Anita Rao
There's often a moment that comes right before I submit to the force that is the Google rabbit hole. I think to myself, is there any other way to figure this out? And luckily, when I'm seeking medical information, the answer is yes. Instead of WebMD, I pick up the phone and text my sister, my dad or both. Dr. Rao and Dr. Rao, I have some questions. So when an email came into the Embodied inbox asking us to do a show on circumcision, the first step in my research was a conversation with my sister. Between her professional work as a pediatrician and the fact that she's the mother to a 4-year-old boy, I was certain she would give me the rundown. Apparently, my brother-in-law had the same thought.
Amit Gupta
The decision to circumcise was an introduction to parenting before we were even parents. I remember hoping that my wife, a pediatrician, would have the correct answer, or that there would be a medically correct answer, but I realized there wasn't one. And ultimately, the decision was a personal one, and just the first of many that we as parents have to make to the best of our ability.
Anita Rao
That's Amit Gupta, I'm Anita Rao and this is Embodied — our show about sex, relationships and your health. Circumcision is the most common surgical procedure for people assigned male at birth in the U.S. Infant circumcision is more common in this country than many places around the world and done for a wide variety of reasons. But if you're a parent feeling unsure about this decision, where do you turn? If you start on the internet, you'll quickly find yourself twisted into a pretzel. Because while information is abundant, clarity is not.
Dr. Emilie Johnson
We have to accept the fact that circumcision is both a cultural decision and has a medical component. You cannot fully disentangle those issues completely. I will say, as a medical professional, I try to be as open and honest as possible about what we know and what we don't know.
Anita Rao
A medical professional that has no trouble being upfront about the unknowns? That is our kind of person. Dr. Emilie K. Johnson is an associate professor of urology at Northwestern University. She's done a lot of research into neonatal circumcision around the country and tracked the evolving thinking around the procedure over time. While circumcision rates in the U.S. are much higher than in a lot of other industrialized countries, they've been declining since the 1970s.
Dr. Emilie Johnson
Historically, the circumcision rates in the United States have been high. I think mostly for cultural reasons. And now we see huge variability by the region of the United States, the ethnic and cultural background of the family. And, I think, some of the decline that we're seeing over time really reflects the changing demographics of the United States. Additionally, there are some changes that we're seeing due to more education about the procedure itself. For many years, I think in some families there was, just, the assumption that if a boy was born, this would be part of the routine after the child arrived. And there are some parents that are questioning that dogma and doing more talking, and listening, and contemplating before, sort of, having it be an automatic decision for circumcision to be performed.
Anita Rao
The history around circumcision rates in this country is pretty fascinating. And if you listened to our vibrator episode, you're not going to be surprised to know that physicians in the Victorian era thought circumcision was important both for cleanliness and as a cure for masturbation. The procedure gained a lot of popularity during World War II, when the U.S. Army encouraged it as a way to protect against sexually transmitted infections. Circumcision rates peaked in the mid-1900s, but what exactly the medical establishment says on the matter has always been a bit murky. The American Academy of Pediatrics has remained relatively neutral, releasing updated guidelines over the decades — culminating with the most recent statement in 2012. It says that the health benefits of elective circumcision outweigh the risks of the procedure, but that the health benefits are not great enough to recommend routine circumcision for all male newborns.
Dr. Emilie Johnson
I will say that the statement was put out many years ago, and there are some groups that have called for an update to this statement, or perhaps questioned the statement altogether. But there are definitely documented medical benefits of circumcision. In particular, circumcision does reduce the risk of urinary tract infections in the first year of life. And later in life, circumcision basically eliminates the risk of penile cancer and reduces the risk of some sexually transmitted infections.
Anita Rao
So you've said that some folks have asked for an update. Why is that? Is there a new research that's come out since that statement that has changed the calculus a little bit?
Dr. Emilie Johnson
I think there's some new research that has come out. And also, there are folks that feel that the medical benefits are not strong enough, or that the research has not been best contextualized within the, sort of, risk rates in the United States to be fully applicable. For example, a lot of the studies done on HIV risk were actually not performed in the United States, so the data presented in studies may not be totally applicable to the United States context.
Anita Rao
Got it. So if someone comes to their pediatrician, they can get that, kind of, general outline of the medical information, but the pediatrician is going to say, "Ultimately, I can't weigh in heavily one way or the other. This is your decision."
Dr. Emilie Johnson
I would say, typically, that's very true. You know, we present the risks and benefits and any specific information that we might know that would be applicable to that child. But yes, ultimately, the decision to perform a circumcision in the newborn period is really up to the parents.
Anita Rao
So as a physician and researcher, you have paid really close attention to particular health trends around the country — including how accessible neonatal circumcision is — and you've documented some emerging health care disparities. I'd love for you to take us into those and what you found.
Dr. Emilie Johnson
Sure. So in my early days as an attending here in Chicago, I noticed that in some of my clinics there would be a group of patients coming in — usually six months of age to about two years of age — whose parents wanted them to have a newborn circumcision. But for some reason, they were unable to have their child circumcised in the desired time period. And when that happens, typically, that means, if the family still wants a circumcision, it's a surgical procedure under general anesthesia, rather than a procedure done under local anesthesia in the hospital or in the clinic. And the short story is that certain hospitals, just, have a difficult time with capacity. And also, patients who are publicly insured, and often who are Black or African American, tend to have a harder time accessing newborn circumcision procedures. What we've found over the years is there's probably a lot of reasons for this, including insurance reimbursement, resources of the hospital, but it tends to be folks who are having trouble accessing health care in general who also have trouble accessing this procedure at times.
Anita Rao
What are the particular concerns you have for parents who do want neonatal circumcision that don't have access to it? What does that mean for their kids and their health?
Dr. Emilie Johnson
Most importantly, I think there is a health benefit of circumcision. And if the family knows that they want this procedure, yet there's a delay, the child doesn't receive as much of the medical benefit. Because, for example, the reduction in urinary tract infection risk is, really, most dramatic in the first year of life. I also worry because it's a burden on a family. There are multiple visits, the child has anesthesia — general anesthesia — when they otherwise wouldn't, and it's more of a burden on the healthcare system.
Anita Rao
I'd love to end with you on, I guess, stepping out one more layer and talking about this topic of circumcision. I mean, as we've referenced throughout the show, it has become increasingly controversial, increasingly heated. And, I'm wondering how that has informed your work as a provider.
Dr. Emilie Johnson
As a pediatric urologist, I would say I have a relatively neutral view of the procedure — except for when it comes to children with very specific urologic issues. And so I really see my role as providing information, providing a safe, high-quality procedure, if together, the family and I have decided that this is the right procedure for their child. And doing the health services research and health care delivery research to make sure that we are performing this procedure in the best, most equitable way possible for children in the United States.
Cynthia
My son was born a preemie. And when he was born, he was so little, and I was so scared. We talked about circumcision, but we decided, finally, to not do that. Mostly because it is an elective, rather cosmetic type of surgery, and we just didn't see the need to put our little preemie son through that. We figured he could make a decision when he was an adult if he wanted to have a circumcision. We feel very comfortable with that decision. Our son is now 20 years old, and he's never mentioned any issues from it, and never has complained that we didn't do the right thing.
Anita Rao
That was a listener named Cynthia. Not all parents are so certain that they're doing the right thing, and it's not just because of the muddy medical guidelines. For those in the Jewish and Muslim communities in particular, circumcision is also tied up in faith, tradition and spiritual values. Islamic circumcision rituals vary widely based on region, country and family preference, but almost two-thirds of circumcised people around the world are Muslim. In Judaism, circumcision is part of a ritual ceremony called a bris, that's been carried out for thousands of years.
Rabbi Elyssa Cherney
The word "bris" is actually Yiddish, and I would say a abbreviation of what is known as brit milah. Brit milah itself means the sign of the covenant, and this has been a part of tradition since the biblical days of Abraham. And it's really about that sign between God and God's people. Mainly males are commanded to circumcise their sons at eight days old.
Anita Rao
Rabbi Elyssa Cherney is a Philadelphia-based faith leader and the founder of an organization called "Tackling Torah" that aims to support younger Jewish folks through big life moments — like having a kid and making a decision around whether or not to perform a bris.
Rabbi Elyssa Cherney
A lot of the work that I do is with interfaith families. And in families where they have more than one religion present, it's not necessarily a given whether they choose to circumcise their son or not. Part of my job is to talk parents through that, and I think one of the major factors that plays a role is whether the parent themself is circumcised as well. So if there is a male partner, they very much want their children to either be in line with what they experienced, and if they are uncircumcised, that becomes a larger question — to circumcise their son when they themselves are not. And if they are circumcised, they want to continue to have their children be circumcised, often so that the children see themselves represented in the parent as well.
Anita Rao
So how do you work with these interfaith couples? I come from an interfaith family myself, and I know that one of the things that gets really sticky for us often is, kind of, differentiating rituals for the sake of rituals from the meaning behind a ritual and what the ritual is trying to represent. And for my father, you know, doing the actual ritual is really important. And for me sometimes, as an interfaith person, figuring out what the meaning is so I can reflect that in a way that feels better to me is, kind of, where I land. So talk to me about how you counsel folks through that. If they want to move away from, maybe, the specific ritual, but keep the idea behind the tradition. Is there a way to do that with a bris?
Rabbi Elyssa Cherney
The main reason that I counsel couples in this decision is to say, what are you looking to have happen when you are welcoming your child into community? What is the meaning behind the ritual for you? And if the ritual of circumcision itself is not meaningful to the family, then I'm going to talk to them about what rituals would be meaningful. So there are a few different ways that we — in both the Reconstructing Judaism movement and other liberal Jewish movements — have thought about how to create meaningful ceremonies to welcome children into this covenant without circumcision being the key piece. I have three or four different ceremonies. One is thinking about the child as living Torah. So the child themselves as being able to teach us so much about life, and reflecting on meaning and being able to see the world anew through a child's eyes. We might wrap them in a prayer shawl called a tallit and pass them down through the generations. Another piece might be using the power of water. So ritually washing a baby's feet. There are several instances within the Torah itself that talk about that welcoming aspect of water, so that's another ritual piece. And one that families have really embraced over time is also awakening the child's mind and body to the five senses. And so I use various items, ritual items like a candle, or singing a song, smelling some of the spices that often get used in ritual moments, to, just, awaken the child to their cultural, religious traditions.
Anita Rao
So there are so many different options that you are offering to people if they're choosing to, kind of, forego the circumcision all together. For you, as a parent, when your son was born, you all did decide for him to be circumcised, but not necessarily in the traditional way a bris has been done. So talk to me about that, and how you all came to that decision.
Rabbi Elyssa Cherney
It actually goes back a little further because when I had my daughter, who's now 7, we waited to share her name until we did a communal naming. And we did that in a synagogue. And when it came time to have our son, we did not know his assigned sex at birth, so we were not sure if circumcision would be something that we would have to make a decision about at that time or not. But we very much, just, felt that we wanted to have a naming at a later date and, just, have something smaller and closer to home. And we decided, if we were to have a bris with a mohel, we would not be able to have just a few people in our home. And so it was more about our decision to have a slower transition for ourselves as a family.
We did, however, get him circumcised in the hospital. And I would say that that experience for us personally was challenging because when a child is circumcised in the hospital, it is generally done in the nursery and not something that you can be present for. And a lot of the traditional pieces — you're with your child when the circumcision is happening. And that just feels emotionally different for new parents to be present or not present for a medical procedure that's happening. I think for many rabbis — and different denominations within Judaism in the United States — I think that a bris is really a given. And it's really only amongst the most liberal rabbis who are having this discussion. And for me, it's come about because families are saying, do I have to do this? Will my child be welcomed? And I consider myself a rabbi to meet people wherever they are at. I also think about families that need that sense of acceptance for whatever decisions they make. And to me, there are so many aspects of Torah that we're not always upholding. And so, questioning circumcision is another one of those pieces.
Erik
We read the research, and the risks and the benefits both seemed really insignificant. And when you remove those, it turns it into, basically, a cosmetic surgery. And because I'm circumcised, the question becomes, do we want his penis to look like mine? The more I asked myself that question, the sillier it felt to have an irreversible surgery done on a day-old infant to make his penis look like mine. I know that there are protective elements to getting a circumcision, but the current research suggests that that protection is very insignificant. It just doesn't seem worth it. And I know that there are a lot of men who were circumcised who wish that they hadn't been. I wanted to give my son the opportunity to make that decision himself. I think it's a lot more difficult to go back once you've been circumcised than working the other way around.
Anonymous Parent
I found it was really hard to find clear, science-backed information that was recent, and relevant and wasn't, you know, dripping with medical bias. So finally, I punted the decision to my husband and told him I would go along with whatever he decided. And his thinking was that he didn't know any guys who were angry at their parents for deciding to circumcise, but he also knew a couple of guys who wished their parents had done the procedure when they were newborns. It's a tough one, but we, kind of, went with the information that we had. And I am sure he will tell me in at least 10 years if we made the right choice, and hopefully he'll understand.
Anita Rao
That's Erik and a parent in Johnston County, North Carolina. As I said at the very top of the show, the whole reason we decided to take this topic on in the first place was that we got a note from a listener who was curious about what people consider when making the circumcision decision. So when our producer, Kaia, came across an article in her research called, "To Circumcise Or To Not Circumcise: A New Father's Question," she had to follow up.
Chris Silva
Some of the feedback I got on Twitter when I posted the article was calling me out for that. Like, you're not even a real man, you know, if you're — if you're worried about, you know, your son looking like you, in terms of, like, the shape of your penis.
Anita Rao
Chris Silva is a father that was bold enough to write about his circumcision decision reflections in the New York Times. It has been seven years since that piece came out, and in it, he laid out the twists and turns in his and his wife's decision making. Their story started with an emergency C-section at 27 weeks of pregnancy. His son was a surviving twin, and for the first few months of parenting, all focus was just on making sure he was growing and healthy. After a long stay at the NICU, he was transferred to the children's hospital, and that was the first time the question of circumcision came up.
Chris Silva
They were talking about doing a hernia surgery. And they said, "Hey, look, when we go in for the hernia surgery, we can also do the circumcision. You know, we can do a two-for-one, and, you know, give it some thought." And so, without really thinking twice about it, I was like, "Sure, let's do it." As it turned out, he went into the surgery, they were successful with the hernia surgery, but they came out and they said, "Hey, look, you know, because of his size and his prematurity, you know, we thought about doing it, but, you know, let's make this an outpatient thing if it's something you still want to go through with."
Anita Rao
So you got the information that your son was too small to circumcise, and it gave you some extra time to think about the decision. And you ended up having a conversation with a friend that really changed your thinking on the subject. Tell me about that conversation and what changed for you.
Chris Silva
So I was talking to a friend — my friend, Brooks — at the time. And, just, the topic of baptism came up — I don't even know how. And I just remember talking about how strongly I felt that, you know, I was not going to baptize my son. You know, I had been baptized, Catholic school for 12 years. Not really a practicing Catholic — I like to say a recovering Catholic — and he goes, "Okay, that all sounds good. You know, what else is going on?" I'm like, "Oh, well, there's this circumcision thing." And, and he's like, "Well, so, what's your thoughts on that? And I'm like, "Well, you know, I'm going to — I'm circumcised, it was done to me." And he's like, "Okay, well, you're not going to have the holy water sprinkled on his head, but you'll easily just let someone, you know, snip his penis, essentially." And, yeah. And the way he put it, I was like, oh, wow, I have not thought this through at all. Meanwhile, you know, my wife was the one who did have reservations. When the hernia surgery was a success, and they said, "You can go back in for outpatient," she was the one who raised the alarm of like, "I don't know about this, but, like, I'll still leave it in your hands." So it was only really then that I thought, man, do I really want to go through with this? And it kind of set us off down the research path.
Anita Rao
So you went on this path of discovery, kind of, trying to figure out, okay, what are my reasons? Why do I feel strongly about this? And some of the things that you wrote about in your piece are things that we've heard echoed by a lot of parents including, what does it mean for my son to have a penis that doesn't look like mine? What was that worry for you, and why do you feel like that was such a sticking point?
Chris Silva
Man, you know, it's funny, because looking back on that, I shake my head. I'm like, wow, I was an incredibly — I guess it was a self-conscious belief or thing to be going through at that time — just, to be worried that, hey, he's not going to look like me, you know, down there. And that's really what it was. It was as basic as that. And I mean, I guess, I could say it was a little shallow, right? Like, I mean, what really is it to just have privates that look the same as my son? I mean, that's all there was to it. And again, I didn't go deep, deep down the rabbit hole of medical research, but just enough, right? I had spoken to a pediatrician and had done some Googling, just to see. I mean, the data was, like — it just wasn't that significant in terms of, like, the reasons for or against. And you take that coupled with, you know, the fact that my wife was having these second thoughts. I'm just like — and back to my conversation with my friend — I'm like, well, what's really the point here? It kind of is, just, like a cosmetic thing. And we just ultimately decided that he's born the way he's born. Let's just, like, leave it be, right? Like, why change anything?
Anita Rao
So you — obviously, you came in with strong convictions, you were beginning to sift through that and questioning like, oh, maybe I don't feel as strongly as I thought I did, or I don't know why I did. Is there a resource that you wish you'd had access to? Or a person or people that you felt like you wish you could hear their perspective?
Chris Silva
Yes. I mean, I do wish that I had other very close dad friends in my life at that point. I think I had many single guy friends or friends who were married, but not with kids. Someone who I could really talk this through with, that would have been helpful. I honestly don't know if another piece of research would have done anything. I think at that point it's, like, you know, you read a couple of reports, they all sound the same. But it would have been nice to, like, be able to, just, like, get real with, like, another dad who you're comfortable with to talk this stuff through with, you know?
Anita Rao
Totally. The rabbi we spoke to earlier was saying that so many parents just want to feel like the decision they make is okay. So even just having, you know, someone to reflect that back to you or share in that experience seems so important to people. And I'm curious about as you, kind of, went forward — you all made that decision, and you began to raise your son — were there things that you thought about to prepare your son for interacting with his body that are informed by him not being circumcised and you knowing experience only of being circumcised?
Chris Silva
Yes. Well, really only in terms of just, like, general hygiene, like, caring for it, really. And that's the only thing I really have gotten to so far. You know, he's 8 years old right now, the topic's maybe came up once or twice in that time with him. And so yeah, outside of hygiene, there really hasn't been any other consideration or thought on my end.
Anita Rao
How has the topic come up between y'all?
Chris Silva
Yeah, it's funny, it didn't come up directly with me. This was something that happened with him and my wife, and it happened during bath time. I believe he was probably around, maybe, 5 years old. And, you know, she just likes to remind him, "Hey, remember, you know, like, make sure we rinse and gently wash your penis." And she used to call it, like, the penis pocket, right? Like, you've got the pocket, you've got to take care of it. And, you know, for a 5-year-old kid, it sticks, right. So he remembers that that's what it is. And truthfully, I don't recall if it was my son or my wife who brought it up, but somehow, like, "Well, Dad's penis looks different, right?" And I believe it was my son, and I think my wife asked, "Well, do you know why that is?" And she went on to just, like, plainly explain to him, "Well, there was a surgery that your dad had when he was a baby, and it's called circumcision. And they cut part of his penis, so he doesn't have a pocket. Dad doesn't have a penis pocket."
And, you know, my son's response was that of shock — from what my wife told me. I'm not sure if there's any horror involved there, but I think he was moreso curious about like, "Well, what did they do with it? Like, what did they do with that piece of skin exactly?" And I'm like, of course, that's totally the mind of a 5-year-old. And I think my wife was just like, "Well, they just discarded it. They just got rid of it." And I think that left him more floored than anything — like, they just cut skin and got rid of it, like, that's all. And so yeah, that's as far as it's really gone. But you know, I mean, we try to be an open family in terms of how we talk about our body and sexuality and things of that nature. I don't want to grow up with anyone having any type of shame, right? Like, that's something my wife and I are very adamant about. And so, I mean, he sees me in the bathroom, and really, it's never come up.
Anita Rao
What advice would you give to parents who are currently in the thick of it, trying to figure out what way to go? What would you tell them?
Chris Silva
I would say don't do it alone. I would say, find someone you can talk to — another parent. I think, you know, the internet is — there's no shortage of information to give you enough tools and research to make some type of informed decision, but really, it does come down to your gut. And I think, like, you know, find someone who's been there and done that — whether they've decided to circumcise their son or not. You know, it's good to bounce it off of other people, and it's probably the biggest thing I wish I did back then.
Anita Rao
Do you have a guiding model for yourself as a parent when you're coming up against these decisions where there's not really a right answer, but you want to feel like it's okay to land where you land? Is there something that you keep coming back to?
Chris Silva
That it's not about me, right? Like if I can put my fears and my biases aside, I can remind myself that whatever choice we do we're making on behalf of our children. And are you going to feel confident and comfortable with the decision you make — knowing that in five, 10, 15, 20 years you might get some questions about it. So I would say it's, like, how can you put your own biases aside, right? And put what's best for the kid, kind of, top of mind, I would say.
Anita Rao
Embodied is a production of North Carolina Public Radio-WUNC, a listener-supported station. If you want to lend your support to this podcast and WUNC's other shows on demand, consider a contribution at wunc.org now.
This episode was produced by Kaia Findlay and edited by Amanda Magnus. Paige Perez is our new Embodied producer, Madison Speyer is our intern and Jenni Lawson is our sound engineer. Quilla wrote our theme music.
Check out the show notes in this week's episode for more on the history of circumcision in the U.S. — you can find some of the best resources we came across while putting together this episode.
If you have a topic you want us to cover or thoughts about a recent episode, leave us a message at our virtual mailbox: SpeakPipe. You can find a link to it in the show notes.
Until next time, I'm Anita Rao, taking on the taboo with you.