Hot Takes
Jan 27
· Written By
Ted Handler, MD

A Jewish pediatrician’s surprising take on circumcision

Hotly debated on internet forums, banned in some, we take on the topic of circumcision from the perspective of Dr. Ted Handler.

As a Jewish man born in New York City in the 1980s, for me, the question of circumcision was never a question. It is part of my culture, heritage, and my professional training (I’m now a pediatrician). Like many things in medicine, our understanding has evolved over time. And like many parenting decisions that are discussed on the internet, two schools of thought have formed with remarkably strong opinions. 

How not to think about this decision

Spoiler alert: I don’t judge parents for circumcising or not. I have my own opinions on the topic, which I’ll share below, but if you’ve already made up your mind on the matter: I have no beef with whatever you’ve decided. 

But if you’re still trying to decide, I think my perspective might be helpful. 

Don’t make the decision based on how you think other people think your child’s penis will look.

Here are a few things I hear from parents a lot that I don’t think belong in the decision making process:

  • “I want my son to look like me.”
  • “I’m worried his future sexual partners will think it’s weird.”
  • “I’m afraid he’ll be made fun of in the locker room.”
  • “I personally think uncircumcised penises are weird/different/foreign”

I do not think it’s appropriate to try and guess how your child will think about their genitalia to make medical decisions. That’s a you thing, not a them thing. And the rates of circumcision are changing rapidly, so guessing about the population they’ll be around during sexual maturity isn’t appropriate. 

If you wouldn’t do plastic surgery on your baby to change their appearance, then I wouldn’t recommend applying these ideas to your decision-making.

In case you're wondering exactly how common circumcision is, as of 2014, circumcision rates were highest in the Midwestern states (74 percent), followed by the Northeastern states (67 percent) and Southern states (61 percent), and are lowest in the Western states (30 percent) [5]. The rate is higher in non-Hispanic White Americans (91 percent) than in non-Hispanic Black Americans (76 percent) and Mexican Americans (44 percent).

Don’t just defer to the male parent.

A lot of mothers will tell me, “well, I don’t have a penis so I don’t think it’s my decision to make.” A parent without a penis is just as well positioned to weigh the pros and cons of circumcision as one with a penis. Two-mother households are not rendered powerless in these positions. Medical decision making should always include all parents involved.

Appropriate decision-making should involve careful consideration of the pros and cons as they apply to you. It’s rare to see the pros and cons laid out in an agenda-free setting, so here goes: 

Arguments for circumcision:

Urinary tract infections

Circumcision very reliably decreases the risk of urinary tract infections (UTIs) in young children (under the age of 1). It decreases the risk by a lot: about 90% relative risk reduction in most studies. This has been proven time and time again, over tons of studies in multiple settings. It makes sense: the space between the penis and the foreskin is warm, moist, and dark, which allows for poop bacteria to be trapped, proliferate, and travel up the urethra.

This is the most significant benefit of circumcision to newborn pediatric health, but it’s worth noting that UTIs are rare occurrences for all men, even in youth. In the most conservative estimates, the incidence of UTI will be up to 14 per 1,000 infants if uncircumcised. Framed otherwise, 98.6% of uncircumcised children will not have a UTI (while 99.8% of circumcised infants will not have a UTI).

What’s the consequence of UTIs in infants? In infants with normal urinary systems (kidneys and bladder), generally antibiotics clear them without issue. In infants that have issues with clearing urine (the urine backs up into the kidney), UTIs risk permanently scarring the kidneys. 

Most pregnant parents have had the kidneys ultrasounded during pregnancy, so you’ll have some idea at birth if the urinary system is suspected to have an issue. And even then, many mild kidney issues will resolve in the months after birth. 

Penile Cancer

It’s been repeatedly shown that the foreskin is a very attractive breeding ground for the human papilloma virus (HPV). HPV is the virus that causes penile warts, as well as some penile cancers later in life. Studies show that circumcised men have about a third of the risk of penile cancer compared to uncircumcised men. But the overall risk is less than 1 in 100,000 of adult men, so the overall risk is very low. If you plan to give your child the HPV vaccine, I do not see this as a compelling reason.

Sexually Transmitted Infections

The foreskin is fragile and vulnerable to cuts, making it a good environment to transmit blood-borne sexually transmitted infections such as HIV and syphilis. It’s been proven repeatedly that circumcision decreases HIV acquisition through heterosexual sex by 50-60%. 

However, it is generally accepted that this benefit outweighs the risk only in areas where there are high transmission rates, such as parts of South Africa and Kenya.

Infections/Inflammatory Disorders

The foreskin is thin and fragile, susceptible to tears and small cuts that can become infected by bacteria that’s already present. Up to 3.7% of uncircumcised men will experience some degree of inflammation or infection, either from normal skin bacteria, fungus, or other injury to the foreskin. Additionally, infected or inflamed foreskin can become taught and restricted, a disease called “phimosis.” However, this risk is significantly decreased by good hygiene and the use of antibiotic creams or antifungals.

Cultural or religious reasons

Religion is an important driver of the decision to circumcise. In devout Jewish faith, the ritual of circumcision is one of the most important events of a young man’s life, and what defines him as a Jew. For some, the benefits of continuing a religious or cultural tradition outweigh the potential drawbacks. 

💌 Note to readers: Want to compare notes with other parents (and experts!) on how to approach the decision on circumcision? Join the community here.

Arguments against circumcision:

Opponents of newborn circumcision can have some very strong opinions! The internet is full of fairly strong arguments. 

Medical Arguments

Opponents argue that there are risks associated with the procedure which are not outweighed by the benefits, including bleeding, infection, and cosmetic injury to the penis. For instance, some approaches to circumcision can leave excess skin tags or uneven skin removal around the head of the penis, which may require surgical revision. Some exposed skin can heal to the newly circumcision glans (head of the penis), which create a bridge of skin that may need to be removed with a repeat surgical procedure.

Philosophical Arguments

Some argue that circumcision is a form of penile mutilation, and that it is unethical to remove a functional and sensitive part of the body without the individual's consent. These opponents argue that circumcision is unnecessary because proper hygiene can prevent the health problems that proponents cite as reasons for the procedure. Many argue that, if circumcision is desired by a patient, they should request it when they’re 18 years of age or older.

This is a tough one to navigate: we do plenty of surgeries on people without their consent because it is of clear benefit to their health (think children with appendicitis or a traumatic leg injury). But there are some clear distinctions between circumcision and these other surgeries. Circumcision is not performed routinely in most of the world, and most of the world does not see significant mortality from the lack of circumcision. Most of the morbidity, such as those listed above, are easily treatable in well-resourced areas. It’s worth noting that this calculation is drastically different for parts of the world with hindered access to medical resources.

Conclusion

Where do I, personally, come down on all of this? In my medical and personal opinion, while I lean slightly against circumcision, I genuinely feel that it’s a close call. I don’t care about convincing others to see things exactly the way I do—I want to help parents make decisions they feel good about. And the most important advice I can give here, aside from laying out all the facts, is: internet outrage is often inversely proportional to the moral clarity of a given issue. Just because a bunch of people get really worked up about something doesn’t mean it deserves that kind of reaction. The boring truth about circumcision? Reasonable people can disagree about what to do. Whatever your penis looks like, let’s all just get along.  

Ted Handler, MD
Ted Handler, MD

Founding Pediatrician at Oath Care and general pediatrician in the San Francisco Bay Area.