By Dave Maass

The foreskin is only the tip of the controversy

“The prepuce is from time of birth a source of annoyance, danger, suffering and death.”

Thus Dr. Peter Charles Remondino describes the foreskin, the sheath of skin surrounding the unaltered human penis, in his 1891 treatise The History of Circumcision.

An Italian immigrant who wore a thick mustache and mutton-chop sideburns, Remondino was a high-ranking Mason in San Diego. He held leadership positions on government health boards and in state and local medical societies. He served as city physician, headed a medical department at University of Southern California and co-founded San Diego's first private hospital.

Remondino suggested his colleagues use his text to ram the “four-and-a-half-foot-gauge fact” of circumcision though a hesitant parent's “two-foot-gated understanding.” His argument for laypeople: The Jewish race “lives better,” because its members ritually remove the tissue from baby boys. The foreskin, he said, keeps the masses “unlucky and unhappy.”

Remondino died in 1926, but his ideas lived on. Federal vital statistics show circumcision among newborn males grew from around 30 percent in 1932 to approximately 70 percent in 1971. In the 1970s, however, the medical community swung around, asserting there was no evidence of any medical benefits to circumcision. Throughout the next four decades, infant circumcision rates dropped to about 50 percent. California is among the states with the lowest: 21 percent of baby boys are circumsized, due in part to an influx of immigrants.

Today, some of Remondino's theories again are proving viable. He proposed that the uncircumcised penis is more susceptible to sexually transmitted disease, and a recent series of HIV studies conducted in Africa bolsters that claim. And while his perception of Jews may be outdated, racial and class disparities are on the minds of circumcision policy makers.

The American Academy of Pediatrics and the U.S. Centers for Disease Control both are re-examining their neutral stances on the “elective” procedure. Such policy changes could have enormous ramifications. It would fundamentally alter the next generation's sexual health, physically and culturally, especially as more insurance plans would be pushed to cover infant circumcision.

Circumcision also has hard-line opponents, even on Remondino's home turf. They call themselves “intactivists” because they ardently believe in “genital integrity”—that is, leaving the penis intact.

Medical ethics are at the heart of the issue: Doctors are operating on the healthy tissue of infants. The intactivists argue that circumcision should be available only to those capable of informed consent, i.e. adults. Remondino argued that the societal and health benefits outweighed all other considerations.

The 2-million-foreskins-per-year question is whether he was right.

Dr. George Kaplan, wearing a blue lab coat with his name on it, leans forward in his chair to explain neonatal, or infant, circumcision. He's been in pediatric urology since he left the Navy 47 years ago.

With one palm atop the other, Kaplan illustrates how the infant foreskin is fused to the head of the penis. Left alone, the skin separates as oil builds up in small pockets. The foreskin becomes retractable several years later.

Kaplan employs the Mogen clamp, a device pioneered in 1958 by a Brooklyn Rabbi. The palm-held metal instrument has two opposing blades that lock together to seal off the skin. The surgeon excises the separated ribbon of tissue. Kaplan always uses anesthetics.

Kaplan, a urologist with Rady Children's Specialists of San Diego Medical Foundation, once published a paper on circumcision complications among infants, from minor bleeding to complete loss of the penis caused by a very rarely used technique involving electricity. Because of his research, in 1999 the American Academy of Pediatrics invited him to join a task force to reexamine its policy, which stated that “there is no absolute medical indication for routine circumcision of the newborn.” It was a solidly neutral position.

“I don't know any other procedure that generates as much literature, fury and passion,” Kaplan says. “There are people who are rabidly anti-circumcision, and I use that word purposely. There are people who are rabidly pro-circumcision, but they're fewer. I like to think most fall somewhere in the middle.”

The new policy concluded there were, in fact, potential benefits, though it neither recommended for nor against circumcision as a routine procedure. AAP reaffirmed the policy in 2005.

“It didn't satisfy either side,” Kaplan says.

Circumcision researchers now are dueling once again in the medical journals.

The January issue of Archives of Pediatric and Adolescent Medicine published an editorial promoting circumcision alongside a review of three promising HIV studies. At the same time, a Royal Australasian College of Surgeons team reviewed those three and five more studies in the Annals of Family Medicine. The Australians proclaimed there was a “paucity” of evidence to support routine circumcision.

The divisive research was conducted in sub-Saharan African countries, particularly Uganda, where one in three adults is HIV-positive. The data showed that adult men who submitted to circumcision were 60 percent less likely to contract HIV.

Remondino would've felt vindicated by the data. Focusing on syphilis and gonorrhea, he proposed that the skin on the head of the penis—in anatomical terms, the glans—is thinner and more absorbent if the subject is uncircumcised. The foreskin, he argued, also incubates microorganisms. With a circumcised penis, the glans' outer layers toughen through a process called “keratinization,” which can block out some viruses.

But Kaplan points out that HIV is, ultimately, a disease that's spread by behavior, a cultural variable.

“I don't think you can apply the African data to the U.S.,” Kaplan says. “It's evidence that there is some benefit to circumcision, but what if you're never going to indulge in behaviors that put you at risk?”

Perhaps what might be more relevant to Californians is a 2004 study conducted by the Naval Medical Research Center in San Diego. The researchers said that “a lack of circumcision was not found to be a risk factor for HIV.” Instead, they reported that men who used condoms irregularly, slept with multiple partners or engaged in anal sex were as much as six times more likely to contract HIV.

Nevertheless, the African studies have spurred two national institutions to begin writing new policies.

The U.S. Centers for Disease Control's official tack is that it likely will take a neutral stance on infant circumcision. More controversially, the CDC indicates that it may recommend circumcision for adult men.

Meanwhile, the American Academy of Pediatrics have formed another circumcision task force. Last week, the group finished gathering literature and a new policy could be ready as early as this summer, task force member Dr. Doug Diekema says.

“I think a lot of people in the physicians' realm would like the Academy to take a stand like they do with immunization, that we ought to be saying, ‘This is something we do to little boys unless their parents say we can't,'” says Diekema, a doctor with the Treuman Katz Center for Pediatric Bioethics at Seattle Children's Hospital.

However, Diekema predicts AAP will not depart radically from its previous stance, though it will likely highlight more of the potential benefits of circumcision. That's important, he says, because parents are too often under-informed on the pros and cons.

“The reality is most parents have decided whether they want their little boy circumcised without any real thought,” Diekema says. “You are removing healthy tissue from your baby, and before you do that or before you don't do that, you must make sure you understand what it is you're doing.”

Remondino claimed the reason Jews were successful in business and less prone to petty crime, the reason they rarely masturbated and lived longer despite living sedentary and “unhygenic” lifestyles, was because they have ritually amputated the penile tissue since the days of Abraham.

That's not an argument that flies in 2010, but Diekema says the AAP task force is certainly considering how circumcision policies impact class and ethnic groups—particularly blacks and Hispanics—who rely on public health systems. Currently, Medi-Cal, California's brand of federal Medicaid, is one of the many state insurers that don't cover the procedure.

“Maybe physicians shouldn't make a recommendation one way or another,” Diekema says, “but that by itself doesn't mean it shouldn't be paid for, particularly given the potential health benefits.”

Even when insurance does cover circumcision, doctors are paid as little as one-sixth as mohels, the practitioners of the Jewish “bris” ritual, says Dr. Mohamed Bidair, a doctor with the Alvarado La Mesa Urology Center.

“I think that there is definitely a feeling amongst the poor population that they are not getting that option,” Bidair says. “They want to have their kids circumcised and they can't, and they're upset about that. There's no question.”

UCSD Medical Center, for example, charges $300 for a circumcision. That's more than many families can afford, and, to some, that represents a fundamental inequality. To others, it's the other way around: Those children are being saved.

Matthew Hess, a Pacific Beach resident who recently turned 40, remembers the first time he saw another kid's “intact” penis. He was 8.

“I actually didn't register it at the time that I had been circumcised,” Hess says. “I just thought his penis was naturally different somehow. I just thought, ‘That's not like mine. That's different. I like mine better.'”

Hess has since changed his mind and engages in therapies to “restore” his foreskin.

“I was in my late 20s when I just started to notice a slow decline in sensation,” Hess says. “Year after year, it started to get a worse and worse after sex. I went to a urologist, and he didn't have much of an answer. It struck me that my circumcision could have something to do with this. I researched online and quickly found a lot of information about what's lost. That made me pretty angry.”

In many studies, circumcised adult men don't report any difference in sexual satisfaction. However, intactivists often circulate a 2007 study from the British Journal of Urology that identifies specialized nerves in the foreskin that detect soft touch and suggests keratinization may desensitize the glans.

Since late 2003, Hess has authored legislation that would ban neonatal circumcision.

“There's absolutely no way a baby boy can consent to having his foreskin removed,” Hess says. “It's one of the most important human-rights issues in the U.S. today.”

Hess targets states with existing bans on female genital mutilation—such as the removal of the clitoral hood (which Remondino also advocated)—and makes the language gender-neutral.

“California law protects girls from any kind of genital cutting, even a prick, yet boys are allowed to have their foreskins amputated for medically unnecessary reasons,” Hess says.

In six years, only the Massachusetts legislature has accepted the bill, and it's yet to receive a committee hearing. This year, Hess and other activists have sent the bill to every member of Congress and to legislatures in 14 states. Locally, he's met with Assemblymember Lori Saldaña and Sen. Christine Kehoe and representatives from U.S. Sens. Barbara Boxer's and Dianne Feinstein's offices. Last year, he protested outside Congress and the White House.

Hess says lawmakers are uniformly reluctant to support the measure, and often cite religious freedom.

“That holds less water because you can't circumcise your daughter for religious reasons, you can't sacrifice animals for religious reasons,” Hess says. “The right of someone to be free of harm supersedes religion.”

A circumcision-friendly stance from the AAP would be a major setback to the legislation, Hess acknowledges, especially as the U.S. pursues health-care reform.

Matt Hess uses these cups to "restore" his foreskin. Photo by Will Parson

If infant circumcision were abolished, men would need to turn to urologists like Dr. Bidair, who advertises his adult-circumcision services through his website, Many are referred to Bidair because of penile problems, such as a foreskin that's become infected or is no longer retractable, a condition called “phimosis.” The rest are looking for aesthetic solutions.

“The vast majority are coming because they've always wanted to be circumcised,” Bidair says. “They don't understand why their parents didn't have it done when they were little.”

While many doctors agree that parents are poorly informed of the benefits and risks of circumcision, that problem is virtually non-existent among adult men.

“Most of them are really well researched,” he says. “I'd say 90 percent have already made their mind up.”

Some have had their minds made up for them.

“There's actually a good percentage that come because their female partner wanted it,” he says.

Bidair uses a clamp, employing numbing medicine first and sutures after the operation. Patients are prescribed Vicodin and told not to have sex for at least two weeks.

“If you're doing a desk job, you can work the next day,” Bidair says. “The spontaneous erections you get at night will definitely get your attention.”

He argues that circumcision isn't different than a vaccine and best done on infants because the healing process is “more forgiving.” Bidair adds that adult men are less likely to opt for the procedure.

The intactivist community says that's the point: If adult men wouldn't stand for it, then parents don't have the right to make the decision for their children. Bidair calls that view “naive.”

“We decide their names, who their friends are, what they eat,” Bidair says. “It's ridiculous to think we don't impact their lives in very major ways.”

One point both sides might agree on: A world without neo-natal circumcision would require better instruction on cleaning the penis. Bidair is “amazed by the very poor hygiene” of his patients.

“People almost ignore that part of their body completely,” Bidair says. “Frankly, I think that's hard to teach somebody who has, through most of his life, not known how to clean it.”

Remondino would be offended
to learn that a book by another San Diego medical historian, Dr. David Gollaher, was hailed 100 years later as the “first” comprehensive academic examination of circumcision—especially since Gollaher takes the polar opposite position: “The threshold for demonstrated effectiveness in surgery, particularly surgery on infants, is far too high.”

Like Remondino, Gollaher wields influence on medical policy—he's a former senior executive of the Scripps Clinic and Research Foundation and current president and CEO of California Health Institute in La Jolla.

“Doctors who circumcise have faith in the operation because it rarely harms patients and is consistent with the way they see the world,” he writes in Circumcision: A History of the World's Most Controversial Surgery. “But doctors have no way of knowing how much worse or better off an individual child would have been without the surgery. Even assigning a statistical likelihood of future disease to a circumcised or uncircumcised baby depends largely on which studies you choose to believe.”

Stripping away religious tenets, Masonic social-engineering conspiracy and disputed research findings, Gollaher boils the circumcision debate down to a single idea that's difficult to counter:

“If routine medical circumcision didn't exist today, no one would dare to invent it.”

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