An age-old religious practice has come under much scrutiny in the past 15 years. Is circumcision "genital mutilation," or in fact a medical procedure that leads to increased sexual satisfaction and decreased physical problems?

Circumcision, the surgical removal of the foreskin from the penis, may be one of the oldest surgical procedures known to mankind. For more than 3,800 years, Jews have circumcised their newborn males as a sign of a covenant with God. Visitors to the Museum of History in Cairo can see a statue showing a circumcised Pharaoh, and in fact, the Egyptian hieroglyphic for penis is the circumcised organ.

Illustrations of the operation itself have been found dating from 3000 BC, and it is the only surgical procedure mentioned in the Old Testament. In 1928, newborn circumcision was bolstered by an editorial in the Journal of the American Medical Association calling for the routine circumcision of all male infants at birth—primarily to prevent masturbation. Most Jews, Muslims, and Ethiopians still routinely circumcise their newborns today.

Outside of the United States, males that are not Jewish or Muslim are almost never circumcised. And in the United States, circumcision rates have dropped from 90% in 1980 to less than 60% in 1995. The topic of circumcision has generated medical, legal, and ethical concerns—much of which is based on conflicting information and data. Why has this age-old procedure become so controversial?

Pros and Cons

The issue here is whether the procedure is beneficial, medically unnecessary, or harmful. Unfortunately, studies are controversial and subject to individual interpretation. Many studies have shown that urinary tract infections are more common in uncircumcised infants. And advocates of the procedure cite studies showing that circumcised men have lower rates of penile cancer (a very rare disorder) and AIDS (most of the studies were done in underdeveloped countries). In fact, recent studies have reported significant drops in rates of HIV infection among men who were circumcised, compared with men who were not. One study involved 5,000 uncircumcised men in Uganda. Half of the men were circumcised, while the other half served as controls. After two years of follow-up, the rate of HIV infection was 51%-60% lower among the men who were circumcised.

A number of studies have also documented higher rates of cervical cancer in women who have had at least one uncircumcised partner. The uncircumcised male is more prone to a build-up of smegma, which is a cheesy substance composed of dead cells and other secretions. This accumulation, which can be easily controlled with proper hygiene techniques, may lead to odors that are deemed aesthetically unpleasant. And on a purely practical basis, the advent of the zipper fly has caused more than one traumatic injury to an intact foreskin. On the other hand, circumcision may occasionally lead to serious bleeding or infection.

Without circumcision, men may develop phimosis, a condition in which the foreskin gets stuck in a “pulled back” state. The majority of these cases, though, can be easily treated without any surgical intervention. Only severe cases of phimosis may require circumcision to prevent recurrence. Circumcision is a painful procedure and requires local anesthesia and about 7-10 days of healing. The forgoing “pros and cons” are based on reasonably solid fact. Much of what follows in this section derives from surveys whose accuracy and validity is somewhat open to question. Readers should regard the “sociosexual” points with some skepticism.

From a sociosexual point of view, there is some indication that circumcised men experience slightly higher rates of sexual activity, and that women with circumcised lovers are more likely to achieve simultaneous climax. Although circumcision is favored by women for appearance and hygiene, women report that an uncircumcised penis is easier to bring to orgasm by hand; the circumcised penis was preferred for oral sex.

When asked in a 1988 survey about their penile preferences, women said that a circumcised penis was "cleaner" (92%); that it looked "sexier" (90%); that it looked "cleaner to touch" (85%); and that it smelled better (55%). Even women who had uncircumcised partners preferred the look of a circumcised penis (76%). This last fact is not lost on erotic movie producers and photographers; they tend to choose men who are circumcised or uncircumcised men whose foreskin is smooth.

As noted previously, there are some risks associated with circumcision. In addition to bleeding and infection, there are occasional surgical mishaps in which too much or too little of the foreskin is removed. Occasionally there can even be injury to the penis itself. These problems may or may not require further surgery and are estimated to occur during approximately one in 15,000 circumcisions.

In 1971, the American Academy of Pediatrics (AAP) Committee for the Newborn stated, "There are no valid medical indications for circumcision." In 1975 that statement was modified to "no absolute valid," and in 1989 it was changed significantly to read that "New evidence has suggested possible medical benefits." The new evidence was primarily a reduced rate of urinary infection in circumcised infants. The latest (1999) statement from the AAP says once again that there is no medical indication for routine infant circumcision, even though the procedure is safe, and with care can be made nearly pain-free for the infant. The recent African trials showing a significant reduction in HIV risk with circumcision may prompt the AAP to update this statement yet again.

Current estimates are that widespread circumcision (currently about 30% of all men have had the operation) could prevent 3 million male deaths from HIV over a 20 year period. This benefit might be offset by a rise in deaths from infection and bleeding if the procedure were not performed in accordance with best practices.

Understanding the Controversy

Until now, much of the circumcision controversy has revolved around human rights and has been concerned more with ideology than with health. The National Organization to Halt the Abuse and Routine Mutilation of Males (NOHARMM) has put together a video promoting the idea that circumcision causes psychological trauma. The producer, Tim Hammond, hopes that "a cultural shift will happen where we recognize and respect the right of all children to bodily integrity."

NOCIRC, the National Organization of Circumcision Information Resource Centers, states in its literature that it opposes "the performance of a single additional foreskin...amputation procedure" and that the only person who may consent to medically unnecessary procedures on themselves are "individuals who have reached the age of consent."

The debate about circumcision is bound to continue. If you're a parent wondering if you should circumcise your child, try to put the issue in perspective. As Ronald Poland, a Pennsylvania pediatrician, reported to the Wall Street Journal, "Compared with the other decisions you've got ahead as a parent, this is trivial. If you can't get past this one, you're in trouble."