Uncut: Dissecting circumcision

Charlie+Anderson%2C+freshman+at+Parkland+College%2C+pulls+up+a+turtleneck+in+front+of+a+mural+off+of+South+Fifth+Street.

Jacob Slabosz

Charlie Anderson, freshman at Parkland College, pulls up a turtleneck in front of a mural off of South Fifth Street.

By Lisa Chasanov and Michael Bales

Dubbed the world’s “oldest planned surgical procedure” by 20th century anthropologist Sir Grafton Elliot Smith, circumcision’s roots can be traced to religious and cultural traditions dating back millennia.

Circumcision is a surgical procedure that involves the removal of all or part of the foreskin of a penis. 

The foreskin, a sheath of retractable loose skin surrounding the tip of a penis, is surgically removed from the majority of baby boys born in the United States. Up to 80% of men between the ages of 18 and 59 are circumcised in the United States, compared to around 38% of men worldwide.

Today the most prominent groups who perform ritual circumcisions are followers of Abrahamic religions, namely Islam and Judaism. 

Roots in religion 

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    (Circumcision) is a very interesting ceremony,” said Thom Lobe, a pediatric surgeon at the University of Illinois Hospital and Clinics. “It is probably the oldest ceremony that we do in Judaism.”

    Lobe specializes in the use of minimally invasive surgery to treat neonatal cancer and has contributed to the development of new laser therapies for the treatment of disease.

    The surgeon is also a prominent Chicagoland mohel, or “mohala” in Aramaic. A mohel is a practicing Jew trained to perform ritual circumcisions.

    Ritual circumcision is a requirement outlined in the Torah, the central religious text of Judaism consisting of the first five books in the Hebrew Bible.

    In the 17th chapter of the Book of Bereshit, the Hebrew title for the Book of Genesis, God appeared to Abraham — who is often described as the founding father of Judaism — with the intention of establishing an enduring covenant with him.

    In exchange for fertility, land, power and “a multitude of nations,” God asked 99-year-old Abraham to circumcise the foreskin of his penis and commit to circumcising all of his descendants.

    Dr. Lobe said that the ritual of circumcision is traditionally observed on the eighth day of an infant boy’s life and never earlier.

    According to an interpretation of Bereshit written by Rabbi Matthew Berkowitz, a faculty member at the Jewish Theological Seminary in Jerusalem, there is a specific reason for this scriptural requirement. 

    It is written in the Torah that on the eighth day of the earth’s creation, God invited humankind to join him in the design of the world. This timeline, according to Berkowitz, is why circumcision, humankind’s contribution to the body, is required to take place after the eighth day of life. In other words, the eight-day minimum is rooted in the idea that the body, like the earth, is the product of both God and man.

    The Jewish ceremony of circumcision, or a “bris,” is traditionally performed by a mohel in a synagogue with input from a rabbi and the child’s family. 

    “For me, it’s always an emotional thing,” Lobe said. “I get very involved, and it’s meaningful to be able to participate with the families. For some Jewish families who don’t practice the religion but have a male child, it may be the only Jewish thing they do in their lives.” 

    In the process of continuing the millennia-old tradition, Lobe underwent a 12-week course from the National Organization of American Mohalim, a reform Jewish organization tasked with mohel training and education. 

    According to Lobe, the course highlighted the importance of inclusivity and understanding in cases where parents are members of the LGBTQ+ community, interfaith or otherwise nontraditional.

    Along with Jewish ritual circumcisions, Lobe has performed many secular circumcisions in a hospital setting, listing social norms, aesthetics and hygiene-related benefits as some of the reasons that a nonreligious family may choose to circumcise their son.

    Lobe said that circumcision is completely optional in most cases and that the decision not to have the procedure done does not make a Jewish person any less Jewish.

    “It’s really in the perception of the family — the belief is that there’s no penalty if you don’t get circumcised,” Lobe said. “There are some reform rabbis who think ‘Yes, while we understand the historical significance, we shouldn’t be doing this to babies without their consent.’”

    Intactivism”

    In recent years, dialogues surrounding the ancient surgical practice have inspired a surge in self-proclaimed “intactivists,” or activists who believe infant circumcision is a human rights violation.

    Intact America is a national organization that advocates against the circumcision of those who are unable to provide consent, especially those who cannot consent on account of their age.

    The Daily Illini spoke with Georganne Chapin, founding executive director of Intact America and former health care executive, to gain insight into the organization’s mission.

    “Intact America grew out of a movement that has really been rolling since the 1970s — there were a number of grassroots organizations that had been advocating against routine cutting of baby boys, but we needed a new organization,” Chapin said. “We had a donor, and at the end of a year-long process … he offered to fund the startup of (Intact) in late 2008.” 

    Chapin said that for many people, the debate over circumcision is one that causes feelings of discomfort or shame.

    “A lot of people don’t want to talk about it, especially if they have been cut or if they’ve agreed to have their child cut or if they’ve actually cut somebody’s foreskin off,” Chapin said. “Doctors — they don’t want to think about it or talk about it.”

    According to Chapin, the organization has been successful so far in promoting its mission and reducing the stigma surrounding dialogues about circumcision. 

    “When we started, it was a conversation that people couldn’t wait to shut down or, you know, they start looking for the exit, right?” Chapin said. “It made people very uncomfortable. We’ve done a lot of research, and I think our main contribution is that we have made this a topic of mainstream conversation.”

    One program conceived by Intact America in an effort to destigmatize the conversation surrounding foreskin was the inaugural Foreskin Festival livestream on April 4, a date the organization hopes will become an annual holiday called “Foreskin Day.” 

    Robin LaVerne Wilson, an activist, poet, storyteller, artist and 2016 U.S. Senate candidate from New York, known to their audience as Dragonfly, served as the host of the event, beginning the livestream with a triumphant mantra.

    We’re here to change hearts and minds — one phallus at a time,” Wilson said, beaming.

    “I am a multidisciplinary performance artist, and I do work that is in the intersections of art, activism, advocacy and education,” Wilson said in an interview with The DI. “The task came to curate this festival, and it really inspired some really serious, in-depth personal introspection as well as conversations with people in my community about the full extent of what bodily autonomy means.”

    Wilson said their experience as a member of the Black community has informed their decision to support the intactivist movement.

    “As someone who is very hypersensitive and conscious of how medical apartheid is used in my community, there is an actual circumcision industrial complex at play in this country that benefits from willful ignorance,” Wilson said.

    Chapin said that the prominence of infant circumcision in the U.S. can be partially attributed to coercion of mothers in hospitals.

    “We did a survey a couple of years ago and found that the average number of times a woman is asked in the perinatal period to sign a consent form for a circumcision is 8.4 — and even more for Black women and Latina women,” Chapin said. “If parents wanted it, they wouldn’t have to be asked (eight) times. It’s a sales job.”

    According to Chapin, the assertion that foreskin removal is linked to lessened HIV/AIDS risk is based almost entirely on studies in sub-Saharan Africa with “imperialist” intentions.

    “These studies are going to go down in history as a travesty, as medical imperialism and as having stolen body parts from Black men, African men who were not given formal consent, who were given money to be circumcised,” Chapin said. “Those so-called ‘studies’ in Africa were circumcision projects. They were not really well-designed, ethically designed research studies. If you look at the studies — that 60% rate that’s trotted out — that is a relative statistic.

    The studies

    The 60% figure that Chapin referenced likely arose from a seminal 2007 research paper written about the connection between circumcision and HIV transmission entitled “Male circumcision for HIV prevention in young men in Kisumu, Kenya.”

    The study was designed by Robert Bailey, a professor emeritus of anthropology at the University of Illinois at Chicago and public health and former adviser to entities including the World Health Organization, the Centers for Disease Control and Prevention and the Republic of Kenya’s Ministry of Health. The study presented the findings of a randomized trial designed to determine whether knowledge of the decreased risk of sexually transmitted infections among circumcised men in Kenya would contribute to unsafe sexual behaviors and thereby greater incidence of HIV, a phenomenon known as risk compensation.

    Bailey’s research found that circumcision had a protective effect of 60% against HIV transmission in the intervention group over two years. In other words, the study found that circumcision was able to decrease the risk of transmitting HIV by 60% within the sample. 

    In an interview with The Daily Illini, Bailey discussed the influential study and his work in the sphere of HIV/AIDS prevention.

    “A provincial medical office in western Kenya heard about my work,” Bailey said. “(They) said, ‘Can you come here? We’re in an area with the highest HIV rates in all of East Africa and men here do not circumcise, whereas people all around us do circumcise and their HIV rates are about a quarter of what ours are.’”  

    Upon receiving the invitation to Kisumu, a city in Kenya, Bailey designed a randomized trial consisting of 2,800 uncircumcised men who indicated that they were interested in having the procedure done for the study.

    “So, I went to Kisumu and did a preliminary study to see what the level of knowledge about circumcision and HIV was and whether or not men would ever accept to be circumcised in a traditionally noncircumcising community,” Bailey said. “I found that actually a lot of the men, about 65%, said they would get circumcised.”

    According to Bailey, the project underwent rigorous ethical protocols. Its purpose was not to promote infant circumcision in the U.S., but rather to demonstrate the harm reductive effect that elective circumcision can have in an area where HIV transmission rates are already high.

    “We spend a lot of time counseling and telling young men the risks and the benefits of circumcision — we’re not doing infant circumcision,” Bailey said. “We do adolescent and adult male circumcision, where the young men are fully informed and they’re capable of asking questions and doubts. It’s fully voluntary — there’s nothing coercive about it. They volunteer, they’re not paid and they’re informed about the risks and benefits of circumcision.”

    According to Bailey, the trial’s design accounted for many confounding variables by being completely random.

    “We recruited almost 2,800 young men between the ages of 18 and 24 and asked them if they would be willing to be circumcised,” Bailey said. “Those that consented were randomly assigned to be circumcised right away or to remain uncircumcised for two years. That random selection is the way you get around possible confounding variables, you know, like sexual behavior, age or cultural beliefs or anything.”

    Bailey identified the study as his most widely influential project and explained that it has contributed to an improvement in circumcision accessibility in areas where the procedure has the potential to make significant differences in HIV risk.

    “We’ve now done 28 million circumcisions of young men in 13 different countries in sub-Saharan Africa, and that all really comes from our trial in Kisumu and two other trials — one in Uganda and one in South Africa,” Bailey said. “These are the seminal studies that have nailed down the protective effect of circumcision and caused the (World Health Organization) in early 2008 to declare that … in areas where most men are not circumcised and HIV rates are high, we should scale up male circumcision.”

    When asked for his response to criticisms of the study’s intentions, Bailey said that the qualms are often misguided and that he has his own ethical reservations concerning infant circumcision. 

    “The benefit of adolescent circumcision is that at least you can get informed assent from an adolescent,” Bailey said. “My major misgiving about infant circumcision is — I think there are a lot of benefits to circumcision — but when you’re permanently altering someone without their consent, I think that raises ethical questions. If people accepted adolescent circumcision here as they do in Africa, in many ways, that would make more sense.”

    Bailey added that his study’s results are not as relevant to HIV risk in the Western world as they are in sub-Saharan Africa. He explained that the most common means of HIV transmission in the United States and Europe are sex between men and intravenous drug use — both cases where circumcision does not have a substantial impact on HIV transmission.

    In sub-Saharan Africa, where the most common means of HIV transmission is sex between men and women, circumcision has a far greater impact.

    “In Europe and the United States, most HIV infections are actually due to receptive anal intercourse and injecting drug use,” Bailey said. “In those two situations, male circumcision is going to have minimal or no impact at all on HIV. So purely for prevention of HIV, advocating for male circumcision in Europe and the United States would not be effective.”

    Bailey said that for men in the U.S., there are numerous benefits to getting circumcised, but he wouldn’t identify HIV prevention as a primary motivation for the procedure. In fact, Bailey said that the decision to circumcise often has nothing to do with religion or health.

    “The benefits of circumcision in general are a lower risk of genital ulcer disease, lower risk of human papillomavirus, which can cause penile cancer and cervical cancer in the female partners,” Bailey said. “However, in many cases, giving a good explanation of the risks and the benefits (to parents) almost falls on deaf ears, because they usually have made the decision themselves. … (Parents make) the decision based on their culture and whether the father was circumcised.”

    According to Bailey, the procedure has over a century of history in the U.S.

    “It started in the First World War,” Bailey said. “A lot of men were circumcised during the war because they were getting infections of the foreskin, and then in the Second World War, it had escalated even more.” 

    The anthropologist then said that the procedure became routine over the decades following World War II. 

    In the 1960s, infant circumcision was routine,” Bailey said. “I mean, literally, the baby would just be taken away, put in another room, circumcised and then brought back to the mother without even asking. But, in 1970, there was an ethical review and the Academy of Pediatrics said that infant circumcision should not be routine and that parents should be informed.”

    Bailey says that he agreed with the Academy’s decision, stating that the option to circumcise a child should be presented to parents in the hospital, but it should include a detailed description of both benefits and drawbacks to the procedure.

    “A sober and objective and realistic explanation of both the costs and the benefits of infant circumcision should be offered to parents,” Bailey said. “They should (be able to) make an informed decision about whether or not to have their infant circumcised.” 

     

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