Circumcision: A Surgery in Search of a Disease
Routine infant circumcision is the only operation we perform on the healthy to fix nothing. We have just agreed not to call it what it is.
A doctor secures a newborn to a molded plastic board called a Circumstraint, which holds the arms and legs in place because the patient cannot consent and cannot be reasoned with. The foreskin is drawn forward, clamped, and cut away. Sometimes there is local anesthetic. Often there is not. The procedure takes a few minutes. The patient is hours or days old. He was born with the tissue and will live the rest of his life without it.
There is a word for the removal of healthy genital tissue from a person who did not ask for it and cannot refuse. The law uses that word without hesitation when the tissue belongs to a girl. It does not when the tissue belongs to a boy. That asymmetry is the heart of the matter.
The foreskin is not a defect. It is rich in nerve endings, that covers and protects the glans and moves freely over it. Removing it cuts away a functioning structure from a body that was not sick. How that is presented to parents matters. It is bundled into the maternity stay and offered as a default, a decision parents opt out of rather than into. The language around it is softened at every step. Snip. Clip. Tidy. The word amputation is accurate, and it is almost never used.
The practice is ancient. The oldest known depiction is Egyptian, a relief in the tomb of Ankhmahor at Saqqara carved around 2400 BCE that appears to show the operation performed on grown men. In Judaism it became covenant. Genesis instructs that every male be circumcised on the eighth day, and brit milah has been a defining rite for three thousand years. Islam adopted it as khitan, though it appears nowhere in the Quran and rests instead on tradition and the example of the Prophet.
None of that explains the United States, where most circumcised men are neither Jewish nor Muslim. The American practice has a separate origin. In the late nineteenth century, English-speaking medicine came to believe that masturbation caused disease, including epilepsy, paralysis, and insanity. Circumcision was promoted as a deterrent, and John Harvey Kellogg recommended that it be performed without anesthetic, so that the child would associate the area with pain. The procedure spread through American and British hospitals as a behavioral measure reframed as hygiene. Britain largely abandoned it after the Second World War, when the National Health Service stopped funding it. The United States did not. By the 1960s it was simply what happened to newborn boys, and the stated reason shifted with the decade: from suppressing masturbation, to hygiene, to disease prevention, to resemblance to the father. The justification changed. The procedure did not.
Some say there is a medical basis for the procedure. Circumcision lowers the rate of urinary tract infections in infant boys. Three randomized trials in sub-Saharan Africa, published between 2005 and 2007, found that voluntary adult circumcision reduced female-to-male HIV transmission by roughly half. It is associated with lower rates of some sexually transmitted infections and of penile cancer. The qualifications matter more than the headline. Infant urinary tract infections are uncommon and are treated with antibiotics rather than surgery, and preventing one requires circumcising on the order of a hundred boys. Penile cancer is rare throughout the developed world, seldom more than one or two cases per hundred thousand men, and in the United States it has been declining for decades. Estimates of how many circumcisions would prevent a single case range from about nine hundred to more than three hundred thousand, and the protective effect largely disappears once phimosis is accounted for, which indicates that the benefit lies in treating a foreskin condition rather than in removing the foreskin. Where penile cancer is rising, as in Denmark, Britain, and Germany, the cause is HPV, for which a vaccine exists. The HIV trials studied consenting adults in a region of high heterosexual transmission, conditions unlike those of an American maternity ward, and a 2021 Danish national cohort study found no protective effect against HIV or other infections from childhood circumcision in a low-prevalence country.
When a procedure’s benefits are marginal, available later to an adult who wants them, and achievable by other means, the rationale for performing it on an infant is no longer chiefly medical. The American Academy of Pediatrics is the last major Western body to maintain that the benefits outweigh the risks. Its 2012 statement reached that conclusion while declining to recommend the procedure. The statement expired in 2017 under the Academy’s own rules and was never renewed.
Outside the United States, medical opinion runs the other way. The Royal Dutch Medical Association concluded in 2010 that there is no convincing evidence circumcision is useful or necessary, and urged that it be discouraged. The Danish Medical Association, representing tens of thousands of physicians, holds that circumcising healthy boys without their consent is ethically unacceptable. In 2013 the children’s ombudsmen of all five Nordic countries, together with their pediatric societies, agreed to press their governments toward a ban, on the ground that an irreversible and painful operation performed without medical need on a person who cannot consent violates basic medical ethics. Germany tested the question directly. In 2012 a court in Cologne ruled that non-therapeutic infant circumcision constituted criminal bodily harm, and the German parliament, unwilling to criminalize a Jewish and Muslim rite, passed a law within months that explicitly permitted it. The reasoning and the outcome pointed in opposite directions, and the outcome was settled by politics.
The contrast with how the United States treats girls is sharp. In 1996 it became a federal crime to remove or cut any part of the genitals of a girl under eighteen for non-medical reasons. The law allows no exception for religion, culture, or family tradition, and it does not distinguish between severe forms and the minimal, symbolic cutting practiced in some communities, a procedure that removes less tissue than male circumcision and heals faster. All of it is prohibited. The principle is that a girl’s body is her own and that her parents’ traditions end at her skin. That principle has not been extended to boys. The anatomy and the severity differ, and advocates who ignore that difference weaken their own argument. But the ethical question does not turn on how much tissue is removed. It turns on consent. A child who cannot agree should not be permanently altered for reasons that are not medically necessary, regardless of the body part and regardless of the tradition. Either bodily integrity belongs to the child, or it is a privilege the parents may waive. Current practice gives one answer for daughters and the opposite for sons.
Set the framing aside and a plain description remains. A newborn is restrained. Functioning tissue is amputated. The procedure carries pain, a risk of complication, and, in rare cases, death. No disease is treated. That is mutilation, used here not as an insult but as a description: the removal of healthy tissue from a person who did not choose it. The boy grows, does not remember the procedure, and in many cases authorizes it for his own son, because it was done to him. That continuity is not a medical justification. It is a custom, performed for generations on people who were never asked, and described as a choice, though the one person whose body is altered has no part in making it.
