The Latest Fight Over the Foreskin

By RONI CARYN RABIN

In the late 19th century, Victorian-era doctors described the male foreskin as a “source of serious mischief.”

Convinced that masturbation led to insanity, and that it was the sensitive, responsive foreskin that stimulated masturbation, surgeons started promoting therapeutic circumcision to cure young men of the “sin” of excessive indulgence and prevent its corollary, “masturbatory insanity,” a catchall phrase for various psychiatric and physical disorders that perplexed physicians.

Now, in the 21st century, the foreskin has been exonerated as far as masturbation and mental illness go. But public health experts are making a pretty strong scientific case that cells in the foreskin act as a magnet for H.I.V. and, as such, may increase a man’s risk of acquiring the virus from an infected woman if he is uncircumcised.

“We definitively know that circumcision reduces male H.I.V. acquisition by at least 50 percent and probably more,” said Dr. Ronald Gray, who led circumcision studies in Uganda. “And one can say that unequivocally: there have been three trials, in different countries, and there’s a lot of prior observational data to support that.”

American health officials said last week that they have been mulling over whether they should offer circumcision as a voluntary option for infants and even adult men who are at risk for HIV. Though they have yet to issue any formal recommendations, controversy is already brewing.

On one side are public health experts who argue the benefits of what they call an inexpensive and relatively risk-free operation, and say they have the backing of the World Health Organization. On the other side are critics with deep moral and fundamental objections to operating on a baby’s healthy genitals for any reason before the child is old enough to understand or give his consent; they say the harm is irreversible.

The debate is likely to be an impassioned one, as circumcision is a very personal choice for many people, laden with cultural, religious and historic overtones and wrapped up in issues of identity and sexuality.

Blacks, Hispanics and foreign-born Americans in general are less likely to be circumcised than white Americans, while for Jews, male circumcision has long been an important identifying mark that dates back to the Biblical figure of the patriarch Abraham, and symbolizes the covenant between God and the Jewish people. Muslims, who trace their roots to Abraham’s son Ishmael, also circumcise their sons.

“Male circumcision is deeply ingrained in our culture and in monotheism — we’re talking Freud, we’re talking the Bible,” said Karen Ericksen Paige, a professor emerita of psychology at University of California, Davis, who has studied the cultural history of circumcision. “It’s hard to set all that aside and be objective.”

As one of the few countries where circumcision is widely practiced for non-religious reasons, the United States is an anomaly. Most European countries have largely abandoned routine neonatal circumcision; the British stopped doing it when they started the National Health Service in 1948. The service refused to cover the practice because it was deemed not medically necessary, and some Europeans will frankly say they find the idea barbaric and unnatural. Yet in the United States, circumcision is the norm, and the vast majority of men — and in all likelihood the majority of doctors — are circumcised, even though rates have dropped in recent years.

Physicians reject any comparison between male and female circumcision because, they say, male circumcision does not injure men or impair any physiological or sexual functioning.

But critics say a double standard prevails: though female genital cutting is also rooted in cultural traditions, it is prohibited by law in America and considered a human rights violation. These critics object to circumcising boys for the same reasons many find female circumcision loathsome: they believe parents have no right to permanently alter the genitalia of a baby who cannot consent, boy or girl, and that far from being a useless flap of skin, the foreskin, which is densely filled with nerve endings, serves a function, protecting and lubricating the head of the penis and maintaining its sensitivity, much like an eyelid does.

How, then, did circumcision become so entrenched in the United States? Medical societies like the American Academy of Pediatrics have gone back and forth on the issue, as did the influential pediatrician Benjamin Spock. Right now, the academy’s guidelines do not recommend routine infant circumcision, and some state Medicaid programs refuse to cover the cost.

David L. Gollaher, author of “Circumcision: A History of the World’s Most Controversial Surgery,” traces the surge in circumcision to an influential 19th-century New York surgeon, Lewis A. Sayre, who believed that many neurological problems were caused by genital irritations.

Dr. Sayre circumcised patients with paralysis and operated on mentally ill patients in psychiatric hospitals; then he published papers about his successes, convincing physicians this was “a very powerful operation,” Dr. Gollaher said.

In the early 20th century, as childbirth moved from the home, where it was supervised by midwives who didn’t practice circumcision, and into hospitals run by doctors, more and more babies from middle- and upper-income families were being circumcised. Being without a foreskin was said to boost hygiene, and became a badge of the educated and upper classes.

Meanwhile, other diseases were added to those circumcision was believed to cure, including epilepsy, syphilis, tuberculosis and cancer.

“It’s almost like circumcision was a cure in search of a disease,” said Eli Ungar-Sargon, who made a film, “Cut,” that questions the practice. “When you look through history, you see that whatever the scary disease of the generation was, that was the one that circumcision would help prevent. So in the early 20th century it was syphilis, a scary disease that there was no cure for then. Later, it was cancer.”

Recent medical studies actually support the contention that circumcision reduces the risk of some sexually transmitted infections other than H.I.V., including the human papillomavirus that causes cervical cancer.

But even modern science is subject to interpretation. We’ve come a long way, but babies were circumcised without local anesthesia until fairly recently because the medical profession was convinced infants had no sensation of pain.

And whether circumcision can make a significant dent in the H.I.V./AIDS crisis in this country is still being debated, because the epidemic in the United States is so different from the one in Africa. The African trials found heterosexual men were less likely to acquire the H.I.V. virus after circumcision, but largely ignored the question of whether women were safer — or possibly put at even greater risk of infection, as one small study suggested — if the man was circumcised; they also focused exclusively on heterosexual transmission, though in the United States, men who have sex with men are at higher risk.

Even Dr. Gray, who led the trials, is not sure the United States should promote circumcision. “If you were to ask me, should the U.S. be promoting circumcision, my answer would be, ‘no,’ ” he said. “What I do think ought to be the policy is that parents should be informed about the potential protective effects.”