t.”
There is also a problem with the information given to those who volunteer for surgery. I met many newly circumcised men who repeated what Gabriel had heard: circumcision reduces the risk of contracting HIV by 60 per cent. Yet this figure is what epidemiologists call the relative risk reduction. It tells us that in the clinical trials there were 60 per cent fewer new HIV infections among the circumcised men than the uncircumcised group. It says nothing about the actual risk of contracting HIV. That risk depends very much on sexual behaviour. Critically, if men have frequent sex with infected women they will likely get HIV, regardless of whether they are circumcised. It’s also crucial, but perhaps not appreciated by all volunteers, that circumcision does not reduce the chances of an HIV-positive man infecting his female partner.
The campaign organisers know all of this, of course. It’s one reason why every man who is circumcised is also counselled in the ABCs of HIV prevention: Abstinence, Being faithful and Condom use. The campaign administrators also talk of “condom fatigue”. They know that men will forgo condoms on occasion, and circumcision reduces the risk when they do. “It’s a single, one-off procedure,” says Ronald Gray, of Johns Hopkins University, who led the trial in Uganda. Because the benefit, however large or small, is conferred for life, it’s worth it, Gray argues.
Still, no one knows what the level of protection will be outside the confines of the clinical trials, in which volunteers were counselled and tested for HIV every few months, receiving money at each clinic visit. The impact of circumcision on HIV rates among women is particularly hard to predict, and it’s possible that the procedure could confer a false sense of protection on circumcised men. “My impression is the campaign is as likely to have a positive effect as a negative effect,” says Garenne. “We’ll know in 20 years.”
Transitioning to routine early infant circumcision, as is happening in Tanzania and a few other locations, is also controversial. “The evidence in adults is also true for infants,” says Emmanuel Njeuhmeli, a senior USAID official working on the circumcision campaign. But so far we only have data on adult circumcision. In the absence of better evidence, should governments be recommending a surgical procedure to citizens who are too young to agree to the procedure? “It’s highly questionable in terms of medical ethics,” says Garenne.
Such concerns aren’t likely to have much impact, because the thinking about circumcision in Africa is settled for now. The procedure is voluntary, but opting out is getting harder. Radio advertisements persuade men that circumcised penises are cleaner and sexier. Food vouchers are sometimes used as incentive to get circumcised. “It’s really increasingly becoming a sort of socially coerced activity,” says Oxford’s Brian Earp. “That’s not voluntary any more.” Njeuhmeli isn’t sure that’s a problem. If circumcision can help halt HIV, why not stigmatise foreskins? “When you reach 80 per cent coverage, the remaining 20 per cent of men are definitely being stigmatised,” he says. “Is it a bad stigma or a good stigma? I honestly don’t know.”
If I were a new mother in a country hit hard by HIV, I would at least strongly consider having my infant son circumcised. There are uncertainties, but if circumcision can put a dent in the epidemic, then I understand why parents would look at the evidence and choose the procedure. In the United States the picture is less clear. HIV rates here are much lower and the route of transmission is usually not heterosexual sex. What should parents do?
After reading the literature, I’m unconvinced by the evidence used to justify circumcision for health reasons. I’ll explain why by means of a thought experiment. Imagine that infant male circumcision had never been a part of American medical practice, but was common in, say, Spain or Senegal or Japan. Based on what we know about the health benefits of the procedure, would American doctors recommend introducing the procedure? And would that evidence be enough for American parents to permanently remove a part of their child’s body without his agreement?
Remember what the evidence tells us. Either the benefits can be obtained by a milder intervention (antibiotics and condoms in the case of urinary tract infections and sexually transmitted diseases), or the risk is low and open to other preventive measures (penile cancer), or the concern is rarely justified (HIV in the United States). Remember also that Western countries where circumcision is rare do not see higher rates of the problems that foreskin removal purports to prevent: not STDs, not penile cancer, not cervical cancer, not HIV. It’s hard to imagine circumcision being introduced on this basis. It’s equally difficult to picture studies on the benefits of the procedure being done.
The main reason we have circumcision in the US today is not the health benefits. It’s because we’re used to it. After all, if circumcision is not definitively preventing a life-threatening issue that cannot be prevented by other means, can removal of a body part without the agreement of the child be justified? We are so accustomed to the practice that operating on an infant so that he resembles his father seems acceptable. I’ve heard many people give this as their reason. It isn’t a good one.
It’s disconcerting to think that circumcising infant boys may be a violation of their human rights. We castigate cultures that practise female genital mutilation (FGM). Rightfully so: no one should be coerced into such a violation. But removal of the clitoral hood, one form of FGM, is anatomically analogous to removal of the foreskin. Some forms of FGM, such as nicking or scratching the female genitalia, are unequivocally deemed a human rights violation but are even milder than the foreskin removal done in US hospitals.
Thinking about male circumcision as an unnecessary and irreversible surgery forced on infants, I can’t but hope that the troubled history of the foreskin will come to an end, and that the foreskin will be known for its presence rather than its absence. I understand why some people demand an immediate end to circumcision. And I understand why a man would stand on a street corner for hours on a cold day wearing red-stained trousers, angry at what was done to him without his agreement and trying to prevent other men from suffering the same fate.
This article was originally published on mosaic.com.
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Next to him, Lauren Meyer, a 33-year-old mother of two boys, held another sign, a white poster adorned only with the words: “Don’t Cut His Penis”. She had on a white hoodie with a big red heart and three red droplets, and a pair of leopard-print slipper-boots to keep her feet warm for the several hours she would be outside. Meyer’s first son is circumcised; she sometimes refers to herself as a “regret mother” for having allowed the procedure to take place.
It was two days after Christmas. Adams and Meyer had each driven about an hour to stand by the side of a road holding up signs about penises. On that same day, a woman stood alone at what qualifies as a busy intersection in the small town of Show Low, Arizona. She also wore white trousers with a red crotch, and held aloft anti-circumcision signs. A few people more people did the same in the San Francisco Bay area.
The protests were triggered by a recent event, but the issue at stake was an ancient one. Circumcision has been practised for millennia. Right now, in America, it is so common that foreskins are somewhat rare, and may become more so. A few weeks before the protests, the Centers for Disease Control and Prevention had suggested that healthcare professionals talk to men and parents about the benefits of the procedure, which include protection from some sexually transmitted diseases, and the risks, which the CDC describes as low. But as the protesters wanted drivers to know, there is no medical consensus on this issue. Circumcision isn’t advised for health reasons in Europe, for instance, because the benefits remain unclear. Meanwhile, Western organisations are paying for the circumcision of millions of African men in an attempt to rein in HIV – a campaign that critics say is also based on questionable evidence.
Men have been circumcised for thousands of years, yet our thinking about the foreskin seems as muddled as ever. And a close examination of this muddle raises disturbing questions. Is this American exceptionalism justified? Should we really be funding mass circumcision in Africa? Or by removing the foreskins of men, boys and newborns, are we actually committing a violation of human rights?
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© Gemma Tickle at East Photographic
The tomb of Ankhmahor, a high-ranking official in ancient Egypt, is situated in a vast burial ground just outside Cairo. A picture of a man standing upright is carved into one of the walls. His hands are restrained, and another figure kneels in front of him, holding a tool to his penis. Though there is no definitive explanation of why circumcision began, many historians believe this relief, carved more than four thousand years ago, is the oldest known record of the procedure.
The best-known circumcision ritual, the Jewish ceremony of brit milah, is also thousands of years old. It survives to this day, as do others practised by Muslims and some African tribes. But American attitudes to circumcision have a much more recent origin. As medical historian David Gollaher recounts in his book Circumcision: A History of the World’s Most Controversial Surgery, early Christian leaders abandoned the practice, realising perhaps that their religion would be more attractive to converts if surgery wasn’t required. Circumcision disappeared from Christianity, and the secular Western cultures that descended from it, for almost two thousand years.
Then came the Victorians. One day in 1870, a New York orthopaedic surgeon named Lewis Sayre was asked to examine a five-year-old boy suffering from paralysis of both legs. Sayre was the picture of a Victorian gentleman: three-piece suit, bow tie, mutton chops. He was also highly respected, a renowned physician at Bellevue Hospital, New York’s oldest public hospital, and an early member of the American Medical Association.
After the boy’s sore genitals were pointed out by his nanny, Sayre removed the foreskin. The boy recovered. Believing he was on to something big, Sayre conducted more procedures. His reputation was such that when he praised the benefits of circumcision – which he did in the Transactions of the American Medical Association and elsewhere until he died in 1900 – surgeons elsewhere followed suit. Among other ailments, Sayre discussed patients whose foreskins were tightened and could not retract, a condition known as phimosis. Sayre declared that the condition caused a general state of nervous irritation, and that circumcision was the cure.
His ideas found a receptive audience. To Victorian minds many mental health issues originated with the sexual organs and masturbation. The connection had its roots in a widely read 18th-century treatise entitled Onania, or the Heinous Sin of Self-Pollution, and All Its Frightful Consequences, in Both Sexes, Considered. With Spiritual and Physical Advice to Those Who Have Already Injur’d Themselves By This Abominable Practice. The anonymous author warned that masturbation could cause epilepsy, infertility, “a wounded conscience” and other problems. By 1765 the book was in its 80th printing.
Later puritans took a similar view. Sylvester Graham associated any pleasure with immorality. He was a preacher, health reformer and creator of the graham cracker. Masturbation turned one into “a confirmed and degraded idiot”, he declared in 1834. Men and women suffering from otherwise unlabelled psychiatric issues were diagnosed with masturbatory insanity; treatments included clitoridectomies for women, circumcision for men.
Graham’s views were later taken up by another eccentric but prominent thinker on health matters: John Harvey Kellogg, who promoted abstinence and advocated foreskin removal as a cure. (He also worked with his brother to invent the cornflake.) “The operation should be performed by a surgeon without administering anesthetic,” instructed Kellogg, “as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment.”
Counter-examples to Sayre’s supposed breakthrough could be found in operating theatres across America. Attempts to cure children of paralysis failed. Men, one can assume, continued to masturbate. It mattered not. The circumcised penis came to be seen as more hygienic, and cleanliness was a sign of moral standards. An 1890 journal identified smegma as “infectious material”. A few years later, a book for mothers – Confidential Talks on Home and Child Life, by a member of the National Temperance Society – described the foreskin as a “mark of Satan”. Another author described parents who did not circumcise their sons at an early age as “almost criminally negligent”.
By now, the circumcision torch had passed from Sayre to Peter Charles Remondino, a popular San Diego physician descended from a line of doctors that stretched back to 14th-century Europe. In an influential 1891 book about circumcision, Remondino described the foreskin as a “malign influence” that could weaken a man “physically, mentally and morally; to land him, perchance, in jail or even in a lunatic asylum”. Insurance companies, he advised, should classify uncircumcised men as “hazardous risks”.
Further data came from studies of the “Hebrew penis”, which showed a “superior cleanliness” that had protective benefits, according to John Hutchinson, an influential surgeon at the Metropolitan Free Hospital of London. Hutchinson and others noted that Jews had lower rates of syphilis, cancer and mental illness, greater longevity, and fewer stillbirths – all of which they attributed to circumcision. Remondino agreed, calling circumcision “the real cause of differences in longevity and faculty for enjoyment of life that the Hebrew enjoys”.
By the turn of the 20th century the Victorian fear of masturbation had waned, but by then circumcision become a prudent precaution, and one increasingly implemented soon after birth. A desire to prevent phimosis, STDs and cancer had turned the procedure into medical dogma. Antiseptic surgical practices had rendered it relatively safe, and anaesthesia made it painless. Once a procedure for the relatively wealthy, circumcision had become mainstream. By 1940, around 70 per cent of male babies in the United States were circumcised.
In the decades since, medical practice has come to rely increasingly on evidence from large research studies, which, as many American doctors see it, have supported the existing rationale. When the CDC made its recent statement, for example, it cited studies showing that circumcision reduces the risk of urinary tract infection, several STDs, penile cancer, phimosis, balanitis (inflammation of the foreskin and head of the penis) and HIV. The CDC even noted benefits for women with circumcised partners, namely a lower risk of cervical cancer linked to human papillomavirus.
The mechanism behind these benefits is simple: the warm and moist region under the foreskin can house the bacteria and viruses that cause disease. A circumcised penis can’t be colonised so easily; without the blanket, it’s harder to hide. Circumcision also removes a large quantity of Langerhans cells, a component of the immune system that, according to some research, is targeted by HIV.
During the second half of the last century, an accumulation of studies demonstrated the beneficial impacts of these mechanisms. At times the research helped all but end the debate over circumcision. By the 1970s, for instance, more than 90 per cent of US men were circumcised, according to one study. The American foreskin had become a thing of the past.
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© Gemma Tickle at East Photographic
Today circumcision is among the most common surgeries in the US: an estimated 1.2 million infants are circumcised each year, at a cost of up to $270 million. Its popularity has fluctuated since the peak of the 1970s; the CDC’s most recent estimate puts the current rate at 60 per cent of newborns. This may in part be because the American Association of Pediatrics (AAP) for a time equivocated over the issue. But in 2012 the AAP announced that benefits of circumcision outweighed the risks, suggesting that rates may rise again.
Yet whether it’s 60 or 90 per cent of American men who are circumcised, what’s more remarkable is that American parents are almost alone in the Western world in their desire to separate boys from their foreskins for reasons other than religion. This difference of opinion is decades old. It began in 1949, when a British paediatrician and scientist named Douglas Gairdner published the first investigation of the rationale for circumcision in English-speaking countries. He found the procedure to be unwarranted.
Phimosis, the condition Sayre held responsible for so many neuroses, was essentially a non-issue, said Gairdner. He discovered something that had somehow gone undocumented before: that most foreskins remain unretracted well into the toddler years. Phimosis is the natural state of the penis, Gairdner concluded. (Later work would confirm that the foreskin sometimes does not fully retract until the teenage years.) This was just the beginning. Gairdner showed that balanitis and posthitis, forms of inflammation that were considered cause for circumcision, were uncommon. He found no data to show that circumcision could prevent venereal diseases and little evidence for a lesser risk of cervical cancer. Cleaning the intact foreskin would do as much to thwart penile cancer as would removing it, he added.
At the National Health Service, which was founded a year before Gairdner’s paper appeared, officials heeded his advice and refused to cover circumcision unless it was medically necessary. By 1958, the circumcision rate in the United Kingdom had fallen to close to 10 per cent. Excluding British men who are circumcised for religious reasons, the rate is now 6 per cent or lower.
The situation is much the same elsewhere in Europe. The Victorian focus on circumcision was concentrated in English-speaking countries, and its popularity never spread. When European experts examine the evidence, they generally see no reason that it should. In 2010, for instance, the Royal Dutch Medical Association reviewed the same studies the AAP looked at. Aside from preventing urinary tract infections, which can be treated with antibiotics, it concluded that the health benefits of circumcision are “questionable, weak, and likely to have little public health relevance in a Western context”.
How can experts who have undergone similar training evaluate the same studies and come to opposing conclusions? I’ve spent months scrutinising the medical literature in an attempt to decide which side is right. The task turned out to be nearly impossible. That’s partly because there is so much confused thinking around the risks and benefits of circumcision, even among trained practitioners. But it’s also because, after reading enough studies, I realised that the debate doesn’t have a scientific conclusion. It is impossible to get to the bottom of this issue because there is no bottom.
Assessing the true risks of circumcision is the first challenge. Immediate complications are usually easily treatable, and also relatively rare – the AAP report states that problems like bleeding and infection occur in up to 1 in 100 circumcisions. But the frequency of later problems is less well understood. Some studies find few; others conclude that as many as one in four patients suffer some kind of complication after the surgery and subsequent wound healing. The possible late problems are many. The remaining foreskin tissue can adhere to the penis. The opening of the urethra may narrow, making urination painful and preventing the bladder from fully emptying, which in turn can lead to kidney problems. Craig Adams, the New Jersey protester, had to have surgery to correct such a problem when he was five years old. Lauren Meyer’s first son had surgery for the same reason when he was three. Other late complications include a second surgery to correct an incomplete circumcision, a rotated penis, recurrent phimosis, and concealment of the penis by scar tissue, a condition commonly known as buried penis.
The AAP acknowledges some uncertainty surrounding the data on risks, but not in a way that a parent looking for advice is likely to fully grasp. “The true incidence of complications after newborn circumcision is unknown,” the AAP’s recent report states. But complications are risks. “They’re saying, ‘The benefits outweigh the risks but we don’t know what the risks are,’” says Brian Earp, research fellow at Oxford University’s Uehiro Centre for Practical Ethics. “This is basically an unscientific document.”
The debate about the effectiveness of circumcision can be just as convoluted. One way of thinking about this is the number needed to treat (NNT), a figure that answers the question: how many people need to be treated with this approach in order to prevent one illness? For the ideal treatment the answer is one. But penile cancer is rare and circumcision doesn’t provide complete protection against it, so around 900 circumcisions are needed to prevent a single case. That’s a very high NNT. By comparison, 50 people need to take aspirin to prevent one cardiovascular problem.
It’s also worth noting that other preventive methods can have a greater impact on penile cancer. The American Cancer Society suggests avoiding smoking, for example. The same logic applies to sexually transmitted diseases. Studies show that circumcision reduces the chances of a man contracting herpes, for example. But the risk of this and every known STD can be stopped or at least dramatically reduced by correct and consistent condom use. “The benefits can all be obtained in other ways,” says Adrienne Carmack, a Texas-based urologist who opposes routine infant circumcision.
Even the premise behind this debate – that the usefulness of circumcision can be determined by weighing the risks and benefits – is questionable. A drug for a deadly disease has a lot of leeway in terms of side-effects. Cancer patients are willing to endure chemotherapy if it means they get to live, for example. But when the person is healthy and too young to weigh the risks and benefits themselves, the maths changes. “Your tolerance for risk should go way down because it’s done without consent and it’s done without the presence of disease,” says Earp.
These uncertainties undermine the case for circumcision. They don’t completely destroy it though. Even after the criticisms are factored in, circumcision does bring some benefits, such as reducing the risk of urinary tract infections in young boys. What the uncertainties do is raise questions about whether those benefits justify the procedure. And this is where an evidence-based approach breaks down. Because the procedure results in the loss of something whose value cannot be quantified: the foreskin. If you view the foreskin as disposable, circumcision might be worth it. For those who see the act as the removal of a valuable body part, the reverse is likely true.
More than the medical data, it’s these unquantifiable feelings about the foreskin that shape doctors’ thinking about circumcision, or at least that of male doctors. Because when it comes to medical opinions on circumcision, the foreskin status of the opiner matters. A 2010 survey in the Journal of Men’s Health found that close to 70 per cent of circumcised male physicians supported the procedure. An almost identical fraction of uncircumcised physicians were opposed. The AAP Task Force behind the 2012 statement was made up mainly of men, all of whom were circumcised and from the US, where newborn circumcision is the norm. “Seen from the outside, cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious,” wrote a group of European physicians in response to the AAP.
It’s also likely that most of these critics were not circumcised. “We never deny that we are from a non-circumcising culture,” said Morten Frisch, lead author of the response and an epidemiologist who studies sexual health at Statens Serum Institut in Denmark. “While we claim that the US view is culturally biased, the opposing view from the AAP was that it’s us who are culturally biased, and to an extent they are right.”
These cultural divisions make it nearly impossible to sort through the medical literature. Rather than clarifying, the debate gets bogged down in accusations of poor research and bias. Brian Morris, a molecular biologist at the University of Sydney who is an outspoken proponent of circumcision, recently circulated a 23-page critique of a study by Frisch. The Danish researcher’s work was “an ideological rant against male circumcision”, said Morris, who asked colleagues to complain to the journal that published it. In response, Frisch called out Morris for citing his own “pro-circumcision manifesto” as source material for his critique and, in a video response on YouTube, said that Morris had accused “us of racism and dishonesty and all sorts of things… in order to have the editors reject the paper”.
“Both sides tend to be highly selective on which bits of evidence they want to quote,” says Basil Donovan, an epidemiologist focused on sexual health at the University of New South Wales and a community-based infectious disease physician. Professional discussions have become so heated that Donovan rarely participates. “I stay out of the area,” he said. “I want to have a life, I don’t want people bombing the front door.”
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None of this is much help to a circumcised man who is wondering about a body part he never knew. Then again, many circumcised men want to know something besides the health benefits. They want to know whether removal of the foreskin negatively impacts sex.
Some of the most compelling data in this area came from a pathologist named John Taylor, who in 1996 published the first description of the cells that make up the foreskin. An uncircumcised Englishman, Taylor was initially motivated by the prospect of his Canada-born children being circumcised. That’s what led him to examine the foreskins of 22 uncircumcised corpses. He wanted to know whether the tissue had any functional value – if foreskin cells are specialised and serve some particular purpose, Taylor reasoned, that should be weighed when considering circumcision.
Specialised cells were exactly what Taylor found. Measuring about 6.5 centimetres long when fully grown, the foreskin is a mucosal membrane that contains copious amounts of Meissner’s corpuscles, touch-sensitive cells that are also present in our lips and fingertips. “We only find this sort of tissue in areas where it has to perform specialised function,” Taylor later told an interviewer from Intact Canada, an organisation seeking to end circumcision. The mucosal inner surface is kept wet by a natural lubricant, and the tip contains elastic fibres that allow it to stretch without becoming slack. “This is sexual tissue, and there’s no way you can avoid the issue.”
One of Taylor’s most noteworthy discoveries was the “ridged band”, an accordion-like strip of flesh about 10 to 15 millimetres long that is as sensitive as the fingertips. During an erection, the band is turned inside out, placing highly sensitive cells at the base of the penis. In later work, Taylor and a colleague described the band as far more sensitive than the glans, the part of the penis left exposed after circumcision. “The only portion of the body with less fine-touch discrimination than the glans penis is the heel of the foot,” they wrote. The penis still works without a foreskin, of course. But the foreskin is erogenous tissue. It also keeps the penis protected and moist. Without it the exposed surface is smoother, drier, more sensitive to changes in temperature and more easily irritated by clothing. A thickening of the surface of the glans, known as keratinisation, can also decrease sensitivity.
Foreskin cells don’t grow back. Efforts to restore the foreskin by pulling the flesh downwards – a practice attempted by some men who’ve experienced sexual problems or who simply dislike having had their foreskin removed without their say – can create an overhang of skin, but can’t replace the sensitive cells. Taylor, who died in 2010, believed that the foreskin is as important as the glans to sexual function. “Doctors doing this procedure don’t know what they’re removing,” he told Intact Canada.
If Taylor is right, circumcised men should have less sensitive penises. One way to test that idea is to touch a lot of penises, circumcised and not, in a laboratory setting. At least one group has done so. In 2006, a team of US scientists and anti-circumcision activists used stiff nylon thread to measure the sensitivity of 19 points on the foreskin (when present) and glans of almost 160 men. The most sensitive spot on circumcised men was the circumcision scar; in uncircumcised men, it was the foreskin.
Many men also wonder if circumcision leads to sexual problems. Again there’s tentative evidence that it does. In 2011, Morten Frisch published data on the sexual experiences of more than 5,500 men and women. (This was the study disputed by Brian Morris.) Few people reported problems, but of those who did – trouble achieving orgasm, for instance, or, for women, pain during sex – most were circumcised men or their female partners.
Another opportunity to study the question arose when widescale circumcision was introduced in South Korea around 1950, largely as a result of the US presence there in the years after World War II. Researchers at Seoul National University asked recently circumcised men about sexual function before and after the procedure. Of the approximately 140 men who were sexually active before and after the surgery, nearly half said masturbation was now less pleasurable. Of the 28 men from this group who said sex was also now less enjoyable, most attributed the difference to a decrease in sensation.
Still, these data are far from conclusive, and other researchers have reached the opposite conclusion. Morris, the circumcision advocate, reviewed 36 studies, encompassing a total of around 40,000 men, and found no impairment in sensitivity, orgasm achievement, erectile function or any other measure of sexual function connected to circumcision. And so the debate goes on, offering little clarity to the people who need it most: parents wondering if they should circumcise their newborn sons.
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© Gemma Tickle at East Photographic
All of this – the benefits, the harms, the bias, the anger – could justify a randomised clinical trial of circumcision. These experiments are the surest way to judge the usefulness of a treatment, and could eliminate the angst over the decision. Yet circumcision has never been the subject of one. It’s hard to see that changing. American parents would presumably be happy to have such a study to inform their thinking, but few would want their babies take part in it.
Actually, that point about trials isn’t entirely accurate: there have been randomised controlled trials of circumcision – three, to be exact. Just not in America. The studies took place in Uganda, Kenya and South Africa between 2002 and 2006. Their primary purpose was to determine whether circumcision reduces the risk of HIV transmission from women to men during sex. Each was large, involving around 3,000 subjects, and lasted around two years. Adult volunteers were randomly assigned to be circumcised or not, and the circumcised men ended up with fewer cases of HIV. Follow-up analyses have confirmed that the protective benefits persist.
This was big news in a region living through some of the worst of the AIDS epidemic. In South Africa, for example, around 6 million people are HIV-positive. The studies suggested that circumcision could reduce the risk of a man in the region acquiring HIV from heterosexual sex by 60 per cent. Based on this, a 2007 analysis estimated that if every man in sub-Saharan Africa were circumcised over a five-year period, countries in the region could cut their HIV rates from 12 per cent to 6 per cent by 2020.
Once the potential became clear donors decided to attempt something almost as ambitious. In 2007, the United States Agency for International Development and the Bill & Melinda Gates Foundation, together with other donor organisations, launched a $1.5 billion campaign to circumcise 80 per cent of boys and men across and southern Africa by the end of this year, a total of about 20 million people.
One afternoon last July I watched the final stages of this extraordinary campaign play out in Iringa, a city in the southern highlands of Tanzania. A pick-up loaded with a DJ and booming sound system was parked at a dirt crossroad bordered by concrete shops and lean-tos covered in corrugated metal. A young woman – peer promoter was her job title – spoke through a microphone. She wore a black T-shirt with “tohara”, the Swahili word for circumcision, across the front. A crowd gathered, and she asked circumcised onlookers to give testimonials about the importance of the procedure. Barefoot children sat listening on fence posts and danced to the music when the peer promoter took a break.
This was a demand-creation activity – an outreach effort designed to generate interest in circumcision. Iringans had good reason to be interested. Sixteen per cent of the local population have HIV, partly because truckers overnight there, and prostitution near the truck stops is common. Jhpiego, a nonprofit health organisation affiliated with Johns Hopkins University that was running the event, has placed circumcision clinics at health facilities in the area, advertised on the radio and posted giant billboards at heavy-traffic intersections.
In the crowd listening to the lessons on tohara I met Violet Msuya, a 21-year-old student holding her niece on her hip. “I want my man to be clean,” she said through a translator when I asked about her interest. “If that man is clean, it will help me avoid cervical cancer and HIV.” She told me that she hadn’t had sex with an uncircumcised man, but had heard from friends that a foreskin makes sex less pleasant.
Later that day, at one of Iringa’s larger hospitals, I talked with Gabriel, a 20-year-old who was about to be circumcised. “Circumcision will reduce my chance of being infected with HIV by 60 per cent,” he told me. He added that it would be easier for him to stay clean without a foreskin, and said he’d heard through the media that circumcision could reduce his risk of cancer.
It was his second visit to the hospital. Gabriel had chickened out the first time, but mustered the courage to return after discovering he could be circumcised with a device known as PrePex, a circular clamp that is applied to the penis. He sat on an operating table as Dennis Fischer, the clinic’s physician, demonstrated the health benefits of circumcision for me using a wooden dildo covered with a brown felt foreskin. Gabriel was still sitting on the table when I left, his thin, jean-clad legs dangling over the side, awaiting the PrePex. In a few days, he would return to have the clamp removed and the dead flesh cut off.
Before the campaign, Tanzania, which is home to over 100 ethnic groups, had a mixed prevalence of circumcision. Some groups, like the Maasai, practised traditional circumcision. So did the country’s Muslims. Others, including the Christian population, had rarely done so. Changing that required millions of dollars in infrastructure and salaries, and a collision with a variety of beliefs. Men feared circumcision would leave them impotent, or automatically convert them to Islam. Parents worried that their son’s penises would not grow. When the programme first began, there were rumours about discarded foreskins being ground up for use in meat stock in America, or being sent to Europe to make cosmetics. Even the country’s administration was resistant. “It took two years to convince government officials,” says Sifuni Raphael Koshuma, a surgeon from Dar es Salaam who leads the PrePex research.
Since then, organisations like Jhpiego have been so successful that circumcision is now fashionable. Even married couples embrace it. After visiting Iringa I drove out to Usokami, a rural clinic where the mud houses have no electricity or running water and bicycles are more common than cars. At the clinic I met Meshak Msigwa, 42, who told me his wife had encouraged him to get circumcised. He spoke to me from behind a blue hospital curtain, and his sentences were punctuated by the metallic click of scissors as a doctor snipped off his foreskin. I asked him if having the surgery implied that he or his wife – both are HIV-negative – would cheat. He told me that won’t happen. “I swore in church I would be faithful to my wife,” he said.
The goal of circumcising 80 per cent of men and boys over the age of ten in Iringa is nearly accomplished. Jhpiego is now conducting what the programme administrators refer to as a “mop-up”, targeting specific clinics where the total number of circumcisions has been low. The organisation is also promoting routine early infant medical circumcision. In Tanzania and other countries in Africa, as in America, the foreskin is becoming a thing of the past.
There is another similarity between the situation in Africa and that in America: in both cases, the scientific evidence for circumcision is less certain than advocates make out. A 60 per cent risk reduction is a long way from total protection, for one thing. Michel Garenne, an epidemiologist at the Pasteur Institute in Paris, notes that many interventions with that kind of efficacy – an early version of the cholera vaccine, the rhythm method as contraception – have not been recommended as wide-scale public health measures because the benefits don’t translate to a broad population that is repeatedly exposed to infection. The same is true of HIV: a man who repeatedly has sex without a condom runs a high risk of contracting the virus, regardless of his circumcision status. “If the randomised controlled trials had shown 99 per cent efficacy, that would be one thing,” says Garenne. “But they haven’t.”
There is also a problem with the information given to those who volunteer for surgery. I met many newly circumcised men who repeated what Gabriel had heard: circumcision reduces the risk of contracting HIV by 60 per cent. Yet this figure is what epidemiologists call the relative risk reduction. It tells us that in the clinical trials there were 60 per cent fewer new HIV infections among the circumcised men than the uncircumcised group. It says nothing about the actual risk of contracting HIV. That risk depends very much on sexual behaviour. Critically, if men have frequent sex with infected women they will likely get HIV, regardless of whether they are circumcised. It’s also crucial, but perhaps not appreciated by all volunteers, that circumcision does not reduce the chances of an HIV-positive man infecting his female partner.
The campaign organisers know all of this, of course. It’s one reason why every man who is circumcised is also counselled in the ABCs of HIV prevention: Abstinence, Being faithful and Condom use. The campaign administrators also talk of “condom fatigue”. They know that men will forgo condoms on occasion, and circumcision reduces the risk when they do. “It’s a single, one-off procedure,” says Ronald Gray, of Johns Hopkins University, who led the trial in Uganda. Because the benefit, however large or small, is conferred for life, it’s worth it, Gray argues.
Still, no one knows what the level of protection will be outside the confines of the clinical trials, in which volunteers were counselled and tested for HIV every few months, receiving money at each clinic visit. The impact of circumcision on HIV rates among women is particularly hard to predict, and it’s possible that the procedure could confer a false sense of protection on circumcised men. “My impression is the campaign is as likely to have a positive effect as a negative effect,” says Garenne. “We’ll know in 20 years.”
Transitioning to routine early infant circumcision, as is happening in Tanzania and a few other locations, is also controversial. “The evidence in adults is also true for infants,” says Emmanuel Njeuhmeli, a senior USAID official working on the circumcision campaign. But so far we only have data on adult circumcision. In the absence of better evidence, should governments be recommending a surgical procedure to citizens who are too young to agree to the procedure? “It’s highly questionable in terms of medical ethics,” says Garenne.
Such concerns aren’t likely to have much impact, because the thinking about circumcision in Africa is settled for now. The procedure is voluntary, but opting out is getting harder. Radio advertisements persuade men that circumcised penises are cleaner and sexier. Food vouchers are sometimes used as incentive to get circumcised. “It’s really increasingly becoming a sort of socially coerced activity,” says Oxford’s Brian Earp. “That’s not voluntary any more.” Njeuhmeli isn’t sure that’s a problem. If circumcision can help halt HIV, why not stigmatise foreskins? “When you reach 80 per cent coverage, the remaining 20 per cent of men are definitely being stigmatised,” he says. “Is it a bad stigma or a good stigma? I honestly don’t know.”
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If I were a new mother in a country hit hard by HIV, I would at least strongly consider having my infant son circumcised. There are uncertainties, but if circumcision can put a dent in the epidemic, then I understand why parents would look at the evidence and choose the procedure. In the United States the picture is less clear. HIV rates here are much lower and the route of transmission is usually not heterosexual sex. What should parents do?
After reading the literature, I’m unconvinced by the evidence used to justify circumcision for health reasons. I’ll explain why by means of a thought experiment. Imagine that infant male circumcision had never been a part of American medical practice, but was common in, say, Spain or Senegal or Japan. Based on what we know about the health benefits of the procedure, would American doctors recommend introducing the procedure? And would that evidence be enough for American parents to permanently remove a part of their child’s body without his agreement?
Remember what the evidence tells us. Either the benefits can be obtained by a milder intervention (antibiotics and condoms in the case of urinary tract infections and sexually transmitted diseases), or the risk is low and open to other preventive measures (penile cancer), or the concern is rarely justified (HIV in the United States). Remember also that Western countries where circumcision is rare do not see higher rates of the problems that foreskin removal purports to prevent: not STDs, not penile cancer, not cervical cancer, not HIV. It’s hard to imagine circumcision being introduced on this basis. It’s equally difficult to picture studies on the benefits of the procedure being done.
The main reason we have circumcision in the US today is not the health benefits. It’s because we’re used to it. After all, if circumcision is not definitively preventing a life-threatening issue that cannot be prevented by other means, can removal of a body part without the agreement of the child be justified? We are so accustomed to the practice that operating on an infant so that he resembles his father seems acceptable. I’ve heard many people give this as their reason. It isn’t a good one.
It’s disconcerting to think that circumcising infant boys may be a violation of their human rights. We castigate cultures that practise female genital mutilation (FGM). Rightfully so: no one should be coerced into such a violation. But removal of the clitoral hood, one form of FGM, is anatomically analogous to removal of the foreskin. Some forms of FGM, such as nicking or scratching the female genitalia, are unequivocally deemed a human rights violation but are even milder than the foreskin removal done in US hospitals.
Thinking about male circumcision as an unnecessary and irreversible surgery forced on infants, I can’t but hope that the troubled history of the foreskin will come to an end, and that the foreskin will be known for its presence rather than its absence. I understand why some people demand an immediate end to circumcision. And I understand why a man would stand on a street corner for hours on a cold day wearing red-stained trousers, angry at what was done to him without his agreement and trying to prevent other men from suffering the same fate.
This article was originally published on mosaic.com.
