The Case for Circumcision

Two East Bay doctors stubbornly maintain that the ancient practice is the kindest cut of all

Gordy Slack, Eastbay Express, May 15, 2000

Like most men, I was interested in foreskins before I set out to write this piece, but now I think it's fair to say that I'm obsessed.

This morning I woke up with the image of detached foreskins inching out of medical waste dumps around the country and converging on roads and highways where they moved like millions of tiny headless zombies. They gathered in Sproul Plaza where they stood erect, a Mario Savio foreskin exhorting them from atop an abandoned police car. Suddenly, they broke into a chant: "The prepuce, united, will never be defeated!"

I first began to seriously wonder about the purpose and meaning of foreskins when I was faced with the prospect of having my first son’s removed. After the amazing ordeal of his birth, my wife and I agreed that the last thing we wanted to do was send him into surgery to have the end of his penis cut off. And the nurses supported our instinct; it was up to us, of course, they said, but there really was "no good medical reason" to do it. Why would we, then? Why would anyone take a perfect little boy and strap him down to an operating table and amputate the end of his dick?

Emotions run high in the delivery room. But even after I had calmed down, the idea that more than a million circumcisions take place in the United States each year seemed astonishing. That friends of mine–not many, but a few–were circumcising their boys seemed alien and brutal.

When I began researching this piece, I was about as sure as I could be that circumcision was a kind of crime against humanity: the residue, proof, and perpetuation of our culture’s hatred of sex. What evidence could anyone possibly muster in favor of the routine genital mutilation of infants? I confidently set out to see.

Well, it’s tough when, in the course of researching a story, the assumptions you brought with you are challenged. But it is even harder in this case than most, because circumcision is so politically incorrect, to say the least. Actually, among the anti-circ crowd, saying circumcision is politically incorrect is like saying that Pol Pot was impolite. continued on page 12

The Bay Area is the epicenter of the American anticircumcision movement. The National Organization of Circumcision Information Resource Centers, or NOCIRC, was begun by the country’s most vocal circumcision critic, Marlyn Milos, in San Rafael in 1979. NOCIRC now has more than 100 groups worldwide. The National Organization of Restoring Men (NORM), formerly Recover a Penis (RECAP), has its international office in Concord. Jim Bigelow, author of The Joy of Uncircumcising! Restore Your Birthright and Maximize Sexual Pleasure, lives in Pacific Grove. Tim Hammond founded the anti-infant-circumcision National Organization to Halt the Abuse and Routine Mutilation of Males (NORMAL) in San Francisco in 1992.

There is no pro-circ movement per se, but within five blocks of each other in Oakland work two of the most influential characters in a small but determined effort to get the increasingly anticircumcision world to rethink the operation’s value once again. Edgar Schoen, a researcher and clinician at Oakland’s Kaiser Permanente Medical Center, is as pro-circumcision as they come.

"Circumcision is one of the best health insurance policies you can give a son," he says flatly. "A circumcised boy has a lifetime advantage over an uncircumcised one."

Fringe quack? Not exactly. Schoen has worked as a researcher and clinician at Kaiser since 1954, and from 1966 through 1990 he was the hospital’s Chief of Pediatrics. His specialty is pediatric endocrinology, but he currently oversees the newborn-child screening program at Kaiser. In 1987, at the age of 62, in the early evening of a successful career, he was asked to chair a committee assembled by the American Academy of Pediatrics that was to develop a policy on circumcision. Thus began Schoen’s new career–as the unwitting spokesman for the pro-circ movement.

Schoen’s neat little office is in the elegant brick Julia Morgan building on Broadway that houses Kaiser’s genetics department. Only a stone’s throw from there is the small home office of Daniel Halperin, assistant professor of anthropology at UCSF’s Center for AIDS Prevention Studies (CAPS). Halperin and Schoen make an odd couple. They are at opposite ends of their careers and while the bow-tied, white-haired Schoen is meticulously groomed with glasses sparkling, pants pressed, every hair in place, Halperin is more the eccentric genius: disheveled hair, sloppy smile, intense brown eyes. While Schoen likes the symphony, Halperin has spent many a Sunday morning playing sax with the choir at the Church of John Coltrane in the Haight. While the bulk of Schoen’s career has been dedicated to a single hospital community, Halperin’s work keeps him in Africa or South America half the time. And when Schoen considers why he supports circumcision, he thinks of urinary tract infections (UTIs), hygiene, and penile cancer. Halperin thinks of AIDS.

Halperin just found out a month ago that his grandfather, as a young man in Russia and then later in Chicago, had been a fill-in mohel, performing circumcisions when the regular mohel wasn’t available. Yet he is surprised to find himself in the role of defending the practice of circumcision. He wrote his master’s thesis at Berkeley on the importance of breast-feeding. He wrote his dissertation, also at Berkeley, on Afro-Brazilian spirit-possession rituals. "I’m natural. I’m organic," Halperin says. "I’m an original Rachel Carson baby. If you’d interviewed me five years ago, I would have been inclined more against circumcision than toward it. I don’t have an agenda about foreskins; I have an agenda about the heterosexual transmission of AIDS and why it is so low in some parts of the world and so high in others. I just stumbled onto circumcision. If the x-factor had turned out to be eating spinach, I’d be dedicated to eating spinach."

The "x-factor" is what Halperin calls the long-recognized yet mysterious discrepancy in regional HIV infection rates. Why, for example, is the rate only 0.06 percent in the Philippines, while in nearby Thailand it is 2.23 percent? Both regions share most of the same risk factors: lots of sexually transmitted diseases, prostitution, a bias against condom use. "If I had a dollar for every newspaper article in the last fifteen years saying that the Philippines or Indonesia or Bangladesh will have the next Thailand-like epidemic, I’d be rich," says Halperin. "And yet today, infection rates in the Philippines are about forty times lower than in Thailand." The main reason for the difference, the x-factor, Halperin claims, may be circumcision.

Of course in the US, and especially in the Bay Area, AIDS has hit the gay community and intravenous drug users disproportionately hard. But in much of the world, especially in Africa and Asia, 80 to 90 percent of AIDS cases are transmitted through heterosexual intercourse and are not linked with drug use. There are biomedical theories about why the heterosexual transmission of HIV never exploded here, the way that it has elsewhere. But none of them seems adequate to really explain the phenomenon. Halperin thinks circumcision might have something to do with this as well.

Why would having an intact penis make a man more likely to be infected with the virus during intercourse with a woman? Both the anti- and pro-circ forces agree that the foreskin is a very specialized tissue with a very high concentration of Langerhans immune cells, which scientists now believe are the main entry portals for sexual transmission of HIV. The delicate mucus membrane of the foreskin is also much more likely to incur lesions during sex than is the rest of the penis. Lesions equal blood transfer; blood transfer equals a high danger of HIV transmission. Finally, if your foreskin is intact, the chances go up that you will get ulcerative sexually transmitted diseases such as syphilis, which are known cofactors for HIV. This probably, again, because the virus passes through open sores.

Evidence for the circumcision-HIV connection first surfaced in the mid- to late-1980s, and was most clearly expressed in a study by D.W. Cameron published in the British medical journal the Lancet in 1989. Studying 422 Kenyan men who regularly visited prostitutes, Cameron and his colleagues wanted to know who got infected and why. They looked at sexual practices, numbers of sexual partners, transfusion, various types of STDs, and a slew of other factors. Blowing away all others was circumcision. The only other really significant predictors of infection were ulcerative STDs, particularly one called chancroid, which is much more common among uncircumcised men.

The study showed that uncircumcised men had a risk of infection 8.2 times greater than that of circumcised men. Since then, at least 35 out of some 45 epidemiological studies have confirmed an association between lack of male circumcision and HIV infection. Among those are seven prospective studies, which follow subjects over time and so are better at proving causal relationships, as opposed to cross-sectional studies that just note correlations. All of these found a significant association. Only one reported an increased risk of infection in men who had been circumcised. And Halperin describes that one contradicting study as "flawed" and "weak." Whether it is or isn’t, 35 studies (including the seven important prospective ones) say it’s much more likely for a man to get HIV if he isn’t circumcised; ten studies say it may not matter too much, and only one of the 45 studies says it’s less likely.

Still more startling evidence came from a controversial study of heterosexual couples in Uganda, reported in the March 30 New England Journal of Medicine. It was a study of so-called "discordant" couples, in which one partner was infected and the other was not. This study got a lot of media attention for two reasons. First, it confirmed the hypothesis that the higher the level of HIV in an infected person’s blood, the higher the risk of passing on the virus through sex. Second, the study’s ethics were called to task because, although the researchers gave the participants in the study condoms and STD treatment, they did not treat infected individuals for HIV and they did not inform the partners of infected people about their HIV status. During about two years of observation, 90 people in the study contracted HIV from their infected spouses.

But what the press pretty much ignored about the study were its findings on circumcision. Forty of the 137 uncircumcised men in the study got HIV over the two-year period. Not a single one of the 50 circumcised men in the study was infected. Not one.

The significance of that is staggering, Halperin says. "But it was pretty much buried in the results of the study itself, and hardly anybody in the press even mentioned it."

On the one hand, this data looks bizarre, but it’s consistent with other studies such as those conducted by Nancy Padian in UCSF’s Department of Epidemiology and Biostatistics. She and her colleagues didn’t specifically look at circumcision, but they have found very, very few cases of female-to-male transmission of HIV in California, among a population born at a time when about ninety percent of males were being circumcised. In contrast, heterosexual transmission studies from Europe, where most men are not circumcised, have consistently reported far higher levels of female-to-male infection–that is, relative to here. The absolute numbers are still tiny compared to the hardest-hit parts of Africa.

This is hardly conclusive, but it suggests that the overwhelming popularity of circumcision in the US through the 1970s might be one explanation for the rarity of heterosexually transmitted AIDS cases here, especially female-to-male cases.

For the most part, even the researchers churning out these staggering results haven’t been looking directly at circumcision, says Halperin. "They just can’t ignore it. It screams out of the data. With the possible exception of heterosexual anal sex, there is probably no other cofactor that is so robust and consistent in heterosexual transmission," he says. "It may not be politically correct to say this, but even the data on condom use isn’t nearly as consistent."

While these studies have shown how much more likely individual men are to get AIDS if they aren’t circumcised, Halperin and his colleague Robert Bailey at the University of Illinois in Chicago compiled data from 28 nations in Africa and Southeast Asia that have similar risk factors for a heterosexual AIDS epidemic. All of the countries with the highest HIV infection rates matched up perfectly with the regions where fewer than 20 percent of men were circumcised. The areas where more than 80 percent of men were circumcised had much lower infection rates. Halperin acknowledges that the geographical correlation between circumcision and HIV infection rates hardly proves a causal relationship. Just because most of the people who toast marshmallows over an open fire also use sleeping bags doesn’t mean that one causes the other. However, given the preponderance of prospective studies indicating a causal relationship and compelling biological explanations for the association, the evidence for circumcision being at least a big part of the x-factor is beginning to pile up.

As I write this, I can see Halperin’s brow furrow as he breaks into his refrain: "Don’t you dare write that I think foreskins cause AIDS epidemics," he says, "any more than mosquitoes cause malaria. Mosquitoes are necessary for malaria, but not sufficient. There are lots of mosquitoes in Minnesota, but no malaria. HIV infection is a very complex thing. Yes, most men in Europe are not circumcised, and no, HIV is not raging across Europe, but that’s because of the other, also necessary co-factors"–probably most important are chronically untreated STDs–"are not present there. You need all these cofactors to get an explosive heterosexual AIDS epidemic, including, evidently, foreskins."

Conversely, Halperin says, you need to use all the interventions you can find, too. "Circumcision availability should definitely not be a replacement for condom promotion but rather a complement to it."

Having said that, he still believes that if you’re a heterosexual man, getting circumcised may go further toward protecting you from getting AIDS than any other single thing except celibacy or nearly 100 percent condom use. Alone, circumcision could not quash the epidemics in Africa or Asia, but it could potentially go further than nearly any other interventions available. And if you’re a gay man, it may go a considerable distance too.

The evidence for male homosexual transmission is somewhat less compelling, but still significant. Three studies have examined HIV transmission and circumcision among homosexuals in the US. All three show a significant relationship, though the relative risk is lower than for female-to-male transmission. Uncircumcised gay men in the US are overall about twice as likely to be HIV infected. Halperin speculates this may be because the inserter is at much greater risk if he is uncircumcised. "It makes sense that the effect is less dramatic than in heterosexuals," he says, "since we know that most gay men get infected from receptive anal sex, where circumcision isn’t going to help one bit."

But Halperin’s focus is on heterosexual transmission, and in that realm the protection offered by circumcision definitely poses much too big an opportunity to just ignore.

But we’re ignoring it anyway, he says. "Millions of people may have died because of it and many more millions stand to. The anti-circ people rhetorically ask how history will judge us for circumcising so many kids. Well, I wonder how history will judge us for allowing such a potentially powerful HIV intervention to go unexploited."


In November, Halperin and Bailey published an article in the Lancet lambasting the public-health community for ignoring circumcision in its programs around the world. The Lancet piece claims that in the ten years since the Cameron study, despite the abundance of evidence, "the association between lack of male circumcision and HIV transmission has met with fierce resistance, cautious skepticism, or, more typically, utter silence." For example, they say, the Johns Hopkins Media/Materials Clearinghouse, which has a collection of over 30,000 publications, has not a single pamphlet, poster, or flier that mentions the relationship between male circumcision and AIDS.

It’s as if you went to a lung-cancer resource center and they had nothing at all about cigarettes. What the hell is going on? Why is everyone ignoring the elephant-sized foreskin in the living room?

For one thing, Halperin says, there is a kind of "biomedical fixation" among the international health community: "The establishment is geared toward pills and high-tech treatments and now clades"–a recent and still unsubstantiated theory suggesting that different strains of HIV are more infectious among heterosexual populations. "Circumcision is too human," he says, "too ‘soft,’" Also, he says, the doctors and epidemiologists working in developing countries think of circumcision, or the lack thereof, as a given. They view the presence of an intact foreskin as if it were a genetic predisposition, not something that can be altered or influenced.

"To them it’s like saying people with brown eyes are more likely to get certain cancers," he says. "What are we going to do, give people eye transplants?"

"As an anthropologist who sees circumcision as a practice more than as a biological given, I got turned on to the idea of the implications for prevention," Halperin says.

So what are you going to do, I ask. Force African men to get circumcised?

"No. Absolutely not," he says. "Just provide access to accurate information and safe and affordable services. These guys in Africa and Asia and Latin America deserve the right to make up their own minds and to protect themselves and their families if they want to. But today, for the most part, they don’t have the information. And if they want to get circumcised, the cutting is often done by amateurs in substandard conditions."

Although American and European AIDS organizations are largely ignoring circumcision as a potential major inhibitor of HIV transmission, traditional doctors whom Halperin and Bailey have talked with in eastern and southern Africa are not. More and more, traditional healers are recommending circumcision, and private clinics in Tanzania, Kenya, Uganda, and elsewhere are advertising foreskin removal as "a way to alleviate chronic STD infection and prevent AIDS." A leader among South African traditional healers’ organizations told another anthropologist cited in the Lancet article, "When tradition and the health of our people are in conflict, it is tradition we must sacrifice."

Halperin and his colleagues have talked to hundreds of men from areas where cutting is not traditional, and they find many of them open to the possibility of getting circumcised. "For men in Africa who are at risk of dying of AIDS, keeping their foreskin is the last thing in the world they are worried about," says Halperin. In fact, he says, many of them enthusiastically embrace the idea. While parts of the American anti-circumcision movement seem to be motivated by a kind of romantic back-to-nature aesthetic, circumcision has a kind of urbane modern appeal in some parts of uncircumcised Africa.

Another reason the AIDS community has avoided looking at circumcision is because it has expected to meet with immovable resistance. Because Muslims, Jews, Filipinos, and others are all so adamant about circumcising their boys, Halperin says, AIDS policymakers just assume that people who don’t traditionally circumcise are equally adamant. But that’s entirely speculative. It took anthropologists like Halperin and Bailey to ask the cultural question: Are East Africans or Zulus or Peruvians adamant about not being circumcised?

"To a great extent, we’re finding it not to be the case," says Halperin. "Many of them are very anxious to get circumcised. If it’s done in a proper clinical setting with anesthesia," he says, "it’s safe and easy, takes about fifteen minutes, and is relatively painless. A lot of men are back at work the next day. And almost all the men I’ve talked to who’ve been circumcised as adults have said their sex lives have actually improved, not been damaged. They’re safer, hygiene is easier, and they like it better."

I ask Halperin whether his being Jewish factors into his work on circumcision. "No," he says. "At least it didn’t during the first couple years I was doing this research. I didn’t think about the Jewish part at all. I’d vaguely heard about a guy in Boston [Ron Goldman] who does a non-cutting ritual bris, and maybe that would have appealed to me, if I had a boy someday. But in recent years the Judaism aspect has crept in now and then. Some [non-Jewish and typically uncircumcised] doctors–for example, an oncologist in northeastern Brazil who has to amputate cancerous penises every week–would tell me, not knowing that I was Jewish, ‘Those Jews were so smart; thousands of years ago they figured out this way to prevent health problems.’ That was one of the things that began to spin my head around from thinking of this as a savage ritual from the dark past to thinking of it as maybe a kind of health/ cultural innovation ahead of its time." Of course, the Egyptians and probably others were doing it before the Jews, though probably not to infants. "So I guess it has made me appreciate my own heritage more. And who knows, maybe finding out to my surprise that my own granddad was an occasional mohel was a weird kind of confirmation that I’m maybe in some small way ‘destined’ to help pass along this health benefit to people in parts of the world where it could really make a difference and perhaps save many lives."

Edgar Schoen traces the anticircumcision movement in the United States back to a single sentence. In 1971, the American Academy of Pediatrics (AAP) published a booklet called Care of the Newborn, which concluded, "There is no valid medical indication for newborn circumcision." "No valid medical indication" means, basically, "no good reason."

Schoen’s voice rises and tightens when he tells me that the only citation for that sentence was an editorial called "Rape of the Phallus," and it wasn’t exactly scientific. "No documentation," he says. "It came right off the top of someone’s head. Basically, it was a mistake. Even then, there was plenty of good evidence that circumcision had health benefits."

Since then, the medical evidence has become "overwhelming." But, Schoen says, the pediatrics establishment has remained anti-circ or, at most, noncommittal. He attributes this both to the growing anti-circ bias in the general population (which is fueled in a feedback loop with the AAP’s statements), and to the fact that neonatologists, the doctors who work strictly with newborns and who were very influential in the AAP’s early prouncements, have a blind spot when it comes to circumcision.

"They don’t see the long-term effects," says Schoen. "They never see a baby after it leaves the nursery. They don’t see the urinary tract infections that show up three months down the line, let alone penile cancer or the STDs that show up decades later. But if there are any problems with circumcision, they do see them. For them, circumcision is an annoyance. They have to keep the baby a little longer. Yet they were the ones leading the committees making the official statements…. The wolves were in charge of the sheep here."

A turning point in circumcision research came in 1987, and an unlikely character brought it about. Tom Wiswell, a neonatologist at Walter Reed Army Medical Center in Washington, DC, was an outspoken critic of the practice. When a report from Texas showing abnormally frequent urinary-tract infections (UTIs) in the first year of life among uncircumcised boys came across his desk, Wiswell set out to shoot the foreskin explanation down. He employed the Army’s huge database on 200,000 boys to look for an association between circumcision and UTIs in the first year of life. To Wiswell’s surprise, his study showed uncircumcised boys to be about 20 times as likely to have UTIs as their circumcised counterparts. He looked at the data every way he could. There was simply no denying it. It was a conversion experience.


Largely motivated by Wiswell’s findings, the American Association of Pediatrics was moved to put together a Task Force on Circumcision to look at the issue, and in late-1987 they appointed Schoen to head it. The task force looked at every available study and paper on the issue. In addition to the UTI research, there was strong evidence –some of it reaching back to the 19th century–that penile cancer was prevented by circumcision. There are only about 1,200 cases of penile cancer a year in the US, virtually all of them among uncircumcised men. It is far more common in the developing world where circumcision is uncommon and hygiene is poor. Wherever it occurs, it is a horrible disease, often leading to amputation and death.

The task force also concluded that circumcision significantly reduced the chances of contracting a variety of STDs. Then there was the nascent HIV research, later reviewed by Halperin, which was still unpublished at the time of the task force’s publication but already suggested something potentially profound. In addition, the task force found that circumcision reduced the chances of a variety of other local infections and dermatological problems.

On the downside, the task force acknowledged that circumcision was painful. Doctors conducting the surgery were just beginning to use local anesthesia at the time, and though this was known to be effective at eliminating the pain, no studies had yet been done on its long-term effects, so the task force didn’t want to sanction it. Also on the downside are the complications that sometimes arise during and after the operation itself. There are some celebrated cases of major botch-jobs, including inadvertent amputations, but these are so rare as to be statistically irrelevant, says Schoen. He and his committee described even the most common of complications as "infrequent and minor."

Schoen pushed for concluding that the advantages of circumcision outweighed the disadvantages. But the neonatologist on Schoen’s committee wouldn’t go along. "Before we even started, says Schoen, "he said, ‘We’re never going to change these recommendations.’ He didn’t contest the data, but like most of these guys, he just didn’t like circumcision. The report required consensus, so they settled on a compromise: they would neither encourage nor discourage cutting. Instead, they would simply recommend that parents look at all the evidence and decide for themselves.

In the eleven years that have passed since the publication of Schoen’s 1989 Task Force on Circumcision Report, more studies have surfaced in favor of circumcision. Nine more studies on UTIs, including one conducted at Kaiser by Schoen himself, have confirmed the circumcision connection. The average risk ratio for these studies suggests that an uncircumcised boy is ten times more likely than a circumcised boy to contract a urinary infection in his first year. And other research suggests that those early infections may lead to renal scarring and possibly hypertension and kidney dysfunction later in life.

"Since about one percent of baby boys gets UTIs, the number who suffer from them later in life may be quite substantial," says Schoen. Schoen also led his own penile cancer study, showing that over a ten-year period uncircumcised men at Kaiser were 22 times more likely to get invasive penile cancer (the deadly form) than cut men. Then there is the HIV research and the documented decrease in sexually transmitted diseases that comes with circumcision. Meanwhile, too, anesthetic techniques for numbing the pain of the operation have been shown to be safe as well as effective.

So in the decade between 1989, when Schoen’s task force report was published, and 1999, when the AAP released its next report on the subject, the medical justification for circumcision took a significant leap. "All the benefits of circumcision we thought were there were confirmed, and HIV protection and protection against other infections were added. Plus, the pain issue is over. When the operation is done using local anesthesia, it doesn’t hurt the baby." Yet the AAP’s 1999 report, which accurately reviews all the evidence, reaches a curiously more anti-circ conclusion than its predecessor, stating that "newborn circumcision is not recommended" and that the procedure is "not essential to the child’s current well-being."

What a difference a sentence can make, Schoen says. If you read the whole report you’re overwhelmed by the advantages. If you just read the conclusion, it sounds like a negative recommendation.

If the child’s "current well-being" were the standard applied for all medical procedures, writes Schoen in an article critical of the 1999 report in the March issue of the AAP journal Pediatrics, "then we would only provide care for acute and chronic illness, taking us back to nineteenth-century medicine on the eve of the 21st century." If doctors are only worried about "current well-being," then "what about immunization, preventive dental care, and nutrition aimed at future health, none of which are essential to current well-being?"

It’s understandable that Schoen feels gypped. He thought the anti-circ movement’s claim that there is "no medical justification" for circumcision was the key issue and that if he could confirm that there were important medical benefits, he’d have the battle won. And he did prove it. But apparently, a big part of the battle was elsewhere. The no-circ movement may have been sparked by the "no medical justification" claim, but that’s not really what it is about. Proving that there are good medical reasons for circumcision is necessary to quiet the growing reluctance of parents like myself to circumcise their kids, but it is not sufficient. Being an old-fashioned nuts-and-bolts type of doctor, Schoen just cannot wrap his mind around this. After summarizing the evidence to me for what must be the fifth time, he throws his hands up in the air: "How much evidence would be sufficient?"

At the conclusion of a grand rounds presentation Schoen gave to other physicians at Kaiser in April, he held up an issue of the glossy Foreskin Quarterly magazine that featured a huge snake wrapped around a muscular, naked, intact man. "This is what I’m up against," he said.

To Schoen, the prepuce is just a little piece of skin prone to infection. But to men in the foreskin restoration movement it represents nature, wholeness, and freedom from authoritarian control. And to the parents of newborns it can represent the hope that their boys will help to usher in a less brutal era than our own. People in the men’s movement see it as something on which to hang their grief, and they have adopted the "amputation of their penis" as a poignant symbol of society’s abuse. The debate goes on over the foreskin, singular, but Schoen and his opponents are mostly talking about entirely different things.

I find consolation in Halperin’s suggestion that more available information–in Africa, Asia, and the Americas–combined with openness toward elective circumcision later in life might be the key to reconciliation, to getting the best of the anti-circs’ human-rights righteousness and the pro-circs’ health benefits. Circumcisions later in life cost up to ten times as much, and the benefit of avoiding first-year UTIs may be lost (though Halperin says that use of more breathable cloth diapers for uncircumcised boys may compensate somewhat). But the really big advantages–fewer cases of HIV, other STDs, and penile cancer–are still gained. It also leaves room for aesthetic preference and personal choice to weigh in, too. Who knows–my boys might hate the decision my wife and I made for them. And they may be angry with us for leaving them intact. But then, if they choose, they can get back at us by cutting off their own foreskins. It could be like piercing their nipples, only healthier. If they want, I’ll even pay for it.