The United States is unique among Western countries in its practice of routine circumcision. From 1.2 to 1.8 million little Americans are circumcised annually, representing from 60% to 90% of newborn boys. The routine, almost compulsory character of this mass circumcision raises multiple questions concerning public health and medical practice. Having originated in particular historical circumstances, this procedure has for decades been the subject of studies aimed at making precise measurements of actual medical benefits, calculating cost/benefit ratios, and attempting to understand the sociocultural implications and ethical issues.
The history of circumcision in the United States can be divided into three periods:
1870-1949: Circumcision as punishment
Routine circumcision was introduced to the United States in stages beginning in the 1870s for one basic purpose: to deprive the male of a prepuce considered essential for masturbation, a practice thought to be the cause of multiple physical and mental pathologies. From Europe, where masturbation was seen as an indication for circumcision, the fear of masturbation spread to North America, where emphasis was placed on its psychological effects.
Routine circumcision made its initial appearance in the United States on February 9, 1870. Lewis Sayre, first professor of orthopedic surgery in the United States, president of the American Medical Association and founder of J.A.M.A., noticed that a 5-year-old boy with multiple tendon contracture of unknown etiology suffered from very painful phimosis and priapism, which Sayre attributed to excessive masturbation. Believing that masturbation could create a “source of irritation” responsible for tendon pathology, Sayre recommended circumcision. According to Sayre, circumcision caused the tendon contracture to disappear within a few weeks, allowing the boy to resume walking.
Sayre’s position at a university gave his first publication an important audience. Sayre led his audience to believe that a simple intervention could cure myriad puzzling diseases thought to be incurable. He encouraged doctors to examine the prepuce every time they encountered unfamiliar pathology. He added a great number of illnesses to the list of indications for circumcision, to the point where many of Sayre’s disciples quite naturally proposed changing over from therapeutic circumcision to preventive circumcision. So great, they said, were the benefits and so innocuous was the operation. Circumcision became progressively established as a simple health precaution, a kind of surgical vaccination.
A few years later, Remondino enumerated the disorders caused by masturbation (alcoholism, epilepsy, asthma, enuresis, kidney disease, gout, prolapse of the rectum, hernia, cancer, syphilis...), reinforcing the prophylactic benefits of circumcision and contributing greatly to making the procedure acceptable in the eyes of the public. Remondino suggested that insurance companies should treat the foreskin as a special risk factor for men, a suggestion that could only provide additional impetus for circumcision. Some doctors applied themselves to perfecting and simplifying circumcision techniques: in 1910 Kistler invented a device that allowed adults to perform self-circumcision.
In a climate so favorable to preventive circumcision, few publications condemned circumcision as a barbaric practice or advised doctors to stop doing mutilations which lacked a scientific basis.
In fact the practice of circumcision grew, especially as the field of general anesthesia progressed rapidly and the rise in the number of surgeons and hospitals (a 20-fold increase in the last third of the 19th century) motivated surgeons to seek new opportunities for profit. Thus after the First World War neonatal circumcision became almost routine, to the point that in 1929, an editorial in J.A.M.A. called for the circumcision of all newborns, with or without the consent of parents.
The period of evaluation
Right into the 1940s, the usefulness of circumcision was taken for granted in the medical birthing culture. Parental approval was almost never requested and the proportion of little Americans circumcised was about 90%--that is, nearly all of them--a situation which explains the first assessment studies.
It was Gairdner’s work that first brought the value of routine infant circumcision into doubt. Drawing up the inventory of indications, which had changed little since the days of Sayre, Gairdner noted that in the West, circumcision was routine only in English-speaking nations and that circumcision was more common in boys from the upper classes.
In 1969, Bolande compared circumcision to tonsillectomy, describing both as ritualistic surgeries having no sound scientific basis. He demanded credible scientific evidence showing that circumcision was useful. In the absence of such evidence, he considered circumcision contrary to the most basic principles of medical ethics, principles also highlighted by Price.
The potential benefits of routine infant circumcision were evaluated in practice guidelines published on several occasions by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The indications assessed by these bodies were prevention of phimosis, facilitation of hygiene, prevention of penile cancer, prevention of cervical cancer (at times considered more frequent in partners of non-circumcised males), and prevention of sexually transmitted infections. Studies showed that:
• usually phimosis in the newborn is physiologically normal and is not an indication for newborn circumcision;
• circumcision could facilitate glans hygiene in conditions of social disadvantage;
• penile cancer can be prevented as effectively by proper hygiene as by circumcision, a procedure whose protective biological mechanism is moreover poorly understood;
• absence of circumcision is not by itself a determining factor in the occurrence of cervical cancer.
With regard to the prevention of urinary tract infections in children, the purely retrospective nature of the studies and the limiting of subjects to children treated in hospital did not warrant recommending routine circumcision for this indication.
The question of preventing sexually transmitted infections (STI) was also the subject of numerous studies, notably because of the implications for AIDS prevention. A study of 300 heterosexual men by Donovan, Bassett and Bodsworth found that circumcision offered no protection against genital herpes, genital warts or non-gonococcal urethritis. Elsewhere, studies conducted in Africa seemed to indicate that heterosexually transmitted HIV was more common in men who had not been circumcised.
In point of fact, most authors note the multiple methodological flaws in the largely retrospective studies, especially the assumption that circumcision is risk-free. The studies depend heavily on the socio-economic status of parents, suggesting that the sexual behavior of circumcised and non-circumcised men may not be the same. This hypothesis was confirmed by Laumann. Due to the bias inherent in these studies, the results in most cases are difficult or impossible to interpret.
These evaluative studies concluded that there was no absolute indication for routine infant circumcision, bringing into question the justification for a practice affecting nearly all male newborns. Moreover practice guidelines emphasized the need to give parents clear information on the risks of circumcision and non-circumcision, to substitute good hygiene for routine circumcision, and to avoid considering newborn circumcision as a defining element in the overall quality of health.
Notwithstanding these recommendations, the practice of routine circumcision scarcely changed and the frequency of circumcision in the USA today remains the highest in the industrialized world. More than 80% of boys are circumcised at birth  while--for reasons that are not well understood--routine circumcision in economically comparable Anglophone societies (Great Britain, English-speaking Canada, Australia) is either quite uncommon or virtually nonexistent. Against the backdrop of a medical consensus that seems to carry little weight, recent articles underscore the importance of social factors in US circumcision practices and provide some insight into the persistence of this practice.
Circumcision in the USA: A social marker
Circumcised men are more likely to be white and socio-economically advantaged. Among blacks, circumcision is half as common. The study conducted by Laumann on a representative sample of about 1500 Americans aged 18 to 59 found that the circumcision rate is higher among whites than among blacks or Hispanics, a finding that was confirmed by Wilkes and Blum. Of the reasons given by parents to justify a request for circumcision, most are social in character, the parents effectively not wanting their sons to have a physical difference that would set them apart from most Americans and hinder their social integration. Moreover the decision to circumcise or not circumcise a newborn is strongly correlated with the circumcision status of the father, illustrating the attraction of circumcision as a physical mark of social identity.
The circumcision decision also depends to a significant extent on the social status of the mother. The circumcision rate was 2.5 times higher in boys whose mother had a university education. Finally, in contrast to the situation in Europe, circumcision in the United States is not generally correlated with the practice of a religion. Thus circumcision reflects social rather than religious differences. The request for circumcision on the part of parents seems to reflect a desire for membership in an elite, and parents belonging to less favored classes are not as strongly committed to circumcision.
Besides behaviors linked to the social profiles of parents, the role of circumcising physicians should not be overlooked. Circumcisions are less frequent in public hospitals where physicians are on salary.
Finally, it should be noted that different studies seem to show that masturbation, whose role in introducing routine circumcision to the USA has been previously mentioned, actually appears to be more common in individuals who have been circumcised.
The history of ritual circumcision shows the complexity and intricacy of the meanings attached to this practice. It also illustrates the social importance accorded to circumcision by all the societies that practice it. Finally, it offers physicians abundant raw material for reflection on the history of ideas in medicine and the cultural meanings of certain medical practices; it draws attention to the difficulties inherent in, and the necessity for, proper evaluation of medical practices that have become routine.