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How Circumcision Works


A little boy cries as a Turkish doctor injects him with a local anesthetic before circumcising him in Kabul, Afghanistan.
A little boy cries as a Turkish doctor injects him with a local anesthetic before circumcising him in Kabul, Afghanistan.
Natalie Behring-Chisholm/Getty Images

It's­ a common scenar­io, but one that most of us don't think about until faced with the decision: If I had a son, would I have him circumcised? Circumcision, the surgical removal of the foreskin that normally covers the head of the penis, is a relatively simple procedure, but it's not one you want to see go badly -- especially if your son (or you) is the patient.

Sometimes, the answer is made easier by a strong religious or cultural belief. Most (but not all) Jews and Muslims circumcise their male children. Throughout Africa, some tribes uniformly circumcise and others uniformly do not. If you were born in the United States in the last 30 years or so, there's about a 3-in-5 chance that you're circumcised (unless you're Hispanic, in which case the odds are much lower) [source: WebMD].

After examining all available data in 1999, the American Association of Pediatrics decided ­not to endorse circumcision for infant boys. The AAP didn't recommend against it either, offering the opinion that parents should make an informed decision for themselves.

­If you're not Jewish or Muslim, what is the basis for your decision? Should the child be circumcised only if the father is circumcised? Would you "cross over," or decide not to circumcise even though all the male members of your family have been circumcised (or vice versa)? Is it a dangerous practice? Does circumcision really lower the risk of being infected with a STD? Is it cruel?

In this article, you'll learn all you can handle about circumcision -- what it is, how it came to be and why it's still around. First up: What's a foreskin? Continue reading to find out.

The Foreskin

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The foreskin (also known as the prepuce) is a portion of skin on the penis that covers and protects the tip of the penis, also known as the glans. It can be a tough world for a glans -- there's abrasion from undergarments, cold winter weather and dry air. It's good to have a protection policy in place, and the foreskin provides that protection for the glans.

When males are born, the skin on the penis extends over the glans, protecting it on day one from the wear and tear it will undergo in that lifetime. The foreskin can account for one-third to nearly one-half of total penile skin.

While its outer appearance is the same as any other skin on the penis, the foreskin is home to many nerve bundles and blood cells, and its inner surface is similar to the inside of your mouth, helping the glans stay naturally lubricated. Between the outer layer and the moist inner layer is a ridged band with additional nerve endings. A piece of tissue called the frenulum connects the foreskin to the glans. It looks (and functions somewhat) like the connective tissue beneath your tongue. When the penis is flaccid, the frenulum tightens to narrow the opening of the foreskin.

Those nerves packed into the foreskin provide additional stimulation during sexual activities. Its lubricating function also assists in sexual intercourse. Additionally, the frenulum (which is removed in some circumcisions) provides stimulation. Since the glans is kept moist and soft by the foreskin, it too is more sensitive to touch.

Some men may have foreskins that cover nearly the entire glans, while others may only have partially covered glans. Some men are naturally circumcised -- either they're born with very little foreskin in the first place or have foreskins that fully retract beneath the glans around puberty.

Though they serve a protective purpose, foreskins can cause problems. Since the foreskin keeps the glans lubricated, it must also be kept very clean to prevent bacteria buildup. When regular hygiene is not maintained, a white cheesy discharge called smegma may accumulate beneath the foreskin. Continued poor hygiene can lead to infections and urinary tract infections.

If a foreskin is too tight and won't properly retract from the glans, it causes a condition called phimosis. This is the main medical determinant for circumcision. Conversely, if a foreskin slides down from the glans but won't properly return, that's a condition known as paraphimosis. This can cause swelling of the glans and foreskin.

Balanposthitis is a swelling of the mucous surfaces of the foreskin. If it becomes a frequent problem, circumcision may be necessary. A skin disease that affects the foreskin, glans and sometimes the urethra, balanitis xerotica obliterans, requires circumcision to prevent pain and worsening phimosis.

Sometimes the frenulum is attached too tightly (a condition known as frenulum breve), which can cause pain and discomfort when the foreskin retracts.

All of these are medical problems that circumcision can help correct. Circumcisions, though, aren't usually medically necessary. In the next section, we'll look at the history of circumcision, along with some other reasons why people may choose to circumcise.

The History of Circumcision

A Jewish man proudly shows off a boy after a circumcision in April 2001 in Jerusalem.
A Jewish man proudly shows off a boy after a circumcision in April 2001 in Jerusalem.

According to the Book of Genesis in the Torah, G­od made a covenant with Abraham (a Jewish patriarch) in which Abraham and his descendents would be given great lands, riches and success, but with one catch: Abraham, his descendants and any slaves purchased or born in his household must be circumcised by the eighth day of life. Not doing so would mean that the uncircumcised male would be separate from his people and live without the favor of God. The Jews have held up their end of the deal. Rates of circumcision remain high in Jewish men: about 98 percent of American Jews are circumcised [source: WHO].

In addition to his son Isaac, who would grow up to lead the Jewish people, Abraham also fathered a child with a slave woman in his household. This child, Ishmael, was circumcised according to God's demands but later cast out at the insistence of Abraham's son Isaac. Considered the forefather of the modern-day Arab people, Ishmael passed down the custom of circumcision to his ancestors, including the prophet Muhammad. When Muhammad's teachings were collected into the Quran, there was no directive regarding circumcision. Nonetheless, most Muslims do circumcise their sons for the simple reason that Muhammad was circumcised. Some Muslims circumcise their infant sons (traditionally by the seventh day of life), while other Muslim young men are circumcised around adolescence. Today, almost two out of every three circumcised men on the planet are Muslim [source: WHO].

Most Christian sects don't endorse circumcision, leaving the choice up to the family.

Other religions, such as Buddhism or Hinduism, don't have a stance on circumcision. Hindus, in fact, may not practice it simply because many people view it as an Islamic practice.

The history of circumcision has such a strong identification with Judaism that it's easy to think the practice got its start in the Torah, but it's believed that Jews were exposed to the custom by the ancient Egyptians, who practiced it for thousands of years before the birth of Christ. Regardless of whether the Jews taught the Egyptians or the Egyptians taught the Jews, people all over the world who had no contact with either group were practicing circumcision.

Both the Mayans and the Aztecs circumcised their male children and the practice has occurred for time immemorial by the native peoples of Australia, parts of Africa, Asia and the Americas. Ancient historian Herodotus mentioned in his writings that circumcision was practiced by Colchians, an ancient people who lived in what is now modern-day Georgia [source: Tierney].

Circumcision for medical purposes seems to have -- in modern times at least -- come into vogue in the 19th century as doctors began treating adult phimosis, although there are indications that the procedure might have been performed much earlier to prevent or treat venereal diseases [source: Dunsmuir].

In the late 19th and early 20th centuries, doctors began performing circumcisions more often, and now with anesthesia. (This isn't to say that all previous operations through history have been performed with an entirely sober and fully cognizant adult patient.) As with various patent medicines and medical beliefs of the time, circumcision was seen by some as a cure for a range of ailments, from impotence to homosexuality.

Before too long, it became a very common practice in the areas that adopted the custom. Next, we'll look at some of the customs and the people of the world who practice circumcision.

Circumcision Trends Around the Globe

An Iraqi child cries as he stands in line to be circumcised July 14, 2005 in Baghdad.
An Iraqi child cries as he stands in line to be circumcised July 14, 2005 in Baghdad.
Muhannad Fala'ah/Getty Images

Circumcision rites and procedures vary around the globe. Jews traditionally circumcise on the eighth day of a boy's life. In Egypt the procedure takes place generally anytime from birth to around 8 years of age. Malaysians prefer to circumcise when the boy is between 10 and 12 years old.

In some Muslim communities, circumcisions are performed once the boy has recited the entire Quran once, making the event a rite of passage. In other parts of the world, however, Muslims may not circumcise at all, or do so at infancy, because of long-standing tribal traditions.

Customs vary in Africa across regions, countries and tribes. Some communities circumcise at birth, while others arrange a large ceremony and treat it as a coming-of-age event. Some parts of Africa aren't frequented by trained circumcisers, so often a villager will perform the procedure, which increases the rate of infection. When a trained circumciser does travel through remote areas of Africa, it's not uncommon for a family to produce boys of many different ages to be circumcised.

The rate of circumcision is high in the Middle East and Central Asia. Countries throughout Asia that don't have large Muslim populations don't tend to practice circumcision, except in South Korea and the Philippines [source: Dunsmuir]. In South Korea, circumcision wasn't practiced until the latter half of the 20th century; some believe it's a direct result of the Koreans' proximity to American service members who were stationed throughout the country, many of whom were circumcised.

From about 1980 to 1999, 65 percent of infants born in the United States were circumcised; in 2005, that percentage had dropped to 56, where it has generally held steady since. Rates of circumcision vary across the regions of the United States: Three out of four Midwestern babies are circumcised, while only slightly more than half of all Southern babies are cut [source: Merrill]. Only about 21 percent of infants are circumcised in the West.

Hispanics are less likely than non-Hispanics to circumcise male children. The greater concentration of Hispanics in the West over the last 30 years is believed to be responsible for the regional decline in circumcision.

Falling rates of circumcision in the United States may also be related to the back-and-forth of private insurers and especially Medicaid over whether or not the procedure is covered. Insurance companies have an interest in seeing circumcision fall out of fashion. Though the cost is included in total billing for hospital births, circumcisions cost around $200. That doesn't seem like too much money, until you consider that of the 2.1 million males born in the United States in 2005, 1.2 million of them were circumcised [source: Merrill]

Next up: the big show.

Circumcision Procedure

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If you do decide to­ circumcise yourself or your son­, don't go for a discount job down in Kenya. Studies have shown that circumcisions performed in Africa with dull, unclean blades wielded by unschooled traditional practitioners result in complication rates of up to 35 percent, with 6 percent of those circumcisions causing permanent problems. To make matters worse, most of the Kenyan patients (boys are circumcised generally between the ages of 8 and 17) don't have the benefit of anesthesia.

That's the bad news. The good news is that if circumcisions are performed with clean, sharp instruments by trained professionals, the procedure itself is fairly safe and simple. Most are performed with no serious problems or complications. There is the chance that the patient may experience pain, bleeding, infection or irritation, but the most likely scenario is discomfort during the healing process.

For infant circumcision, the baby is placed on his back and his arms and legs are strapped down to prevent movement during the procedure. The baby will either have a topical anesthetic applied to the surface of the penis or have numbing agents injected into the penis or around its base.

The person performing the procedure can choose from one of several different clamps or specialized devices -- most often the Gomco clamp, Mogen clamp or Plastibell device. While there are differences in these devices, they perform the same basic function: separating the glans from the foreskin, protecting the glans, and crushing or cutting a ring of skin from the penis. The clamps provide for an immediate procedure, while the Plastibell device stays attached for several days before falling off.

If all goes as planned, the child will feel better (although probably irritable) in three to four days. The appearance of the area will improve in a week or so, but the baby can be taken home the same day as the procedure.

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An infant's newly circumcised penis must be kept very clean. Often it's bandaged or covered with gauze or petroleum jelly to prevent fecal matter in the baby's diaper from coming into contact with the still-healing penis and creating infection.

In adult circumcision, a dorsal slit is usually made (cutting from the top of the skin -- the opening -- down toward the corona, the rounded border at the base of the glans) followed by a support stitch at the frenulum. The foreskin is held away from the penis and carefully cut off. The remaining skin is then sutured around the glans. The entire process takes about 30 minutes. The patient should avoid sexual activity for a couple weeks to ensure the penis is completely healed.

Next, we'll take a look at some more arguments for and against circumcision.

Why Circumcise?

Shalom Hen, the father of eight-day-old Ofir Hen, holds his child during a circumcision ceremony by the local rabbi inside a bomb shelter on July 26, 2006, in Haifa, Israel.
Shalom Hen, the father of eight-day-old Ofir Hen, holds his child during a circumcision ceremony by the local rabbi inside a bomb shelter on July 26, 2006, in Haifa, Israel.
Christopher Furlong/Getty Images

Supporte­rs of circumcision often give the following reasons for their belief in the practice:

  • If you're raised in a culture or religion in which the majority of males are cut, then it may seem like a natural decision to circumcise.
  • Many times, the decision comes down to a simple belief that the son's penis should look the same as the father's. One study showed that nine out of 10 circumcised fathers elected to have their sons circumcised as well, while nearly 75 percent of uncircumcised men chose not to have their sons cut [source: WHO].
  • Regardless of whether or not they themselves were circumcised, some parents simply want their sons to fit in as best as possible and will make the decision based on what the majority of people in the region do.
  • Uncircumcised men are about twice as likely to be infected with human papillomavirus (HPV) and pass it along to sexual partners, resulting in higher cervical cancer rates in regions where the majority of men are uncircumcised [source: Infectious Diseases Society of America]. It also appears that circumcision helps protect against infection from chlamydia and syphilis [source: JAMA].
  • Recent studies have shown that circumcision can dramatically reduce the rate of HIV infection. According to these studies, a circumcised man is 60 percent less likely to contract HIV than an uncircumcised man [source: Timbert]. (This holds true only in the case of female-to-male transmission -- circumcision hasn't been seen to influence the rate of male-to-male HIV transmission [source: JAMA].)
  • A majority of people around the world believe that it's easier to maintain the cleanliness of a circumcised penis than an uncircumcised penis [source: WHO]
  • Some people believe that a circumcised penis is more attractive, or, more importantly, more attractive to other people.

In the next section, we'll look at some of the arguments against circumcision.

The Case for the Uncircumcised

A group advocating stopping infant circumcision demonstrates on the U.S. Capitol lawn in Washington, D.C., in March 2008.
A group advocating stopping infant circumcision demonstrates on the U.S. Capitol lawn in Washington, D.C., in March 2008.
David Hardman/Scoopt/Getty Images

There are many­ who believe circumcision is a practice that is antiquated, unethical and unnecessary, if not outright barbaric. Here are a few reasons they provide for this viewpoint:

  • It's often an unnecessary procedure. Circumcisions for infants are usually considered routine, when in fact there is often no medical reason to permanently change the child's genitals. The American Academy of Pediatrics doesn't endorse the practice.
  • Risks of the procedure include scarring, removal of too much or too little skin, and life-threatening bacterial infection. Even if it doesn't happen often, circumcisions can go wrong, resulting in permanent damage and, in extreme cases, partial or total amputation of the penis.
  • A male loses his right to choose for himself what he wants to do with his own genitals.
  • Female genital mutilation is banned in many nations around the world, and male circumcision should be viewed in the same light.
  • The health benefits of circumcision are overstated. Circumcision may drastically cut down on HIV and other STD infection rates, but so do safe sex practices.
  • Men lose a degree of sexual pleasure and stimulation when the foreskin is removed. Many unique nerve endings -- found only in the foreskin -- are lost forever.
  • A child might remember the physical pain, resulting in lingering psychological repercussions.
  • The ability of the uncircumcised penis to slide within its own sleeve provides for "nonabrasive" sexual intercourse and masturbation.
  • Some people believe the penis is more aesthetically pleasing in its natural, uncut state.
  • Circumcised men subconsciously -- and sometimes consciously -- don't feel "complete."
  • If we didn't need it, we wouldn't have it.

We'll look at some related issues in the next section.

Other Issues in the Circumcision Debate

After this girl’s circumcision in November 2004, she is shown to neighbors to prove the surgery was successful. In the background is her future husband. She will be married immediately after her healing period is over.
After this girl’s circumcision in November 2004, she is shown to neighbors to prove the surgery was successful. In the background is her future husband. She will be married immediately after her healing period is over.
Ziyah Gafic/Getty Images

Language of the Debate

Those ­who are against circumcision point out that the language of the debate is skewed toward the pro-circumcision side. For instance, using the term "uncircumcised" can lead one to believe that this is the unnatural state, or the exception to t­he rule. Anti-circumcision activists usually use terms such as "natural," "full length" or "intact" to refer to an uncircumcised penis.

Foreskin Restoration (Epipasm)

Some men who were circumcised as infants desire to return to an uncircumcised state. While this isn't completely possible, due to the permanent removal of tissue with specialized cells and nerves, men can use surgical and nonsurgical methods to recreate a foreskin:

  • Nonsurgical. One method is, over time, stretching the existing foreskin using weights, straps or manual stretching until it covers part of the glans. Another method involves inflating tiny balloons under the penile skin to prompt new skin cell growth, which will result in permanent skin gain. There are also a number of devices sold to the public that claim success in stretching out or restoring a cut foreskin.
  • Surgical. Plastic surgery may be performed in which skin from another part of the body is grafted onto the remaining foreskin of the penis. As with any elective surgery, there's the risk of infection, and the operation itself isn't cheap -- or covered by insurance. Additionally, the final result may not be the one hoped for, as the surgically attached skin may have a different color and texture than the pre-existing penile skin.

Female Genital Mutilation

Female circumcision -- now more commonly known as female genital mutilation (FGM) -- is a cultural practice performed most often in Africa and the Middle East. It involves the unnecessary removal of the clitoris or the cutting or mutilation of any other part of the female genitalia. There is no medical reason whatsoever for doing such a thing. Between 100 million and 140 million women worldwide have been victims of FGM [source: WHO]. FGM may take place at any time between infancy and adulthood, though most often it occurs before or during adolescence. It can result in severe infection, the inability to reproduce, the need for corrective surgeries and many other recurrent problems, such as urinary tract infections.

It's performed for many of the same reasons as male circumcision -- cultural norms and the belief that FGM promotes marital fidelity later in life. Several health and human-rights organizations, such as the World Health Organization (WHO) and UNICEF, are acting to increase awareness of this problem, decrease cultural acceptance in the parts of the world where it is practiced and encourage practitioners to abandon the practice.

For related HowStuffWorks articles you might like, see the links on the next page.

Related How­StuffWorks Articles

More Great Links

Sources

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  • Dunsmuir, W.D.; Gordon, E.M. "The history of circumcision."
  • BJU INTERNATIONAL, Volume 83, Suppl. 1: Pages 1-12. Jan. 1, 1999.http://www.cirp.org/library/history/dunsmuir1/
  • Farley, David. "Who stole Jesus' foreskin?" Slate. Dec. 19, 2006.http://www.slate.com/id/2155745/
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