Men – boys – of my generation were either Roundheads or Cavaliers. They either had one, or they didn’t: foreskins. The Roundheads had been circumcised, the Cavaliers not. Male circumcision, the surgical removal of the skin covering the tip of the penis, is one of the oldest and most common surgical procedures performed globally, Hong Kong specialist in paediatric surgery Dr Jennifer Sihoe says. It is estimated that one in three males worldwide are circumcised. It is most commonly done for religious reasons among Muslim and Jewish populations, Sihoe says – and maybe because old habits die hard. In North America, the surgical removal of a baby boy’s foreskin was common. It became popular in the mid-1900s – shockingly – as a way to stop boys masturbating, and as many as 80 per cent of baby boys underwent the procedure, she says. “Then, in 1971, the American Academy of paediatrics [AAP] reported that there was no valid medical indications for circumcision in the neonatal period, which led to a decline in the practice,” she says. In 1989, the AAP issued another statement that claimed circumcision had “potential benefits”, leading to a temporary halt in the decline of such procedures, followed by yet another statement a decade later that the data on potential benefits was insufficient to recommend the practice of neonatal non-therapeutic circumcision. Chinese device cuts surgery time for male circumcisions to 5 minutes “More parents began to opt for ‘genital integrity’ and the percentage of boys circumcised once again began to decline, with some states reporting an incidence as low as 30 per cent and some states erasing neonatal circumcisions from their medical insurance coverage,” Sihoe says. The AAP has since stated, though, that evaluation of the evidence suggests that there are health benefits to circumcision – fewer urinary tract infections , less risk of penile cancer and a lower vulnerability to sexually transmitted diseases . So insurance companies again support having the procedure. Supporting circumcision among those who chose it for their sons was not the same as a recommendation that all baby boys be circumcised. Georganne Chapin is a lawyer and public health expert, and executive director of Intact America, a non-profit group set up to advance the view that the circumcision of non-consenting minors is unethical and medically unnecessary, and therefore should be abandoned. Chapin’s interest in the subject is drawn from global resistance to female genital mutilation, or FGM, the removal of some or all of the external female genitalia. “Why are we so upset about this [FGM] when we circumcise little boys?” she asks. She strongly disagrees with the AAP’s support of circumcision. “There are many reasons why the procedure should be viewed as mutilation. The foreskin is not ‘extra skin’, but a natural, necessary part of the male anatomy that protects the head of the penis, provides natural lubrication, and enhances sexual pleasure for men and their partners. “The foreskin is a healthy, functional body part which protects the glans penis [head of the penis], keeps it moist and lubricated, and gives men more control over ejaculation. Removing a boy’s foreskin is not medically necessary.” Why aren’t men given a choice in this, she asks? The surgery is usually performed before boys are old enough to know enough about what is involved to grant their consent. “Since 1997, the World Health Organisation has worked alongside many other groups on eliminating female genital mutilation (FGM). Therefore, it has also been argued that male circumcision should be viewed in the same way as FGM.” Aside from the consent issues, because it’s not offered as a matter of course in hospitals in Europe, for example, it can, she warns, “be performed by non-medical providers, which increases the risk associated with circumcision surgery”. I recall a friend whose husband insisted on having their first son circumcised – because he himself had been – even though the operation wasn’t available in the local hospital. Though neither parent was Jewish, they contacted a local rabbi, who did it – on their kitchen table. Sihoe says surgical circumcision “takes around 15 to 20 minutes”. That’s a long time listening to a baby howling on a kitchen table. Philippines’ circumcision season begins. Is it a rite of passage for boys or child abuse? Chapin has little truck with the touted advantages to circumcision; women experience far more urinary tract infections than men do – and like women, men can take antibiotics, she says. Not just men, but everyone, should self-check for cancers and be mindful of sexual health and sexually transmitted diseases, irrespective of whether they are circumcised. Chapin also explains how circumcision may hamper a man’s sexual experience. “A baby boy whose genitals are cut will suffer several adverse effects when he grows up. He will have lost 15 square inches (97 sq cm) of his genitals and the part of the penis that is most sensitive to touch. He is likely to have trouble reaching orgasm as he ages. His glans, which will not be protected by foreskin, will keratinise (or harden). There can be scarring that impedes sexual pleasure, and removal of a large amount of foreskin will keep men from achieving a full erection,” she suggests. There may be psychological damage, too, she says. “Often men who didn’t realise they were cut as babies until they see an intact penis experience anger and/or depression upon realising what happened to them.” How prevalent is the practice in Hong Kong or in Asia? Not very, says Dr Sihoe. “We are not a high-risk country for HIV, we do not have a large population of Muslims or Jews who perform religious circumcisions, and our public medical service does not routinely perform neonatal circumcisions as it is not a medical necessity. “In 2010, WHO estimated that one in three men [globally] were circumcised. A paper published in Hong Kong in 2012 surveyed a group of primary schoolboys and found 10.7 per cent were circumcised.” Chapin notes that the Canadian circumcision rate – reported as 32 per cent in 2009 – is lower than America’s, where it is estimated at 75 per cent. The estimate for Europe is just 10 per cent. “The United States is the only country in the world that routinely removes baby boys’ foreskins as a (pseudo) medical procedure, although South Korea began the practice as a result of the US military presence during the Korean war,” Chapin says. Muslims make up the greatest portion of circumcised men in the world. Although most Jews also circumcise, their numbers are much smaller, and many reformed Jews in the United States and elsewhere are discontinuing the practice. “A number of countries – mostly in Scandinavia – have seen efforts to make circumcision illegal in males under the age of majority, although religious groups have opposed these efforts,” Chapin says. Choice, it seems, should underline circumcision – as it does so much today where it once didn’t – in sexual preference, for example. And choices can only be made when a person is properly armed and empowered with the right information.