Foreskin: Keep or Cut?

The foreskin is "like some of the evil genii or sprites in the Arabian tales," wrote the physician Peter Charles Remondino in his 1891 book, History of Circumcision from the Earliest Times to the Present. Left intact, he warned, it can affect men "with all kinds of physical distortions and ailments, nocturnal pollutions, and other conditions calculated to weaken him physically, mentally, and morally; to land him, perchance, in the jail, or even in a lunatic asylum."

Oh, the uncircumcised penis, that driver of insanity and moral disarray. In the last century and a half of American history, many claims have been made about the effects of keeping or removing one's foreskin, both passionately in favor of and passionately against it. In the medical community, the question has always been whether the potential benefits of the procedure outweigh any possible risks.

This week, in a report free of references to jails or lunatic asylums, the Centers for Disease Control and Prevention said research on circumcision points toward a lot of potential benefits and not a lot of risks, beyond "minor bleeding and inflammation." The report suggests that circumcision might reduce the rate of transmission of some diseases, including HIV, because germs can get trapped under an intact foreskin. But it also hints at the cultural tensions surrounding the procedure.

Circumcision is a religious ritual in certain faiths, including Judaism and Islam. Historically, this has been an important marker of identity, said Shaye Cohen, a Jewish studies professor at Harvard who has written on cultural interpretations of circumcision. "Many Jews see circumcision as an essential marker of Jewishness," he said.

In the book of Genesis, God commands Abraham to become circumcised, and to have all of his sons and members of his household circumcised as well. This is part of his covenant with the Jews; God warns that "any uncircumcised male, who has not been circumcised in the flesh, will be cut off from his people."

"Even if Jews don’t observe anything else, they see [rejecting circumcision] as akin to rejecting Judaism," Cohen said.

In Islam, the ritual is slightly different; it's not in the Quran, and there are conflicting interpretations of Muslims' responsibility to get circumcised. But it's still an ingrained part of the faith; Muslims are the largest group that practices male circumcision in the world.

But outside of these minority faith communities, religion probably hasn't shaped American cultural views on circumcision. In the New Testament, circumcision isn't seen as necessary for salvation: "If you be circumcised, Christ shall profit you nothing," Paul says in Galatians.

Yet for Christians in America, this probably didn't shape their views on circumcision, said Cohen. "The original medical establishment that saw the benefits of circumcision was not a Jewish one—it was WASP-y," or white, Anglo-Saxon, and Protestant. As the procedure became more popular and common during the late 19th century and into the first part of the 20th, he said, "I don't think Christians worried about the fact that they're somehow defying what Paul said in the New Testament."

For most people, removing the foreskin was a strictly medical decision, even if it did have slight moral overtones. “A circumcised penis was seen as healthier, neater, cleaner—and that it would inhibit male masturbation. There was a terror of masturbation in American society," Cohen said.

According to Cohen, American circumcision hit its peak during the mid-20th century, partly coaxed along by the influence of the United States military. In his book On Circumcision, a doctor named Ed Schoen describes an anecdote from an American veteran who served in the navy during World War II. Upon their arrival at boot camp, new recruits were lined up and asked, "Are there any Jews in the group?"

"The U.S. army in World War II wanted men to be circumcised ... it was thought to reduce inflammation and masturbation," Cohen said. "That's the moment when circumcision became well-nigh universal among the white citizenry."

But starting in the mid 1980s, a small number of groups began voicing their opposition, including the National Organization of Circumcision Information Resource Centers. Over time, arguments against the procedure have taken roughly three forms, Cohen said.

"On the medical side, there's a growing movement to try and cut back on procedures: Why do we perform surgery on a child who has no symptoms whatsoever?" he said. Those who call themselves "intactivists" advocate a similar idea: There's nothing wrong with male bodies as they're made by nature, and they should be left "intact."

But the most common argument, Cohen said, is about human rights. Some people argue that "we don't have the right to mutilate our children—if an adult wants to get circumcised, that's fine, but the child is not an adult."

This is an argument against infant circumcision, which is practiced in Jewish and Muslim communities and is the most common form of circumcision in American hospitals. The CDC's newly proposed recommendations  hint at some of these human rights concerns.

"Circumcision is simpler, safer, and less expensive for newborns and infants than for adult males," the guidelines say. "However, delaying circumcision until adolescence or adulthood enables the male to participate in—or make—the decision."

And on the medical side, the report says, the research is pretty clear: There are a lot of benefits to being circumcised, with few risks.

For men who have sex with women, being circumcised lowers the risk of contracting HIV from an infected partner by 50 to 60 percent; reduces the chance of contracting genital herpes by 30 to 45 percent; and lowers the risk of infection from cancer-causing strains of human papillomavirus (HPV) by about 30 percent.

For women who have sex with men, the risk of getting HIV isn't necessarily lower if he's circumcised, but the chances of contracting bacterial vaginosis or trichomoniasis or developing HPV infections or cervical cancer are lower.

Among circumcised baby boys, urinary tract infections are less common. Also, just in case you were wondering: "Adult men who undergo circumcision generally report minimal or no change in sexual satisfaction or function."

For now, these findings are most relevant to people outside of the gay community; the risk of contracting HIV and sexually transmitted infections has not been proven to be lower among circumcised men who have anal sex with other men. As the CDC points out, circumcision may have important health benefits for some individuals, but it won't be a panacea for the transmission of HIV. This is because the major routes of transmission are sex between two men, or from a male partner to a female partner, and circumcision hasn't been shown to decrease transmission among these groups.

And ultimately, the organization says, cutting off your foreskin—or that of your child—isn't just a medical decision; it's a personal choice. And this shapes its final recommendation for patients:

"The decision regarding circumcision should be made in consultation with a health care provider, taking into account personal, cultural, religious and ethical beliefs."