Why Is Circumcision So Popular in America?

The recent decision by the U.S. Centers for Disease Control and Prevention (CDC) to endorse circumcision as a prophylactic measure against disease has once again drawn media attention to America’s most controversial surgery. In draft guidelines issued in December, the CDC emphasized that the most up-to-date medical science indicates clear health benefits of circumcision—including a 50%-60% reduced risk of female-to-male HIV transmission, a 30% reduced risk of transmission of the human papilloma virus (HPV), and lower risk of urinary tract infections during infancy. On the basis of these data, the CDC is recommending that health care workers counsel uncircumcised adolescent boys and men, as well as the parents of newborn males, on the potential benefits and risks of circumcision. The guidelines are currently undergoing a 45-day review period, during which the CDC is actively soliciting feedback.

According to the CDC, 80% of American males are circumcised.

According to the CDC, roughly 80% of American men are circumcised.

The CDC guidelines follow similar pronouncements made by the American Academy of Pediatrics (AAP). In 2012, the AAP’s “Task Force on Circumcision” issued a revised policy statement and technical report, which concluded that the health benefits of circumcision outweigh the risks, and argued that the procedure should be reimbursed by insurance.

These recent “favorable” reviews of circumcision by the CDC and the AAP come at a time when peer medical organizations in other Western countries are moving in the exact opposite direction. Medical organizations in England, Canada, Australia, Finland, Denmark, Sweden, the Netherlands, and Germany all oppose routine infant circumcision on medical grounds. Several national medical organizations go further and suggest that infant circumcision constitutes a violation of human rights.

It’s not just on policy matters that the U.S. differs from other nations. The strange truth is that the U.S. is the sole country in the world where a large majority of its male population is routinely circumcised at birth for non-religious reasons. According to the World Health Organization, approximately 30% of the world’s males are circumcised. Of these, most (69%) are Muslim men living in Asia, the Middle East, and North Africa; less than 1% are Jewish men; and the rest (13%) are non-Muslim, non-Jewish men living in the United States.

How did the U.S. come to be so out of step with the rest of the world on this issue? America has a long and peculiar relationship with circumcision, and it is impossible to understand the CDC’s and the AAP’s positions without appreciating that history.

Clean Cut

Circumcision, or removal of the foreskin from the penis, is the most common surgical procedure performed in the United States. More than a million newborn males are circumcised by doctors every year. You might think, given these numbers, that circumcision has sound scientific logic behind it. You would be wrong. In 1971, when the rate of neonatal circumcision in the U.S. was near its peak of around 80-90%, the American Academy of Pediatrics concluded that, “there are no valid medical indications for circumcision in the neonatal period.”

To be sure, various health benefits have been proposed over the years, but none that has ever stuck. In the midst of the latest debate about HIV transmission and other risks, it is easy to forget that circumcision has long been, in America, a cultural practice looking for a medical justification.

circ egypt

Ritual circumcision has been around forever. The earliest known depiction dates from 2400 B.C. in Egypt. National Library of Medicine.

As medical historian David Gollaher shows in his engaging book Circumcision: A History of the World’s Most Controversial Surgery, the American medical fascination with the procedure can be traced to the enthusiasm of a New York-based orthopedic surgeon named Lewis Sayre. In the 1870s, Dr. Sayre—who would go on to become president of the American Medical Association—developed a theory about the value of circumcision in treating muscle paralysis. The theory depended on the then-popular notion of reflex neurosis, which held that many diseases were caused by persistent stimulation of the nervous system by “irritation.” Dr. Sayre believed that by removing the foreskin he could eliminate one form of this “irritation” and thereby relieve the paralysis. (Interestingly, this was also the basis for removing a woman’s ovaries to combat hysteria and backache.) Sayre’s intervention, which he first performed on a 5-year-old boy suffering from leg paralysis, was the beginning of the American medical appropriation of what had been a primarily religious ritual.

What Sayre began, other physicians continued with gusto. Circumcision was used to treat conditions as varied as asthma, epilepsy, hernia, and indigestion. When reflex neurosis eventually fell out of medical fashion as an explanation for illness, other uses were found for the procedure. Increasingly, doctors said circumcision could prevent a number of conditions, including venereal diseases like syphilis and gonorrhea, masturbation, and cancer.

Integral to this new emphasis on prevention was the emergent germ theory of disease, which linked numerous deadly diseases to microbes. Americans became obsessed with germs during this period, pursuing cleanliness with an almost religious zeal. And in this pursuit, the genitals were found “filthy by association” (89). Smegma, the oily white substance that accumulates under the foreskin in uncircumcised males, was increasingly seen as a source of contamination, and the area itself became a kind of breeding ground for disease. Circumcision, American doctors thought, made patients cleaner (85).

The angel of cleanliness keeping watch at Ellis Island. From Harper's Weekly (1885). National Library of Medicine.

The angel of cleanliness keeping watch at Ellis Island. From Harper’s Weekly (1885). National Library of Medicine.

This obsession with cleanliness was class inflected. At the turn of the century, as millions of immigrants from southern and Eastern Europe poured into U.S. cities, circumcision became one important way that middle class Americans distinguished themselves from poor, dirty immigrants. In fact, Gollaher suggests that it was this meaning of circumcision as a mark of “civilization” that enshrined it in American popular culture (106-107).

That Americans’ germ obsession didn’t simply call for more vigorous cleaning with soap and water, Gollaher attributes to the increasing popularity of surgery as a discipline at the end of the 19th century. The development of antisepsis and anesthesia, “dramatically lowered the threshold for using the scalpel (97),” he notes. With these advances, it became increasingly feasible to prescribe circumcision as a prophylactic measure against disease.

Doctors’ new enthusiasm for prophylactic circumcision notwithstanding, it’s unlikely that the procedure would have ever become routine if it required adolescent boys and men to agree to genital surgery. As Gollaher ruefully notes, “The ultimate popularity of circumcision depended not on convincing normal men to undergo the ordeal of surgery, but on targeting a group of patients who could not object” (100). Infant circumcision proved to be the perfect solution. By 1920, neonatal circumcision performed by doctors in hospitals was standard procedure in America (105).

“The ultimate popularity of circumcision depended not on convincing normal men to undergo the ordeal of surgery, but on targeting a group of patients who could not object.”

The situation in England was similar to that in the U.S. for the first half of the 20th century; Sayre was widely read in England, too. But by World War II, things began to change. After the war, as Britain began creating its system of national “cradle-to-grave” health insurance coverage, the cost-benefit ratio of various medical procedures became a central concern. And, it turns out, circumcision didn’t make the cut. A British doctor, Douglas Gairdner, who reviewed the issue in 1949 found that scientific understanding of the foreskin was woefully inadequate; little research had ever been done on its normal development, including the time it takes for the foreskin to fully separate from the head of the penis and become retractable. This was remarkable, since one of the most common indications for circumcision since the late 19th century had been “phimosis,” or the abnormal adhesion of the foreskin to the underlying glans. Doctors in both America and Britain believed that the foreskin was normally—that is, in healthy infants—separate from the glans at birth; when it was not, circumcision was indicated. But Gairdner discovered that no one had bothered to find out what happened to the foreskin when it was left alone. Contrary to common wisdom, Gairdner found that boys differed widely in the time it took for the foreskin to naturally separate from the glans—anywhere from birth to 3 years. Circumcision as a treatment for so-called “adherent prepuce” before this time was therefore unnecessary. The National Health Service agreed, and in the years following the circumcision rate in Britain fell, from about 33% in 1948 to less than 10% today, with most of those being done for religious reasons.

Things were very different in the United States. Lacking a national heath care system concerned with cost-containment, the U.S. was not forced to conduct similar cost-benefit analyses of circumcision. Health insurance companies were happy to provide reimbursement for the procedure, and doctors were content to continue to collect payments for performing it. Technical innovations also made the procedure simpler, allowing it to be performed by obstetricians rather than by surgeons. As a result, circumcision became even more common.

The neonatal circumcision rate peaked in the U.S. in the late 1960s, at around 80-90%. Since then, the procedure has been slowly declining—in part due to the skepticism of parents who no longer place blind faith in the medical establishment and in part due to the profession’s own writings.

Risks vs. Benefits

In 1971, the American Academy of Pediatrics issued its first policy statement on circumcision, declaring that there were “there are no valid medical indications for circumcision in the neonatal period.” It issued this same view again in 1975 and 1977. In 1989, the AAP shifted course, finding now that there were some potential benefits of circumcision, including a reduced risk for urinary tract infections, yet still it refrained from recommending routine circumcision of infants. In 1999, the AAP policy statement on circumcision read, “Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.”

The AAP’s most recent policy statement, issued in 2012, went further than it had in previous years, arguing that the health benefits of newborn male circumcision outweigh the risks. What happened in the interim to tip the scales? Most important were several influential epidemiological studies conducted in Kenya, Uganda, and South Africa, which showed that circumcision greatly reduced the rate of female-to-male HIV transmission. Specifically, the studies showed that the rate of female-to-male HIV transmission was reduced by 50%-60%, from about 2.5% to 1.2%, in areas where HIV transmission occurs mainly through heterosexual sex. Though the AAP still declined to endorse routine neonatal circumcision on the basis of this evidence, it did say that if parents elected to have it performed, then it should be covered by third-party reimbursement.

The AAP’s revised policy statement generated quite a bit of media attention. The big news, judging from the American press coverage, was the impact the AAP’s conclusion could have on reversing what some saw as the “alarming” reduction in the number of circumcisions being performed in the U.S. These advocates predicted a “health-care doomsday” marked by a “steep rise in infections and medical-related spending if circumcision rates continue to fall.” In recent years, 18 states have eliminated Medicaid coverage for routine neonatal circumcision, citing lack of medical justification. What that means in many cases is that poor families who lack private medical insurance, and must pay out of pocket, elect not to have it done. For circumcision advocates, the AAP’s statement provides hope that state Medicaid programs will be forced to cover the procedure and American boys will no longer be denied access to it.

Among circumcision opponents, the AAP report also generated passionate responses, though these seem not to have gotten as much press coverage (to judge from popular matches in a Google search).

Circumcision opponents—which include groups such as Intact America, Stop Infant Circumcision and Doctors Opposing Circumcision—level several different arguments against the procedure. First, they doubt the medical rationale, pointing out, for example, that urinary tract infections in uncircumcised newborns are rare (incidence of 0.7%, according to the CDC), and when they do occur can be treated with antibiotics. They also note that rates of STDs, including HIV, are actually higher in the U.S., where circumcision is very common, than in many countries in Europe, like Sweden, Finland, and Denmark, where it is essentially nonexistent.

640px-Global_Map_of_Male_Circumcision_Prevalence_at_Country_Level

While not necessarily disputing the findings of the African HIV studies, circumcision opponents do doubt the relevance of these findings to the American context. In the U.S., most new cases of HIV transmission occur between homosexual men. There is no evidence that circumcision reduces risk of HIV transmission in this population (something that the CDC and AAP freely admit). Moreover, circumcision alone does not prevent HIV transmission to either men or women; condoms are still required for that. Advocating circumcision as a way to curb HIV transmission when the U.S. has both the highest rates of circumcision and the highest rates of HIV infection in the industrialized world strikes many critics as misguided.

What about cancer? The rate of penile cancer is exceedingly rare (just under 1 case in 100,000 men per year in the U.S., which translates into a lifetime risk, for any man, of 0.07%, according to the CDC). Circumcision opponents acknowledge that circumcision does lower a man’s risk of getting the condition. Removing one-third to one-half of the skin of the penis, it turns out, is an effective way to protect against contracting what is, after all, a skin cancer. Nevertheless, performing surgery on newborns to prevent such a rare cancer does not, to opponents, rise to the level of medical justification. As Gollaher notes in his book, “A high percentage of skin cancers eventually develop on the nose. But this has not led physicians to recommend prophylactic rhinoplasties” (145).

The American Cancer Society (ACS) agrees that infant circumcision is not a valid or effective measure to prevent penile cancer. “Although infant circumcision can lower the risk of penile cancer,” the ACS website notes, “based on the risk of this cancer in the US, it would take over 900 circumcisions to prevent one case of penile cancer in this country.”

What’s more, penile cancer is caused by infection with the human papilloma virus (HPV). Though neither the CDC nor the AAP documents mention it, there are safe and effective vaccines to prevent HPV infection. And the vaccines, unlike circumcision, offer strong protection against HPV infection.

The second, and closely related, argument opponents raise is ethical. They argue it is unethical to perform a medically unnecessary operation on a human who is not old enough to consent to it. Because most of the purported benefits of circumcision (with the exception of a reduced risk of UTIs) apply only to sexually active individuals, the decision to circumcise or not can be postponed to when the individual is old enough to decide for himself. Removing healthy tissue from an infant, critics say, represents a violation of the Hippocratic oath: primum non nocere. First, do no harm.

(For their part, circumcision advocates invoke their own ethical arguments, likening not circumcising to not vaccinating.)

To many critics, what is most galling about the CDC and AAP guidelines is that they completely ignore the value of having an intact foreskin. Very little attention is paid to the natural function of the foreskin, or to the foreskin as a source of pleasure. Nor are the risks of the procedure—including partial or complete amputation of the penis—ever properly acknowledged.

“Seen from the outside, cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious.”

Interestingly, though infant circumcision in the U.S. is now routinely done under local anesthesia, this is a relatively recent development. It was not until 1987 that infant pain was taken seriously by doctors. Before that, anesthesia was rarely used (Gollaher, 136).

A third common critique is to accuse American doctors of cultural bias. When the AAP’s 2012 report came out, pediatricians in Europe and Canada took the opportunity to issue a published response, entitled “Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision.” The article, co-authored by 38 physician representative of societies of pediatrics, pediatric surgery, and pediatric urology from 19 countries, argues that the purported benefits of circumcision do not rise to the level of medical justification, and certainly not before someone is old enough to consent. But the authors also make the point that this same evidence has been reviewed by doctors in other parts of the world where the conclusions reached were exactly the opposite of physicians in America. “Seen from the outside, cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious,” they write.

The AAP responded, essentially accusing their European and Canadian counterparts of being biased in the other direction, owing to the cultural norm of non-circumcision in these regions.

Sometimes the critiques can get quite personal. A published commentary on the AAP report written by the group Doctors Opposing Circumcision accuses the members of the AAP’s Task Force on Circumcision of bias verging on outright corruption. The commentary names several members of the task force and lists their potential conflicts of interest, including strong religious beliefs in favor of the procedure, economic incentive in the promoting it, and, in one case, deriving financial income from a medical practice devoted to treating boys with circumcision-related problems. Lest it go unnoticed, an additional potential source of bias is noted: “It appears that no member of the task force had a foreskin.”

* * *

Gollaher

To anyone interested in learning more about the peculiar history of circumcision in America I heartily recommend Gollaher’s book. It provides a valuable context within which to view the recent controversy over the health benefits of prophylactic circumcision. I’ll leave you with an interesting “thought experiment,” courtesy of Gollaher. Imagine, he says, that circumcision never caught on in America—that it was more like Norway in this respect. Now imagine that at a meeting of the American Academy of Pediatrics a doctor proposes in a talk that the genitals of all baby boys should be operated upon in order to achieve marginally lower incidences of urinary tract infections and perhaps a lower risk of STDs in adulthood. No one in his or her right mind would take him seriously, leading Gollaher to conclude, “If routine medial circumcision didn’t exist today, no one would dare to invent it.”

 

References

American Academy of Pediatrics Task Force on Circumcision (2012). Male circumcision [Technical Report]. Pediatrics. 130(3). [link]

Centers for Disease Control and Prevention (2014). Recommendations for providers counseling male patients and parents regarding male circumcision and the prevention of HIV infection, STIs, and other health outcomes. [link]

Earp, B. D. (2012). The AAP report on circumcision: bad science + bad ethics = bad medicine. Practical Ethics. University of Oxford. [link]

Earp, B. D. (2014). Do the benefits of male circumcision outweigh the risks? A critique of the proposed CDC guidelines. Frontiers in Pediatrics, in press. [link]

Frisch, M. et al. (2013). Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision. Pediatrics. 131;796-800. [link]

Morris, B. J., Bailis, S. A., Wiswell, T. E. (2014). Circumcision Rates in the United States: Rising or Falling? What Effect Might the New Affirmative Pediatric Policy Statement Have? Mayo Clin Proc. 89(5); 677–686. [link]

Svoboda, J. S. & Van Howe, R. S. (2013). Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision. J Med Ethics. Published Online First: doi:10.1136. [link]

World Health Organization/UNAIDS (2007). Male Circumcision. Global Trends and Determinants of Prevalence, Safety and Acceptability. Geneva, Switzerland: World Health Organization. [link]

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Posted on January 5, 2015, in Uncategorized and tagged , , , , , , , , , , . Bookmark the permalink. 21 Comments.

  1. A thoughtful, level-headed critique which rightly points out that in the United States routine circumcision is so deeply embedded in medical culture that it has become a social ritual rather than a mere surgical procedure – and thus very difficult to eradicate. The essential step in making it so common was the success of the turf-hunting ob-gyns, who managed take the operation over from surgeons and paediatricians, and make it an automatic (routine) part of the childbirth process. I have attempted to shed some light on the United States conundrum in my short book, The Sorcerer’s Apprentice: Why Can’t the United States Stop Circumcising Boys? Amazon e-book, 2013: http://www.amazon.com/dp/B00AXPRD1Q

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  2. One further point is not to exaggerate the antiquity or the prevalence of circumcision. The so-called Egyptian image here is a modern fake, based on an old bas-relief that is so eroded that it is very difficult to make out what it shows; there is no certainty that it depicts circumcision and quite unlikely that it does: see Frederick Hodges’ analysis:

    http://www.cirp.org/library/history/hodges2/

    The only firm evidence that the ancient Egyptians practised circumcision is a few passing remarks in Herodotus. We do know that the Ethiopians practised both male and female circumcision from very early times, and this may well be the point of origin from which it spread to other parts of Africa and the Arabian peninsular.

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  3. Thanks for your comments! The original caption referenced the fact that this is an illustration of a bas-relief, but I changed it in the revision. I admit I was following Gollaher here, whose book reproduces a picture of the bas-relief, and who interprets it as circumcision. I was not aware of the Hodges piece.

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  4. The Royal Society of Medicine has put the full weight of its influence and authority behind the groundbreaking research out of Denmark, by Prof. Morten Frisch, that circumcision is linked with an increased risk of autism. We shouldn’t have to prove that circumcision can screw up a baby’s mind. It’s self-evident to any thinking, compassionate person. BABY CIRCUMCISION IS AN ASSAULT UPON HUMAN DIGNITY AND FREEDOM. All the medical gobbledygook can’t hide that essential truth. Circumcision is an ancient punishment that American & other doctors have inflicted on their nations. They will have to explain themselves someday.

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  5. The AAP makes an interesting observation in its 2012 circumcision statement. It notes that penile cancer rates are similar between intact and circumcised men, but that risk goes up tremendously in men with pathological phimosis. That would suggest that when that group is removed from the intact cohort, the penile cancer risk may actually be lower among intact men with normally retractable foreskins than among circumcised men.

    As an economist, I am interested in a possible connection between postwar inflation and the dramatic rise in the US infant circumcision rate. After WWII the United States recovered economically faster than European nations; inflation was enough of a national concern that President Harry Truman instituted rigorous wage and price controls. When employers were no longer able to compete primarily by raising salaries, they focused on more generous benefits. One of these was family health insurance, and everything but the kitchen sink was included in the policies purchased by companies for their employees. Routine infant circumcision became a standard feature of these policies, particularly after popular clamor following the advice in Dr. Benjamin Spock’s famously popular book, Infant and Child Care, in which he incorrectly declared that parents of newborn sons had only 2 options: easy circumcision, or a painful routine of daily ripping back the snug and adherent foreskin and cleaning the glans. This advice first appeared in print in 1946, about three-and-a-half years before Douglas Gairdner’s questioning of the practice. Sayre, Remondino and Spock are three of the names associated with getting the American fad of circumcision to near-universal levels; only Spock later recanted his position and stated that he no longer advocated circumcision and would keep a son intact.

    Thank you for an erudite and objective article. Your history is accurate, but I do hope for a day soon when the word “uncircumcised” is viewed with the same bewilderment and disdain as the word “unappendectomized” or “unraped”. It’s a normative word based on widespread intervention or violation, and describes the natural in terms of the unnatural. More and more intact men deeply resent the word, which is destined to go the way of “negro” in American vocabulary.

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  6. Thank you for your thoughtful comment. I think you are right about the U.S. post-war economic context and the generosity of health insurance. Robert Darby talks about this on his website http://www.historyofcircumcision.net. It helps to explain why U.S. insurance companies weren’t as concerned about cost-benefit analyses that would have helped their bottom line.
    And yes, there are certainly many other docs who one could cite in this history – I wish I had had more space. In addition to Sayre, Remondino, and Spock, one could also include John Harvey Kellogg (of fiber fame) as well as more recent proponents like Wiswell, Morris, and Schoen. Gollaher treats these other folks too.
    The relationship between circ and masturbation also probably gets short shrift here – worthy of more in-depth treatment.

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  7. The history of routine circumcision in the USA, offered in Gollaher (2000), is not very satisfactory (Gollaher at least drew attention to the role of Lewis Sayre). It is evident that Kellogg, Remondino and others in the gaslight era touted routine circumcision. That leaves unanswered why anybody listened, and why routine infant circumcision (RIC) became much more than a passing fad. Around 1890, Elisabeth Blackwell, the first American woman to qualify as a doctor, wrote eloquently against RIC, and she opined that it sexually damaged adult sexuality. Not all Victorians were prim prudes.
    The world between the Civil War and WWI had a horror of boyhood masturbation, but I am not convinced that everyone bought into the notion that masturbation was damaging to health. Masturbation was deplored for moral reasons, by a world that believed that the only moral outlet for the sexual urge was PIV involving a married couple. Masturbation was especially feared because it could be indulged without a partner. The notion that circumcision made masturbation mechanically impossible, or deprived the act of enjoyment, was prudish naivete.
    The clinical training offered in USA medical schools and teaching hospitals during the first half of the 20th century did not leave an ample paper trail. Everybody involved in medical education at that time is now dead and hence unreachable by oral historians. I think it likely that we will never really understand why the circumcised penis became the American norm. Be that as it may, routine infant circumcision has become the most controversial aspect of pediatric medicine, and the biggest open question in the social psychology of American sexuality.
    I conjecture that what I call prophylactic circumcision emerged in reaction to the emergence of the germ theory of disease. That theory gave a compelling reason to pay attention to the hygiene of the preputial sack. Grown men could satisfy this hygienic requirement by sliding back the foreskin every time they took a bath. But hygiene during boyhood remained a perceived problem. You see, the foreskin detaches from the glans and becomes retractable on its own sweet time, and that time can come as late as the late teens. Before puberty, many boys are unretractable, and 100 years ago, this fact was seen as a serious sanitary problem. And so the foreskin had to go. In those days, local anesthesia did not exist, and general anesthesia was much more dangerous than is the case now. Even then, people had enough common sense to admit that to circumcise a boy old enough to be aware of what was done to him could give rise to troubling psychosexual disturbances. And thus the protocol emerged of circumcising newborn boys very soon after birth, without any pain management. This protocol was not revisited when lidocaine, a powerful local anesthetic widely used in dental surgery, was first marketed in 1950.
    Elizabeth Blackwell believed, on common sense grounds, that circumcision could be sexually damaging, but nobody appears to have noticed or taken her seriously. A common theme, invoked as recently as my baby boom youth, was that if circumcision harmed sex, the Jews would have figured that out and would let us know. Everyone saw that circumcised British and American men came of age, married and reproduced. It soon became clear that circumcised boys masturbate. This fact was taken as further evidence that circumcision does no sexual harm, and not as a reason to question circumcision. Circumcising doctors evidently believed that these casual observations satisfied the requirement for due diligence. Nobody gave any thought to the possibility that some circumcised men cannot enjoy PIV, or that some women married to circumcised men find PIV to be a chore. Or to the possibility that circumcised men were more likely to suffer from ED, especially starting in middle age. Or to the possibility that circumcision speeds up the aging of the penis, in a way that seriously detracts from the quality of sex after age 40 or so. Circumcised men were naively believed to be free of PE, but this reflected a naive understanding of the neurophysiology of the tip of the penis.
    In the 1980s, anecdotal and academic evidence began to emerge suggesting that circumcision detracted from the quality of the sexual experience for one or both genders. The reaction of American medicine and sexology has largely been one of denial and cognitive dissonance, and the usual patronising attitude towards anecdotal evidence and case reports. The AAP and CDC seem to believe that the burden of proof rests on the critics of RIC when in fact it is up to the advocates of RIC to convince us that it is safe. Absence of evidence is not evidence of absence. There are no American or Canadian studies of the possible correlation between circ status and the usual sexual dysfunctions, or of the sexual histories of women who report that they have been in long term intimate relationships with both kinds of men. Absent such studies, it is specious and wrong to claim that RIC does not harm normal marital sex.

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  8. By 1920, RIC was the urban white middle class norm in the USA, for boys born in maternity wards. A great many boys still escaped the knife. What changed since then was the rise of health insurance in the 1940s, the fall of home birth, and RIC being made automatic in maternity wards catering to the middle class. The creation of Medicaid in the 1960s made RIC affordable by all families regardless of means. RIC peaked in the 1970s, when the rate was at least 90%. But in 1971 and 1975, the AAP ruled that RIC was unnecessary. In 1982, California removed RIC from its list of covered practices, and 17 other states gradually followed suit. The emerging progressive parenting movement deemed RIC contrary to its principles. Thus RIC rates began to decline. Today, about 55% of boys emerge from the maternity ward shorn of their foreskins. We do not know how many boys are circumcised later as outpatients in doctors’ offices, because HHS does not count such procedures.

    Maternity ward circ rates vary across states to an astonishing degree, from 90% in West Virginia, to 10% in Nevada. Major sociological factors behind the comeback of the American foreskin are a rising Latino demographic, large post WWII immigration from cultures that do not circumcise, and a growing belief that circumcision detracts from the quality of the sexual experience. A major economic factor is that Medicaid and private insurance sometimes do not cover the cost. Social media have done much to make people aware of anecdotal evidence of the drawbacks of circumcision. Women who have been intimate with both kinds of men are, surprisingly, willing to air their impressions of how circ status has affected their sexual satisfaction. Most of all, the internet is rife with detailed images of the human genitalia, so that Americans can see for themselves what the natural penis looks like. Some turn up their noses, some say “what’s the big deal?”, and some are excited.

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  9. MURICA!

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  10. All comments here very valid and the very fact a doctor trade group, AAP, recall its not an academic school, squeak a funny trumped up defense of routine baby circumcision smacks of great hubris and deception. RIC is forced genital mutilation of one sex, males and for this the members of the ACOG collect a fee. The average baby doctor today in the US is massing 400,000 a year. We can without to much analysis determine why they want RIC to be funded for ever.

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  11. You could come up with all kinds of rationale for or not for circumcision until the cows come home and you will not be able to convince the pros and cons whether it is the right thing to do or not. Americans circumcise their male babies because it is symbol of being American. If you don’t want to circumcise your male babies, that’s fine too.

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  12. Circumcision has been looking for a reason to be beneficial since it became introduced in the US years ago. The truth however the AAP male group of doctors were themselves all circumcised. Three were in fact Jewish and did not recuse themselves. The African studies were always in debate and in fact done and proposed by several very pro-active doctors and public health professionals in line to get WHO, CDC and USAID grants. They lied about the 60 percent advantage. Its absolute benefit was less than 1.5 percent between circumcised and control groups. Many other egregious and intentional slight of hand experimental errors were done. They had to get positive results to get funding.
    The Oxford University reviews clearly show their bias.

    The sad thing, the Africans still have HIV and in fact may increase the rate of its spread because of circumcision. Its not a magic bullet. It does make circumcisers millions. USAID has already wasted 50 million dollars in several African countries, even circumcising theor favorite targets, male babies.

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  13. Amazes me the AAP and CDC bring routine infant circumcision back again like a dog you thought you drowned. Its clear the Uros are right. Western Europe rarely sees a cut penis and has an STD rate a fractions of US where 80 percent are said circumcised. Could we do a study to show risk and circumcision lead to unsafe sex. No, not in the US that’s contrary to the agenda. Its not about science, ethics or much else than money. Infant circucmsion is a half billion dollar industry in the US. When it declines doctors whine.

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  14. Just when you think its dying, like a slime monster, some slime feeds it to again demonize the foreskin. What next, CDC, AAP.. on it goes forever and this when its shown HIV/AIDS was a scam in Africa and the 60 percent was a fabricated lie. But, what drives it is the brain has unconscious motives and even its promoters are unable or unwilling to see the illogic in what they’re preaching.

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  15. It seems somewhat bizarre(to say the least) that anyone ever had the idea that cutting a piece of your penis off would be a desirable thing to do. All this hokum about it being a disease preventative is ludicrous, you could justify removing lungs, hearts, breasts BRAINS! with the same reasoning!

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  16. Dr. Annie Houser

    Impressive. I am sharing your article with my cultural anthropology class in conjunction with a lesson on ethnocentrism and cultural relativism. I ended the class today asking the students to critically think about why RIC is so common in the US–what are the arguments for and against. My hope is that your article inspires voluntary research on RIC on the students’ part to be more informed when we argue about this next week. Thank you for an objective read!

    Liked by 1 person

  17. I’m so glad it was useful! And hope your students will think so too.

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  18. Hi Matthew,

    A few years back in a women and gender studies course, I learned about female circumcision. With that, I became interested in why male circumcision is so common in the US. I asked my classmates what they thought about male circumcision and the reaction was that they couldn’t believe I was questioning it. To them it was as if the answer was obvious and concrete, “it’s done because of hygiene” and “because uncircumcised penises are ew”. Annoyed, I brought the same question to my ethics class. Again, It was quickly brushed off by other students with more of the same reaction, “it’s just what we do”.

    I was unsatisfied with these responses but ultimately put the idea in the back of my mind until I discovered that people are actually using forskin in skin care products. After reading your article and thinking about our vane culture, I’m wondering if another reason we continue to blindly accept male circumcision is because of the market it creates.

    Hmm…

    -Sara

    Liked by 1 person

  19. Sara, its always what I do, have done or am is always the right choice! What astounds me is the scam pulled off by Bailey et-al in Africa. The cash payments were in hundreds of millions and kick backs to local health officials completely corrupt.

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