In Defence of the Foreskin

This piece originally appeared in Areo Magazine here.

Part One: The Masturbation Panic

Did you make fornication with yourself, took your manly member in your hand, and so slide your foreskin and move [it] with your own hand so as by delight to eject seed from yourself?
—Eleventh-century confessional text, cited in Robert Darby’s A Surgical Temptation

Routine medical circumcision of infants and boys first became popular in late Victorian England. Though never a majority practice, it was widespread among the British middle and upper classes from the 1890s until the 1940s. From the UK, the vogue spread to the other Anglophone countries. The practice remained very popular until the mid-1970s in New Zealand, Canada and Australia. The US continues the practice: in America, around 50–60% of male infants are still routinely circumcised (down from a high of 85%). In 2007, the World Health Organisation estimated that one in three men have been circumcised worldwide—but the majority are Muslims, circumcised for religious reasons (see also here). The US is the only developed western country that routinely performs non-religious circumcision on infants. Since the practice was adopted from Britain, to understand its origins we need to trace its history in the mother country.

Prior to the Victorian era, few westerners were circumcised. In classical Greece and Rome, the intact male body was considered an object of beauty and circumcision thought of as a mutilation; the Catholic Church explicitly banned the practice for Christians in 1442; westerners often associated it with the outlandish heathen customs of Jews and Muslims; and scare stories of Christian captives forcibly circumcised by Barbary pirates abounded. For opinion on the practice to experience such a dramatic reversal from revulsion to enthusiasm took an emergency. Early advocates hoped that it could prevent a practice they believed threatened the fabric of society: masturbation.

“The heinous sin of self-pollution,” as a bestselling medical treatise calls it, was held responsible for a litany of diseases from whooping cough to cerebral palsy. The 1896 Medical Record warns of “infantile convulsions, hip-joint disease, kidney disease, paralysis, eczema, stammering, dyspepsia, pulmonary tuberculosis, constipation, locomotor ataxia, rheumatism, idiocy, insanity, and lust,” while another popular medical source describes the consequences as “debility of body and of mind—infecundity—epilepsy—idiotism—extreme wretchedness and even death itself.” In an attempt to prevent masturbation, many penises were cauterised, blistered, burnt with acid—and circumcised. The imaginary disease of spermatorrhea—unwanted ejaculations—was likewise held responsible for a world of ills and treated with the insertion of needles through the perineum and into the prostate, with catheterization of the urethra and bladder with a caustic solution of silver nitrate and, later, with circumcision.

Like their predecessors in the more sex-positive seventeenth and eighteenth centuries, most early advocates of circumcision recognised that the foreskin was a source of exquisite erotic sensation, the locus of “such tender and sensible flesh, that nature hath there established the throne of sensitivity and pleasure.” As Robert Darby has shown in his detailed study, A Surgical Temptation, there was almost unanimous agreement on this point, from both enthusiasts and detractors.

It is only since the sexual revolution of the 1960s that advocates of circumcision have begun to claim that removing the foreskin does not affect sexual pleasure. Until that time, almost everyone agreed that it does—that was one of the main reasons why they championed it.

There is a misconception that, since Victorian Britain was a patriarchal society, its denizens’ well-known anxieties about sex led them to police and pathologise female sexuality, while allowing men free rein. In a traditional society, many argue, moral double standards encourage men to oppress women for perceived faults they themselves indulge with impunity. There is some truth to this: the consequences of being pronounced a fallen woman—a category that included many rape victims—were more dire than those of being thought a libertine. But this presents a vastly oversimplified picture. The Victorians observed that men, on average, are more motivated by sex than women—and many of them found the male sex drive debasing and bestial and attempted to suppress it, especially in children, who are easiest to control. Men were encouraged to regard their natural desires as sinful and pathological. Wrestling with his homosexuality, John Addington Symonds, for example, confesses that he “treated the purely sexual appetite … as a beast to be suppressed and curbed, and latterly to be downtrampled by the help of surgeons and their cautery of sexual organs.” He found many doctors all too willing to assist him.

The release of semen was thought to debilitate men; sex was considered depleting, even within marriage; false analogies were made between arousal and irritation, the contractions of orgasm and epileptic fits; the natural sleepiness that follows climax was likened to nervous exhaustion. Natural sexual impulses were demonised—no wonder an integral part of the normal male genitalia was considered, by some, “a source of annoyance, danger, suffering and death.” In an age without reliable contraception, fears of overpopulation, stoked by Malthus’ 1798 Essay, probably also contributed to the desire to curb male lust.

Contemporary commentators did not understand the nature of the male sex drive or its vital evolutionary purpose. Its mechanisms are neurological and hormonal. It cannot be significantly dampened by reducing the touch sensitivity of the penis or removing the foreskin. To my knowledge, there is no evidence to suggest that men who have been circumcised are less motivated by sex, more likely to remain chaste, less inclined towards sexual violence or less likely to masturbate. The Victorians were trying to control the impulses of men’s minds by castigating their bodies. They administered ever more extreme corporal punishments in their efforts to control male desire—a totally futile endeavour.

The contemporary purity movement was equally obsessed with keeping the mind free from impure thoughts and the body free from dirt. Following John Snow’s discovery, in 1854, that drinking water contaminated with sewage caused cholera, the Victorians carried out major urban sanitation projects, clearing slum districts, in which poverty and overcrowding provided ideal conditions for the spread of epidemics. Many doctors believed that, like cities, bodies had pockets of squalor where filth could fester, breeding disease.

William Morton’s discovery of anaesthesia in 1846 and Lister’s development of germ theory in the 1860s facilitated major advances in surgery, which had previously been terrifying, agonising and extremely dangerous. Using the new anaesthetic and aseptic techniques, surgeons excised supposedly vestigial body parts—such as tonsils, adenoids, teeth and even colons—which they believed might harbour germs, as a preventative measure. Easily accessible, the foreskin was an obvious candidate for prophylactic removal. Despite its practical uses in surgery, germ theory was little understood by many doctors. Older theories persisted: among them the idea that disease could occur spontaneously, as dirt trapped in bodily nooks and crannies—such as beneath the foreskin—fermented. Naturally, then, circumcision was adopted as a preventative measure against venereal disease, until the link between foreskins and syphilis was disproven.

In the 1930s, as paranoia over the ill effects of masturbation began to subside and doctors were becoming much less inclined to view the male sex drive as intrinsically pathological, circumcision became less popular. The medical debate turned to whether or not it prevented other diseases. Even at the height of the craze, only around a third of Brits had been circumcised, making comparative studies easy. Since the operation was not without serious risks, some British surgeons had always remained opposed. Douglas Gairdner’s widely read 1949 paper in the British Medical Journal, “The Fate of the Foreskin,” successfully debunked many of the claims made by proponents and emphasised the risks of death and deformity. Gairdner’s arguments were to carry the day.

Part Two: A Cure in Search of a Disease: Medical Circumcision in the US Today

What dreadful thing will happen if a baby’s prepuce [foreskin] is left entirely alone?
—R. Ainsworth, British Medical Journal, 1935

Meanwhile, however, the practice had been exported to the US. Early American proponents, like their British counterparts, viewed circumcision as an effective means of dulling penile sensation and hence preventing masturbation. John Harvey Kellogg considered it a remedy for masturbation in boys—he suggested burning girls’ clitorises with carbolic acid for the same purpose. He even advised against using anaesthetic: “as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment.”

But, even when attitudes towards sex liberalised, Americans didn’t abandon the practice. Instead, advocates switched rationale. After the sexual revolution of the 1960s, when reducing erotic feeling was considered a bad thing, suddenly circumcision was claimed to have no effect on sensation—instead, it was said to be more hygienic and to reduce the risk of certain illnesses.

Circumcision is a surgical anomaly: it involves the removal of healthy tissue from an especially vulnerable patient group—new-borns—without consent and without imminent medical necessity. The American Academy of Pediatrics (AAP)’s much criticised—and now officially expired—policy statement on circumcision from 2012 is therefore curiously worded:

Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child.

“Existing scientific evidence demonstrates,” the statement confidently begins, only to undercut that with the vagueness of “potential benefits” and data which are “not sufficient” to recommend the practice. The surgery is prophylactic, recommended on a just in case basis, and the responsibility for this irreversible medical decision is delegated to the parents.

The language implies that parents are often called upon to decide whether to submit a child to medically non-essential surgical bodily modifications—yet this seems to be a relatively rare occurrence. For example, a parent cannot schedule an appendectomy unless her child has appendicitis or is considered at high risk because of an abnormal CT scan. According to Harvard Medical School, inflamed or enlarged tonsils can cause conditions like sleep apnea, “which can be serious and lead to health and behavioral problems.” Yet, even in the case of recurrent infections, they recommend tonsillectomy only in extreme cases, stressing that “the decision should not be taken lightly.” Parents can opt to have a child’s wisdom teeth extracted prophylactically, but the way the decision-making process is described is tellingly different from the AAP’s justification for circumcision: “we must rely on the clinician’s experience and expertise in recognizing the likelihood that pathology will develop and his or her ability to communicate this in realistic terms to the patient.” The emphasis is on weighing up the possibility of future medical harm—not on respecting the cultural preferences of parents. Asking parents to make major clinical decisions without clear guidance from doctors places an impossible burden on them and is an unconscionable way for the medical community to shirk responsibility.

Four main conditions that circumcision is said to protect against are usually cited by the procedure’s advocates: phimosis, urinary tract infections (UTIs), HIV/AIDS and penile cancer.

Pathological phimosis is an uncommon condition in which the foreskin is uncomfortably tight and cannot easily be retracted. Treatment options include steroid creams or other ointments, which have around 90% effectiveness, and only occasionally may surgery be necessary (but even then, it is a minor surgery called preputioplasty—which preserves as much of the foreskin as possible—that is normally indicated, rather than wholesale circumcision). Physiological phimosis, however, is not a medical condition at all, but a natural stage of development. In early childhood, the foreskin adheres tightly to the penis, like a fingernail to its bed, forming a protective sheath. The adhesions attaching foreskin to glans gradually dissolve until, at some point between birth and puberty—and, in almost all cases, by the age of eighteen—the organ becomes loose, mobile and easily retractable, a process speeded along by children’s natural tendency to fondle and explore. If the foreskin is prematurely, forcibly retracted, it can cause tearing, bleeding and scarring and may make the child more susceptible to infections. The AAP has been widely criticised for failing to adequately describe penile anatomy in their guidelines and it seems likely that many American doctors and nurses, unfamiliar with the intact penis, may be continuing to cause injury by forcibly retracting boys’ foreskins or advising parents to do so.

Urinary tract infections are far more common in girls than in boys. Only around 1% of boys will have a UTI before age ten and most will not go to develop subsequent infections. This means that it takes one hundred circumcisions to prevent one—probably easily treatable—urinary tract infection. UTIs can be treated with antibiotics and usually clear up within a week.

Studies of heterosexual female-to-male transmission of HIV conducted on adult African men showed an absolute reduction in risk of 1–2%, though the studies were stopped early and there was no long-term follow up beyond twenty-four months (see also here). Some critics have expressed concern that, if circumcision is touted as preventing HIV, the circumcised men may neglect to use condoms, putting them and their partners at greater risk (the evidence for this so far is mixed). Given that, even if circumcised, you still need to practise safe sex to be protected, the operation does not seem like a very effective measure, even in the African context—and HIV from heterosexual contact is very uncommon in the US. In any case, these adult sexual concerns are irrelevant to infants.

Penile cancer is a rare disease, mostly affecting older men with severe hygiene problems—for example, those experiencing homelessness—who have neglected to seek treatment for early symptoms. Since neither penile cancer nor heterosexually transmitted HIV are likely to impact children, anyone concerned about these risks could be circumcised as a consenting adult.

The objection that an intact penis is intrinsically unhygienic is a frivolous reason for surgery. The female genitalia have a lot more flaps, folds and creases; the vagina produces natural secretions ranging from clear slippery liquids to thick, sticky blood and is rarely odourless. In the west, we do not advocate surgery to try to correct this “problem”—and rightly so. Genital organs do not need to be sterile and to prevent them from becoming overly pungent, you only need to wash.

Hygiene is often cited as the reason why the Israelites—desert dwellers with little access to water—advocated circumcision, and given as a good reason to imitate them. However, this motive is never mentioned in the Torah or midrash. In fact, the early Jews’ ignorance of germ theory and sepsis made the operation extremely dangerous, especially for new-borns, whose immune systems are not yet fully developed. Traditional practices like tearing the foreskin with a fingernail and metzitzah increased the risks. Rabbinical commentary suggests that deaths from post-circumcision infections were common in earlier periods. Circumcision was undertaken for spiritual reasons, in spite of the health risks, not as a health practice.

Teeth require much more elaborate care than penises and are highly prone to decay, which can have serious sequelae—caries has been implicated in heart disease and periodontitis is dangerous in pregnancy—but most dentists are extremely reluctant to perform extractions. Caps, crowns, root canals and other treatments are employed to preserve as much as possible of even a diseased or rotten tooth; uncomfortable and costly braces and Invisalign are used to reposition aesthetically challenging or obstructive teeth. We do not usually remove teeth prophylactically, despite our species’ well known love of sugar and susceptibility to caries. It seems therefore odd to suggest removing a body part which can be cleaned in a few seconds, by retracting and rinsing with water.

Part Three: Sexual Sensation

I believe that the intention of the rite [of circumcision] was to … advance … the chastity of the race by blunting mechanically the sensibility of the organ of sexual appetite.
—Anonymous letter to the Lancet, 1874

The foreskin is frequently dismissed as a flap of skin. Yet skin varies greatly in its haptic qualities. The skin of the fingertip is far more sensitive than that of the elbow; the skin of the clitoral hood is more responsive to touch than that of the heel. The mobile skin system of the foreskin is richly supplied with blood vessels and nerves, including a dense network of fine touch receptors. It may also serve to protect the skin of the glans from thickening and keratinising due to constant exposure and friction.

Despite the foreskin’s profusion of nerve cells, pro-circumcision activists frequently argue that the operation results in no loss of erotic sensation. Of course, erotic feelings are, like other qualia, difficult to quantify and compare. There are strong indications, however, that feeling is reduced in circumcised men.

First, studies using objective methods to measure sensitivity thresholds have consistently shown that the foreskin is the most light-touch sensitive part of the penis. Removing the foreskin obviously eliminates any sensation that would be experienced in that excised tissue, with its particular sensitivity to light touch.

Additional evidence for greater sensitivity in the uncircumcised is behavioural. This is anecdotal evidence, but it should not therefore be dismissed, as it comprises observational data of a kind we happily use to make deductions in other situations. For example, if we see someone scratching lightly we conclude she has a slight itch. If we see her scratching hard and repeatedly, digging her nails in, we assume she feels a strong itch or irritation. Likewise, if we compare the masturbation techniques of circumcised versus intact men (see here for an illustrative video of the latter), we note that the former generally grasp the penis more firmly and rub much faster and harder. This strongly suggests that more pressure is required to achieve the same level of sensation. We also note that uncircumcised men do not usually opt to touch the glans directly. Instead, they generally manipulate the foreskin itself, often holding it lightly between two fingers and a thumb and moving it backwards and forwards over the glans. This would be an inexplicable choice if the foreskin were merely an obstruction. This behaviour implies that the feel and/or movement of the foreskin enhances sensory pleasure.

It is also possible to guess at the sensitivity of our sexual partners from their physical and verbal responses. While individuals clearly vary a lot, direct experience and the testimony of those who have sex with men reveal certain patterns. Some lighter touches, which elicit delighted responses from intact men, are barely felt or even go unnoticed by those who have been circumcised. More pressure is required to spark pleasure: the threshold is higher. Like the clitoris, the glans in intact men can also become overly sensitive and, as with the clitoral hood, touching through the foreskin dials that feeling down from discomfort to pleasure.

During penetrative sex, intact men can often also enjoy gentler, slower movements, while circumcised men require more vigorous and sustained thrusting to maintain erection. This can be a disadvantage for female partners, since many women report that they get most pleasure from stimulation of the external clitoris. Gentler actions that allow the lovers to rub their pubic areas together during intercourse can be very rewarding for both parties. Also, not everyone enjoys being on the receiving end of sustained forceful pumping actions and this can be frustrating for the lovers, if the man has been circumcised and needs very strong movements to remain sufficiently stimulated. I mention these details because female preference is often cited as a justification for circumcision. Nevertheless, the primary consideration here should be the sexual experience and wishes of the man—about which we can know nothing while he is an infant.

Heterosexual circumcised men frequently argue that they do not wish to be more sensitive because that would lead to premature ejaculation, leaving their female partners unsatisfied. This implies that sensitivity is a volume dial and that the only variations are up or down. It seems likely, however, that different degrees of firmness may produce different sensations, just as being tickled feels different from receiving a deep tissue massage. Dr Ali Amjad Rizvi has described sex without a foreskin as like “listening to a symphony orchestra without the string section”: the light touch receptors produce a distinct timbre of pleasure. In addition, while it is possible to reduce sensitivity—by using condoms or desensitising gels or masturbating to orgasm before sex—it’s very difficult to increase it. Sensitivity varies among individuals and tends to decrease with age: those with a naturally slightly less sensitive glans, as well as older men, may particularly benefit from remaining intact.

Circumcised men are frequently resistant to the idea that they may be less sensitive than the intact. No one wishes to feel sexually inadequate or lesser—nor should they. Imagination, creativity, empathy, tenderness—all of these make an enormous difference in our experience of sex. Even in casual encounters, we generally relate to each other as people, not as mere collections of anatomical parts. Women vary greatly—arguably more than men—in our sexual responsiveness: some enjoy multiple orgasms, others have difficulty reaching orgasm at all. But penises and vaginas are attached to people. For caring people, finding ways to pleasure each other is a loving game. We explore our partners’ needs and preferences: we don’t judge them. Always, we must work with what we have and respect the needs and wishes of the individual partner. Comparisons are especially odious in sexual relationships.

One common argument made in favour of circumcised penises is that some people prefer their appearance. This seems counterintuitive. Equipped with a foreskin in all primate species, the male sexual organs have co-evolved with their female equivalents over millennia and their appearance may even have been partially shaped by female choice. Distaste for foreskins may be the result of unfamiliarity with intact penises among American women in particular and of the prevalence of pornography. It can be easier to see what is going on without a foreskin partially obscuring the view and, in porn, of course, visual considerations are more important than the pleasure of the participants. That some are repulsed by the natural appearance of the human body and prefer surgically altered to intact genitalia seems troubling and can reflect sexist or misanthropic attitudes. But consenting adults should choose their sexual partners using whatever criteria they wish. However, imposing cosmetic surgery on an infant because of adult preferences seems perverse.

Part Four: The Rights of the Child

Your children are not your children.
They are the sons and the daughters of life’s longing for itself.
—Kahlil Gibran, “On Children.”

I often hear the argument that, since an infant retains no memory of his circumcision, he cannot be said to suffer. This implies that suffering is an entirely future-based phenomenon and that we cannot suffer in the moment. Yet a baby’s high-pitched screams, struggles and sometimes catatonic silence all suggest that he can and does experience pain. We don’t use this reasoning to excuse any other torture inflicted on children. Also, can we be sure that such a traumatic experience never has detrimental long-term effects, even if it is not consciously remembered? If one of a child’s first experiences on entering the world is to be strapped down and subjected to excruciating pain, can we be certain this will never have any effects on his emotional and psychological development? Some research suggests adverse consequences. It seems both prudent and humane to err on the side of caution here.

Part Five: What About Those Who Enjoy Their Circumcised State?

Many circumcised men feel perfectly happy with their penises. They have no memory of any trauma, no direct means of comparison. They cannot tell what they might have felt had they been intact—and are delighted by what they are able to feel now. For many, sex is a joyful experience. That’s wonderful. The problem is those who aren’t happy: the men who are conscious of their reduced sensation and sexual possibilities, who have scarring, adhesions or deformities as a result of botched circumcisions or who are resentful at the violation of their bodily autonomy. Circumcision is irreversible. The remaining skin can sometimes be stretched to provide the appearance of a foreskin, but nerve cells cannot be regrown. If you are intact, you have a choice. You can be circumcised painlessly, under anaesthetic, as an adult: a low-risk procedure in the west. But if you have been cut, you have no choice. You cannot be uncircumcised.

Circumcision is not, in itself, a mutilation. Some men choose to have it done in adulthood—though, tellingly, this is an unusual choice. Some natal male trans women even choose to have the entire penis removed, during gender reassignment surgery. These are valid options for informed, consenting adults. But no one should have the right to remove healthy genital tissue or to manipulate your sexual organs against your will or without your consent. We should perform irreversible surgeries on children only when the child’s life, health or full development are threatened. Children’s bodies are not the property of their parents, to be modified to reflect our desires or values. Most parents agree—but many have been misled by the medical profession or have not fully thought through the ways in which forced circumcision violates these principles.

All this also applies to children of religious parents. The right to bodily integrity is a human right and, like all human rights, it is lodged in the individual, not the group. A Jewish or Muslim boy should enjoy as full human rights as any other child. As adults, they may decide to be circumcised as a religious sacrament. But this must be their free choice. Circumcision is said to be a covenant between god and man, signed on the body: how can an agreement be valid when one of the parties was coerced and did not even know what was happening? This genital modification is deeply meaningful to many Jewish and Muslim men, as a spiritual practice and marker of identity and it can and should remain so for those who wish—but it should be delayed until the person concerned is old enough to freely choose it.

Circumcised fathers may want their sons to look like them. Wanting your children to resemble you is a deep-seated and natural urge. But, for most parents, there is an even stronger wish: to see their child happy. Why risk permanently altering his body in a way he may come to resent and which you may later regret? He can always opt to be circumcised painlessly, in adulthood, under anaesthesia. Why not give him the freedom of choice you were denied?