Figure 1 Techniques of newborn circumcision
Male circumcision—the surgical removal of the foreskin of the penis—is one of the most common surgical procedures performed globally. One in three males undergoes this procedure worldwide. The foreskin develops during the third month of pregnancy when a fold of skin pops out from under the head of the penis (glans), like a collar, and then slowly grows until it covers the head. It’s on there pretty tight right at birth, and it’s not until about age 5 that it can be partially rolled back without discomfort. By 17, most teenage boys can pull the foreskin back easily.
Circumcision is one of the oldest surgical operations known to have been performed. Some experts think it started in the region of Egypt more than 15,000 years ago. The earliest mummies, dating to 1300 BC, were found to be circumcised, and Egyptian wall paintings depict circumcision many thousands of years earlier.1 There is even some evidence aboriginals required it as a rite of passage for becoming a man before 10,000 BC.2
In Judaism, the Covenant of Circumcision includes a religious circumcision ceremony called a brit milah, or bris. The ceremony is performed by a mohel (“circumciser”) on the 8th day of a male infant’s life, as described in the 17th chapter of the book of Genesis.
Then God said to Abraham, “As for you, you must keep my covenant, you and your descendants after you for the generations to come. (Gen. 17:9) This is my covenant with you and your descendants after you, the covenant you are to keep: Every male among you shall be circumcised. (Gen. 17:10) Any uncircumcised male, who has not been circumcised in the flesh, will be cut off from his people; he has broken my covenant.” (Gen. 17:14)
Later in the Book of Genesis, circumcision is used as a military tactic. According to the text, Shechem the Hivite prince had “relations” with the patriarch Jacob’s daughter Dinah in a dishonorable way. Now, he was not a Jew but he really wanted to make an “honest woman” of her. Dinah’s brothers were infuriated and they hatched a plot.
They said to them, “We can’t do such a thing; we can’t give our sister to a man who is not circumcised. That would be a disgrace to us. We will enter into an agreement with you on one condition: that you become like us by circumcising all your males. Then we will give you our daughters and take your daughters for ourselves. We’ll settle among you and become one people with you.” (Gen. 34:14–17)
Prince Shechem agreed and they all got cut on the same day. Talk about taking one for the team! Well, 3 days later, as all of the men in the kingdom were recovering from their surgical procedures, Dinah’s brothers attacked them while they were in their delicate state.
Three days later, while all of them were still in pain, two of Jacob’s sons, Simeon and Levi, Dinah’s brothers, took their swords and attacked the unsuspecting city, killing every male. They put Hamor and his son Shechem to the sword and took Dinah from Shechem’s house and left. The sons of Jacob came upon the dead bodies and looted the city where their sister had been defiled. (Gen. 34: 25–28)
In Islam, the act of circumcision is one of the rules of cleanliness pertaining to the “fitrah.” Fitrah is an Arabic term used to represent the innate disposition and natural character and instinct of the human creation. In the Qur’an, the Prophet Muhammad is reported to have said:
Five are the acts quite akin to fitrah: Circumcision, shaving the pubic hair, cutting the nails, plucking the hair under the armpits and clipping (or shaving) the moustache. (Qur’an Sahih Bukhari 7:779)
Islamic circumcision can be performed at any age but it is often performed during the teen years as a rite of passage. Circumcision in certain southeast Asian countries is also performed as a rite of passage or coming of age. In some cases, such as in Timor, several boys at once may undergo circumcision as a group activity, using fairly primitive techniques.3
With the rise of Christianity, circumcision was typically discouraged and there was some pushback against it, as well as in the Reform movement of Judaism.4
It wasn’t until 1865 (in England) and 1870 (in the United States) that circumcision also became a medical practice. There wasn’t a lot of science behind it at first; it mostly served as a way to discourage masturbation.5 Nowadays there are several reasons why millions of circumcisions are carried out, some religious, some cultural, some medical, and some just personal.
According to the World Health Organization, about 1 in 3 males worldwide is circumcised. It has become the norm for most boys born in Canada, Israel, Australia, central Asia, Bangladesh, Pakistan, Turkey, Indonesia, the Philippines, the Republic of Korea, and also much of the Middle East.6, 7 Americans are big tippers, but it varies by ethnicity. Caucasians get cut (91 percent) more than African Americans (76 percent) who get cut more than Hispanics (44 percent).8, 9
The Brits don’t like to mash their bangers. Circumcision rates are opposite those in the United States: Only 16 percent of British men in their forties report their wankers being whacked, and the rates get lower with younger generations.10
Turtlenecks are the style in Latin America, most of Asia, and Europe, where circumcision is rare. Africans, on the other hand, are increasingly going for V-necks; in Africa, studies have shown that circumcision lowers the risk of contracting HIV because the delicate foreskin is more susceptible to the virus than the rest of the penis.
NEWBORN CIRCUMCISION: Circumcision of a newborn is a fast, safe procedure when performed by a skilled practitioner. To lessen pain for newborns, a mild analgesic may be used after the procedure. Some health care practitioners also use a sweetened pacifier. A jewish mohel may give a few drops of sweet kosher wine. The penis can be numbed with local anesthesia such as EMLA cream or a small injection. Circumcision is usually done within 10 days of birth. There is some evidence that babies may be less likely to feel pain 7 to 10 days after birth because newborns have a high level of endorphins (substances made by the body that reduce pain). With prep time, a modern circumcision for an infant male today takes about 10 minutes to complete. Approximately 70 percent of obstetricians, 60 percent of family practitioners, and 35 percent of pediatricians practice newborn circumcision.11
There are several ways to perform a circumcision. The most common technique uses a tool called the Gomco clamp. With this device, a little safety helmet is put on the head of the penis, separating it from the foreskin, and a platform is put below it that pinches the skin while it is trimmed away. The cut typically heals in 5 to 7 days. The Plastibell device utilizes a plastic safety helmet and has a groove at its bottom that the skin gets pinched into by a tightly wrapped string. In 5 to 7 days, the strangulated foreskin and the plastic covering fall free from the penis or can be trimmed away, leaving a completely healed circumcision. The Mogen clamp pinches the foreskin beyond the head of the penis, where it is then trimmed off with a scalpel along the groove of the clamp.
After circumcision, caring for the penis is easy, but important. The area should be washed gently with warm water mixed with mild, unscented soap. A new bandage with antibiotic ointment can be placed with each diaper change.
Some swelling, redness, and perhaps a little blood are common early on, but if these problems persist several days or get worse or there is a fever, the baby should be seen by a doctor. Another indication for a doctor visit is a dry diaper for more than 12 hours following a circumcision.
Figure 1 Techniques of newborn circumcision
Figure 2 Stages of healing following newborn circumcision
CHILD/ADULT CIRCUMCISION: Circumcision is more complicated for older boys and adults. The penis is bigger, so anesthesia is required and so are actual stitches. Devices are usually not used, but instead the skin is cut directly with a scalpel or scissors or both. The bandages come off the next day in a warm tub or shower. The stitches dissolve in about 7 to 14 days. Ice is helpful to reduce pain and swelling for the first day or two. Soaking the penis in warm water a couple times a day will keep it healing cleanly for the first week or two. Athletic activity and sex should be avoided until it is well healed, which can take 3 to 4 weeks. Clothing should be comfortably loose. Minor bleeding is common and usually just requires some pressure with a clean dressing for a few minutes.
For many centuries, newborn circumcision has been a hot topic of debate. On one side are those who argue that foreskin is a natural part of the male anatomy and should not be mutilated, saying that doing so may create potential negative psychological effects, desensitize the penis, and subject newborn boys to numerous potential adverse medical complications. In an online survey, circumcised men reported less sensitivity and more discomfort in certain parts of their penis shaft and head compared to men who were not circumcised.12 Actual testing of the nerve sensation of the penises of men who were and weren’t cut revealed few to no differences, however.13 Nor were there any differences in the ability to get aroused and erect.14
The medical benefits of a newborn male circumcision are many, including:
•REDUCED RATE OF URINARY TRACT INFECTIONS (UTIs): Circumcised boys are less likely to have a UTI in their first 6 months of life, when they are most vulnerable. Over their lifetimes, 1 in 12 circumcised males experiences a UTI, compared with 1 in 3 uncircumcised males.15
•REDUCED RATE OF FORESKIN-RELATED PROBLEMS: Things can go wrong with the foreskin. Its delicate, floppy structure makes it more prone to get infections than the rest of the penis skin. Over time smegma, a combination of sloughed skin cells, can accumulate under the foreskin and cause inflammation and odor. Yeast likes to grow in the moist environment under the foreskin too. Foreskin infections are painful and they can lead to contractions and scarring resulting in a foreskin that is too tight to pull back, like a turtleneck you just can’t pull over your head. Even without infections, the foreskin can become too tight, particularly as a man ages, and especially if he has diabetes or other conditions that curtail the bloodflow in the foreskin. This condition, called phimosis, affects approximately 10 percent of uncircumcised teens and adult men, and the treatment is circumcision. Even worse, but much less common, is paraphimosis, a condition in which the foreskin cannot be rolled back over the head of the penis. It becomes a medical emergency because the blood in the rolled-back foreskin can’t circulate properly and the foreskin swells up and gets tighter and more swollen in what becomes literally a vicious circle (around the penis shaft). If you sport a convertible, never leave the “top” down for too long.16, 17, 18, 19, 20, 21
•REDUCED RATE OF SEXUALLY TRANSMITTED INFECTIONS: Circumcised men have lower rates of catching and spreading certain viruses and bacteria.22 Several medical studies have also shown that circumcision reduces the risk of female-to-male transmission of HIV by about 60 percent. This is because the foreskin is fragile and can tear during sex, allowing the virus to get into the blood. Also, the foreskin has a high concentration of a type of white blood cell called Langerhans cells, which the HIV virus likes to attach to. The protective effect occurs even if circumcision is performed on an adult. Based on these findings, in 2007 the World Health Organization endorsed circumcision as a way to help stop the spread of HIV.23 Circumcision also lowers the risk of catching and spreading genital herpes, syphilis, chancroid, trichomoniasis (caused by Trichomonas vaginalis), and mycoplasma infection (caused by Mycoplasma genitalium).24
•LOWER RATES OF PENILE CANCER AND CERVICAL CANCER: Genital warts are caused by one of the most common sexually transmitted viruses, called human papillomavirus, or HPV. Circumcision lowers the risk of getting genital warts. More importantly, certain strains of the HPV virus cause penile cancer and also cervical cancer in the partners of men with this infection. Penile cancer affects approximately 1 in 1,000 uncircumcised men over a lifetime. Infant male circumcision reduces penile cancer later in life by 95 to 99 percent.25 Cervical cancer is 10 times more common than penile cancer, and it occurs 5 times more often in women whose male partner is uncircumcised.26
•LOWER RATES OF PROSTATE CANCER: Male circumcision lowers the risk of prostate cancer by about 15 percent if performed prior to his becoming sexually active. This may be because some prostate cancer is a result of a viral infection.27
A 2017 article in the World Journal of Clinical Pediatrics summed up the myriad benefits of circumcision this way: “Our risk-benefit analysis showed that benefits exceeded procedural risks, which are predominantly minor, by up to 200 to 1. We estimated that more than 1 in 2 uncircumcised males will experience an adverse foreskin-related medical condition over their lifetime. Wide-ranging evidence from surveys, physiological measurements, and the anatomical location of penile sensory receptors responsible for sexual sensation strongly and consistently suggested that male circumcision has no detrimental effect on sexual function, sensitivity, or pleasure.”28
There are several complications that can occur during or after circumcision, ranging from the insignificant to the tragic (i.e., severing of the penis). The overall rate is quite low, at 0.5 percent of all newborn circumcisions. Almost all of these complications are preventable with experience and proper technique. Most of these complications occur at the hands of novices who are neither urologists nor surgeons. There’s not a large margin of error with a newborn penis.29 Here is a rundown of the key risks associated with circumcision.
•BLEEDING: Excessive bleeding is rare but can occur.30 In the ancient Jewish tradition, circumcision was not performed if two older brothers had already bled to death. (Hey, the first one could have just been a fluke.) This was likely a situation of hemophilia, a genetic bleeding disorder.31
•INFECTION: The circumcision wound may become infected, but the rate in newborns is very low at 0.4 percent, while in older boys it may be as high as 10 percent. Most of the infections are minor and are not of significant consequence. However, occasionally there can be a terribly severe “flesh-eating” infection resulting in severe permanent disability or death. The risks of bleeding and infection are greater with adult circumcision because there is more skin that must heal.
The remaining risks are more likely in newborn circumcisions, where the small size of the structure increases the risk of complications.
•CONCEALED PENIS: This condition occurs when too much skin is removed on the shaft but not enough from the tip, and the head of the penis gets retracted into the body by the short shaft skin while still being hidden by the excess tip skin. If there is a large fat pad around the pubic area, the penis gets pulled to under the level of the skin of the fat pad and foreskin remains past the head.
•PHIMOSIS: If not enough foreskin is removed at the time of the circumcision, when it heals it may scar down back around the head and be too tight to roll back all the way. This requires a repeat surgery to fix it.
•SKIN BRIDGE: Sometimes, when the penis is healing, a small bridge of skin can form between the edge of the head of the penis and the edge of the shaft skin. It can get thicker with time and can tether the penis, making erections constrained or painful. Surgery is required to cut things loose.
•NECROSIS: A very rare complication of circumcision is the loss of some or all of the penis itself. This can happen if there is a severe infection or there has been a slip of the knife.
•FISTULAS: A hole below the normal urethra opening can form through the skin if the urethra gets injured during the circumcision and heals improperly. Sometimes a boy is born with the urethra opening up on the shaft before it reaches the tip of the penis. A boy with this condition, known as hypospadias, should not be circumcised as a newborn because the intact foreskin will be needed for a later surgery that will correct this problem.32
The American Academy of Pediatrics and the American Urological Association both acknowledge the risks but recognize the health benefits of circumcision as well. On the other hand, in the Netherlands, the Royal Dutch Medical Association called for a ban on circumcision in 2010, stating that it is “medically unnecessary and violates children’s rights.” The debate against circumcision is often framed in terms of human rights, but these arguments can also be construed as anti-Semitic or anti-constitutional. The issue is tricky, even medically, because some of the benefits of circumcision, such as cancer prevention, are lost if it is not performed on a newborn but delayed to the age of consent.
For those concerned enough, there are techniques to “restore” the foreskin by using mechanical devices to stretch the remaining penis shaft skin slowly but surely until it covers the head of the penis once again. There are also surgical techniques that are infrequently performed.33 Some work is being done on tissue engineering, and there are even foreskin substitutes made out of fabric or latex designed to be worn over the penis so as to make the head more sensitive over time.34 Keep in mind, scientific studies show that the sensitivity of circumcised penises is not really different than that of uncircumcised penises, so these efforts may be a long run for a short slide, as it were.
Circumcision is a complex topic because it is not necessarily a personal choice. The advantages of circumcision are several, but some of these require the procedure to be performed before the age of consent. Cultural, scientific, and spiritual influences all come to bear on the decision. Careful scientific study has failed to demonstrate a significant difference in sexual sensation and function in men who are circumcised versus those who aren’t. I personally have performed many circumcisions on adult men who suffered from foreskin complications, and they have not complained of negative impact on their sexual experience following the procedure. If circumcision is pursued, it is best performed at the hands of a trained medical professional.