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Click here to return to the Articles Home Page The circumcision decision For most of the century, in this country, the decision was easy. Nearly everyone - Jews and non-Jews of every ethnic, religious and political stripe - chose circumcision for their sons. Circumcision was widely considered to be cleaner, safer, healthier, and the one sure way to keep from standing out in the locker room. Major medical studies beginning in the 1930s backed up the general wisdom that circumcision prevented cancer of the penis and furthermore, seemed to contribute to the low incidence of uterine cancer in Jewish women as well. Then, somewhere in the '70s, this all started to change; in part an outgrowth of the organic, back to nature movements; in part the inevitable result of exploding social consciousness, which had people questioning all knee-jerk truisms, medical ones among them. Among a certain type of middle-class educated parents (including Jewish parents), choosing not to circumcise became a form of genital chic. A new phenomenon began to appear in the land: the uncircumcised Jewish boy. As a pediatrician in charge of a large group practice, I have treated a number of young Jewish boys in recent years for foreskin diseases and defects - for example, a three-year-old boy in considerable pain, with severe swelling and redness of the end of the penis, and discharge from the tip of the foreskin. He had balanoposthitis, infection of the foreskin and head of the penis, a condition most often seen in two-five-yearold uncircumcised boys. It is treated with oral antibiotics and warm compresses but has a tendancy to recur, often requiring later circumcision. Another example: The parents of a four-year-old boy, during a routine exam, complained of inability to push back their son's foreskin and properly clean his penis. Examination showed that although the foreskin had properly separated fron the head of the penis (glans), the end of the foreskin, which is normally lax and retractable, was constricted to pin-point size, which allowed the passage of urine but permanently prevented reteaction of the foreskin. This foreskin defect is called phimosis, and the treatment is circumcision, which at this age is not only more difficult and expensive than in the newborn, but more risky, as general anesthesia is necessary. A final example: Having been awakened at 2 a.m. by the screams of their eight-month-old boy, the parents noticed that he was hot, flushed and trembling. Upon finding that he had a fever of 104.8, they rushed him to the Children's Hospital Emergency Department, where tests included a spinal tap, blood test, chest x-ray and bladder tap through the penis. Had the baby been circumcised, an ordinary urine sample would have ben sufficient. A bladder tap ras required to avoid bacterial contamination in the urine from the foreskin. The studies showed a severe urinary infection, requiring hostitalization for a week. After discharge he had to be tested to assess kidney damage; many infants with severe urinary infection in infancy are later found to have kidney damage and scarring. Foreskin diseases in uncircuncised Jewish boys may not be surprising given the increasingly secular nature of American Jews. The religious basis of circumcision goes back to Genesis 17, when Abraham made a covenant with God that all males would be circumcised at eight days of age. This covenant has been almost universally kept by Jews over the millennia, including Jesus and the early Christians. It wasn't until Paul began proselytizing among non-Jews that he ruled that circumcision was not a requirement. Baptism or "circumcision of the heart," was an acceptable substitute [Romans 2:29] - probably a wise marketing decision. Odly enough, circumcision has long been associated with non-Jewish upper classes and with royalty. Ancient Egyptian priests were circumcised. King Louis XVI of france and Queen Victoria of England popularizes the proceedure among their subjects. Louis XVI was circumcised at 22 to cure phimosis, a permanently unretractable foreskin, which caused painful erections and unsuccessful intercourse with his wife, Marie Antoinette. Queen Victoria, convinced that the British royal family was decended from King David, had her male offspring circumcised. This tradition continued through Edward VII, the Duke of Windsor, and Charles, the current Prince of Wales, who was circumcised by a well-known physician and mohel, Dr. Jacob Snowman. This tradition of British royalty has now ended, however. The young princes William and Henry are "intact," in keeping with current fashion. Currently, newborn circumcision is not a benefit covered by the British health service. By the early 1900s in the United States, newborn circumcision among non-Jews was increasing, mainly among professional families. The germ theory of disease had become well accepted among the educated, and high value was placed on hygiene in maintaining good health, supposedly made easier by circumcision. By the 1930s, about 30 percent of non-Jewish U.S. newborn boys were being circumcised. New evidence that newborn circumcision essentially eliminated the likelyhood of cancer of the penis caused the numbers to risr even more. But it was World War II that made universal circumcision the standard in the United States. Poor hygene and desert sand resulted in many cases of severe foreskin infections among soldiers, especially in the North African campaign. Observations by military surgeons convinced them that circumcision protected agains certain venerial diseases, particularly syphilis and chankroid (a nasty ulcerating infection of the head of the penis). The foreskin provided a warm, moist environment for dangerous bacterial growth, and the delicate inner surface tore easily during intercourse, allowing infections to enter. By the middle of the war, to prevent infections, young recruits were being circumcised in U.S. training camps. The American public took heed; by the 1950s almost all American newborn boys were being circumcised. In the early 1970s, a series of events contributed to changing the fate of the foreskin. The idea of protecting newborns against trauma became popular. It became fashionable to have birthing centers featuring soft music, soothing lights, and warm tubs for newborns. Parents became aware that infants felt pain, and circumcision, performed without anesthetics was painful. A new pediatric specialty, neonatology, focused on newborns. The immediate problems and complications of circumcision recieved more attention from these specialists who were less likely to appreciate the preventative health benefits of circumcision later in life. In 1971 the American Academy of Pediatrics (AAP), neonatology section, issued a statement that there was "no valid medical indication for newborn circumcision." No references were made to the substantial body of medical evidence on circumcision's health benefits. It wasn't until 1989 that an AAP task force, which I chaired, reemphasized the previous medical evidence favoring circumcision and introduced data suggesting new benefits. By this time though, the activist anticircumcision movement was well under way, preaching the message that the natural, intact state of the foreskin was "genitally correct." The largest organization involved, a California-based group called the National Orginization of Circumcision Information Resource Centers (NOCIRC) catered to upper-middle class educated women and found a ready audience among young, secularized Jewish mothers. In the 1990s, other organizations, often male dominated. were formed, such as the National Organization to Halt Abuse and Ritual Mutilation of Males (NOHARM). Even more extreme are the "foreskin reconstructionists," men who favor skin grafts (and stretchings, ed.) to replace missing preupices (Recover a Penis [RECAP], Brothers United for Future Foreskins [BUFF]). The ultimate voice for this viewpoint is the Foreskin Quaterly, a magazine published in San Francisco that caters to foreskin-intact gay men seeking others similarly endowed. Ironically, as young parents were opting out of newborn circumcision, powerful evidence was accumulating in the medical literature which indicated that circumcision prevented urinary infections in young infants and helped protect against the acquisition of the human immunodeficiency virus __(HIV) in sexually active men. In the 1980s, a U.S. Army neonatologist, Dr. Thomas Wiswell, who was anti-circumcision at the time, reviewed the records of about 200,000 male infants in the database of the Armed Forces and found that severe urinary infections were 10 to 20 times more commom in uncircumcised infants. Since then nine other studies have confirmed this finding, and Dr. Wiswell has become a prominent circumcision proponent. Electron microscopy studies have shown how infections of the kidneys are related to the foreskin. Disease-causing intestinal bacteria adhere to the moist, sticky mucous surface of the foreskin and then migrate up the urinary tract as far as the kidneys. Further, recent special imaging studies have shown evidence of kidney damage and scarring in infants and young children folowing severe urinary infections. Another problem is that the "colonization" of the foreskin can contaminate the urine with bacteria, so to get a valid urine specimen from an uncircumcised infant, the foreskin must be bypassed, usually by inserting a needle into the bladder. In a circumcised boy, however, voided urine is equivalent to a bladder speciman, resulting in less traumatic interventiion in testing the urine. The increased risk of HIV in uncircumcised men was originally discovered in Kenya in the late 1980s, when it was found that uncircumcised men exposed to HIV infected prostitutes were three to four times more likely to become HIV positive within a year. This risk becomes even greater if there is a sore on the penis from another venereal disease, such as syphilis or chankroid. The results are cumulative; an uncircumcised man with a penile sore has about seven times the risk of contracting HIV after exposure as does a a circumcised man without a sore. This supports the theory that tears in the delicate foreskin, like a penile venerial ulcer, allow the virus to enter. More than two dozen studies from around the world have confirmed this increased risk of HIV in uncircumcised men, including observations on homosexual men in Seattle. This documentation, mostly in the past five years, has led led to recommendations to expand male circumcision, even among adults, to control the AIDS epidemic in sub-Saharan Africa. The issue of pain is a real one. This was addressed about 20 years ago by a classic St. Louis study, which found that newborns feel and react vigorously to pain but recover quickly, so that in less than 24 hours, no behavioral differences can be found between circumcised and uncircumcised infants, even when local enesthesia is not used, and there have been no demonstrated long-term emotional effects. Further, there are now safe and effective means of managing pain in the newborn, inclucluding sucking on a sugar solutiion (mohels have used a little sweet wine) or using a local anesthetic. General anesthesia should never be used in newborns. If the foreskin is more of a hindrance than a help, why is it there, and what about sexual pleasure? We can only guess about its purpose. Perhaps far back in time, when man was running naked through through thornbushes and brambles, the foreskin served a protective function. Other organs have become detriments as man has evolved, including the appendix and wisdom teeth, which have valuable functions in lower species. Unfortunately, these organs are not easily removed. As for sex, there is no evidence that uncircumcised men have more fun or better performance. On the contrary, improved cleanliness and aesthetics makes for more pleasure. In Iowa City, America's heartland, a published survey of 100 young sexually active women found that the circumcised penis was preferred by a margin of 3 to 1; it looked sexier (75%), felt better (85%), stayed cleaner (92%), and interestingly, 77% of the women stated that it seemed "more natural" (environmentalists take heed). The National Health and Social life Survey (NHSLS), published this year in the Journal of the American Medical Association, found that uncircumcised men were more likely than circumcised men to have sexual dysfunction, particularly later in life. Difficulty in achieving or maintaining an erection was significantly higher in uncircumcised men. From the medical standpoint a one week old circumcised boy has significant health advantages over an uncircumcised boy during a lifetime. In addition, the ease of genital hygene offers esthetic benefits for every day cleanliness and later sexual pleasure. The long-known benefits of circumcision in preventing penile cancer, foreskin problems and local infections have been confirmed. Evidence over the past decade indicates other advantages in lowering the risk of urinary infection, kidney damage, and acquisitiion of HIV. Jews who reject circumcision are ignoring the requirement of the covenant and the tradition of their ancestors going back millenia. The decision against circumcision is usually made on the basis of social class and popular trends. Now that the medical evidence favoring circumcision is making its way into the media, there are signs that the circumcision rate is again increasing. It seems likely that secular, rather than religious, pressures will end the current phenomenon of Jewish boys with foreskins, just as they started it. Mohel Joel Shoulson | 610-523-3393 | 1-800-700-JOEL (5635) | www.MohelJoel.com |