Are circumcisions necessary?


Announcer: Welcome to Stuff Mom Never Told You from howstuffworks.com.

Cristen: Hey there and welcome to the podcast. This is Cristen.

Molly: This is Molly.

Cristen: So Molly, today we are talking about circumcision.

Molly: Yes.

Cristen: And you know, in another episode, we did what is the lipstick index or the lipstick indicator as it's sometimes called, which is basically - and we've talked about this in multiple episodes now - but for those of you who haven't heard about it, it's this idea that lipstick sales are correlated to the economy. Basically, when the economy goes down, lipstick sales go up because women buy it as a small luxury.

Molly: Mm-hm.

Cristen: So with our circumcision research, Molly, I've come up with something new that I think economists need to pay attention to, and that's called the circumcision index.

Molly: Yes, Cristen's already looked into trademarking this term and patenting it, so that if anyone else says circumcision index, they have to pay her.

Cristen: Yeah, pay up, people. The reason why I came up with the circumcision index, aside from my innate brilliance, is because circumcisions are actually down in the down economy because it's an extra few hundred dollars on top of the medical bills for having a little baby boy.

Molly: Mm-hm.

Cristen: So ever since insurance companies started cutting off payments for circumcisions, they've seen a drop in the number of boys getting their foreskin removed.

Molly: Right. And in the states where it's still a covered procedure, the rates of circumcision are still high basically.

Cristen: Mm-hm.

Molly: So the thinking goes that without health insurance, circumcisions drop.

Cristen: Yeah, and this comes from a story in Newsweek from April 2009, and there was a report by researchers at UCLA that said that the circumcision rate in states offering coverage was on average 24 percent higher than states that don't. So the economy might be influencing men's foreskins.

Molly: Now perhaps at this point you're thinking, "Hey, it's Mom Stuff. Why are they talking about circumcisions?" Because we're all about periods here, but you know, we heard all about women's periods. We want to hear about men's penises.

Cristen: Yeah, you know, at the end of the day, foreskins affect us all.

Molly: Yes. I mean let's say you're a new mother, you've got to make this decision. You got $300 at your disposal to have the circumcision? Or do you skip that?

Cristen: Yeah. And if you're a guy, you know, it's part of your anatomy, so -

Molly: We've got to cover it.

Cristen: - that's obvious. Yeah. So let's talk about foreskin.

Molly: And if y ou're a girl encountering that part of the anatomy for the first time, you might be thrown.

Cristen: Yeah. What's that like? Let's talk about circumcision, Molly. Let's talk about the wonderful world of the male foreskin.

Molly: Right. So let's talk some anatomy first, Cristen.

Cristen: Okay.

Molly: We've got the foreskin, which is a portion of skin on the penis that covers and protects the tip of the penis, also known as the glans.

Cristen: And the foreskin is basically a protective shield for the flacid penis. It protects it against nicks and cuts and excess rubbage.

Molly: Yes, as the writer of this article How Circumcision Works, Tom Sheve put it, "It's a tough world out there for a flacid penis because you've got abrasion from undergarments. You've got cold weather and dry air." Apparently, a lot of things can hurt that sensitive organ.

Cristen: Yeah, and it's a pretty significant part of male genitalia because the foreskin can account for one-third to nearly one-half of total penile skin. And then on the inside of the foreskin, he describes it as similar to the inside of your mouth because it helps keep the penis naturally lubricated.

Molly: Yes, and it's also not dead skin. It's got all these nerve bundles, blood cells. This will be important later because our question today is, are circumcisions really necessary? And some people say that those very nerve bundles may be the reason that it's not.

Cristen: And there is a little piece of skin called the - or tissue, I should say - called the frenulum, and that's what connects the foreskin to the glans, and the frenulum will come more into play when we talk about how a circumcision procedure actually happens.

Molly: Now, Cristen, just as all penises are different, all foreskins are different. Some men have foreskins that just cover the entire glans. Some only have partially covered.

Cristen: Yeah, and there are different conditions that can be associated with that because sometimes in the case of a man who has phimosis, his foreskin is not going to fully retract when his penis becomes erect, which can be really painful. And then, on the flip side of that, you can have paraphimosis, in which the foreskin will retract, but it won't cover the penis back up once it has gone to rest.

Molly: Yeah, so it causes a lot of swelling. There's also balanoposthitis. Is that right, Cristen?

Cristen: Sure, sounds good.

Molly: That's the swelling of the mucous surfaces of the foreskin, which can, if that happens a lot, then you may need circumcision. And there's also a skin disease that affects that area called balanitis Xerotica obliterans.

Cristen: Yee.

Molly: Perhaps, I'm going to call it BXO, and that can cause pain and it can also be linked with phimosis. So there are a lot of medical reasons why you might not want your foreskin around.

Cristen: And on top of that, since we've got all this lubrication going on on the underside of the foreskin, and bacteria that can get caught up in there, men need to keep that area clean or else they're going to have a build-up of something called smegma, which is a cheesy discharge, which doesn't sound very pleasant.

Molly: So you do have your foreskin, you've got to clean it basically, is the point. Because no one wants any smegma hanging around. And that can lead to infections. You can get a urinary tract infection. It does not sound pleasant. Which I think, you know, these are just a few of the reasons - we're going to get into all of them later - why people thought, "Hey, let's just get rid of this problem. Let's get rid of the foreskin. Let's do a circumcision." So let's talk about how you actually get rid of the skin.

Cristen: Yes, let's go into the hospital room with that little infant boy, and find out what doctors do. They either use a clamp or something called a plastobel device to get rid of that foreskin.

Molly: So here's how you use a clamp. You separate the foreskin out and then protect the rest of the penis, and then as the writer of this article puts it, "You crush or cut a ring of skin from the penis." And so it happens really fast, and if you use that other device, a plastobel, it just kind of like, you stay - it stays in there and then the skin just falls off.

Cristen: Yeah. It clings on to it for a while. Now if you are an adult male and you decide to get circumcised, things are a little bit different. It's a little more involved of a procedure, where they actually have to snip off, manually cut off the foreskin.

Molly: Yes. On the one hand, it's probably positive to know you're not going to have a clamp involved. On the other hand, you're going to have some scissors involved.

Cristen: Yes. Pick your poison, men.

Molly: So what they do is they make a slit in the foreskin and cut it away basically. And they make a stitch to hold it in place. And it takes about 30 minutes. Now in both procedures, both for a child and for an adult, you're probably going to have some local anesthetic, a little anesthesia. You're not going to be under. You're going to be awake -

Cristen: Yeah.

Molly: - for that.

Cristen: And it's going to take some healing, even for - for the child, I think the healing process is a little shorter, but you know, for men, obviously there's not going to be any sort of intercourse or anything like that involved for the next little while. And you know, I mean it's a sensitive area. So it's not going to be entirely painless.

Molly: Now I'm not going to lie, Cristen. When I read how the actual procedure worked, even though it was a medical procedure, I was just like, "Why would anyone do this?" It seemed like a bad thing. So let's talk about historically, why people have chosen to cut away the foreskin.

Cristen: Molly, people have been circumcising penises for quite a while. There is a rich history of male circumcision. And a lot of times we think of it as going back to the story of Abraham in the Bible, where he makes a covenant with God to protect the Jewish people and he goes ahead and circumcises himself, if I'm not mistaken -

Molly: At the age of 99.

Cristen: - at the age of 99. And then beyond that, he was directed to circumcise males by the eighth day of life, and if not, uncircumcised men would have to be cast away from the Jewish tribe.

Molly: So he circumcises his sons and this sets this precedent that now about 98 percent of American Jews are circumcised. And he of course goes through and circumcises his son Ishmael, but he gets cast out and he becomes the forefather of the modern-day Arab people. And so he passes down that tradition to his ancestors, which include the Prophet Mohammed.

Cristen: Yeah, and since Mohammed - well, there's nothing in the Karan which explicitly says, "You must circumcise your male children," but since Mohammed was known to have had a circumcised penis, a majority of Muslims will circumcise their sons. And in fact, according to the World Health Organization, almost 2 out of every 3 circumcised men on the planet are Muslim.

Molly: Yeah, fun fact.

Cristen: Yes.

Molly: Now Muslims will differ when they actually do the procedure. Some will do it when the baby is an infant, like the Jewish people do. Or they'll wait until it can be more of like a rite of passage. Now it's not so much a big deal in Christianity. No one - most Christian sects don't endorse the procedure. You kind of do your own research. And other religions such as Buddhism and Hinduism, they don't have a stance on it either.

Cristen: But the thing is, it did not start just with Abraham and the Jewish people because if you go back and look at historical documents, the ancient Egyptians probably passed the practice on to the Jews. And they were practicing this thousands of years before the birth of Christ.

Molly: Yes, I was reading about priests who would have like this golden thumbnail, and that's how they would just like sort of press off the foreskin, was this big thumbnail.

Cristen: Ooh.

Molly: But so even though we think of it as this ancient biblical directive, it was probably practiced before then. There's evidence that Mayans and Aztecs did this. It's in ancient history, going all the way back.

Cristen: Well, and it's also interesting because, like you mentioned, Mayans and Aztecs also practiced this, but it also happens in native parts of Australia, Africa, Asia. It's a pretty global practice.

Molly: It's pretty global except in a few places - it looked like Europe and South America, are not really on the circumcision train.

Cristen: Yeah.

Molly: So ladies, if you're traveling.

Cristen: Now circumcision for medical purposes, for those health reasons that you and I touched on briefly, really come into vogue in the 19th century when doctors began treating adult phimosis. But one little fun fact too, is that during Victorian era, doctors became fans of circumcising men to treat, as a therapeutic treatment, for masturbation because they thought that masturbation led to insanity. And since the foreskin is basically like a nice little lubricated sock that can make it easier to do, according to some sources. Obviously I'm not a primary source on that. They thought that by circumcising the men, it would make them less likely to masturbate, and then less likely to become insane.

Molly: Yes, as the article put it, it was a source of mischief.

Cristen: Yes.

Molly: And we just need to nip that right in the bud with a little snip, snip.

Cristen: You've got to love Victorian era medical practices.

Molly: You really do.

Cristen: Yeah.

Molly: You can't fault them at all.

Cristen: They were creative.

Molly: So that's when the number of circumcisions really begins to spike, when it becomes sort of like the default thing to do, even if you're not religious about your reasons for circumcising. They do at this point bring anesthesia into it, which I think was a great directive. And you know, the sad thing is, is that it was used as sort of a thing that you could do for all sorts of ailments, everything from impotence to homosexuality. They thought cut off the foreskin, everything will be better.

Cristen: Yeah.

Molly: Yikes.

Cristen: But Molly, in recent years, the rate of circumcision has actually dropped in the U.S. And it does, I think, have something to do with the circumcision index that I mentioned earlier, that extra $200 or $300 that will be tacked on to the tab that parents have to pay if they want to have their child circumcised. But in 2005, the percentage of circumcised boys dropped from 65 percent of male infants to only 56 percent. Wh ich I was surprised at.

Molly: I was more surprised about where the breakdowns occurred. Did you know that 3 out of 4 Midwestern babies are circumcised? While only slightly more than half of all Southern babies are circumcised.

Cristen: Yeah, but then in the West -

Molly: Very little circumcision. Only about 21 percent of infants are circumcised. And the group that probably is least likely to be circumcised are Hispanics. Another fun fact.

Cristen: There we go.

Molly: Once I read this article, I started walking around just looking at people, trying to guess. Is that wrong? I don't know.

Cristen: It's odd, but not wrong, Molly.

Molly: Okay.

Cristen: So the next question, Molly, that we have to address in this circumcision discussion is whether or not there are any health benefits associated with removing the foreskin. Because we have all of these religious traditions, these cultural traditions. But is there really any medical point in putting that plastobel clamp on that little baby penis and making the foreskin fall off a few days later?

Molly: Well, as I mentioned, they avoid all those problems of phimosis, of an unclean penis, of the smegma. And you've probably heard about how in Africa, they're making circumcision a huge part of their campaign to lower HIV rates.

Cristen: Yes. They have found that circumcising men can lower the rate of female to male HIV transmission, and this year, the Bill and Melinda Gates Foundation just donated $50 million for, I think it's up to 650,000 male circumcisions in Africa to hopefully lower the rate of HIV transmission.

Molly: And the thinking behind this that the cells in the foreskin are particularly susceptible to binding with HIV.

Cristen: Yeah, these are called Langerhans cells, and they are present in the foreskin. And they are sentinel cells that are supposed to detect antigens, which are bad things coming into your body, and then alert the immune system to fight it off. But the problem is, they attach to these HIV cells and obviously the immune system can't fight them off. And since the foreskin is so sensitive to ripping and tearing, it makes them a lot more susceptible to getting those HIV cells in the body and binding to those Langerhans cells, and then HIV spreads throughout the body.

Molly: Right. So it will cut down the rate, as Cristen said, of female to male transmission. It has no effect on male to female transmission or on male to male transmission. So some critics will be against this practice mainly because isn't it better to educate them about things like condoms? You know, once you circumcise a guy, is he going to go out and just think that he's immune from this? So it's somewhat controversial. But the studies that they've done it with have been like really effective.

Cristen: Right. In one study from 2005 in South Africa, they found a 63 percent decrease in HIV transmission for circumcised men. In a Ugandan study, there was a 48 percent reduction in AIDS infection. And then in Kenya, they had a 53 percent reduction. And because they had such staggering results, they actually ended the study prematurely because it was basically unfair to the uncircumcised control group because the circumcision was so effective against HIV transmission.

Molly: Mm-hm. And it's not just HIV in Africa. Also uncircumcised men are about twice as likely to be in infected with HPV, and they're also more at risk for chlamydia and syphilis. But then the people who are anti-circumcision will say, "Hey, just use a condom. Same diff."

Cristen: Yeah, you just need to practice good hygiene, keep the foreskin clean, keep the bacteria out, put on a condom, and you're going to lower your rates of HIV and STD transmission anyway.

Molly: Right. So let's go through a few of the reasons why you wouldn't circumcise a boy besides those.

Cristen: First of all Molly, and this is something we talk about a lot on Mom Stuff, choice.

Molly: Yes. If you circumcise a baby boy, what choice does he have in the matter? Would he make the same decision to cut off part of his penis when he was 12, 20, 30? And then, like I said, there are all those nerve bundles. So some people think that an uncircumcised male has a little bit more fun when it comes to sex.

Cristen: Yeah. There's the nerve bundles and that natural lubrication from the foreskin. So they could be missing out on more sexual pleasure. And it also has a lot to do with whether the father is circumcised or not. There's a study from the World Health Organization that found that 9 out of 10 men who were circumcised will have their sons circumcised as well. And 75 percent of uncircumcised men will have their sons stay natural.

Molly: Right. You know, and while we talked about some of the health problems that you could face if, you know, you never have phimosis, then it is an unnecessary procedure. What else would you put your baby under the knife for that was unnecessary?

Cristen: Yeah, and they think that it could have psychological repercussions down the road of that childhood trauma of pain and suffering.

Molly: Yeah.

Cristen: It's a compelling argument.

Molly: It is. And you know, one thing, a topic that Cristen and I will cover at some point on Mom Stuff, is female genital mutilation, where they cut out, you know - it depends how much they'll cut out, but sometimes they'll cut out all of a woman's reproductive system, and obviously, that is wrong. And so they're saying that if you think that's wrong, then this is sort of the equivalent for a male, is a circumcision. Now I was reading one article that said that female genital mutilation is more like cutting off half the penis for a guy.

Cristen: Yeah, it takes away all pleasure for a woman. It's not like once you cut off the foreskin, a man can't become aroused.

Molly: Yes. So it's not necessarily a one-to-one argument, but I do think that that's interesting to think about, is we really would frown upon just putting a girl unde the knife for the same reason.

Cristen: Mm-hm. But like you said, we're going to save female genital mutilation for another podcast at a different time. But let's say, Molly, a baby boy was circumcised and he grows up, and he's really not happy about the fact that he does not have his foreskin.

Molly: Feels a little incomplete.

Cristen: Wants that foreskin back. What can he do?

Molly: There are a few options. There are nonsurgical means, which means you stretch what you've got left. It involves using weights, straps and manual stretching. So I don't know if it sounds exactly fun. I've never talked to anyone who's done this, but that's one option to try and just get it to come back up and cover a little bit more.

Cristen: Yeah, and there's this other method that involves inflating tiny balloons under the penile skin to prompt new skin cell growth, which will result in permanent skin gain. I don't really understand exactly how that happens with the tiny balloons, but it's a nonsurgical option.

Molly: There are surgical options. If you want plastic surgery on the penis, that is an option. They will take skin from another part of the body and graft it onto the remaining foreskin. They do say in this article that the one drawback is that the skin might be different colors.

Cristen: Yeah, and [inaudible] too.

Molly: So it would be sort of like a - I would like to think of it as a rainbow foreskin.

Cristen: Yes.

Molly: That makes it sound a little nicer than actually how the article puts it. But I probably shouldn't make jokes about foreskin.

Cristen: But you know, Molly, our listeners can make jokes about foreskin if they'd like. If you guys have any opinions about circumcision, whether or not you think that it is necessary or is not necessary, and men, we definitely want to hear your thoughts on circumcision because like I said, me and Molly are only secondary sources on this. We cannot personally relate. So we would like to hear your thoughts. Please email us with your foreskin jokes or other more elevated conversation at momstuff@howstuffworks.com. And in the meantime, let's read some listener mail.

Molly: All right. I'm going to kick off listener mail today with an email from Russell, who wrote about our episode on whether women's magazines do more harm than good. And I have to say, Cristen, that whenever a guy wrote in on women's magazines, they always gave them the big thumbs down. They liked that men's magazines had the horribly embarrassing stories. But here's what Russell writes. "As for the sexual tips, more often than not, they are way off base and the best advice to either member of the couple when it comes to sex is to communicate with your partner. But that is only one line of text, and it would be tough to sell a subscription based on that alone. Even though that might be the only thing a couple needs. Perhaps these magazines should rely less on the idea that each new episode will unlock secrets that your guy is just too embarrassed to bring up himself. Perhaps they should dedicate their sexual sections to ideas and things to do and experiment with, with your partner. And as for the idea of them damaging the youth, I think it lies more with how the child is raised. If a young girl sees her mother treating Cosmo like a Bible, she will likely do the same. But if her mother says it's just trash or fluff, with little or no real value, much like any grocery store romance novel, she will hopefully take on that same attitude."

Cristen: All right. I've got an email from Jackie, and this is in reference to our hair podcast. She says, "Hello Molly and Cristen. I have had long, and I mean long hair my entire life. It was ridiculously long, as it went to my butt. Sure, I've known people with longer hair than that, but that was the style that I maintained. I thought I was pretty happy with my hair for the most part, but recently my life had been feeling a little weighed down. I felt as though there was something that wasn't right." So she decided to cut her hair. "Initially, I went to the shoulder and donated all of my hair to Locks of Love, and I adored my new hair. But a lot of friends were very upset about it. None of them knew me any other way, and a lot of them acted as though I betrayed them in cutting off the hair. They got over it, and once they did, I went for a boy cut, not bothering to warn them this time. I've got nothing but compliments since then. People say I look more mature and less princess, which is the word used to describe me in the past. I'm more energetic and just all around more awesome. And most importantly, I no longer feel weighed down. I love my hair and so does my boyfriend. Not that his opinion would have changed my mind in this case. After 21 years, I finally have a haircut I actually like, and not one I was maintaining for everyone around me. It's short, easy to take care of. It looks cute on me and I don't have to schedule my life around my hair. I say phooey on people who shun short hair on women. It's made a better woman out of me."

Molly: Sounds good. Shall we read one more?

Cristen: Yes, please.

Molly: This is from Amy, and her subject line caught my eye. It was "Nerdy blonde has something to say about hair."

Cristen: All right.

Molly: She writes, "I just finished listening to your podcast on hair, and I wanted to write you about this blondes have more fun stereotype. First of all, I was a very nerdy piano and clarinet playing, book reading, completely unpopular library rat as a child and as a teenager. It really didn't seem to make a difference that I had blonde hair at the time. My teachers and peers always seemed to respect me, and they didn't seem to expect me to act like a blonde. Mostly, I believe because everyone had known me for a long time. This changed however, and really adversely affected me in college and especially in graduate school. All of the successful and smart brunettes made snide comments about my hair, while my male professors either dismissed me as stupid or asked me out on dates. In fact, eight different professors asked me out over the course of four years in college. In graduate school I was told by my advisors that my students would like me more if I was more like a cheerleader. How was I supposed to cheerlead my students through the history of western music was beyond me. Give me a B-A-C-H? I don't think so. I might add that the men in my program could be boring and dull, and no one ever thought twice. When I meet new people, they seem to expect a fun-loving, not-too-serious cheerleading blonde girl. And when they get a dorky, serious, slightly sarcastic music historian, it either makes them really angry or at least throws them for a loop. My hair always seems to come up as a topic of conversation. Cristen and Molly, will you please tell your listeners that women with blonde hair can be just as serious and successful as you brunettes."

Cristen: You heard it. There you go. It's true. And if you guys want to write us, again, please feel free to. Molly and I love listener mail. Our email is momstuff@thowstuffworks.com. And during the week, you can check out our blog called How To Stuff, where we talk about how to do stuff. And if you -

Molly: That's clever.

Cristen: And if you want to read how circumcision works, is circumcision really necessary, and why would circumcisions decrease a man's risk of contracting AIDS, you should head over to howstuffworks.

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