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Circumcision Decision

Male circumcision rates in Utah decline as parents reconsider the procedure



Spenst Hansen knows better than to take his body for granted.

Born in the midst of his parents' divorce, the 24-year-old Salt Laker was, of course, a major sticking point in the split. More surprisingly, so was his circumcision status.

"My mother and her side of the family really wanted to get [the procedure] done—so much so, apparently, that they were threatening to get it done behind my father's back," Hansen says. "My father was very adamant and very passionate about letting me keep my whole and unaltered body. From what I understand, he actually put out a court-ordered cease and desist for every pediatrician in the state."


To Hansen's relief, his father's legal threat proved remarkably effective. "No doctor would even see me at that point," he said. "I met the lawyer personally and thanked him."

Today, Hansen honors his father's efforts with work of his own. As a local "intactivist," Hansen is an active participant in the growing fight against the widespread nontherapeutic removal of infant foreskin.

"My father raised me with an attitude that my body is my body, and it should be my choice and nobody else's what happens to it. I've always had the same attitude after seeing how important it was to him," he said. "It's a very empowering feeling."

Few cultural customs boast a history as long or as complex as that of the world's oldest known surgical procedure, which has cropped up relatively independently in dozens of faiths and cultures throughout the Middle East and Africa. Its significance ranges from that of a customary coming-of age ritual, as in the many African tribes who circumcise at puberty, to that of an eternal covenant with divinity.

Circumcision was first introduced to Judaism roughly 2,000 years before the birth of Christ, with God's commandment to his aging servant, Abraham. "By age 99, Abraham had fulfilled all of God's commandments ... with the exception of circumcision," said Rabbi Avremi Zippel, the youth and program director for Sugar House's Chabad Lubavitch synagogue. "He was told that this would be his final test, the final commandment, and that he would be found to be complete and whole and pure in the eyes of God."


Abraham was later instructed to circumcise his newborn son, Isaac, on his eighth day of life, giving rise to the traditional Jewish "bris" ceremony. The commandment to circumcise has since remained in force, compelling the orthodox Jews of Chabad Lubavitch to circumcise in exactly the same manner.

"Heritage is something that remains with us forever," said the rabbi. "Once you start adapting and changing and modifying, I believe you kind of lose the beauty of it. This is the way Jewish boys have been brought into the faith for nearly 5,000 years. Who are we to change the way it's always been done?"

With few exceptions, circumcision remained confined to religious and cultural circles until the Victorian era, where it found myriad champions among sexophobic medical professionals desperate to curb children's "endemic" self-stimulation. As the human male's primary erogenous zone, the hyper-sensitive foreskin found a particularly dedicated opponent in Battle Creek, Mich., medical doctor John Harvey Kellogg. The puritanical breakfast-cereal czar produced volumes on the subject, and wrote in 1888 about possible solutions to "self-abuse":

"A remedy for masturbation, which is almost always successful in small boys, is circumcision," he wrote. "The operation should be performed by a surgeon without administering an anesthetic, 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. In females, the author has found the application of pure carbolic acid to the clitoris an excellent means of allaying the abnormal excitement."

To the relief of many, Kellogg's zeal for clitoral excision failed to gain popularity. His hatred of the foreskin, though, spread through the medical field like herpes through an "abstinence only"-educated high school. David L. Gollaher's 1994 Journal of Social History article, "From Ritual to Science: The Medical Transformation of Circumcision in America" explains how Kellogg's smear campaign, in conjunction with advancements in anesthesiology, created the perfect medical environment in which routine circumcision could thrive.

By the end of the 19th century, America's obsession with moral purity had evolved to a fixation on physical cleanliness. But with doctors only just beginning to understand germ theory, their desire to eliminate dangerous microbes far outstripped their practical ability to do so. Information was scarce, fear was abundant and, as a result, the science conducted was poor.

Genitalia's "unclean" association with both sexuality and bodily function/excretion made them a perfect medical scapegoat. They were associated with any number of illnesses, especially those relating to sex or immorality. Physician Peter Charles Remondino, a vice president of the California Medical Society, who wrote in his 1891 book History of Circumcision From the Earliest Times to the Present, "The prepuce seems to exercise a malign influence in the most distant and apparently unconnected manner. ... beginning to affect him with all kinds of physical distortions and ailments, nocturnal pollutions and other conditions calculated to weaken him physically, mentally and morally; to land him, perchance, in jail or even in a lunatic asylum."

Post-circumcision improvements observed in a child's physical, mental or spiritual integrity were often carelessly attributed to the procedure, ultimately earning it a reputation as a sort of miracle cure. An 1890 study revealing that Jews, then the nation's largest circumcising out-group, were less likely to suffer from syphilis and gonorrhea sparked the sloppy conclusion that circumcision offered protection from sexually transmitted infections. This, in turn, led to a recommendation that all newborn males be circumcised as a form of preventative treatment of venereal diseases.

The National Organization of Circumcision Information Resource Centers (NOCIRC) is, according to its website, committed to "securing the birthright of male, female and intersex children and babies to keep their sex organs intact." Heading up the Utah chapter of NOCIRC is longtime foreskin advocate Steve Scott, who thinks doctors continue to canonize observable health correlations as causal. "Whatever disease was prominent during any specific time in U.S. medical history, that disease was caused by the foreskin and curable through circumcision," Scott told City Weekly. "It is an industry in constant search of a reason to exist."

Despite now-glaring logical and procedural errors, anti-foreskin findings were generally accepted by the medical community with little dissent. According to David L. Gollaher's journal article, circumcision was seen as both so common and so beneficial by the end of the century that medical textbooks began depicting circumcised penises as the standard. Additional diagrams and fine print fell away over time until no indication was given that those penises had ever looked any other way.



Circumcision also enjoyed a brief period of popularity in Australia, New Zealand, Canada and the United Kingdom. The practice erupted especially quickly in the U.K., where doctors were circumcising more than half of all middle-class infants by the time World War II began.

But British doctors were less united on the efficacy of the surgery than American professionals, and zealots were few. Dr. Robert Darby, an Australian historian who has studied circumcision since the late 1990s, said the crown's finances played a key role in eliminating the practice. Still reeling from the war's financial impact, the impoverished British government opted to omit circumcision from the list of procedures covered by the newly established National Health Service. Parents were welcome to circumcise their children, the government said, provided they paid the surgical fees out of pocket.

By the early 1960s, the Brits had all but eliminated circumcision. Circumcision rates (at less than half of 1 percent of all births) experienced a similar post-war plummet throughout the Anglosphere, quickly falling to negligible levels. Today, circumcised men in former outposts of the British Empire (the U.S. excepted) are typically assumed to be Jewish or Muslim.

In contrast, America's rates of the surgery continued to climb after World War II. Numerous variables have a made a mess of circumcision statistics—neither the government nor the medical community keep official records—but based on sampled hospital records, the anti-circ organization NOHARMM—the National Organization to Halt the Abuse and Routine Mutilation of Males—estimates circumcision peaked in the United States in 1981 at 85 percent of all male infants.


These days, NOHARMM puts the circumcision rate at 60 percent, slightly above estimates from the Nationwide Inpatient Survey (56.3 percent in 2008) and Charge Data Master (54.7 percent in 2010). State attitudes toward the procedure are remarkably diverse, with Nevadans circumcising just 10 percent of their babies and West Virginians circumcising all but 10 percent of theirs. Generally speaking, the procedure becomes less common as you move farther west; no West Coast state circumcised more than 20 percent its infants in 2010.

The American Academy of Pediatrics has a rather embattled history regarding circumcision, having continued to defend its validity decades after peer organizations denounced and abandoned the practice. The association's most recent statement on the issue, released in August 2012, marks a notable departure from previous statements in that it does not recommend routine infant circumcision for all newborn boys; however, the AAP still claims that "the health benefits of newborn male circumcision outweigh the risks of the procedure." Those health benefits include, according to the AAP, helping prevent urinary tract infections, acquiring HIV, transmission of some sexually transmitted infections and penile cancer.

A task force of eight physicians representing general medicine, pediatrics and pediatric urology associations throughout Scandinavia and western Europe responded to the AAP's statement with a four-page critique titled "Cultural Bias in the AAP's 2012 Technical Report and Policy Statement on Male Circumcision." The critique stated:

"Seen from the outside, cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious. ... Claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts, and penile cancer, are questionable, weak, and likely to have little public-health relevance in a Western context, and they do not represent compelling reasons for surgery before boys are old enough to decide for themselves."

Still, local doctors generally follow the American Academy of Pediatrics party line—that, at least in most cases, the risks presented by circumcision are worth taking. "It's like anything," says Anthony Schaeffer, a pediatric urologist at University of Utah Hospital. "There's no perfect answer. I present the facts and certain medical indications. ... [For instance,] we will recommend circumcision pretty strongly if the boy has urinary-tract infections in the first year of life." Ultimately, though, the decision is left entirely to the boy's parents.

As "a very esteemed practice," Schaeffer says, circumcision is a sensitive topic.

"It behooves us to respect what each culture holds to be true," Schaeffer says. "It's not my role to put values on it."

Though far from simple, the arguments against circumcision can be broken into distinct camps. Anti-circumcision activists have attacked the procedure for reasons rooted in medicine, sociology, finance and ethics.


For Spenst Hansen, the moral concerns are the only concerns. "I don't want to make the medical or cultural arguments," he said in an attempt to identify the core of his convictions. "The issue is simply that everyone should have the choice over what happens to their own body."

Far and away the most common neonatal procedure, circumcision is also the only surgery routinely performed without the consent of the patient—the only consent that matters, Hansen said.

"Parents often say things like, 'It's my parental choice,' or, 'It's my right as a parent.' And while there are certain things that I consider a parental right, like where you choose to send your child to school, if you choose to raise your child with or without religion or if you decide your kid needs to be on a special diet or something—those are parental choices." Hansen says. "But circumcision is typically classified as a cosmetic surgery, which means there's no medical need for it. To impose that on someone else without their informed consent is a radical violation of their rights."

"It's an issue of human rights, not parental rights," said Adrianna Costello-Martin, a midwife's assistant and natural-birth instructor at The Birth Center in Murray. "It's about the bodily integrity of that baby boy and his right to his own body. It is his body. Why are we making unnecessary changes to it without his consent?"

But Schaeffer says the question of circumcision is one of many medical decisions for which the parents of underage children are responsible. "Until the child is 18 years old or a liberated minor, parents are acting in what they see as the best interest of their child," Schaeffer said. "The same [consent] argument could be made for not giving children vaccines."

Rabbi Zippel worries that requiring a child's informed consent, necessarily given after an "age of consent" (16, 18, 21, etc.), would damage the spirit of the covenant represented by circumcision. "We believe the purpose is to form an everlasting covenant between this young man and the almighty God, and a covenant is not subject to human intellect," the rabbi said. "If we were to allow this young man to make the decision himself ... the drive and inspiration and motivation he found to make that covenant might one day dry up. When performed on an 8-day-old baby, circumcision forms a covenant that transcends the boundaries of human intellect, and we are confident it will last forever."

Other intactivist arguments focus on the operation's physical risks. "People think circumcision is a perfect procedure, but there is a long list of complications that can, and frequently do, occur," Hansen said.

According to research published in the British Journal of Medicine in 1993, infection occurs in up to 10 percent of circumcision patients. Moreover, research from the University of California San Francisco says that 2 percent of all circumcised infants experience serious hemorrhage as a result of the surgery, potentially ending in blood loss, brain damage or even death. Deaths from circumcision are rarely reported as such, but a 2010 study by Dan Bollinger, director of the International Coalition for Genital Integrity, concluded that between 117 and 120 American infants die each year as a direct or indirect result of their circumcision, yielding a relatively high mortality rate of one in 11,000 operations. For context, only one in 16,000 uncircumcised infants will need therapeutic circumcision in life, and only one in 30,000 will choose it for religious or aesthetic reasons.

Simply put, said Murray midwife's assistant Costello-Martin, "Your risk of dying from the procedure is greater than your risk of needing it later on."

Statistics related to circumcision complications are hard to come by. Death is "never recorded as a complication of circumcision," NOCIRC's Scott said. "The one thing you can count on in anatomy is diversity. A blood vessel might not be where it's supposed to be, and you might get a bleeder. ... So the child dies of exsanguination, but not of a 'circumcision,' of course. There are no numbers on those deaths."

Other post-circumcision problems don't manifest themselves until the child reaches puberty. Even the research of Dr. T.E. Wiswell, one of circumcision's strongest advocates throughout the 1980s and '90s, estimates as many as 1.7 percent of circumcised men will experience one or more postneonatal complication of circumcision, including preputial cysts, meatal stenosis and bowed or "tight" erections from excessive skin removal.

"There are a lot of complications that occur as the child grows into his adult penis," Hansen said. "With a doctor cutting a little infant's penis, there's no gauge. You don't know what it's going to grow into. They don't always know how tight to go, and for that reason, even if you have a 'perfect' circumcision, when you grow up, a lot of people have problems with tension or it healing wrong or brittle scar tissue."

Even a best-case-scenario circumcision is a step down from the naturally intact penis, function-wise, Scott says.

"You've removed half of the skin covering his most vulnerable organ, and it's anatomically the most complex half, physiologically the most dynamic. These are the external moving parts of the penis, these are the parts of the penis that have the highest concentration of specialized nerve endings," he says.

Both intact men and their partners are quick to identify the foreskin, not the glans, as a man's primary erogenous zone. In a survey published in the 2004 book Flesh and Blood: Perspectives on the Problem of Circumcision in Contemporary Society, 22 of 38 sexually active men circumcised in adulthood for medical, religious or aesthetic reasons (58 percent) said that the pleasure of intercourse was lessened and that they would not choose circumcision again, given the option.

Furthermore, women report higher sexual satisfaction when partnered with an uncircumcised male. A 1999 survey by O'Hara and O'Hara, published in the British Journal of Urology, of women who had been with both circumcised and uncircumcised partners reported that women preferred their partner to be uncircumcised by a ratio of 8.6-to-1, citing fewer problems with vaginal dryness, condom compliance and reaching orgasm/multiple orgasms.

"Most men never think to connect their circumcisions to certain sexual dysfunctions, like the fact that their female partner can't orgasm through penetration," Costello-Martin said. "I know that some women anatomically can't, but I've always wondered if it has something to do with how many men are circumcised here."

Of course, it doesn't matter how good the sex is if it isn't safe. Intact genitals' alleged proclivity for venereal-disease transmission, would certainly negate their abundant tactile benefits. But despite America's long-running malignment of the foreskin as a risk factor for sexually transmitted infections, the international medical community has repeatedly failed to prove such a link between one's circumcision status and his likelihood of contracting an STI.

In a report released by Seattle-based organization Doctors Opposing Circumcision, researchers Gregory J. Boyle and George Hill detail a host of methodological problems with the commonly cited African randomized clinical trials, including "selection bias, inadequate blinding, problematic randomisation, trials stopped early with exaggerated treatment effects; and not investigating non-sexual transmission." The trials' oft-touted 60 percent reduction in HIV transmission is a relative risk, they write, impacted by unmeasured confounding variables (for instance, African Muslims' low STD contraction rates could be due to Islam's prohibition of premarital sex, not its espousal of circumcision). After controlling for associated variables like religiosity, promiscuity, drug use, etc., Boyle and Hill concluded the absolute decrease in transmission risk after circumcision is roughly 1.3 percent.

The World Health Organization has persisted in beating the circumcision drum, drowning out concerns about the effectiveness and appropriateness of prophylactic circumcision. Citing the same randomized clinical trials debunked by Boyle and Hill as "compelling evidence that male circumcision reduces the risk of heterosexually acquired HIV infection in men," the WHO is encouraging all adult African men to volunteer themselves for the procedure, shooting for an 80-percent circumcision rate across the continent.

"Um, can you say, 'condom?'" Costello-Martin said, raising an eyebrow. "Like, why are we cutting people? What happened to handing out condoms?"

If WHO efforts have had an impact on HIV transmission, it may have been to actually increase transmission rates. Circumcised men may actually be less likely to wear condoms, motivated both by the fear of further loss of sensation and by the belief that they are impervious to STIs. "If people are led to believe that circumcision is actually 'protective' in the sense of conferring full immunity, this could be seriously counterproductive, resulting in behavioural disinhibition in circumcised men and their abandonment of other preventive methods," wrote University of Cape Town professor J. Myers in a 2007 South African Medical Journal article.


Perhaps because of this, Myers wrote, Ugandan women with circumcised partners appear twice as likely to contract HIV as women partnered with uncircumcised men, and 90 percent of new HIV cases appearing in South African 15- to 24-year-olds are occurring in women.

Utah intactivist Nathan Kennard is one of many Utahns questioning the integrity of doctors promoting African circumcision. Kennard stumbled across the anti-circumcision movement in 2002 while researching a complication of his son's circumcision. Among other things, Kennard learned that in 2002, Utah Medicaid public insurance covered the costs of nontherapeutic neonatal circumcision to the tune of $379,964 annually.

"It's a very, very irresponsible use of taxpayer dollars," Kennard said. "There's just no reason to submit an infant to that."

At the time, 10 U.S. states (either through administrative action or legislation) had already eliminated Medicaid funding for elective circumcision. After Kennard met briefly with NOCIRC's Steve Scott, Kennard began researching both issues of circumcision and of state funding on his own, ultimately creating and personally distributing factsheets and CD-Roms to each member of the Utah Legislature. "My goal was to ask, 'How much is it? How much can you save? What else can you fund?' " Kennard said.

Somewhat to Kennard's surprise, he said, in 2003, the Legislature agreed to defund nontherapeutic circumcision, joining North Carolina and much of the Western United States. "It's a huge victory," Kennard said, 12 years later. "It's change that's measurable, and that's huge."

Without state funding, Utah's circumcision rates have quickly dropped off, mirroring those of the U.K. after circumcision was removed from its state-sponsored procedures. State statistics reflect a fall from 56 percent to 33 percent of all male births, although officials seem to agree that both the starting and ending numbers are, in reality, significantly higher.

Today, NO-CIRC reports that 39 percent of all male babies born in Utah are circumcised before leaving the hospital. No official records of clinic, home or religious circumcisions exist, but Scott imagines their existence would boost the statistic above 50 percent, and possibly even above the national average of 55 percent to 60 percent.

Why, despite mounting scientific and sociological evidence against the benefits of circumcision, do doctors continue to recommend it? What gives this ritual its outsize staying power? "The bottom line is that circumcision is a cultural phenomenon," Scott said. "That's what drives it. It's the sheer force of power of social practice. There's no greater legitimizer than social custom, and that's what's at work here."

"It's a strong societal and medical norm just to circumcise," Hansen says. "It's sort of assumed, 'Oh, you have a baby? Let's circumcise it. Let's cut his umbilical cord, give him a bath, and then we'll circumcise him.' It's a very routine procedure."

But tradition alone hardly seems a compelling enough argument to offset circumcision's apparent ethical and health concerns. Many of the procedure's proponents, it seems, have developed personal stakes in the continuation of the practice.

"It gets to be a very personal thing for a lot of people," Scott said. "If you're a man, and you're circumcised, and you've hired someone to circumcise your child, you're going to have a very hard time accepting that you've done something wrong.

"That's hard on mamas, too," says midwife's assistant Costello-Martin. "That regret, that guilt, that, 'What did I put you through?' It's tough."

Of course, there's also the ability to charge between $50 and $125 for a five-minute operation, making circumcision a rather profitable procedure. According to Scott, nontherapeutic neonatal circumcisions alone generate over $1 billion annually.

"And it's quite clear that the money that's made on circumcision-complication repairs is more, even, than that made on circumcisions," he said gravely. "I'm starting to look at this as an entire circumcision industry. It has to defend itself."


Scott predicts the "circumcision industry" will face a backlash once the numbers of uncircumcised males approaches 50 percent, noting the proximity of current rates to the midline. "Once more than half of the U.S. is not circumcising, for the same locker-room reasons that it rose to popularity, circumcision will die out. We're at critical mass now."

"I'm hoping it's looked on like bloodletting, or like we look at some of our weirder former practices, just within a generation or so," Costello-Martin says. "I really think that even boys who have been cut today will not cut their sons."

As it stands, Utah's inactivist community isn't much more than a decentralized collective of passionate people working individually. But the future looks bright, says David Lee of Foregen, an Italian-American nonprofit dedicated to regenerating amputated foreskins by repopulating the cell matrices of donated prepuces with recipient's' stem cells (see sidebar).


"The thing that's exciting about Utah is that this is a community of people who want to make the world a better place, and they're looking for outlets for that," Lee says. "We've got such diverse culture with our two polar opposites that people vacillate between. You've got the religious side, which is very interested in ethical standards and moral behavior and creating a safe happy community, in making things positive. And then we've got sort of a counterculture which gravitates around the university, which is into intellectuality and knowledge and openness and truth. The two aren't mutually exclusive, and I think, between the two of them, we have a lot of people that are interested in learning more."

Meanwhile, Spenst Hansen keeps trying to connect with people and raise awareness of the issue. "Even people that don't right now think about it, because they've never had the chance to, but once presented with the facts—it's an unnecessary procedure that people don't necessarily consent to, and maybe they should—once presented with those ideals, they'd be like, 'Of course, I absolutely support this cause,'" he said.

"I just wish we could find each other more easily."

Allison Oligschlaeger is Salt Lake City-based writer and journalism student at the University of Utah.

An earlier version of this story incorrectly named the American Academy of Pediatrics.