Do You Know the Many Reasons for Circumcision?

Circumcision is a medical procedure that involves the partial or complete removal of the foreskin, the thin, mobile sheath of flesh that typically covers the penis head at birth. It's a practice that dates back thousands of years, crosses hundreds of disparate social groups, religions and regions, and carries cultural implications.

The decision to circumcise or not is a weighty one for all of these reasons and more, especially considering that parents are often tasked with making the choice for their child at birth.

But while custom and commonly followed medical practice have often dictated that circumcision be performed shortly after the child is born, there are cultures where the ritual is performed when the boy is older.

Today, adult or teen circumcision for aesthetic or health considerations is practically mainstream in a way that would have been unheard of even a couple of decades ago.

What do people need to know if they're considering circumcision for their newborn or older child, or for themselves as adults? Why might it be a good idea and what are some issues that might come up? What are some medical conditions that might influence your choices or alter the reasons for circumcision?

Culture and religion

Cultural signifiers and history are at play when it comes to circumcision. It's a tradition that's not only a key part of the Jewish faith but also of Islam. With some 1.9 billion people—about 24 percent of the global population—identifying as Muslim, circumcision is truly a worldwide practice.

"I think for patients born in New York, circumcision is relatively common," said Amanda North, M.D., the director of urology at the Children's Hospital at Montefiore in the Bronx in New York City. "Now, we do have a lot of immigrants from parts of the world where circumcision is not normal. One of the most interesting parts of my practice is we have a large Bengali population here. And circumcision is practiced in Bengali culture, but it's not done until the prepuberty age, around 8 to 10 years old. So we do a ton of circumcisions on patients from Bangladesh."

Sexual health

Apart from culture and religion, people have a number of other reasons to circumcise their children or themselves as adults or adolescents. One of the key motivators is the relationship between being circumcised and sexual health.

It's important to preface this section by noting that there is nothing inherently wrong or unhygienic about having foreskin, as long as people are taught the proper way to keep the area clean.

However, plenty of evidence shows that your risk of catching a sexually transmitted infection (STI), including HIV, is significantly lower if you're circumcised.

Circumcised men also put their female sexual partners at lower risk of contracting STIs, including the cancer-causing human papillomavirus (HPV), according to a 2019 metastudy that examined 82 relevant papers.

HIV risk was significantly lower even if the men were circumcised as adults, according to trials, including two African studies in 2006 in Kenya and Uganda. They were performed by the National Institute of Allergy and Infectious Diseases under the auspices of the National Institutes of Health. Those studies, although they were brought to an early close, suggested that men who had undergone an adult medical circumcision were between 48 percent and 53 percent less likely to contract HIV than participants who were not circumcised. That's despite the fact that both groups were extensively counseled on risk-reduction techniques and how to prevent HIV transmission.

One success story that came out of this data set was the way rates of HIV could be lowered by using cheap, nonsurgical devices to perform adult circumcisions in the hardest-hit areas in Africa, which are also among the most impoverished.

"When the studies came out showing the decreased transmission of HIV in circumcised men, and people were going to Africa where there was a very high rate of HIV, people were using Plastibell devices on adult men because it was expedient," North said. "You didn't need stitches, you didn't need general anesthesia. You left the device on and waited for [the foreskin] to fall off. Anything you can do in a setting where operating rooms aren't readily available, like putting a Plastibell on someone, really reduces the cost."

The Plastibell technique for circumcision involves placing a plastic ring between the head of the penis and the foreskin. A string is tied tightly around the foreskin, crushing the skin against the ring. The excess skin is removed, and the ring stays in place for a week or so before spontaneously falling off.

Medical considerations

A couple of medical conditions, such as phimosis and paraphimosis, may prompt someone to opt for circumcision later in life. Both are conditions in which the foreskin is too tight. Either it can't be retracted at all (phimosis) or, once it is retracted, the foreskin becomes trapped behind the penis head and can't be pulled back over the glans easily (paraphimosis).

Sometimes, especially with paraphimosis, an emergency circumcision is needed to relieve pressure on the penis head. But these conditions are not all that common. Just 0.2 percent of uncircumcised children between the ages of 4 months and 12 years experience paraphimosis, according to Cleveland Clinic. For people 16 and older who have a foreskin, that rate rises to 1 percent.

"We do see some teenagers who really cannot retract their foreskin," North said. "And I find in younger kids, if they can't retract their foreskin, we give them steroid cream which helps the foreskin get stretchier, and in most cases, they can then retract it. Once the kid has gone through puberty, I find that the steroid cream doesn't really work as well. So we definitely see teenage boys who cannot pull their foreskin back."

Paraphimosis constitutes a medical emergency, as the tightness of the trapped foreskin can restrict blood flow to the penis head and potentially cause tissue damage or even necrosis, the death of body tissue.

Aesthetic choices

For North and her team, by far the most common reason a teen or adult gives for wanting circumcision is aesthetics. These aesthetic choices often involve adapting to a new culture.

"In my patient population, the most common reason for a patient to ask for a circumcision is because the girlfriend prefers the 'crewneck' look to the 'turtleneck' look," North said. "Now, I never support the idea that a 16-year-old with a normal foreskin should remove his foreskin to please a girl that he's probably not going to talk to a year from now, but that's not how teenage boys think."

Circumcision surgery and recovery have come a long way, though, making it a relatively safe procedure with a fairly easy, low-intensity recovery.

Conclusions

There's nothing inherently unhygienic about a penis with foreskin, just as there's nothing inherently clean about a penis that doesn't have it.

But there are a number of reasons someone might choose to be circumcised at almost any age. It's not a terribly traumatic or dangerous procedure. If it's something that the person thinks will make them happier, and they've taken the time to consult their healthcare provider and loved ones about it and given it some sober thought, there's very little reason not to do it.