Circumcision

• 1. Introduction

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  Circumcision is the oldest known surgical procedure still practiced today, and depictions of circumcised penises appear in Paleolithic art, predating even the earliest signs of trepanation. Roughly 37 to 39 percent of men on earth have undergone the procedure. That global footprint raises a set of questions that resist simple answers: why does a surgery that began in the ancient Sahara now shape public health policy in sub-Saharan Africa? How did a practice rooted in religious covenant become a contested tool of disease prevention? And why does the same procedure that is obligatory in one faith tradition be abhorrent in another? The history that follows moves through rock-carved images in Algeria, a Victorian physician's published convictions, three randomized controlled trials stopped early on ethical grounds, and arguments still unresolved in medical journals today.

• 2. Ancient Origins

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  At Oued Djerat in Algeria, engraved rock art featuring masked bowmen that include depictions of male circumcision has been dated to earlier than 6000 BP, during the Bubaline Period; some walls from that same period may date as far back as 10,000 BP. The cultural practice is thought to have spread outward from the Central Sahara, moving south into Sub-Saharan Africa and east toward the Nile. Ancient Egyptian mummies dated as early as 4000 BCE show physical evidence of the procedure, and the earliest historical record of it as a performed act is a carved image on the tomb of Ankh-Mahor at Saqqara, dated to roughly 2400-2300 BCE.

  Egyptian sources suggest the practice was connected to purity, spiritual development, and rites of passage rather than health alone. No single well-accepted theory explains its full significance, but it appears to have been treated as a mark of distinction, possibly reserved for elites. The Egyptian Book of the Dead describes the sun god Ra as having circumcised himself. Evidence from the fourth millennium BCE indicates that by the time the Sumerians and Semites moved into what is now Iraq, the practice was already present in the broader Middle East.

  Among Aboriginal Australians and Polynesians, the procedure most likely began as a blood sacrifice and a test of bravery, and only later developed into a formal initiation rite. Often seashells were used to remove the foreskin, and the bleeding was stopped with eucalyptus smoke. Christopher Columbus reported observing circumcision among Native Americans, and scholars link its origin in South American tribes to similar ideas of ritual sacrifice or a test of endurance.

• 3. Covenant and Conflict

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  Genesis chapter 17 records the covenant in which God instructs Abraham and his descendants to be circumcised as "a sign of the covenant between me and you." That single passage became foundational for both Judaism and Islam, though the two traditions arrived at different rules and interpretations. In Judaism, the brit milah ritual requires circumcision on the eighth day of a newborn son's life, performed by a trained mohel. Mainstream Judaism requires that the glans be left bare, and failure to observe the rite is described in Jewish teaching as leading to Kareth: the extinction of the soul and denial of a share in the world to come.

  In 1984, Deborah Cohen became the first certified Reform mohelet, certified by the Berit Mila program of Reform Judaism. That milestone reflects a tradition that has continually adapted its rules. During the second century CE, Jewish leaders changed the requirements of circumcision to demand complete removal of the foreskin, partly in response to Hellenized Jews using a device called a pondus Judaeus to stretch residual foreskin and appear uncircumcised in Greek and Roman public spaces.

  The political pressure behind that change was severe. Antiochus IV's restriction on Jewish circumcision was a major factor in the Maccabean Revolt. Hadrian's prohibition is considered by some scholars to have contributed to the Bar Kokhba revolt. According to Silverman, writing in 2006, these restrictions were part of a broad Roman campaign to "civilize" the Jewish people, with Roman leaders viewing the practice as analogous to castration. Hadrian's successor, Antoninus Pius, later altered the edict to permit brit milah again.

  Islam does not mention circumcision explicitly in the Quran, but regards it as a sunnah, a tradition established directly by the Prophet Muhammad. The procedure spread across the Middle East, North Africa, and Southern Europe with the expansion of Islam. In Southeast Asia, indigenous forms of genital cutting predated Islam's arrival; in the Indonesian archipelago, Meccan jurists issued fatwas in the late 19th century disapproving of the older local incision practice, which was then largely replaced by full circumcision. In the Philippines, the traditional practice called tuli historically involved only a dorsal slit, distinct in form from Islamic circumcision, suggesting an indigenous origin.

• 4. Victorian Prophylaxis

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  In 1855, British physician Jonathan Hutchinson published findings from his venereal disease patients showing that Jewish men had a lower prevalence of syphilis. From that observation, he argued that circumcision lowered the risk of contracting syphilis. He also believed the procedure would prevent masturbation, and in an 1893 article titled "On circumcision as a preventive of masturbation" he wrote: "I am inclined to believe that circumcision may often accomplish much, both in breaking the habit of masturbation as an immediate result, and in diminishing the temptation to it subsequently." Hutchinson pursued this position for the next fifty years, eventually earning a knighthood for his broader contributions to medicine.

  In 1870, orthopedic surgeon Lewis Sayre, a founder of the American Medical Association, introduced circumcision in the United States as a purported cure for paralysis and other significant gross motor problems in young boys. Sayre's theory rested on the then-prominent idea of "reflex neurosis": a tight foreskin, he believed, could inflame nerves and cause systemic problems. The foreskin was also thought to harbor smegma that caused infection, which fit neatly with the emerging germ theory of disease. Publications such as Peter Charles Remondino's History of Circumcision helped spread these views, and by the late 19th century circumcision had become common throughout the Anglophonic world: Australia, Canada, the United States, the United Kingdom, and the Union of South Africa.

  During the interwar period, medical organizations in mainland Europe, including in France, experimented with recommending universal routine circumcision. Prevalence in France and continental Europe remained low regardless. Researchers Yosha, Bolnick, and Koyle, writing in 2012, suggested the divergence between Anglophonic adoption and European rejection may partly trace to different attitudes toward Judaism. They noted that in Britain, circumcision was associated with the nobility as much as with Jewish religious practice, which helped break any racial-religious stigma.

• 5. Diverging Rates After 1945

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  Douglas Gairdner's 1949 article "The Fate of the Foreskin" argued that the evidence showed risks outweighing benefits, and that article drove a significant reduction in circumcision rates within the United Kingdom after Britain implemented its National Health Service. American pediatrician Benjamin Spock took the opposite position in his widely read The Common Sense Book of Baby and Child Care, and rates in the United States rose substantially as a result. In the 1970s, national medical associations in Australia and Canada issued recommendations against routine infant circumcision, and rates in both countries fell. The United States issued similar statements but stopped short of recommending against the procedure.

  South Korea underwent one of the most rapid and distinctive shifts in circumcision practice recorded anywhere in the world. Koreans did not circumcise males throughout their long history until 1945, when Korea gained independence after 36 years of Japanese occupation. The arrival of American military trusteeship in the southern half of the country meant that 1950 can reasonably be regarded as the year when widescale circumcision started in South Korea.

  An association between circumcision and reduced heterosexual HIV infection rates was first suggested in 1986. Three randomized controlled trials were then commissioned to establish a causal relationship, conducted in South Africa, Kenya, and Uganda. All three trials were stopped early by their monitoring boards because circumcised participants contracted HIV at a substantially lower rate than the control group, and continuing the trials was judged unethical given the strength of the evidence. The WHO described these as "gold standard" studies. Their findings reshaped international health policy, and in 2007 the WHO and UNAIDS recommended adolescent and adult circumcision as part of a comprehensive HIV prevention program in areas with high endemic HIV rates.

• 6. Medical Evidence Today

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  Approximately half of all circumcisions worldwide are now performed for reasons of prophylactic healthcare. The procedure is associated with reduced rates of urinary tract infections, a factor of 3 to 10 fewer UTIs in boys under two, with roughly 100 circumcisions preventing one UTI. There is approximately a 1 percent risk of UTIs in boys under two, with most cases occurring in the first year of life.

  Circumcision is associated with a reduced prevalence of oncogenic types of HPV, meaning a randomly selected circumcised man is less likely to carry cancer-causing HPV strains than an uncircumcised man. A 2010 review found that circumcision reduced the incidence of HSV-2 infections by 28 percent. A 2006 meta-analysis found it was associated with lower rates of syphilis and chancroid. Neonatal circumcision decreases the risk of penile cancer and has been shown to nearly eliminate the risk increase introduced by phimosis.

  Major medical organizations hold differing views on prophylactic circumcision in developed countries. The WHO, UNAIDS, and American medical organizations hold that benefits outweigh risks; European, Australian, and New Zealand organizations generally hold the opposite. The American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention have stated that potential benefits outweigh risks. The WHO noted in 2010 that programmes promoting early infant circumcision are likely to have lower morbidity rates and lower costs than those targeting adolescent boys and men.

  Complication rates increase with patient age. Acute complications occur in approximately 0.13 percent of procedures, with bleeding being the most common in the United States. Minor complications occur in approximately 3.8 percent of procedures. In neonates, minor complication rates are roughly 1.5 percent; in adolescents, that figure rises to about 6 percent. The most common long-term complication is meatal stenosis, seen almost exclusively in circumcised children, and treatable by meatotomy. A Hankins et al. analysis from 2011 estimated that a 1.5 billion US dollar investment in circumcision for adults across 13 high-priority African countries would yield 16.5 billion dollars in savings over 20 years.

• 7. Ethics and Law

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  Worldwide, most countries have no laws governing male circumcision, and religious infant circumcision is legal in every country. Germany permits routine circumcision; South Africa and Sweden regulate non-religious neonatal circumcision. No major medical organization recommends universal circumcision, and none recommends banning the procedure.

  The academic literature shows general agreement, among both supporters and opponents, that an outright ban would be largely ineffective and harmful. The Royal Dutch Medical Association, which expresses some of the strongest opposition to routine neonatal circumcision, has argued that banning it could lead parents who insist on the procedure to seek out poorly trained practitioners. During the 2010s, several right-wing nationalist parties in Europe called for banning circumcision; researcher Randi Gressgård of the Centre for Women's and Gender Research at the University of Bergen argued that Norway's proposed ban was debated in a manner constituting ethnocentrism.

  The ethical debate is not only about banning the practice. Major medical organizations advise practitioners to yield to some degree to parental preferences, and economic analysis has become part of the policy conversation. A CDC study found neonatal circumcision to be cost-effective in the United States based on HIV efficacy alone. The American Academy of Pediatrics recommended in 2012 that neonatal circumcision be covered by Medicaid and insurance. The Rwanda data found circumcision cost-effective across a wide range of age groups from newborn to adult, with the greatest savings in the newborn period.