Uncovered

Last December, about a week after my son was born, my wife and I invited a few people over to our house for the bris. In English, that means that we asked our friends to witness a bearded stranger removing the foreskin from our son’s penis.

I have been to a number of such ceremonies, and I have always found them stressful. Now, with my own offspring involved, the stress was multiplied by a factor of 50. I was also outrageously sleep-deprived. All that taken together means that my memories are hazy. I recall sweating, crying, and feeling sick. I also recall my son shrieking as the mohel made the cut. My thoughts could have been summarized thusly: Are you insane? You’re supposed to protect him! Instead you’re letting a Chasid operate on him in your living room!

Still, over the next few days, the boy seemed okay. At least, he wasn’t any fussier than usual. And I felt a bearable sense of ambivalence. I swore that I would never again cause my son any unnecessary pain, and yet I had to admit that I was glad that I had fulfilled my religious duty.

But then, about a week later, while changing his diaper, I saw blood well up on the tip of his penis.

The pediatrician—who, it occurs to me now, may have been hiding his distaste for circumcision with blank-faced courtesy—assured us there was nothing to worry about. The wound had merely stuck to the gauze and temporarily reopened.

So the baby was fine. But my ambivalence had turned to unease. I became obsessed by the question of whether we had made the right decision. Over the next week or so, I spent every spare second online, looking for information about circumcision.

For once, my preoccupation was in the zeitgeist. Circumcision has been part of the news cycle again, thanks to the initiative in San Francisco, where an anti-circumcision referendum will be on the November ballot. My friend Lee Rose Emery’s piece on CNN.com about not circumcising her son received some 2,500 comments, many of them angry, one way or the other. Months later, the issue is still generating noise. This spring, another ballot measure was attempted, then abandoned, in Santa Monica. More recently, Russell Crowe, an actor renowned for his tact and sensitivity, tweeted that circumcision is “barbaric and stupid.”

Despite all the discussion, few journalists were actually parsing the claims of both sides and evaluating the science. I was looking for a rational synthesis of the arguments; instead, as usual, the media focus was on the controversy, which is (a) easier to write and (b) creates more web traffic.

I suppose I should have known better, but, as I mentioned, I was sleep-deprived.

So what did the doctors think about it? In its Circumcision Policy Statement, The American Academy of Pediatrics explains that while “the data are not sufficient to recommend routine neonatal circumcision,” “parents should determine what is in the best interest of the child.” The medical authorities in the UK and Canada are similarly against routine circumcision, while allowing for, as the Canadian Paediatric Society puts it, “religious or cultural factors.”

In other words, they see no compelling reason for everyone to do it, and they see no compelling reason to bar religious people from doing it.

A sensible person would have stopped there. But I was disturbed by the rhetoric coming from the radical-fringe “intactivists,”—those who want to ensure that everyone’s penis should remain uncut, or “intact.” They see circumcision as “mutilation” and “permanently damaging.” Their claims, combined with my anxieties, compelled me to do some real research—as in scour the research databases and the library—in order to take a better-informed look at their arguments.

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First, I needed to learn about the foreskin itself, since I have no memory of my own. Sometimes known as the prepuce, it’s a cone-shaped bit of skin that covers that head of the penis. (That much I knew.) And it seems safe to say that its function is to protect the glans. Some believe that it also protects the member of a developing fetus, although it’s hard to imagine something sharp floating by in utero. Dr. Brian Morris, author of In Favour of Circumcision, presents the possible-but-improvable assertion that foreskins protected our ancestors’ members from “long grass and the like when humans wore no clothes.”

The foreskin plays a role in reproduction (obviously). It has a mucus membrane, which aids in lubrication during sex; it bristles with nerve endings. But even this basic naming of parts leads to contention—what we can call the sexual or anatomical argument. Advocates for circumcision are sure that men can do just fine without it, and, as a circumcised man, I have to agree. Meanwhile, intactivists suggest that without a foreskin, sex is like using a sandpaper condom—dry, joyless, and chafing.

In support of this assertion, intactivist websites frequently cite “The Prepuce: Specialized Mucosa of the Penis and Its Loss to Circumcision,” the electrifying title of a 1996 study from The British Journal of Urology. The pathologist John R. Taylor and his colleagues set themselves the unenviable task of dissecting 22 cadavers to investigate the structure of the foreskin. They convincingly argue that it’s no mere flap of skin, but “a structural and functional unit made up of more and less specialized parts.” (You could say the same thing about a car or a blender, but never mind.) They also make a case for its sensitivity, finding that the nerve-endings in the foreskin are similar to those found in the fingertips or lips of the mouth.

The problem is that Taylor’s findings are often distorted by intactivists. For instance, in his watershed 1997 article in Mothering, “The Case Against Circumcision,” Dr. Paul Fleiss, a Los Angeles pediatrician, claims that “the foreskin is as sensitive as the fingertips or the lips of the mouth.” (Emphasis mine. And, yes, that’s the father of Heidi Fleiss, the Hollywood madam.)

Taylor’s study itself is problematic. Its authors make a number of strange assertions, such as that the glans “is insensitive to light, touch, heat and cold and, as far as the authors are aware, to pin-prick.” (This makes me wonder if they held ice cubes to their dicks but balked at pins.) In addition, they believe it possible that the glans “protects the prepuce”—which is like saying that the brain protects the skull.

Look, Taylor’s investigation is actually important, especially if, as he claims, there is a “tendency to eliminate the prepuce from anatomy textbooks.” And maybe I am missing something in my own ignorance of anatomy and pathology. Nevertheless it seems at least awkward to form conclusions about the sensitivity of the foreskin when all the subjects in the study were dead.

There is no shortage of living subjects, after all—men who were circumcised as adults and are willing to talk about their sex lives before and after the procedure. Spend enough time with the literature, and it seems like they won’t stop talking about it. But these reports are anecdotal, which means they’re unhelpful as evidence. For every man claiming that his sex life was ruined, there’s another claiming that he’s going gangbusters, thanks very much.

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If the sexual arguments are inconclusive, are there sound medical reasons for removing the foreskin? The short answer is, maybe. The long answer is that there are issues associated with uncircumcised penises, like balanitis, an inflammation of the foreskin and penile head, and phimosis, when the foreskin can’t be retracted. Both are painful and sometimes have to be resolved with circumcision. But phimosis is rare—the incidence rate seems to be around 1 to 2 percent—and balanitis can usually be cured with soap and water. Thus circumcision as a prophylactic measure seems drastic.

The same logic applies to more serious ailments, like—shudder—penile cancer. Circinfo.net, a pro-circumcision website, claims that a snipped American male has virtually zero chance of getting penile cancer, as opposed to 1 in 400 for his uncut counterpart. While this sounds relatively high, there’s another way to look at it: the same website also cites that there were “1,280 new cases of penile cancer in 2007, with 290 deaths”—out of a total male population of around 150 million. Now, if you see the photos of cancerous penises on circinfo.net (please, trust me, don’t do it) you will feel immense relief if you are circumcised. Still, when you consider the discomfort of the procedure, my impression is that most men would live with the miniscule risk of penile cancer.

But consider this. In recent years, study after study has shown that it is more difficult to contract all sorts of sexually transmitted diseases—HIV, HPV, syphilis, herpes, you name it—if one is circumcised. Researchers aren’t quite sure why—perhaps the warm, moist environment beneath the foreskin is hospitable to viruses. Or maybe the part of the foreskin that is exposed when the penis is erect is more prone to infection. Either way it seems that circumcision can in fact reduce the risk of STDs.

This reduction can be significant. According to Male Circumcision, a 2007 report by the World Health Organization and Joint United Nations Programme on HIV/AIDS, “Three randomized controlled trials, in Kenya, South Africa and Uganda, have found that circumcised men are at 48–60% reduced risk of becoming infected with HIV.”

Intactivists will tell you that this is a “myth,” but their rebuttals are largely bullshit. They love to obsessively scrutinize the literature on circumcision and STDs for flaws or bias, taking the tiniest discrepancies as evidence of bad faith—without, of course, applying the same scrutiny to the literature that supports their view. An additional tactic, typical of internet pseudoscience, is to cite each other’s websites, creating a closed circle of disinformation masquerading as evidence.

Dr. Fleiss even argues that “circumcised American men are at a greater risk for bacterial and viral STDs” (again, emphasis mine). Unfortunately, the five studies that he cites don’t even remotely support this assertion.

Bullshit aside, we can’t necessarily argue that the lowered risk of STDs means that all male babies should be circumcised. Especially when there are other ways of preventing STDs, like keeping it in your pants or wearing a condom. (Don’t wear a condom in your pants. That won’t accomplish anything.) Nevertheless, the medical issues, when taken together, may present a reasonable argument for prophylactic circumcision.

Except, of course, if circumcision creates medical issues. Intactivist websites are packed with stories—and often horrifying photos—of botched willies. Still, at least in the West, the complication rate is extremely low. A study published in Pediatrics in 2000, “A Trade-Off Analysis of Routine Newborn Circumcision,” claims that out of approximately 130,000 newborns circumcised in Washington State between 1987 and 1996, the complication rate was .2 percent. And most of these complications were minor.

But I would be a hypocrite if I did not mention the terror that I felt when I spotted my son’s minor complication—and if I did not acknowledge that, however rare, all such complications could be avoided if no one were circumcised.

There are more arguments against circumcision, but I prefer to restrict the discussion to the most reasonable (or least unreasonable) ones. Thus I won’t bother countering the more egregious claims—that circumcision causes brain damage (bullshit); that it’s analogous to female circumcision (bullshit); that it’s a conspiracy perpetrated by biotech companies (bullshit); that it encourages anti-Semitism (a huge, steaming pile of bullshit).

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The only intactivist arguments that really give me pause concern ethics. In the 2004 symposium in the Journal of Medical Ethics, Dr. J. M. Hutson, a British surgeon, puts it succinctly: “The most fundamental principle of surgery is that no operation should be done if there is no disease, as it cannot be justified if the risk of the procedure is not balanced by the risk of a disease.”

Okay, then what is the real risk of not circumcising? The aforementioned study from Pediatrics—the “Trade-Off Analysis” one—explores that very question. The results are worth quoting: “Based on our findings, a complication can be expected in 1 out of every 476 circumcisions. Six urinary tract infections can be prevented for every complication endured and almost 2 complications can be expected for every case of penile cancer prevented.”

As the title says, it’s a trade-off. The risk of complication is slight, and the risk of disease is slightly less slight. Thus, keeping in mind Dr. Hutson’s fundamental principle of surgery, I probably should have avoided subjecting my son to the pain of circumcision.

But my decision was not based solely on epidemiology (I’m not that neurotic), or hygiene (only the criminally stupid can’t keep themselves clean), or the urge to make my son’s John Thomas look like mine (who cares?). I got him circumcised because I’m a Jew, and my religion obliges me to do it.

I wanted the bris because (and I am almost embarrassed to admit this) I believe that God and the Jews have a covenant, and that circumcision is the record of that covenant. Why we couldn’t just sign something I don’t know, but I’m not in charge of such decisions. Also, since I’m being honest, I wanted the bris for tribal reasons: we do it because historically it has set us apart from the people that don’t do it.

Here we come back to ethics. Does my right to exercise my religion interfere with my son’s human rights? Yes—if circumcision is harmful. And certainly, while doing my research, there were times when I regretted it. In the end, however, I’ve concluded that if it is an integral part of my tradition, and if it provides an edge against some nasty diseases—well, I will never be comfortable with knowing that I subjected my infant son to a painful elective procedure. But I can live with the bris.

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It’s obvious why people have strong opinions about circumcision. Every man has strong feelings about his penis, and what parent isn’t concerned about doing what’s best for his or her child? But you have to wonder why intactivists are so angry. Even if in the end I came out mildly against prophylactic circumcision, or at least (if I may) pro-choice, I am a little amazed at the gap between the depth of their indignation and the relative weakness of their arguments.

Perhaps its useful to compare intactivists to conspiracy theorists like truthers or birthers, other motivated groups who begin with a claim and then find whatever they can to support it, regardless of quality or relevance. Certainly some intactivists are conspiracy theorists, men who view themselves as victims of greedy doctors, rather than merely as recipients of an unnecessary but ultimately harmless procedure.

But the comparison only takes us so far. Unlike truthers or birthers, intactivists are actually performing a public service by making their opponents defend a procedure that, for decades, most Americans have accepted without question.

What, though, are we to make of the ones attempting, through various forms of quackery, to “restore” their foreskins? Some may snigger, but I find something pitiable in the “tugging devices” and “taping methods,” which can’t be comfortable and can take years. Instead of accepting themselves as they are, these men are obsessed with how they feel they should be—to they point where some undergo “foreskin restoration surgery,” once again putting the most sensitive part of their anatomy under the knife.

But this is the fringe of the fringe. For the rest of us—the concerned expectant parents, the sleep-deprived new fathers and mothers—here, then, is my advice. Jews and Muslims should do it if they like, and everybody should use anesthetic. However, since the procedure can never be entirely painless, I wouldn’t blame any parent for leaving it out—or on. That’s why if one day my boy is blessed with a son of his own, I hope I will remember to butt out. And until they can come up with some real arguments, intactivists should do the same.