© Gemma Tickle at East Photographic

Today circumcision is among the most common surgeries in the US: an estimated 1.2 million infants are circumcised each year, at a cost of up to $270 million. Its popularity has fluctuated since the peak of the 1970s; the CDC’s most recent estimate puts the current rate at 60 per cent of newborns. This may in part be because the American Association of Pediatrics (AAP) for a time equivocated over the issue. But in 2012 the AAP announced that benefits of circumcision outweighed the risks, suggesting that rates may rise again.

Yet whether it’s 60 or 90 per cent of American men who are circumcised, what’s more remarkable is that American parents are almost alone in the Western world in their desire to separate boys from their foreskins for reasons other than religion. This difference of opinion is decades old. It began in 1949, when a British paediatrician and scientist named Douglas Gairdner published the first investigation of the rationale for circumcision in English-speaking countries. He found the procedure to be unwarranted.

Phimosis, the condition Sayre held responsible for so many neuroses, was essentially a non-issue, said Gairdner. He discovered something that had somehow gone undocumented before: that most foreskins remain unretracted well into the toddler years. Phimosis is the natural state of the penis, Gairdner concluded. (Later work would confirm that the foreskin sometimes does not fully retract until the teenage years.) This was just the beginning. Gairdner showed that balanitis and posthitis, forms of inflammation that were considered cause for circumcision, were uncommon. He found no data to show that circumcision could prevent venereal diseases and little evidence for a lesser risk of cervical cancer. Cleaning the intact foreskin would do as much to thwart penile cancer as would removing it, he added.

At the National Health Service, which was founded a year before Gairdner’s paper appeared, officials heeded his advice and refused to cover circumcision unless it was medically necessary. By 1958, the circumcision rate in the United Kingdom had fallen to close to 10 per cent. Excluding British men who are circumcised for religious reasons, the rate is now 6 per cent or lower.

The situation is much the same elsewhere in Europe. The Victorian focus on circumcision was concentrated in English-speaking countries, and its popularity never spread. When European experts examine the evidence, they generally see no reason that it should. In 2010, for instance, the Royal Dutch Medical Association reviewed the same studies the AAP looked at. Aside from preventing urinary tract infections, which can be treated with antibiotics, it concluded that the health benefits of circumcision are “questionable, weak, and likely to have little public health relevance in a Western context”.

How can experts who have undergone similar training evaluate the same studies and come to opposing conclusions? I’ve spent months scrutinising the medical literature in an attempt to decide which side is right. The task turned out to be nearly impossible. That’s partly because there is so much confused thinking around the risks and benefits of circumcision, even among trained practitioners. But it’s also because, after reading enough studies, I realised that the debate doesn’t have a scientific conclusion. It is impossible to get to the bottom of this issue because there is no bottom.

Assessing the true risks of circumcision is the first challenge. Immediate complications are usually easily treatable, and also relatively rare – the AAP report states that problems like bleeding and infection occur in up to 1 in 100 circumcisions. But the frequency of later problems is less well understood. Some studies find few; others conclude that as many as one in four patients suffer some kind of complication after the surgery and subsequent wound healing. The possible late problems are many. The remaining foreskin tissue can adhere to the penis. The opening of the urethra may narrow, making urination painful and preventing the bladder from fully emptying, which in turn can lead to kidney problems. Craig Adams, the New Jersey protester, had to have surgery to correct such a problem when he was five years old. Lauren Meyer’s first son had surgery for the same reason when he was three. Other late complications include a second surgery to correct an incomplete circumcision, a rotated penis, recurrent phimosis, and concealment of the penis by scar tissue, a condition commonly known as buried penis.

The AAP acknowledges some uncertainty surrounding the data on risks, but not in a way that a parent looking for advice is likely to fully grasp. “The true incidence of complications after newborn circumcision is unknown,” the AAP’s recent report states. But complications are risks. “They’re saying, ‘The benefits outweigh the risks but we don’t know what the risks are,’” says Brian Earp, research fellow at Oxford University’s Uehiro Centre for Practical Ethics. “This is basically an unscientific document.”

The debate about the effectiveness of circumcision can be just as convoluted. One way of thinking about this is the number needed to treat (NNT), a figure that answers the question: how many people need to be treated with this approach in order to prevent one illness? For the ideal treatment the answer is one. But penile cancer is rare and circumcision doesn’t provide complete protection against it, so around 900 circumcisions are needed to prevent a single case. That’s a very high NNT. By comparison, 50 people need to take aspirin to prevent one cardiovascular problem.

It’s also worth noting that other preventive methods can have a greater impact on penile cancer. The American Cancer Society suggests avoiding smoking, for example. The same logic applies to sexually transmitted diseases. Studies show that circumcision reduces the chances of a man contracting herpes, for example. But the risk of this and every known STD can be stopped or at least dramatically reduced by correct and consistent condom use. “The benefits can all be obtained in other ways,” says Adrienne Carmack, a Texas-based urologist who opposes routine infant circumcision.

Even the premise behind this debate – that the usefulness of circumcision can be determined by weighing the risks and benefits – is questionable. A drug for a deadly disease has a lot of leeway in terms of side-effects. Cancer patients are willing to endure chemotherapy if it means they get to live, for example. But when the person is healthy and too young to weigh the risks and benefits themselves, the maths changes. “Your tolerance for risk should go way down because it’s done without consent and it’s done without the presence of disease,” says Earp.

These uncertainties undermine the case for circumcision. They don’t completely destroy it though. Even after the criticisms are factored in, circumcision does bring some benefits, such as reducing the risk of urinary tract infections in young boys. What the uncertainties do is raise questions about whether those benefits justify the procedure. And this is where an evidence-based approach breaks down. Because the procedure results in the loss of something whose value cannot be quantified: the foreskin. If you view the foreskin as disposable, circumcision might be worth it. For those who see the act as the removal of a valuable body part, the reverse is likely true.

More than the medical data, it’s these unquantifiable feelings about the foreskin that shape doctors’ thinking about circumcision, or at least that of male doctors. Because when it comes to medical opinions on circumcision, the foreskin status of the opiner matters. A 2010 survey in the Journal of Men’s Health found that close to 70 per cent of circumcised male physicians supported the procedure. An almost identical fraction of uncircumcised physicians were opposed. The AAP Task Force behind the 2012 statement was made up mainly of men, all of whom were circumcised and from the US, where newborn circumcision is the norm. “Seen from the outside, cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious,” wrote a group of European physicians in response to the AAP.

It’s also likely that most of these critics were not circumcised. “We never deny that we are from a non-circumcising culture,” said Morten Frisch, lead author of the response and an epidemiologist who studies sexual health at Statens Serum Institut in Denmark. “While we claim that the US view is culturally biased, the opposing view from the AAP was that it’s us who are culturally biased, and to an extent they are right.”

These cultural divisions make it nearly impossible to sort through the medical literature. Rather than clarifying, the debate gets bogged down in accusations of poor research and bias. Brian Morris, a molecular biologist at the University of Sydney who is an outspoken proponent of circumcision, recently circulated a 23-page critique of a study by Frisch. The Danish researcher’s work was “an ideological rant against male circumcision”, said Morris, who asked colleagues to complain to the journal that published it. In response, Frisch called out Morris for citing his own “pro-circumcision manifesto” as source material for his critique and, in a video response on YouTube, said that Morris had accused “us of racism and dishonesty and all sorts of things… in order to have the editors reject the paper”.

“Both sides tend to be highly selective on which bits of evidence they want to quote,” says Basil Donovan, an epidemiologist focused on sexual health at the University of New South Wales and a community-based infectious disease physician. Professional discussions have become so heated that Donovan rarely participates. “I stay out of the area,” he said. “I want to have a life, I don’t want people bombing the front door.”