|The sorcerer's apprentice|
Why can’t the United States stop circumcising boys?This is an expanded and more fully referenced version of an essay of mine published in Contexts magazine, Spring 2005.
People have always eaten people,
What else is there to eat?
If the Juju had meant us not to eat people
He wouldn’t have made us of meat.
— Flanders and Swan, “The Reluctant Cannibal”
The unquestioning acceptance of routine circumcision of a newborn … deserves a hard look and wide-ranging debate.
— Marianne Legato, “Rethinking circumcision” 
The pediatrician spent hours resuscitating and assessing the injuries of a boy who had been born unable to breathe, without a pulse, and with a broken humerus and depressed skull fracture resulting from a difficult forceps delivery. He then visited the mother, whose first question was “When can he be circumcised?”  Such a sense of priorities spotlights the privileged place of male circumcision in modern America and highlights the difficulties in explaining what Edward Wallerstein has called “the uniquely American medical enigma”: why routine circumcision  persists in the United States long after it has been abandoned in the other English-speaking countries which originally took it up. Despite statements from the American Academy of Pediatrics and the College of Obstetricians and Gynecologists in 1971, 1975, 1978 and 1983, he noted in 1985 that the practice had abated little.  Even today, after further statements in 1989 and 1999, the operation is performed on well over half of all of newborns. 
An American paradoxThe American situation remains a conundrum: why has a custom initiated by our Victorian forebears continued to prosper in the age of medical miracles, and in the world’s most scientifically advanced superpower at that? Some doctors blame parents for demanding circumcision, while parents accuse physicians of suggesting, and even urging the operation, and of not warning them about possible risks and adverse effects. Critically-minded pediatricians admit that the “circumcision decision” is no longer a medical one, but a “cultural ritual”,  and call for “the organized advocacy of lay groups … rather than the efforts of the medical profession”,  while others object to the interference of “outsiders” in what they insist is a strictly clinical question. Wallerstein felt the practice continued because both “medical and popular literature abounds in serious errors of scientific judgement, equivocation and obfuscation”, with the result that the medical profession is reluctant to take a firm and consistent stand. Although few think there is any compelling value in circumcision, and many regard it as cruel and harmful, doctors seem mesmerised by the force of parental demand and social expectation; like the sorcerer’s apprentice in Fantasia, they watch helplessly as the waters mount, waiting for the master magician to return and restore normality.
The US experience stands in sharp contrast with that of the other countries in which routine circumcision became common. In Britain the procedure was widely recommended in the 1890s, reached its peak of popularity in the 1920s (a rate of about 35 per cent), declined in the 1950s and all but disappeared in the 1960s. In Australia the incidence of circumcision peaked at over 80 per cent in the 1950s, but declined rapidly in the 1980s after statements by pediatric authorities, and now stands at about 12 per cent. The Canadian pattern is broadly similar to the Australian, though the decline was slower until the late 1990s, when rates fell sharply. In New Zealand the procedure was nearly universal between the wars, but fell so precipitately in the 1960s that it now affects less than 2 per cent of boys.  We thus face a classic puzzle of comparative sociology: Why did routine circumcision arise in the first place? Why only in Anglophone countries? Why did it decline and all but vanish in Britain and its dominions? Why does it survive in the United States?
Nobody has firm answers to these questions. The rise of circumcision was associated with the “great fear” of masturbation and anxiety about juvenile sexuality generally; the misidentification of infantile phimosis as a congenital abnormality; the rise of puritan moralities in the nineteenth century; dread of many incurable diseases, especially syphilis; and the rising prestige of the medical profession, particularly surgeons, leading to excessive faith in surgical approaches to disease control and prevention. Most of these features were common to all European countries, however, and the factors which provoked the Anglophone Sonderweg remain obscure. (Perhaps language itself is the key.) The fall of circumcision in Britain was associated with the rise of modern medicine, especially the discovery of antibiotics; the decline of anxiety about masturbation; concern about complications and deaths; and the development of a more positive attitude to sexual pleasure. In 1979 an editorial in the British Medical Journal attributed much of the trend to better understanding of normal anatomical development and the consequent disappearance of fears about childhood phimosis. 
Incidence of circumcisionThere has been remarkably little research into this problem. Circumcision is a highly controversial subject, and the literature is vast, but most of the debate remains at a fairly childish level (the “pros and cons”) and focuses on whether it should be done, not on why the practice continues; defenders of the practice regard circumcision of infants as an unproblematic hygiene precaution, or at least a parent’s right to choose, and often become annoyed when critics ask them to justify it. Discussion of the issue has been hampered by uncertainty as to the incidence of routine circumcision, its social distribution and the reasons parents want it or agree to have it done. There has been a significant decline since the 1970s, but it has been neither steady nor uniform across the country. From 85 per cent of newborns in the 1970s, the rate fell to 60 per cent in 1988, rose again to 67 per cent in 1995, then fell slightly to 65 per cent in 1999 – the last year for which authoritative figures are available, though a substantial reduction since then has been claimed.  The incidence of circumcision varies significantly by region, and nearly all the reduction observed has occurred in the west, particularly California, where it fell from 63 per cent in 1979 to 36 per cent in 1999. In the north-east the rate has remained constant at about 65 per cent over the same period, while in the mid-west and south it has actually increased – from 74 to 81 per cent and 55 to 64 per cent respectively. 
Other variations are found on the basis of ethnic origin and education level. When Edward Laumann and colleagues analysed data from the National Health and Social Life Survey (covering men aged 18 to 59) he found that while 81 per cent of whites were circumcised, the figure was only 65 per cent for Blacks and 54 per cent for Hispanics. Where 87 per cent of men whose mothers were college graduates were circumcised, the figure for those whose mothers did not complete high school was only 62 per cent.  Laumann also found that circumcision was less common among conservative Protestants, but noted that all these differences shrank as the sample got younger, suggesting that the trend was towards homogeneity. We can thus say that circumcision is rarer among Blacks and Hispanics (though more common than it was), and probably non-Muslim Asians; among the less educated; and in the western states; but we can’t know which of these is the decisive variable. It may be that Blacks, Hispanics and Asians tend to be less educated than whites, and also to be concentrated in the south and west. Laumann did not consider the impact of economic factors such as financial incentive, yet there is evidence that this may be the most important influence of all: in 1982 California dropped medically unnecessary circumcision from the schedule of benefits covered by Medicaid, and the practice went into steady decline.
Medical arguments invalidPreventive posthectomy has always been an experimental and controversial surgery, never one endorsed by the medical profession as a whole. Given the uncertainty of its benefits, the high risk of harm, and the significance of the organ being so dramatically altered, you might expect a few ultra-nervous adults to elect it for themselves, but not that it would be inflicted on millions of babies who had never even inquired. These days it is only a few superannuated diehards who seriously believe that circumcision confers meaningful health benefits, and nobody suggests that the practice continues because the inhabitants of Indiana are healthier than those of California, or Americans in general are healthier than the populations of countries where the practice is rare. Indeed, readily available statistics suggest the opposite scenario. Although health spending per head in the USA is vastly greater than anywhere (over 14 per cent of GDP), health outcomes on key indicators such as infant mortality, life expectancy and the incidence of STDs are significantly worse than in comparably developed countries where most men retain their foreskins. (See Tables 1 and 2.) Far from circumcision being a protection against STDs as often claimed, Laumann found that circumcised men had more STDs, both bacterial and viral, than the uncut; and it is well known that the USA has the highest incidence of HIV infection of any country in the developed world except Portugal.
Although advocates of mass circumcision as a strategy against AIDS are constantly calling for randomised trials, the circumcision experiment has already been performed in the United States. How successful has it been? With the highest rate of circumcision, the USA also has higher rates of infant mortality ans shorrter male life-expectancy than similar developed nations; the highest rates of sexually transmitted diseases of any developed nation; the highest rates (by far) of heterosexually transmitted HIV infection of any developed nation; and rates of cervical and penile cancer that are similar to those of other developed nations. (See Table 3.) Yet these are the very diseases that circumcision has been touted as a sure preventive for: any impartial observer must conclude that the century-long experiment has failed.
A similar informal experiment in Australia has actually found that children's health has improved as circumcision has declined. A report issued by the Australian Institute of Health and Welfare in 2005 (A picture of Australia's children) found that since 1983 children's health had improved markedly, and that infant mortality had halved, from 9.6 per 1000 live births in 1983 to 4.8 live births in 2003. These dates are very significant, since 1983 was the year in which the Australian College of Paediatrics issued a policy to discourage circumcision, and it was the start of the huge slide in circumcision incidence, from about 40 per cent to less than 12 per cent of baby boys. The report is striking proof that "lack of circumcision" does not increase child health problems. Even more significantly, it is a decisive refutation of "scientific" predictions by circumcision crusaders such as Terry Russell and Brian Morris that the fall in the circumcision rate would lead to an explosion of genito-urinary problems in boys. No such problems are identified in this report. In fact, if one were to be as unscrupulous in conflating correlation with causation as many pro-circumcision zealots tend to be, one might conclude that Australian children have become healthier not just at the same time as the incidence of circumcision has fallen, but because the incidence has fallen. But at the very least it is incontrovertible that there is zero connection between circumcision and improved health outcomes.
The report can be downloaded in several pdfs here.
The very scale and status of the American health industry may be part of the problem, for as Shannon Brownlee has observed, there is good evidence that too much medical care may be worse than not enough.  A recent investigation into hospital safety found that “adverse events” occurred so frequently in hospital admissions, and so many of these led to death, that errors in medical treatment could be the eighth highest cause of death – at 44,000 per year, exceeding deaths from motor vehicle accidents (43,458), breast cancer (42,297) and AIDS (16,516).  Since the risk of dying from medical misadventure is so much greater than the risk of dying from penile cancer or AIDS, it would seem that the most prudent course would be for parents to minimise their children’s exposure to the dangers of medical treatment by avoiding unnecessary surgery.
If American health outcomes are no better than those of non-circumcising countries, why does this “health precaution” survive on a mass scale? Robert Van Howe has suggested seven lines of inquiry. (1) The foreskin is the focus of myths, misconceptions and irrationality affecting medical profession and public alike. (2) Lack of respect for the rights and individuality of children. (3) A contrasting exaggerated delicacy with respect to the presumed sensibilities of religious minorities which practise circumcision for cultural reasons. (4) The reluctance of physicians to take a firm stand against circumcision and to refuse parental requests. (5) Bias in American medical journals, which tend to favour articles with a pro-circumcision tendency and are reluctant to publish critiques, much less developed arguments against. (6) Failure to subject circumcision to the normal protocols for surgery, such as the need for informed consent, evidence of pathology and proof of prophylactic benefit. (7) Strong financial incentives to perform the operation, usually guaranteed by medical insurance coverage. 
Financial incentivesThe last of these points has been stressed by a number of critics. In their analysis of Medicaid funding, Amber Craig and colleagues found that low and declining rates of circumcision correspond to regions where the procedure is not funded, most noticeably in California. Even more striking is their finding that the higher the rebate, the higher the incidence of circumcision: in states where it is $50 or less the incidence is 20 per cent; in those which pay $50 to $60 it is 27 per cent; and in those which pay more than $60 it is 38 per cent – vivid proof of the power of market signals.  Such observations might seem to justify the bitter observation of one critic that, in the eyes of many MDs, little boys are born with a redeemable tag of skin on the end of their penis; all they have to do to make a quick dollar is to cut it off and cash it in, like a huntsman turning in dingo scalps.
Nor do the advantages of circumcision end there. Despite optimistic claims that the rate of injury and death is low, there has never been an adequate assessment of long term complications, and they are certainly more frequent than most people think. (Does David Reimer’s recent suicide  count as a circumcision-related death?) The dirty little secret in pediatric surgery is that badly performed circumcisions, causing discomfort or poor cosmetic outcomes, often necessitating repeat operations and repair jobs, are common; one attorney who specialises in medical malpractice reports that some urologists see at least one such case each week. In this way the division of professional labour ensures that the benefits of circumcision are spread far beyond the original operator: his botches provide work for many colleagues, and the disasters add lawyers to the equation.
Yet the physicians may not be the major beneficiaries. In the age of biotechnology and tissue engineering, human body parts have a high market value, and baby foreskins are especially prized as the raw material for many biomedical products, from skin grafts to anti-wrinkle cream. The strongest pressure for the continuation of circumcision may not be from doctors at all, but from the hospitals which harvest the foreskins and sell them to commercial partners.  This would explain why so many mothers are still pressured to sign consent forms when they arrive for their delivery. 
Historical factorsAs well as Van Howe’s suggestions as to why circumcision continues, we should consider the distinctive features of the American past which brought the practice into prominence. Among these the medicalisation of childbirth and the role of the armed forces are the most significant. Although experts in venereal disease such as Abraham Wolbarst had called for universal circumcision as early as 1914,  it was the obstetricians and gynecologists who were responsible for realising his dream. It may seem strange that the most influential advocates of routine male circumcision within the medical profession have been experts in women’s health, but from the 1930s onwards it has been the obstetricians and gynecologists who most vigorously touted the advantages of the procedure and performed most of the operations. Symptomatic of their power was the introduction of the Gomco clamp by the obstetrician Hiram Yellen,  who wanted a device that was so simple to use that his colleagues would be able to claim the circumcision procedure from fussy and expensive surgeons who still insisted on anaesthetics and strict control of bleeding. As maternity hospitals and clinics replaced home births, and as the ob-gyns displaced midwives, circumcision came to be seen as part of the birth process, often performed within a day or even a few hours of the boy’s arrival in the world – a procedure no more surgical or problematic than tying his umbilical cord. 
The armed forces also played a significant role. During the two world wars the US military made a concerted effort to circumcise servicemen, ostensibly because it was believed that this would make them less susceptible to venereal disease, though partly because true believers in circumcision held powerful positions within the Medical Corps. Military discipline forced men to submit to a procedure they would not otherwise have agreed to, and thousands of men were circumcised in their late teens and early 20s. When they returned home and became fathers, doctors began asking whether they wanted their sons circumcised. Remembering the ordeal that they or their buddies had endured from the operation as adults, many said yes, thinking it would avoid the need to do it later, when the pain was thought to be worse than in infancy. With two generations circumcised, the foreskinned penis became a rare sight, and few men now had the personal experience to refute the derogatory stories told about it.
Confusion in the American medical establishmentLack of unanimity and conviction among the medical profession has been stressed by Lawrence Dritsas,  who attempts to deconstruct the AAP’s unwillingness to make a firm recommendation and corresponding tactic of throwing the burden of decision onto parents. Dritsas quotes from one article which explained that
we are reluctant to assume the role of active advocacy (one way or the other) because … the decision is not usually a medical one. Rather it is based on the parents perceptions of hygiene, their lack of understanding of the surgical risks, or their desire to conform to the pattern established by the infant’s father and their own societal structure. 
He translates this to mean that circumcision is irrational but that, contrary to the usual protocol, “parental wishes become sufficient, while medical necessity, normally a guiding rule for the surgeon’s knife, takes a back seat”. Dritsas contrasts this hands-off approach with the AAP’s ethically-based rejection of female genital mutilation (where the possibility of health benefit is not even entertained) , and even more tellingly with its position statement on informed consent:
Providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses. … the pediatrician’s responsibility to his or her patient exists independently of parental desires or proxy consent. 
Except when it comes to circumcision.
Dritsas is genuinely puzzled by the glaring contradictions in AAP policy and explains them in terms of medical culture and the apprenticeship model of professional training, which do not encourage students to question authority. “For a physician to cease performing circumcisions represents a condemnation of past practice and an admission of error”, he writes, and nobody holding the power of life and death wants to be seen as doing that. The doctors are thus in much the same position as the parents themselves, whose unconsidered assumption that the baby will be circumcised is an expression of the authority of past generations of physicians who convinced their grandparents that it was the done thing. But if a previous cohort of doctors was responsible for establishing circumcision, is it not the responsibility of their successors to put a stop to it? Dritsas condemns the stance of the AAP as reminiscent of the response of Pontius Pilate when confronted with the problem of what to do with Jesus. In his view, what they are really saying is that “As scientific doctors we find ourselves unable to recommend or deny this procedure; therefore, you will decide, and we shall be your scalpels.” As he concludes, the AAP “decided not to make a decision and absolved itself of all guilt while continuing to perform a questionable operation”.  This sort of acquiescent hand-washing contrasts with the proactive stances of pediatric bodies in Britain, Australia, New Zealand and, most forcefully, Canada, which have seen it as their duty not only to discourage parents from seeking circumcision, but to educate them as to the value and correct care of the prepuce and, in the end, to refuse to perform the operation.
Demonization of the foreskinThere must be an explanation for these national differences. The medical profession is not an independent force; its members are subject to the same social pressures which mould the beliefs and condition the actions of everybody else. Several recent commentators have thus argued that circumcision should not be seen as medical issue at all, but as an expression of social norms. At a superficial level this has long been known. In the 1950s Dr Spock urged circumcision because it would help a boy to feel “regular”, and pediatricians since then have noted that “entrenched tradition of custom is probably the greatest obstacle faced by those who would decrease the number of circumcisions done in this country”.  But it is only recently that the sociological aspect of the question has received serious attention. In a comprehensive survey of the history of modern circumcision and the debate over its “advantages”, Geoffrey Miller shows in brilliant detail how late Victorian physicians succeeded in demonizing the foreskin as a source of moral and physical decay. Acting as “norm entrepreneurs” they “reconfigured the phallus”, transforming the foreskin from a feature that was regarded as healthy, natural and good into one which was feared as polluted, chaotic and bad. The incessant quest for novel associations between the foreskin (often expressed as “lack of circumcision”) and nasty diseases is a tribute to the lasting success of their enterprise.
As a legal scholar, Miller is surprised at the law’s indifferent and often supportive attitude to what one might expect it to regard as an assault, or at least a mutilation, but he points out that the law is itself an expression of the surrounding culture and cannot be expected to be too far ahead of prevailing norms. Even so, he considers routine circumcision in the mainstream community to be on the way out. Although still normative, it is in decline, and edging towards the critical half-way mark, or “tipping point”, where the incidence can be expected to fall precipitously as parents come to believe that their children will now suffer stigma if they are circumcised. Like foot-binding in China or wife beating in nineteenth century Britain, a widely accepted social convention is “likely to collapse as the culture reaches a ‘tipping point’ and turns against the practice”.  The increasingly desperate search for new “health” reasons to circumcise – urinary tract infections (1985), HIV-AIDS (1989) and cervical cancer in potential future partners (revived in 2002) – may delay the process, but cannot permanently halt it. 
Cultural normsExtending Miller’s argument, Sarah Waldeck  offers a subtle analysis of how norms contribute to a person’s behavioural cost-benefit calculations, how the desire to have a child circumcised fits into this assessment, and thus why parents continue to seek it. She is particularly interested in the “stigma” supposedly attached to the uncircumcised penis in a society where most of the males are cut, and considers the role of the popular media in perpetuating a stereotype of the foreskin as somehow disagreeable. (Indeed, if the malevolent jokes fired casually at normal male anatomy in popular American soaps and movies were directed at targets seen as entitled to protection from vilification there would be howls of outrage.)  She also notes that few parents have any clear reasons for wanting their sons circumcised and produce them only when challenged; the most common justifications then turn out to be the supposed need to look like the father or peers, and not to be teased in the proverbial locker room. If “health benefits” are mentioned at all, they enter as an afterthought or when other arguments fail. Waldeck still subjects the medical case to scientific, legal and ethical scrutiny, and finds it inadequate to justify the removal of healthy tissue from non-consenting minors. She also cites a study from 1991, which found that, even if the claims for its health benefits were true, circumcision was not a cost effective means of achieving these outcomes. 
Waldeck concludes with a thoughtful discussion of how the American norm might be changed and suggests three specific strategies: requiring parents to pay for the procedure; requiring doctors who perform the operation always to use effective pain control; and tightening the informed consent process. The first of these is partly achieved by dropping circumcision from the schedule of procedures covered by Medicaid, though Waldeck warns that private and company health insurance schemes must also be considered. The value of such a move arises not only because it is good public policy to encourage people to place a value on services by requiring them to pay, nor just in the cost disincentive, but in the fact that not being covered by a government program implies that circumcision is not an approved procedure. If not publicly funded, it is less likely to be seen as either beneficial or normative.
Doctors as cultural brokersThe USA thus presents the paradoxical picture of a cultural ritual justified in medical terms and a surgical procedure justified as a cultural necessity. Defenders of ritual circumcision point to the health benefits claimed by those who perform it for medical reasons; while those who perform it for medical reasons try to justify it as an ancient operation, performed by “many different cultures”, without which ethnic or religious identity would be lost. The whole thing ends up rather circular. When doubt is thrown on the medical benefits of circumcision, supporters of the operation stress its cultural importance; when its cultural necessity is questioned, they stress the alleged health benefits. Many medical personnel who regard circumcision as unnecessary or harmful still urge respect for cultural traditions, and show little hesitation in cutting boys from traditionally circumcising cultures (mostly Islamic, these days) at the request of their parents.
The claims of culture are taken very seriously in this age of globalization, but the problem with this particular claim is that it is applied inconsistently. First, there is discrimination based on gender. No matter how important circumcision of girls may be to the cultural/ethnic/religious groups that practise it, American opinion has determined that girls’ bodies are more important than tradition, and that any cutting of the female genitals is Female Genital Mutilation, now banned by law. Secondly, the cultural argument seems to be a one-way street. When faced by parents from circumcising cultures, doctors say they must respect their traditions and accede to their wishes, at least in relation to boys. But when it comes to non-circumcising cultures (the great majority) the argument is suddenly reversed: instead of enjoying automatic respect for their traditions, parents from non-circumcising cultures are pressured to conform to the American norm and to consent to have their sons circumcised, so that they will be “like other boys”. Here it is not the traditional culture or the condition of the father’s penis that matters, but American custom and medical ideology, to which the immigrants are expected to conform, and often coerced into doing so.
When discussing this issue, defenders of children’s rights have argued that doctors should not be cultural brokers, but this formulation does not quite grasp the complexity of the situation. What they are really suggesting is that it is not the role of doctors, nurses etc to enforce the rules of a given sub-culture against its members, particularly when the issue is one of conformity or outdated rituals. Concerns with identity are important in the traditional, monocultural societies where practices such as male and female circumcision originated; in such tribal situations, circumcision functions as an age card and passport. But such rituals are unnecessary, and certainly do not need to be nurtured, in the modern, multicultural societies to which these people have relocated, where identity and entitlements are registered in other ways. Immigrants from backward regions don’t expect to retain all their village customs (infanticide, widow burial, walking round naked, tribal medicine?) when seeking to improve their condition in the industrialised world; the main reason circumcision tends to be retained is that those with power (the parents and other adults) would not personally benefit from dropping the operation, while those who would enjoy the benefit are only helpless children, who lack the power to voice, much less enforce, their opinion. There is no harm in nurturing cheerful customs like dance, dress and food, but why privilege cruel or harmful ones?
In practice it is inevitable that doctors and other providers of professional services will act as cultural brokers when dealing with families from foreign cultures, and this is not necessarily a bad thing at all. It is actually quite appropriate that they should help people from backward collectivist cultures (in which the rights of children as individuals and citizens are not recognized) to negotiate the transition to a culture based on the autonomy of the individual and respect for personal rights. The problem is not that doctors act as cultural brokers, but that they do so in an inconsistent and discriminatory manner, respecting the traditions of the circumcisers but not the traditions of non-circumcising cultures – American Indian, Hispanic, Catholic and other Christian, European, South American and most Asian, to name a few. Circumcising cultures are a small minority: Islamic, some Africans and Jewish. You would think that the one of the first acts of cultural retrieval performed by American Indian peoples, none of which ever practised circumcision, might be to revive such historic traditions. If the “respect for culture” policy was applied consistently, the vast majority of American immigrants and ethnic subcultures would not be circumcised, and half-drugged mothers would not be obliged to fight off the advances of scalpel-happy ob-gyns in maternity wards.
The lessons of historyIn 1979 the British Medical Journal applauded the decline of routine circumcision in Britain from about 35 per cent in the 1930s to under 6 per cent in the 1970s,  and contrasted the British case with the situation in the United States, where the majority of boys were still circumcised, and doctors still defended the procedure with vehemence. It offered no suggestions as to why the experience of the two leading anglophone powers should have diverged so sharply after the 1940s, but a clue may be found in the relatively low incidence of circumcision in Britain and its brief lifespan: even at the height of its popularity it was still a minority practice, and it lasted scarcely more than two generations. Where the practice affects the majority and endures for more than two generations, however, there will soon be few doctors and parents who have any familiarity with the normal penis, and thus know how to manage it; and most circumcised fathers will want their sons to be treated likewise. In Britain there were always doctors and relatives who had not lost touch with the way things used to be.
In my research on the British and Australian experience, I found that routine circumcision began slowly as a doctor-driven innovation; became established in the medical repertoire and spread rapidly; and then declined slowly as doctors ceased to recommend it but parents, having absorbed the advice of the generation before and many fathers being circumcised, continued to ask for it. The fundamental reason for circumcision of children is a population of circumcised adults. A significant factor in the decline of circumcision in Australia during the 1960s – before the paediatricians took a stand – was the arrival of large numbers of immigrants from non-circumcising European countries (particularly Greece and Italy), most of whom settled in the cities. In contrast with the situation reported by Laumann, a recent study in Western Australia found a far higher incidence of circumcision in country areas, with their greater proportion of older, less well educated Anglo-Celtic stock, than in major urban centres, with their more multicultural and better educated populations. 
As a celebrated German-Jewish philosopher once observed, “the tradition of all the dead generations weighs like a nightmare on the brains of the living”. When preventive circumcision was introduced in the late nineteenth century, concepts of medical ethics, informed consent, therapeutic evidence and the cost-benefit trade-off were rudimentary. Neither the morality nor the efficacy of the procedure was seriously debated, nor was there any study of its long-term consequences, and it became established in the medical culture of Anglophone countries by virtue of the authority of its early promoters. No matter how many statistics-laden articles get published in medical journals, circumcision cannot shake off the traces of its Victorian origins. It remains the last surviving example of a once respectable proposition that disease could be prevented by the pre-emptive removal of normal body parts which, though healthy, were thought to be a weak link in the body’s defences. In its heyday this medical breakthrough, described by Ann Dally as “fantasy surgery”, enjoyed wide esteem and included excisions of other supposed foci or portals of infection, such as the adenoids, tonsils, teeth, appendix and large intestine.  Few doubted that if the doctor thought you, or your children, were better off without any of these it was your duty to follow his orders.
The burden of proofBecause there was no real debate about the propriety or efficacy of pre-emptive amputation as a disease control strategy when it was introduced, those who wanted to remove healthy body parts from children were able to throw the burden of proof onto their opponents. Instead of the advocates having to demonstrate that the gain outweighed the loss, it was up to the doubters to prove that the loss outweighed the gain – or as Abraham Wolbarst put in it his call for universal infant circumcision in 1914: “If there is any objection to circumcision it should be based on valid, scientific grounds.”  The consequence is that what should have been a debate about the introduction of preventive circumcision in the 1890s has turned into a debate about its abolition a century later. Miller and Waldeck may be right to argue that circumcision will not die out until the uncut penis becomes an acceptable – and perhaps the preferred – option. But the transformation of attitude will not seem so improbable, nor the task of effecting it so daunting, if it is remembered that there is no need to invent a new norm, merely to restore the sensibility that governed the Western world before the late nineteenth century.  In her popular midwifery manual of the 1670s, Jane Sharp wrote that a few people believed that the “Venerious action” might be performed better without the foreskin, but pointed out that circumcision had been forbidden by St Paul and hoped that
no man will be so void of reason and Religion, as to be Circumcised to make trial which of these two opinions is the best; but the world was never without some mad men, who will do anything to be singular: were the foreskin any hindrance to procreation or pleasure, Nature had never made it, who made all things for these very ends and purposes. 
Table 1: Male infant mortality and male life expectancy at birth, 2004
Table 2: HIV prevalence, 2000
Table 3: Circumcision compared with male life expectancy, HIV prevalence and incidence of cervical cancer, 2001
Australia, Canada and Britain were selected because of their cultural similarities with the USA and because they have an intermediate level of circumcision prevalence. The Scandinavian countries and Japan were selected because they have very low rate of circumcision.
There is nothing in the table to suggest that circumcision confers any health advantage at all, let alone a significant one, to males in the USA compared with males in the other countries. There is a strong correlation between circumcision prevalence and HIV prevalence, and a negative correlation between circumcision and life expectancy. The association between male circumcision and cervical cancer is also very weak.
1. Marianne Legato, Rethinking circumcision: medical intervention, religious ceremony or genital mutilation?, Journal of Gender Specific Medicine, Vol. 5, July-Aug. 2002, pp. 8-10
2. Robert Van Howe, Why does neonatal circumcision persist in the United States?, in Marylin Milos and George Denniston (eds), Sexual mutilations: A human tragedy (London and New York: Plenum Publishers, 1997), p. 112.
3. By routine circumcision I mean circumcision of healthy male minors, showing no signs of abnormality or disease, on the decision of adults and without the consent of the child. Since the operation excises a normal mammalian anatomical feature in the belief that its loss will provide protection against fairly rare diseases, the risk of which lies mostly in the distant future, a more accurate term would be preventive or pre-emptive posthectomy (posthe being the Greek for foreskin).
4. Edward Wallerstein, Circumcision: The uniquely American medical enigma, Urologic Clinics of North America, Vol 12, Feb. 1985, 123-32. Statements from medical organizations are conveniently collected at http://www.cirp.org/library/statements/
5. The frequency of circumcision did fall more sharply after the 1989 statement, then rose again in the mid-1990s, before levelling off; data released in early 2005 suggests that the more critical policy issued in 1999 has made a noticeable impact. See footnote 11.
6. M.S. and C.A. Brown, “Circumcision decision: Prominence of social concerns”, Pediatrics, Vol. 80, 1987, pp. 215-19
7. Wallerstein, p. 129, citing M.J. Maisels et al, “Circumcision: The effect of information on parental decision-making”, Pediatrics, Vol. 71, 1983, p. 453
8. See Robert Darby, A surgical temptation: The demonization of the foreskin and the rise of circumcision in Britain (Chicago and London: University of Chicago Press, 2005), conclusion
9. Editorial, The case against neonatal circumcision, British Medical Journal, 5 May 1979, 1163-4
10. Dan Bollinger, Normal versus circumcised: US neonatal male genital ratio (2003):
11. National Center for Health Statistics More recent statistics based on data from the National Hospital Discharge Survey show that the incidence of neonatal circumcision declined from 61.5 per cent in 1999 to 55.9 per cent in 2003, the largest falls being recorded in the south and west, and hardly any in the north-east. If this trend continues, circumcised boys will indeed soon be in the minority. See http://www.cirp.org/library/statistics/USA/
12. Edward Laumann et al, Circumcision in the United States: Prevalence, prophylactic effects and sexual practice, Journal of the American Medical Association, Vol. 277, 1997, 1052-7, Table 1
13. Shannon Brownlee, “The overtreated American”, Atlantic Monthly, Jan-Feb 2003; see also Ted Halstead, “The American paradox” in the same issue
14. Linda Kohn et al (eds), To err is human: Building a safer health system (Washington: National Academies Press, 2000), p. 1. Available online here.
15. Robert Van Howe, “Why does neonatal circumcision persist in the United States?”
16. Amber Craig et al, Tax dollar funding of medically unnecessary circumcision through Medicaid (2001): pdf available at http://www.icgi.org
17. After they burned off his entire penis during a routine circumcision procedure, doctors decided that it would be better if David was turned into a girl. The experiment did not work. See http://www.circumstitions.com/News13.html
18. Lori Andrews and Dorothy Nelkin, Body bazaar: The market for human tissue in the biotechnology age (New York: Crown, 2001); Norm UK, Where do all the foreskins go?
19. In 2004 Allena Tapia was asked four times to allow doctors at a hospital in Michigan to circumcise her newborn son, and on two of these occasions she was so drowsy from drugs that it is doubtful if she was capable of giving informed consent. Informant (Newsletter of Nocirc Michigan), December 2004. In 2003 there was a case in which Spanish mothers who could barely understand English were bamboozled into signing consent forms – now the subject of litigation.
20. Abraham Wolbarst, "Universal circumcision as a sanitary measure", Journal of the American Medical Association, Vol. 62, 1914, p. 92-7
21. Hiram S. Yellen, “Bloodless circumcision of the newborn”, American Journal of Obstetrics and Gynecology, Vol. 30, July 1935, pp. 146-7; Julian Wan, “Gomco circumcision clamp: An enduring and unexpected success”, Urology, Vol. 59, 2002, pp. 790-94. Further details on the Gomco clamp
22. Richard Miller and Donald Snyder, "Immediate circumcision of the newborn male", American Journal of Obstetrics and Gynecology, Vol. 65, 1953, p. 1-11
23. Lawrence Dritsas, Below the belt: Doctors, debate and the ongoing American discussion of routine neonatal male circumcision, Bulletin of Science and Technology, Vol. 21, 2001, 297-311
24. Dritsas, p. 363, citing Maisels et al, 1983
25. Available from the American Academy of Pediatrics
26. American Academy of Pediatrics, Committee on Bioethics, Informed consent, parental permission, and assent in pediatric practice, Pediatrics, Vol. 95, 1995, pp. 314-17.
27. Dritsas, p. 310
28. Thomas Metcalf et al, “Circumcision: A study of current practices", Clinical Pediatrics, Vol. 22, 1983, p. 578
29. Geoffrey Miller, Circumcision: Cultural-legal analysis, Virginia Journal of Social Policy and the Law, Vol. 9, 2002, pp. 497-585
30. The reasons are desperate because the remoteness of the theoretical benefits do not justify the real damage, the absence of consent or the urgency. In the case of cervical cancer it has been repeatedly shown that a male partner’s circumcision status is not a significant factor in whether a woman develops cervical cancer, and, even if it was, Sarah Waldeck (see Ref. 31) has pointed out that Western medical ethics do not permit a person to be mutilated without consent in order to benefit a third party, and all the moreso if the identity, or even the existence, of the supposed beneficiary is unknown. On top of this, an effective vaccine will soon be available. See http://www.cirp.org/library/disease/cancer/; Waldeck, pp. 486-491; http://www.circinfo.org/cervical.html. Urinary tract infections seem to be problem only in countries with a history of widespread circumcision, and where incorrect foreskin care (such as premature retraction) is thus common. In any case, UTIs are usually minor infections which clear up quickly with antibiotics; persistent infections may indicate a malformation of the urinary tract or bladder, which will indeed require surgery, but not on the foreskin. For further information, see http://www.cirp.org/library/disease/UTI/ and http://www.circumstitions.com/Utis.html. As to HIV, the debate about how to control AIDS in the Third World, where the disease is an epidemic mainly affecting heterosexuals, both male and female, has no relevance to conditions in developed countries, where it is a less serious problem mainly affecting small subcultures, such as promiscuous male homosexuals and intravenous drug users. It has no relevance at all to infants and children, who are not at risk of sexually-transmitted HIV because they do not have sex with carriers of the virus. See http://www.cirp.org/library/disease/HIV/ and http://www.circinfo.org/hiv.html.
31. Sarah Waldeck, Using circumcision to understand social norms as multipliers, University of Cincinnati Law Review, Vol. 72, 2003, 455-526
32. See the astounding analysis of movies and of TV shows at circumstitions.com
33. Waldeck, p. 500, citing Theodore Ganiats et al, “Routine neonatal circumcision: A cost-utility analysis”, Medical Decision Making, Vol. 11, 1991, pp. 282-93. (Abstract available here) This conclusion has recently been confirmed in an exhaustive study by Robert Van Howe, A cost-utility analysis of neonatal circumcision, Medical Decision Making, Vol. 24, 2004, pp. 584-601
34. The case against neonatal circumcision
35. Katrina Spilsbury et al, Routine circumcision practice in Western Australia 1981-1999, ANZ Journal of Surgery, Vol. 73, 2003, pp. 610-14
36. Ann Dally, Fantasy surgery, 1880-1930: With special reference to Sir William Arbuthnot Lane (Amsterdam: Rodopi, 1996)
37. Abraham Wolbarst, “Universal circumcision”
38. Frederick Hodges, The ideal prepuce in Ancient Greece and Rome, Bulletin of the History of Medicine, Vol. 75, 2001, 375-405
39. Jane Sharp, The midwives book: Or the whole art of midwifery discovered (London 1671; facsimile reprint, New York: Garland, 1985), pp. 31-2
40. Richard Burton, Love, war and fancy: The customs and manners of the East from writings on the Arabian Nights, ed. Kenneth Walker (London: William Kimber, 1964), p. 106