News Sexual Health

Voters in Two California Cities Asked to Ban Male Circumcision Based on Scientifically Inaccurate Claims

Martha Kempner

Activists opposed to male circumcision hope that someday cutting a boy's foreskin will be a federal crime. In the meantime, they're working to ban the procedure in two California cities.

In my parents’ living room, there is a special section on the bookshelf that, were one to label it, might be called, “books by our family” or “books we wrote.”  It’s a small section; just three deep. It contains the children’s book my mother wrote in 1969 (Nicholas, a now-inappropriate tale of a young boy riding the subway alone and getting lost), Predictable Pairings (a psychological profile of marriages by my grandfather), and Preventing V.D. and Cancer by Circumcision, which was written by my great-grandfather, Abraham Ravich. Now I admit that while I felt some sort of family pride (and have always hoped to add my own tome to the shelf), I haven’t read them all. I can quote Nicholas, but I only got as far the dedication in my grandfather’s book (it is, in part, dedicated to my sister and me), and haven’t even cracked open the book on circumcision, so what I know about it is second or third hand.

My great-grandfather was a urologist in Brooklyn in the 30s, 40s, and 50s. To hear my family tell it, many of his patients were Jewish immigrants and he observed that they had a lower rate of what was then called V.D. (now I suppose STDs or STIs) and prostate cancer.  He theorized that circumcision played a role in these reduced rates.  I have to admit, it never struck me as particularly interesting and it never occurred to me that it would be quite controversial but as my mother says, you learn something new every day. Today, in writing this story, I learned that in some circles Poppy Abe (whose formal portrait now hangs in my downstairs bathroom) is considered a “zealot” who “invented” the claims of a cancer connection to advance the practice of male circumcision.

In fact, there is a growing movement against male circumcision which activists (who like to use the term “intactivists”) call “male genital mutilation.” Activists in California collected over 7,100 signatures in order to get a new initiative on the November ballot in San Francisco that would ban the practice of male circumcision within the city limits.  They argue that the procedure is medically unnecessary and say that they hope this initiative is the start of a wave of laws on this issue.  Matthew Hess, the author of the San Francisco measure and a similar measure slated for Santa Monica’s November 2012 ballot, explained: “The end goal for us is making cutting boys’ foreskin a federal crime.”

Jena Troutman is also advocating for the ballot initiative. Ms. Troutman, who is the mother of two boys, runs a website called wholebabyrevolution.com. She explains that through her activism she is just trying to “save little babies” from a procedure that “can do serious damage.”  Ms. Troutman apparently approaches pregnant women on the beach to warn them of the dangers of circumcision. 

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In truth, there are few dangers in circumcision. A study conducted by SDI Health for the Centers for Disease Control and Prevention (CDC) in 2010 found that there was very low rate of complications associated with newborn circumcisions, that most complications were considered mild, and that no babies died. The claims that male circumcision is akin to female genital mutilation are also refuted by many.  Dr. David Baron, a family physician, certified mohel (someone who performs Jewish ritual circumcision), and former chief of staff at Santa Monica-U.C.L.A., told the New York Times that that he viewed the effort to ban the procedure as “ridiculous and dishonest.” He added: “to say it is mutilation is wrong from the get-go.”

There is also new research that suggests my great-grandfather may not have been all that far off when he said that circumcision could prevent V.D. and cancer. Based on scientific evidence, male circumcision is now being promoted in Africa as one of the most important ways to prevent HIV. And, a couple of weeks ago, I wrote an article on a new research study that suggested the male foreskin could be a reservoir for HPV, the virus that causes genital warts and is responsible for most cases of cervical cancer. 

That said, there is not enough evidence for medical experts to suggest routine circumcisions of male infants in this country. As the American Pediatric Association explains:

“Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child.”  

If voters in San Francisco and elsewhere pass measures like this, however, parents will not have a choice. Moreover, these measures do not contain any religious exemptions despite the fact that to many—Jews and Muslims in particular—circumcision is a religious ritual of the utmost importance.  As Brad Greenberg of the godblog.org explains 

“This custom is as old as Judaism itself. Commanded by God to a 99-year-old Abraham, circumcision was to signify fidelity to the Lord. It has been a central part of Jewish tradition ever since, so much so that even Yom Kippur—the holiest of holidays—doesn’t delay the circumcision of an infant.” 

In fact, some have gone as far as to call the ballot measures themselves anti-Semitic and likened them to bans on circumcision that existed in Soviet-era Russia and Eastern Europe and in ancient Roman and Greek times.

Even without such bans, however, the “intactivists,” may be making more progress than we realize as rates of circumcision are dropping all over the United States.  While over 90 percent of infant males in the United States were circumcised in the 1970s this was down to 64 percent in 1995 and just 33 percent in 2009. 

I wonder what Poppy Abe would think?

Analysis Sexual Health

American Academy of Pediatrics Releases New Guidelines Supporting Male Circumcision

Martha Kempner

As European nations debate banning male circumcision entirely and states continue to cut Medicaid coverage for the procedure, the American Academy of Pediatrics releases a new opinion which says the health benefits outweigh the risks.  Still, the organization stopped short of recommending routine circumcision for newborn males. 

A few weeks after my first daughter was born, I talked to my childhood best friend who was pregnant with her second child and had just found out that she was having a boy.  I passed on a tidbit I had learned when I was pregnant; you should have your obstetrician circumcise your baby instead of your pediatrician because the OB is trained a surgeon.

She surprised me by telling me that she was not planning on circumcising her son at all.  I wasn’t opposed to that decision, it had just never occurred to me as an option. As a Jewish mother-to-be residing in New York City, everyone, including me, had assumed that if my child were male he would be circumcised and I guess I carried that assumption to my friend even though she was not Jewish and was living in California at the time. 

When I was born in the 1970s my assumption would have been a safe one but today there is a major debate raging across the globe over the practice of male circumcision. While public health professionals argue that it has important health benefits and certain religions still require it, a vocal anti-circumcision movement calls the practice cosmetic at best, barbaric at worst, and seeks to outlaw it.

The majority of male infants (80 percent) born in the United States were circumcised as recently as the 1980s, these numbers, however, have been steadily declining in the past couple of decades to just 55 percent in 2010. In Europe, the practice has fallen almost completely out of favor with just 10 percent of male infants circumcised at birth.   

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This week, the American Academy of Pediatrics (AAP) weighed in on the debate with an opinion that shows strong support for the procedure but stops short of calling for routine circumcision.

How the Guidelines Changed
When the AAP last took on this issue in 1999, it concluded that there were “potential health benefits” but that the scientific research was not sufficient to recommend routine circumcision. It went on to take what could best be called a standoffish stance when it said:

“As in any circumstance in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child.”

The tone of the new opinion suggests more support for the procedure and it has been called a step toward endorsement by some experts. The new statement says

“Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it.”

This increase in support appears to come from a review of recent research; a 23-page technical report was released along with the policy. The report looked at a number of studies conducted between 1995 and 2010 which found that potential health benefits of circumcision include preventing urinary tract infections, HIV, and penile cancer. Some studies found that circumcision can also prevent the transmission of certain sexually transmitted infections, including the human papillomavirus and genital herpes.

There has been a great deal of research in Africa suggesting that circumcision of adult men can reduce the risk of heterosexually transmitted HIV in men by approximately 60 percent. As a result of this research, the World Health Association (WHO) recommends:

“efficacious intervention for HIV prevention in countries and regions with heterosexual epidemics, high HIV, and low male circumcision prevalence.”

A CDC spokesman points out, however, that it’s difficult to predict the impact of male circumcision on the HIV rates in the United States because the current circumcision rates are higher than in the areas studied, the epidemic is different, and there is still a lot we don’t know about the effect of circumcision on male-to-male transmission of HIV. 

While the relationship of circumcision and HIV has gotten a lot of attention worldwide, a number of additional studies have suggested other potential health benefits. A 2011 study presented at the American Urological Association meeting, for example, found that the foreskin of uncircumcised males can be a reservoir for HPV.  This year, researchers released another study that found that men who are circumcised before they first have sex have lower rates of prostate cancer than those who are uncircumcised or have the procedure after they’ve already been sexually active.   

The technical report released along with the opinion also says that the risks are quite low.  In fact, major complications from circumcision, including death were “so infrequent” that the academy excluded them from the review. Two hospital-based studies found that the most common risks from circumcision were “bleeding, infection and penile injury.” The report concluded that when done by trained professionals in a sterile environment the procedure is generally well-tolerated by infants (though the opinion does suggests that even infants need more pain management that the sugar-coated pacifier that is standard in some places). The report also noted that the procedure has more risk when done on older men.  

Unlikely to Sway Parents

Whether or not a baby is circumcised in this country varies widely across religions, ethnic groups, and geographic regions. Jewish and Muslim children are usually circumcised, Hispanic parents are far less likely to circumcise their children than white or black parents, circumcision is more common in rural and suburban areas than in metropolitan cities, and 75 percent of boys born in the Midwest in 2009 were circumcised compared to just 25 percent in the West. Differences between states are striking–-89 percent of boys born in Michigan in 2009 were circumcised compared to just 15 percent in Washington state–-yet state health officials are unable to completely explain the differences. The most telling determinant may actually be whether the father is circumcised; a Denver study found that 90 percent of males who were circumcised chose to circumcise their sons compared to just 23 percent who were uncircumcised.

Like the previous opinion, this new version says the decision should ultimately be up to the parents. Dr. Marvin Wang, director of newborn nurseries at Mass General Hospital for Children, explains it this way:

“This new policy still puts the decision-making in parents’ hands. But what the AAP says now is, ‘We have enough to say that you can make the decision based on religion, cultural and family issues. But guess what? You can now throw health in as a reason for doing it if you want to.’”

Wang, however, does not expect that the committee will sway many parents’ decision.  In 2010, he released the results of a study he conducted in which parents of newborn males were shown both the AAP’s 1999 opinion and summaries of new research on HIV/HPV and circumcision. Neither made much of an impact on what parents chose to do. As Wang put it:

“Nothing was going to change their mind. What they come into it with is what they go out of it with.”

Paying for the Procedure

Where this new opinion may make a big difference, however, is with insurers.  As Douglas Diekema, a member of the AAP’s circumcision task force, explains:

“… it recognizes that there are clear medical benefits that outweigh the risks of the procedure, and that those benefits are sufficient to justify coverage by insurance.”

According to the CDC, the procedure costs between $200 and 600 dollars and coverage varies widely among private insurers. Moreover, at least 18 state Medicaid programs have recently stopped covering it. 

Arizona, for example, stopped paying for the procedure in 2002 apparently as part of an effort to trim one billion dollars from the budget. (Cutting circumcision saved the state 400,000 dollars a year.) The year before this change was made, 41 percent of male infants in the state were circumcised, two years later that number was down to 21 percent. Indeed, coverage for the procedure seems to be a strong predictor of whether or not parents choose it; according to a report by the Health & Human Services Department’s Healthcare Cost & Utilization Project, circumcision rates are 24 percent higher in states where Medicaid covers the procedure. 

A new study, published in this month’s Archives of Pediatric and Adolescent Medicine, suggests changes to coverage like the one Arizona made may be short-sighted when it comes to saving money. The study was conducted by public health experts and economists at Johns Hopkins University School of Medicine and found that if circumcision rates in the United States were to fall to the same levels as in Europe, we could face more than four billion dollars in increased health care costs over a decade to pay for treatment of urinary tract infections, syphilis, herpes, penile cancer, and HIV.

Probably Not the Last Word

As always when I write about this topic, I feel it necessary to say that my great-grandfather, Abraham Ravich, wrote about many of the same health benefits noted in the technical report in his book Preventing V.D. and Cancer through Circumcision. The book, which was published in 1974, was based on his experiences as a urologist in primarily Jewish neighborhoods in Brooklyn from the 1930s, 40s, and 50s. Having mentioned him before, though, I know that Poppy Abe was considered by many to be a zealot and that there is a very vocal community who still do not believe these health benefits. 

In advance of the statement’s release, Georganne Chapin, founding executive director of the anti-circumcision advocacy group Intact America accused the AAP committee of “scientific blindness.” She said of the committee:

“They also appear to be totally ignoring the fact that their European colleagues are not only unimpressed by the supposed ‘benefits’ of cutting up baby boys’ penises but are actually considering whether child circumcision should be banned on the basis that it violates children’s rights.” 

Ronald Goldman, the head of another opposition group, expands on these complaints saying that studies show circumcision causes loss of sexual satisfaction and can be psychologically harmful but the AAP says the research does not support these claims. Both Goldman and Chapin call the new statement “out of step” with what is going on in the rest of the world where many are calling for a complete ban on the procedure.

In Germany, for example, a regional court ruled in June that circumcision amounts to “irreversible interference in the integrity of the human body” because the procedure is performed on non-consenting minors who cannot object. (Jewish and Muslim leaders are protesting this verdict.) This decision was spurred by the case of a four-year-old Muslim boy who suffered a great loss of blood as a result of a botched circumcision. According to the Jewish Daily Forward, this case has led to debates about the ethics of what many see as an unnecessary procedure not just in Germany but in Switzerland, Austria, Denmark, and Norway. In fact, the move to ban circumcision entirely recently came to the United States when both San Francisco and Santa Monica entertained the possibility of ballot initiatives to prevent the practice within city limits. 

Such bans, however, instantly raise questions of religious freedom, and some have gone as far as to call them anti-Semitic and liken them to bans on circumcision that existed in Soviet-era Russia and Eastern Europe and in ancient Roman and Greek times. Moreover, bans seem to fly in the face of mounting public health evidence about the potential value of circumcision. California’s governor, Jerry Brown, agreed signing legislation in October 2011 that makes such bans illegal in his state and effectively killed the two that had been proposed.

The AAP’s new opinion is not quite that decisive.  Even its co-author says the opinion should not be considered the “verdict from on high” and that everyone needs to decide for themselves.  Still he adds, “but from a medical standpoint, circumcision’s benefits in reducing risk of disease outweigh its small risks.” 

In the 30 years since Poppy Abe died, public opinion and professional opinions on this topic have swung back and forth many times.  While I doubt this newest statement from the AAP will cement it in either direction, I do believe my great-grandfather would consider it a step in the right direction.    

Analysis Sexuality

How Modesty Doctrines Made Me Hate My Body

Vyckie Garrison

Modesty taught me that my first priority needed to be making sure I wasn’t a “stumbling block” to men. Not being sexually attractive was the most important thing I had to consider when buying clothes, putting them on, maintaining my weight (can’t have things getting tight!), and moving around (can’t wiggle those hips, or let a little knee show). Modesty taught me that what I looked like was what mattered most of all. Not what I thought. Not how I felt. Not what I was capable of doing. Worrying about modesty, and being vigilantnotto be sexy, made me even more obsessed with my looks than the women in short shorts and spray tans I was taught to hate  

by No Longer Quivering guest writer, “Sierra”

This isn’t a story about how modest clothes allowed me to “let myself go” and conceal a growing figure. It’s not even a story about how wearing modest clothes kept my self-esteem at rock bottom and thrust me into a too-close relationship with Ben & Jerry. It’s a story about how modesty doctrines impacted my mind, in ways that had real, negative effects on my body. Modesty was one of the reasons my defining relationship with my body became whether or not I was “fat.” Modesty was one of the engines that pushed me into a full-blown eating disorder. It’s not just a dress code: it’s a philosophy, and it’s one that destroys young women, mentally and physically.

Modesty taught me that my first priority needed to be making sure I wasn’t a “stumbling block” to men. Not being sexually attractive was the most important thing I had to consider when buying clothes, putting them on, maintaining my weight (can’t have things getting tight!), and moving around (can’t wiggle those hips, or let a little knee show). Modesty taught me that what I looked like was what mattered most of all. Not what I thought. Not how I felt. Not what I was capable of doing. Worrying about modesty, and being vigilant not to be sexy, made me even more obsessed with my looks than the women in short shorts and spray tans I was taught to hate.

Modesty taught me that I was always on display. There was no occasion in which it was acceptable to be immodest. Not the beach, not at the pool with friends, not in my own backyard (sunbathing was out because a neighbor might glance over and see me). This took my normal self-consciousness as a teenage girl and amped it up to an impossible degree. I once had a bee fly down my (acceptably loose) shirt and, in flailing around to get it out, had a family member comment that I’d just “flashed” my own grandfather. I was horrified for the rest of the week. That’s not normal. The normal order of priorities is getting dangerous animals out of your clothing first, and then worrying about making your own relatives perv on you second. Not so with the modesty doctrine. I should have let it sting me, apparently. Getting stung was the lesser risk.

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Modesty was not just about dress. It was also about moving like a lady. Knees together, butt down, breasts in, arms down. It is impossible to get physically fit while adhering to ladylike movements only. You might be able to run, but only if you wear two sports bras to keep anything from jiggling inappropriately. You certainly can’t do anything with weights. In college, I had the chance to join a horseback riding team for a couple of semesters. I soon realized that staying on the horse required starting some kind of fitness regimen. In the gym, I found a couple of hip abductor/adductor machines that were handy for building the thigh strength necessary to grip the horse. The problem? I was so embarrassed that somebody might walk in front of me while I was on the machine with my legs spread that I started going to the gym the moment it opened in the morning and avoiding exercise when men were present. In this instance, modesty was literally keeping me weak. Eventually, I grew comfortable enough with my own body to exercise without worrying about other people happening to look at me. Now, I do an exercise routine that would have scandalized my old self: squats, deadlifts, and barbell rows. I have so much more energy and my mood is so much improved – plus, I can move my own furniture! But I couldn’t have got to this point without dumping the modesty doctrine. Because I couldn’t concentrate on hauling iron while worried that some perv behind me might happen to glance my way and pop his gym shorts. That’s not my job anymore. I’m not responsible for men’s souls, because I no longer think of myself as an object to be looked at and evaluated.

Backing up to before I got to college, modesty contributed to my eating disorder. How? Because I noticed that the best way to keep men from staring at my ass was not to have one. Ditto boobs. The skinnier I got, the less womanly I looked, and the more “modest” I felt, until I was 25lbs underweight. I was perpetually “fat” in my own mind – because in my own mind, the only acceptable body type was an androgynous one – one that could not possibly provoke a man to lust. I’m sure I don’t need to explain why that was a bad thing.

Modesty taught me that I was a decoration. Everything about my life was governed by whether or not a man was watching. How I moved and what I ate or wore all depended on the male gaze. Modesty taught me that nothing I did mattered more than avoiding sexual attention. Modesty made me objectify myself. I was so aware of my own potential desirability at all times that I lost all other ways of defining myself. I couldn’t work out or get fit without worrying about attracting men. I couldn’t relax my eating habits for a moment lest my shirts start to pull a little in the chest. I couldn’t grow like a normal human adolescent because staying slim and sexless was the biggest priority in my world.

When you argue that what’s modest and what isn’t is a valid concern for women, you tell them that their appearance matters most. You objectify them. You tell them that whether or not you are sexually aroused by their actions or their dress is more important than anything they want to do or wear. You tell them that they must, at all times, be thinking about you when they are making decisions about their own lives. That’s arrogant. That’s immoral.

When you argue that modesty is just a “debate” that must be won by those whose arguments are strongest in the abstract, you ignore the fact that the “debate” has consequences you don’t have to live with. Women have to live with the consequences of modesty debates. Those debates impact every sphere of their lives: work, play, even their own health and wellbeing. If you think that, as a man, you can somehow argue “objectively” about what women should or shouldn’t wear and “win” a debate fair and square, let me remind you of a few things. If a man “loses” a modesty debate, nothing about his life changes. If a man “wins” a modesty debate, nothing about his life changes. But if a woman loses a modesty debate, the entire fabric of her existence changes. If a woman loses a modesty debate, she has lost whole areas of freedom in her life. She now has more things to worry about not doing so that men will not get aroused. There is no such thing as an “objective” argument in which the stakes are astronomical for one side and nonexistent for the other. Furthermore, by even accepting modesty as a valid area of concern for women, you have accepted a premise that defines women by their looks and objectifies them. Women have already lost the moment a modesty debate begins.

Modesty made me “fat” because it defined my relationship with my body in terms of appearance. Not action. Not gratitude. Not the joy of movement. Just appearance. It also defined my relationship with men as one of predator and prey. It was my job to hide from men so that their sex drive would lie dormant, like a sleeping wolf. But if that wolf ever awakened, it was not because it had been sleeping for a long time and its circadian rhythm kicked in, or it was just naturally hungry. It was my fault because I had done something to “bait” the wolf. Just by being visibly female, or by moving in “unladylike” ways. You cannot consider women full human beings unless you recognize that their lives do not revolve around the male sex drive. Modesty is a philosophy that dehumanizes. It incites constant fear and vigilance in one sex while excusing the other of all responsibility. It’s immoral.

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Sierra is a PhD student living in the Midwest. She was raised in a “Message of the Hour” congregation that followed the ministry of William Branham. She left the Message in 2006 and is the author of the blog The Unspoken Words: A Non-Prophet Message.