Uncircumcised boys are about 10 times as likely to get serious kidney infections in the first year of life as are circumcised infants; even in adults circumcision protects against UTIs. These kidney infections are most dangerous in the first 3 months, during which time they often lead to hospitalization and can result in overwhelming blood infection and other serious infections. Kidney scarring has been shown to occur later. There is concern that future kidney failure and high blood pressure may follow infantile UTIs. Abnormal kidney function and hormonal secretion can occur with infant UTIs. Fecal contamination of the moist inner foreskin layer with bacterial attachment leads to these kidney infections. Circumcised infant boys also are able to avoid invasive procedures, such as catheterization and bladder tap in order to get a valid urine specimen to test for infection. Voided urine is sterile in circumcised boys but because the uncircumcised penis is often colonized with bacteria a voided specimen in the presence of a foreskin is likely to be contaminated.

For documentation see Reference Section, pages 124-135 from the book "Ed Schoen, MD on Circumcision Timely Information for Parents and Professionals from America's #1 Expert on Circumcision, RDR books, 2005."

Uncircumcised men were first shown to be more likely to acquire heterosexual HIV infection almost 2 decades ago, in articles in the leading medical journals "Lancet" and "New England Journal of Medicine". Since then over 40 separate studies have shown that uncircumcised men are more likely to become infected with HIV on heterosexual exposure. The ease with which the foreskin tears during intercourse, leaving mini-abrasions through which the virus enters, can lead to the infections. It has been shown that certain specialized cells in the foreskin, Langerhans cells, trap the HIV virus but cannot kill it and serve as a means of allowing HIV to enter the system. A randomized control study recently published showed that circumcision offers a 60-70% protection against acquiring HIV on exposure.

For documentation see Reference Section, pages 124-135 from the book "Ed Schoen, MD on Circumcision Timely Information for Parents and Professionals from America's #1 Expert on Circumcision, RDR books, 2005."

3. Sexually Transmitted Disease (STDs):

As with HIV, mini-abrasions of the foreskin during intercourse is one explanation for the fact that uncircumcised men are more likely to acquire certain other (though not all) STIs. The STIs for which uncircumcised men are at greater risk include syphilis, chancroid and genital herpes, all of which involve ulceration of the penile surface through which the infection enters. In 2002 it was shown that uncircumcised men are 3 times as likely to be carrying the human papilloma virus (HPV) as are circumcised men. HPV is not only the cause of genital warts but is the agent that causes both cervical and penile cancer. In 2005 a multinational study showed that Chlamydia infection is also 3 times as common in the presence of a foreskin. Chlamydia infection is one of the most common STIs and can lead to infertility.

For documentation see Reference Section, pages 124-135 from the book "Ed Schoen, MD on Circumcision Timely Information for Parents and Professionals from America's #1 Expert on Circumcision, RDR books, 2005."

It has long been known that in population groups where circumcision is performed e.g. -Jews and Muslims - cancer of the cervix is rare and penile cancer almost nonexistent. In recent years the role of human papilloma virus (HPV) in both penile and cervical cancer has been proven, and these cancers are now being thought of as sexually transmitted diseases. A recent study of over 1900 couples in 5 countries found that penile HPV infection is about 3 times as common in uncircumcised males as in circumcised males and there is about a 2.5 fold increased risk of cervical cancer in women whose sexual partner is uncircumcised and has had multiple partners.

For documentation see Reference Section, pages 124-135 from the book "Ed Schoen, MD on Circumcision Timely Information for Parents and Professionals from America's #1 Expert on Circumcision, RDR books, 2005."

It has been known for over 100 years that circumcised men almost never get invasive penile cancer, a devastating disease which is more deadly than breast cancer (higher 5 year mortality rate). Each year about 1400 U.S. men get this disease and over 200 die, almost all of them uncircumcised. As with cervical cancer in women, in penile cancer the etiologic agent is HPV, and HPV is found 3 times more often on the uncircumcised than the circumcised penis

For documentation see Reference Section, pages 124-135 from the book "Ed Schoen, MD on Circumcision Timely Information for Parents and Professionals from America's #1 Expert on Circumcision, RDR books, 2005."

Local foreskin infections (balanoposthitis) can occur at any age in uncircumcised males, but is most common at age 2-5 years, an age when the foreskin has often not yet completely separated, and cannot be fully retracted, and genital cleanliness is more difficult to accomplish. In addition between 0.5% and 1% of boys will never be able to retract their foreskin due to a pinpoint opening at the end (phimosis) and will have to be circumcised at a later date when the procedure is more complex and difficult, and about 10 times as expensive. Phimosis becomes most troublesome beginning with puberty; painful erections occur since the foreskin can't retract over the glans. An incomplete form of phimosis, called paraphimosis, occurs when the foreskin is tight but can be retracted over the glans. The glans may then become trapped resulting in severe pain and swelling. Newborn circumcision leads to improved genital hygiene throughout life, but most importantly in infancy, early childhood and old age when personal hygiene may be inadequate. Uncircumcised males are more likely to develop a wide variety of skin disorders including psoriasis, lichen planus, and seborrheic eczema.

For documentation see Reference Section, pages 124-135 from the book "Ed Schoen, MD on Circumcision Timely Information for Parents and Professionals from America's #1 Expert on Circumcision, RDR books, 2005."

Circumcision has been performed for thousands of years and is part of a number of religious and cultural traditions. From the religious standpoint, it is part of the Judeo-Christian belief. Circumcision was a covenant between Abraham and God in the Old Testament, and the New Testament tells us that Jesus was circumcised in the accepted Jewish fashion at age 8 days. Moslems also perform circumcision, but it is done at various ages in childhood. From the secular standpoint it has been theorized that desert-dwelling people in tropical lands began to be circumcised for reasons of cleanliness ("circumcision and sand") and to avoid severe foreskin infections. During World War II, poor hygienic conditions during the African invasion in the desert areas resulted in foreskin problems in over 146,000 US soldiers, and led the Armed forces to perform adult circumcision among many recruits. This WW II experience is the likely explanation for the fact that following the war in the 1950s and 1960s almost 90% of US newborns were circumcised.

For documentation see Reference Section, pages 124-135 from the book "Ed Schoen, MD on Circumcision Timely Information for Parents and Professionals from America's #1 Expert on Circumcision, RDR books, 2005."

Sexual function is not adversely affected by newborn circumcision. On the contrary, published evidence shows that circumcised men have a wider variety of sexual activity, and women prefer circumcised men, mainly because of better genital hygiene. Over the past 5 years multiple clinical studies involving men circumcised as adults have shown that it is a myth that the foreskin is important in sexual pleasure and sensitivity. It was found that there was no significant difference in sexual pleasure or sensitivity before or after circumcision. This is not surprising in view of the complicated cascade of neurological, hormonal, metabolic, emotional and vascular factors involved in the sexual act. A survey of U.S. Midwestern women who had sex with both uncircumcised and circumcised men found that they preferred circumcised men by a margin of 3 to 1. The main reason was improved genital hygiene, but the women felt the circumcised penis looked and felt better, and interestingly, most of them felt that it looked “more natural”. A survey of prostitutes published in the London Times found that 90% preferred the circumcised penis, again for reasons of improved hygiene. Issues of smegma, debris and odor apparently are important to women who deal with many penises.

For documentation see Reference Section, pages 124-135 from the book "Ed Schoen, MD on Circumcision Timely Information for Parents and Professionals from America's #1 Expert on Circumcision, RDR books, 2005."

Recent statistical evidence from the Center for Disease Control (CDC) agencies (see figures) indicates that in the United States (US) newborn circumcisions among non-immigrant boys have increased over the past 2 decades. The CDC found that the total US newborn circumcision rate rose very slightly (from 64% to 65%) over the two decade period, from 1979-1999, but the breakdown of these statistics is revealing. There have been increases in circumcision among blacks (from 56 to 64%) and in newborns from the Midwest (from 74 to 81%) and the South (from 56 to 61%), areas of the country with the fewest new immigrants. In specific communities high circumcision rates are being reported: 84% in Atlanta, Georgia, 85% in Houston, Texas, and 92% in a Wisconsin community served by a pediatrician opposed to circumcision. Falling circumcision rates in the West, particularly in California, reflect the fact that over 50% of births in the state are in Hispanics who do not circumcise on a cultural basis. Among non-Hispanic males the rate remains about 80%. The NIH incidence figures must be viewed with caution since they only represent coded data from the hospital of both. In Alaska and Georgia it was found that about 15% of newborn circumcisions are not coded on discharge. Further, recent published evidence shows that 7-10% of males are circumcised for medical reasons after the newborn period. These errors in coding and post-neonatal circumcisions accounts for the discrepancy between the 60-65% newborn rate reported by the NIH and the 80-85% circumcision rate found in surveys of older boys. A survey reported in 2005 found that the U.S.circumcision rate was increasing recently, a finding attributed to the increasing awareness by the American public of the preventive health benefits of circumcision.

For documentation see Reference Section, pages 124-135 from the book "Ed Schoen, MD on Circumcision Timely Information for Parents and Professionals from America's #1 Expert on Circumcision, RDR books, 2005."

The AAP issued statements on circumcision in 1971, 1975, 1989, and 1999. The statements have been contradictory, often biased and not supported by medical evidence. The original 1971 statement by the AAP that there were “no valid indications for newborn circumcision” represented a single undocumented sentence and the anonymous author(s) was apparently unaware of the large amount of published data on penile cancer, local infections, phimosis and genital hygiene. The most recent report, in 1999, although referencing the data showing preventive health benefits against infant UTIs, penile cancer, HIV and local problems unexplainably concluded that the “potential benefits” were “not sufficient to recommend newborn circumcision”, but no benefit to risk ratio was offered and the AAP did not say how many benefits would be sufficient. In the period since the report (1999-2005) there have been multiple published studies confirming the protective benefits against infant UTIs, penile cancer, penile dermatoses, and HIV. In addition there has been compelling evidence that uncircumcised men are more likely to be carrying HPV and the Chlamydia organism and female sexual partners are more at risk for cervical cancer. It was recommended that in the face of this new evidence the AAP update amend it’s position, since the last reference in the 1999 reported was to a 1998 publication. Rather than update the 1999 report, the AAP in 2005 reaffirmed the flawed outdated 1999 report. The position of the AAP on circumcision beginning in 1971 and continuing to the present has been misleading and confusing at best and erroneous and irresponsible at worst.

For documentation see Reference Section, pages 124-135 from the book "Ed Schoen, MD on Circumcision Timely Information for Parents and Professionals from America's #1 Expert on Circumcision, RDR books, 2005."

There are 3 acceptable methods for performing newborn circumcision: 1) Plastibell method, 2) Gomco clamp, and 3) Mogen clamp. All 3 methods should be done with local anesthesia. The key to a quick, safe, painless newborn circumcision depends more on the experience of the operator than on the technique used. The methods of local anesthesia include dorsal penile nerve block (DPNB), ring block and anesthetic cream. Having the baby suck on a sucrose (sugar) pacifier also decreases pain. The risks of a properly performed circumcision are rare (0.2-0.6%) and usually minor. Local infection and bleeding are the most common complications, but are generally easily controlled. In over 500,000 circumcisions in New York State there were no deaths or penile amputations. The rare reported deaths have almost all been due to general anesthesia, which in my opinion, should only be used in special circumstances. An experienced operator is the key to a quick and safe circumcision.

For documentation see Reference Section, pages 124-135 from the book "Ed Schoen, MD on Circumcision Timely Information for Parents and Professionals from America's #1 Expert on Circumcision, RDR books, 2005."

Beginning in the 1970s many lay anti-circumcision organizations with picturesque acronyms have sprung up. The longest - lived and probably largest is NOCIRC (National Organization of Circumcision Information Resource Centers). Others include NOHARMM (National Organization to Halt the Abuse and Routine Mutilation of Males), NORM (National Organization of Restoring Males), RECAP (Re-cover A Penis), and BUFF (Brothers United for Future Foreskins). A San Francisco magazine, Foreskin Quarterly, aimed at gay men, focuses on the sexual advantage of the foreskin. These activist organizations, particularly NOCIRC, mainly using anecdotes and testimonials, have gained a good deal of media attention and have had some influence in discouraging newborn circumcision, particularly in middle class educated “trendy” parents in certain sections of the country. The lay anti-circumcision organizations are well organized and dominate the media and the internet. Although the anti-circumcision forces consist mainly of laymen, there are some physician supporters. We have cited comments and opinions from some of these physicians. It is suggested, that before accepting the comments of these anti-circumcision physicians, you check the published medical evidence which can be found in the references and illustrations in other sections of this website. There are problems of credibility with a number of these physicians.

For documentation see Reference Section, pages 124-135 from the book "Ed Schoen, MD on Circumcision Timely Information for Parents and Professionals from America's #1 Expert on Circumcision, RDR books, 2005."

Compelling medical data much of it accumulated in the past 2 decades, have conclusively shown that a boy circumcised as a newborn has multiple lifetime health advantages compared to one with an “intact” foreskin. These include protection against serious kidney infections in infancy, sexually transmitted diseases (STDs) including human immunodeficiency (HIV) infections, Chlamydia infection and human papilloma virus (HPV) in young men, and invasive cancer of the penis in middle and old age. In addition, all through life uncircumcised males are more susceptible to penile infections (balanoposthitis) and a variety of skin disorders of the penis such as eczema and psoriasis, as well as more difficulty maintaining good hygiene. About 1% of boys are born with only a pinpoint opening at the tip of the foreskin (phimosis) preventing retraction, leading to painful erections, and requiring future circumcision, at a time when the procedure is more difficult, risky and costly. Further, women sexual partners of uncircumcised men with HPV infection are at significantly greater risk of developing cervical cancer.

How convincing is the scientific evidence of circumcision advantages? Overwhelming in the cases of infant kidney infections, penile cancer and local disorders, and compelling for HIV, Chlamydia, HPV and risk of female partners of uncircumcised men with HPV infections. In the mid 1980’s, Dr. Tom Wiswell, a military pediatrician initially opposed to newborn circumcision, examined the United States (US) Armed Forces records of over 200,000 newborn boys and to his surprise found that uncircumcised boys were 10 to 20 times more likely to develop severe kidney infections in the first year of life. Since then a dozen published reports confirm this protective effect of circumcision against infant urinary infections and explain how these infections occur. The warm, tight, moist undersurface of the infant foreskin provides an ideal home for the harmful fecal bacteria that cause kidney infections. These bacteria (“uropathic, fimbriated E. Coli”) have tentacles which attach to the foreskin and then climb up the urinary tract to the kidney. The resultant infection leads to kidney scarring in almost half the cases, as well as body salt loss and hormonal changes in some instances. Although there is no proven long-term evidence so far of permanent kidney damage, these renal effects are disturbing.

All studies on invasive penile cancer from 1930 to the present have shown that this devastating malignancy is almost entirely limited to uncircumcised men. In 1932 it was reported from what is now the Sloan Kettering Institute, that of 120 men with penile cancer none were circumcised; all subsequent studies have confirmed this overwhelming preponderance. In Kaiser Permanente Northern California Region (KP), a large health maintenance organization (HMO), recently published studies found that uncircumcised males are about 22 times more likely to get invasive penile cancer and 10 times more likely to get infant kidney infections as are circumcised males (Schoen, Pediatrics 2000).

In the case of HIV, reports published in the late 1980’s in two of the world’s leading medical journals, the New England Journal of Medicine and Lancet, found that uncircumcised men in Africa had about four times the risk of acquiring the virus following sexual exposure. In the ensuing 19 years this observation on the protective effect of circumcision against HIV has been repeated in over 30 separate series, including all 8 prospective studies (looking forward from exposure, rather than backwards from diagnosis). Further, the likely reasons for the role of the foreskin in the spread of HIV have been clarified. In addition to the risk of the virus entering through foreskin tears, it has been found that the foreskin is rich in special cells, Langerhans cells, which trap and normally help kill invading infectious organisms. But in the case of HIV the trapped virus is not destroyed but binds to these special cells and is introduced into the body.

As for HPV penile infections and cervical cancer, in 2002 a report in the New England Journal of Medicine reviewed over 1900 sexual partners from 7 different studies in 5 countries. It was found that uncircumcised men were 3 times more likely to develop penile HPV infection as were circumcised men and female partners of the uncircumcised men were at significantly greater risk of developing cervical cancer. Using data from the same study Chlamydia infections, common in young adults and teen-agers and an important cause of infertility, was found to be 3 times as likely if the man was uncircumcised.

During World War II, particularly during the North African desert campaign, the combination of sand and lack of hygienic conditions proved disastrous to uncircumcised men. The loss of these soldiers to active duty in combat areas resulted in prophylactic circumcision being performed on many recruits at training centers. A World War II medical report from the U.S. Army referred to the “enormous man-hour loss from disease peculiar to the uncircumcised man,” and stated that “hospital admission from paraphimosis, phimosis, balanitis and condyloma accuminata during 1942 – 1945 totaled 146,793. Had these patients been circumcised before induction, this total would probably have been close to zero”. A similar though less well-documented loss to active duty occurred in uncircumcised servicemen in Operation Desert Storm during the Gulf War.

If the evidence favoring circumcision is so strong, why is the public given contradictory and misleading information? The reasons are at least twofold. Probably most important is the lack of interest and objectivity of organized medicine, particularly the American Academy of Pediatrics. The second source of misrepresentation is by the activist, lay anti-circumcision groups, which dominate the media and the Internet and concentrate on anecdotes, testimonials and undocumented opinions.

The problems with the position of the American Academy of Pediatrics (AAP) began in 1971 when the Newborn Section, which would be least likely to see the preventive effects later in life, issued a single, undocumented sentence --“There are no valid medical indications for newborn circumcision”. This statement, unsupported by data or references, revealed an unawareness of the large and growing body of evidence on the protection against penile cancer, as well as the World War II Army data on the elimination of local foreskin problems. Due to dissatisfaction with this 1971 statement, an AAP Task Force was convened in 1975, which, after looking at the evidence, found that there were indeed valid reasons to perform newborn circumcision. But, rather than admit that a mistake had been made, the AAP, still under the Newborn Section, chose to obfuscate the issue by semantics, concluding “there are no absolute indications for newborn circumcision”. Since there are few absolutes in the world, the issue was only further confused. With the misleading position of the AAP and the rapid growth of the lay anti-circumcision groups the newborn circumcision rate fell from 85 – 90% in the 1950’s – 1960’s to about 65% by the late 1970’s. The AAP reassessed its position on circumcision following published evidence in the 1980’s of protection against infant kidney infection and the suggestion of HIV prevention. The report of this AAP Task Force, published in 1989, confirmed the advantages of circumcision in prevention of penile cancer, foreskin diseases and hygiene promotion, and listed the disadvantages of pain and possible surgical complications. The possible advantages of avoidance of infant kidney infections (UTIs) were considered suggestive but not yet proven at that time. In a non-directional manner the parents and providers were advised to consider these confirmed benefits and risks in their decisions.

With increasing published research showing advantages, the AAP studied the evidence again in a report issued in 1999. In the ensuing years since 1989, the evidence on protection against penile cancer and infant kidney infection had become overwhelming, and prevention of HIV compelling, adding to the advantages of neonatal circumcision. At the same time, local anesthesia has become established as effective and safe, eliminating the pain disadvantage. Unexplainably, in the face of this increased evidence of support for the procedure, documented in the report itself, the 1999 conclusions discouraged newborn circumcision. Proven evidence was referred to as “potential benefits” and the Task Force said it could not recommend newborn circumcision but did not say why. Anti-circumcision jargon was used – circumcision was referred to as “amputation” of the foreskin, and a known anti-circumcision pediatrician appeared before the group and refers to himself as a “consultant”. Further, this anti-circumcision stance, discordant with the evidence, was accompanied by a statement that newborn circumcision is not necessary for the acute management of the newborn, a puzzling and irrelevant statement since newborn circumcision, like immunization, is a preventative health measure, not a treatment for acute illness. The misleading nature of the 1999 AAP report has been challenged by pediatricians and other professionals (Schoen, Pediatrics 2000), and diminishes the credibility of the AAP on this topic. In the period from 1999-2005 multiple compelling published studies have confirmed the previous preventive effects of circumcision and given evidence on protection against HPV, cervical cancer , and Chlamydia. Rather than update its position to reflect this new evidence the AAP, in an irresponsible move, simply reaffirmed the 1999 report, thus ignoring all the evidence accumulated over the past 7 years.

The lay activist, anti-circumcision groups, beginning in early 1970’s, have dominated the media and recently the Internet, and have been successful in gaining public attention for their cause. They have grown in number, and fringe groups have become increasingly bizarre, with picturesque acronyms. Among the oldest of these organizations are NOCIRC (National Organization of Circumcision Information Resource Centers) and NOHARMM (National Organization to Halt Abuse and Routine Mutilation of Males). Recently, circumcised men desiring replacement of the missing foreskin have joined into groups such as NORM (National Organization of Restoring Males), RECAP (Recover a Penis) and BUFF (Brothers United for Future Foreskins). In addition to being featured in the print and broadcast media, a slick anti-circumcision magazine (“The Foreskin Quarterly”) was published in San Francisco, which contained a large classified advertisement section with uncircumcised homosexual men seeking partners similarly endowed.

How has the U.S. population reacted to the anti-circumcision groups and the confusing position of the AAP? As a measure of the independence of the public in assessing information relevant to infant health, the circumcision rate of newborn from non-immigrant families has actually risen over the past 2 decades. The Center for Disease Control (CDC) recently published statistics on newborn circumcisions from 1979-1999 and found the total rate rose from 64% to 65%, in this period. But the changes within the various parts and ethnic groups of U.S. are more significant than the totals. Circumcision rates increased from 56% to 64% among blacks, in the Midwest (from 74% to 81%) and the South (from 56% to 61%). The Midwest and the South represent the areas of the country with the fewest immigrants. On the other hand in the West, particularly in California where the majority of newborns are now from immigrant families coming from cultures which do not circumcise, the circumcision rate fell from 64% in 1979 to 37% in 1999. In 1979 the majority of births in California were in non-immigrant whites. By 1999 non-immigrant whites constituted only 31% of California births, with 6% in Blacks; 47% of newborn births were in Hispanics and most of the rest were in Asians. Since Hispanic and Asian immigrants rarely have their newborn boys circumcised, even if 100% blacks and non-immigrant whites were circumcised the total circumcision rate would be under 40%, offering an explanation for the 37% Western rate. Interestingly, there is a suggestion that even among Hispanics the attitude toward circumcisions changes as they remain in the U.S. longer. In Southern California where the most recent immigrants are found, almost no Hispanic infants are circumcised, while a recent survey at San Francisco General Hospital found that 29% of Hispanic newborn boys were being circumcised. In the 3 years since the misleading 1999 AAP Task Force circumcision report, published studies have reinforced the evidence of circumcision protective effects against HIV and HPV infections and cervical cancer, kidney damage following infant urinary infections and local skin disorders, and confirmed the effectiveness of local anesthesia on pain relief. In the face of this proof it seems likely that the rates of newborn circumcision will continue to rise in the U.S. as the public increasingly realizes the medical benefits of this preventive procedure, which is analogous to infant immunizations in the sense of promoting health and preventing future disease.

For documentation see Reference Section, pages 124-135 from the book "Ed Schoen, MD on Circumcision Timely Information for Parents and Professionals from America's #1 Expert on Circumcision, RDR books, 2005."