One man in three
About 37 to 39% of men worldwide are circumcised, 1.2 billion, two thirds of them for religious reasons (Muslims and Jews, where the rate is close to 100%). Rates by country tell of cultures: over 90% in the Philippines (the tuli, a rite of passage around 10–12), in South Korea (a custom taken from the Americans after 1945, over 75% of young men), in Israel, North Africa, Turkey, West and East Africa; 58% of newborns in the United States (down from 65% in 1979, with wide gaps: 75% in the Midwest, 40% in the West); 30% in Canada (higher in Ontario and the Prairies, low in Quebec and BC); about 20% in the UK (mostly older generations and Muslim and Jewish communities; under 10% of newborns); 10 to 15% in Australia and New Zealand (down from 80% in the 1950s, still high among Māori and Pacific communities); near-universal in Nigeria, Ghana, Kenya (except the Luo), Uganda among Muslims and some peoples; a rite of adulthood among the Xhosa of South Africa's Eastern Cape, with dozens of deaths each year in unhygienic initiation camps; India mainly among Muslims (about 13%), Pakistan near 100%; below 5% in the Nordic countries, Spanish-speaking Latin America, China and Japan.
Three reasons, and what medicine says of each
- Religious: the Jewish brit milah on the eighth day of life, by a mohel; the Muslim sunnah, recommended rather than prescribed by the Quran, between 7 days and puberty depending on the country; the Coptic and Ethiopian Churches practise it too.
- Cultural or hygienic: United States (generalised at the end of the 19th century for reasons of hygiene and "morality", then by hospital routine), Korea, Philippines, southern and eastern Africa.
- Medical: true phimosis (a foreskin that does not retract after age 5–6 and causes problems, or lichen sclerosus), paraphimosis, recurrent balanitis; as first-line treatment, a steroid cream and gentle retraction resolve 80% of childhood phimosis without surgery. A small boy's adherent foreskin is normal until at least 3 and must never be forced.
Established benefits: about a 60% reduction in the risk of acquiring HIV for a man during heterosexual intercourse (three randomised trials in South Africa, Kenya and Uganda, 2005–2007) — hence the WHO-UNAIDS voluntary medical circumcision programme, which has reached 35 million men in 15 countries of southern and eastern Africa since 2007; lower transmission of HPV and herpes, fewer penile cancers (already very rare) and cervical cancers in partners; ten times fewer urinary infections in the first year of life (but they are rare: 1%). It does not protect against gonorrhoea, syphilis or chlamydia, nor the receptive partner, and does not replace condoms. Paediatric bodies diverge: the American Academy of Pediatrics (2012) finds the benefits outweigh the risks without recommending it for all; the Canadian Paediatric Society (2015) and the Royal Australasian College of Physicians do not recommend it routinely; the Royal Dutch Medical Association (2010) and the Danish Medical Association (2016) oppose it without medical reason; the BMA leaves it to parents with safeguards; the WHO recommends it only in high-HIV-prevalence countries.
Complications
Done well, newborn circumcision has 0.2 to 0.5% complications (bleeding, infection), that of an older child or an adult 2 to 4% (haematoma, wound separation, too much or too little removed, meatal stenosis in 5 to 10% of cases after early circumcision, adhesions). Serious accidents — partial amputation, fistula, sepsis, death — are exceptional in a medical setting (under one in 100,000) but very real outside it: traditional razor circumcisions in southern Africa kill dozens of young men each year (over 800 deaths in the Eastern Cape since 2006 according to the South African authorities); in New York, ritual oral suction of the wound (metzitzah b'peh, practised by an ultra-Orthodox minority) transmitted herpes to infants (some twenty cases and two deaths between 2000 and 2017); mass circumcisions without sterilisation transmit hepatitis and HIV. Loss of sensitivity is debated: contradictory studies (Sorrells 2007 versus Bossio 2016) conclude at most a small difference, but a circumcision that is too tight can make erection painful. For an adult, the operation takes thirty minutes under local or general anaesthesia, healing four to six weeks without intercourse.
What the law says
- United Kingdom: legal on a minor with the consent of both parents (the courts have ruled that one parent cannot impose it against the other, Re J, 1999); not funded by the NHS without medical reason; the GMC requires proper training, anaesthesia and record-keeping; community programmes supervised by the NHS (Birmingham, Bristol, Leeds) followed accidents in home circumcisions; several prosecutions of unregulated practitioners. Ireland: legal; a 2005 death in Waterford led to guidelines requiring a doctor.
- United States: legal everywhere; Medicaid no longer covers it in 18 states, which has lowered rates; the AAP requires analgesia; a proposed San Francisco ban was struck from the ballot in 2011 and California then prohibited local bans. Canada: legal, not covered by provincial plans (Ontario stopped in 1994, Quebec in 1970). Australia: legal, public hospitals no longer perform it without medical reason (since 2007 in most states), Medicare still rebates it. New Zealand: legal, not publicly funded.
- Germany: after the Cologne court ruled in May 2012 that religious circumcision was bodily harm, the Bundestag passed in December 2012 § 1631d of the Civil Code: lawful if done according to medical standards, with anaesthesia, by a doctor (or, in the first six months, by a trained person appointed by a religious community). Sweden (2001 law): only by a doctor, or by a licensed person before two months, always with anaesthesia; Norway (2015): public hospitals must offer it, a doctor must be present; Denmark: legal, the medical association has recommended since 2016 to wait for adulthood, a petition to ban it was rejected by Parliament in 2018 and 2020; Iceland: a 2018 ban bill was dropped; Finland: tolerated by the Supreme Court (2008), a non-medical ban promised by the government in 2023 has not been passed; the Council of Europe (resolution 1952, 2013) called it a violation of physical integrity, without binding effect. No country in the world bans it.
- South Africa: the Children's Act 2005 bans circumcision under 16 except for religious or medical reasons, and requires consent and counselling over 16; the Eastern Cape regulates initiation schools (Customary Male Initiation Practice Act 2021) after hundreds of deaths. Kenya, Uganda, Zambia, Zimbabwe, Botswana, Namibia, Tanzania, Malawi, Rwanda: WHO-supported medical circumcision offered free, with the Shang Ring and PrePex devices for adults. Nigeria, Ghana: legal and near-universal, mostly neonatal, increasingly medical. India, Pakistan, Bangladesh: legal, religious; mass free camps in Pakistan.
Making it safe
A trained practitioner, a clean place, sterile single-use instruments, systematic anaesthesia (cream and penile block in infants, general in children aged 2 to 12, local in adults: untreated newborn pain is documented and leaves traces), a suitable technique (Plastibell, Gomco or Mogen in infants, conventional surgery afterwards), written aftercare instructions and a number to call; never during an infection or with an anomaly of the penis (hypospadias), never without asking about bleeding disorders in the family. And if the reason is neither religious nor medical, most European learned societies suggest waiting until the boy can decide for himself. Female "circumcision" is not comparable and is a crime throughout the English-speaking world: see Female genital mutilation.