The adult circumcision decision: why, where and how?

What is circumcision? 

Circumcision is commonplace in many parts of the world - more than 9 in 10 adult men are circumcised in 63 countries¹.

When you are circumcised, the retractable skin that covers the tip of the penis is surgically removed. This changes the way the penis looks, with the head being permanently exposed.  

This procedure has been carried out for thousands of years, often on newborn babies. This said, adult circumcision is nothing out of the ordinary anymore.

Circumcision has been carried out as a religious rite of passage for thousands of years. Today, it's also common in many previously non-circumcising cultures - and motivations can range from cultural identity to medical necessity. 

Where in the world? 

Dr Farhan Malik is medical director at Atlanta Innovative Medicine and a sexual health expert and experienced circumcision surgeon. He has seen patients undergo the procedure for many reasons: "circumcision practices vary widely across cultures, often influenced by cultural norms, views on hygiene, and religious traditions. 

"According to data, circumcision rates range from over 90% in Israel and Arab countries to just 0.1% in Honduras. Western countries like the UK and Australia have much lower rates than the US' 80.5% - around 20% and 58% respectively. Asian countries like China and Japan also have relatively low circumcision rates, under 15%²."

Why do adult men get circumcised? 

 "Speaking from my years of experience, I have found that there are a few main reasons why an adult may choose to undergo circumcision," says Dr Malik. "Ultimately, perspectives on circumcision are complex, personal, and tied to cultural values."

Medical necessity and views on hygiene 

For the US-based doctor, the most common motivations for adult circumcision are: 

• Improved hygiene - a cultural view linked to the reduced risk of the below infections.

• Lower risk of urinary tract infections (UTIs) - a significantly lower lifetime risk³. 

• Lower risk of sexually transmitted infections (STIs) - as it can reduce the risk of heterosexually acquired HIV by 60% - WHO/UNAIDS support voluntary circumcision to fight HIV epidemics⁴.   

• Correction of a tight foreskin (phimosis) - circumcision is the main treatment for a tight foreskin that causes symptoms.  

Adult circumcision to prevent other conditions 

Dr Malik says: "from interacting with my patients, I have seen a definite decrease in the medical need to circumcise adults. Conditions like phimosis (tight foreskin), balanitis, and penile cancer used to be more common, but have become less prevalent with modern treatments and preventative care."

• Recurring balanitis - inflammation of the penis head. A non-sexually transmitted infection.  

• Penile cancer - the HPV vaccine has lowered penile cancer rates. Penile cancer is still very rare.

• Recurrent balanoposthitis - inflammation of the foreskin and head of the penis. 

• Paraphimosis - where a tight foreskin has been pulled back and cannot return to its original position. If this occurs, you need to go to your nearest emergency department immediately. 

In the UK, circumcision is only provided by the NHS for medical reasons.

Religious ritual 

Then there are men who view circumcision as an important religious landmark and an outward sign of commitment to their God. Whilst the procedure tends to be carried out in infancy when boys are born into religious families, there are times when a grown man might choose this for himself. 

"For example, a man marrying into the Jewish faith may choose circumcision to align with religious tradition. Or an individual may desire the procedure to conform to social norms in their community," says Dr Malik. 

• Islam - the largest religious group to practice circumcision, typically during infancy. 

• Judaism - male babies are traditionally circumcised on their eighth day of life.

• The Coptic Christians in Egypt and the Ethiopian Orthodox Christians - this are two of the oldest surviving forms of early Christianity, when male circumcision was practiced. 

Cultural identity 

In ethnic groups around the world, circumcision has also been practiced for non-religious reasons for many thousands of years. This includes: 

• Sub-Saharan Africans. 

• Aboriginal Australasians. 

• Filipinos and Eastern Indonesians. 

• The Aztecs and Mayans in the Americas. 

• Fijians and Polynesians in the Pacific Islands. 

Most of these diverse cultures have this in common: circumcision is an important rite of passage to manhood.  

Belonging and discrimination

Circumcision is often tied up with a sense of belonging. In some cultures, there's also a dark side to this, where not being circumcised can lead to ridicule, punishment, and forced circumcisions. These aspects play out differently in cultural groups across the globe. 

What happens during circumcision surgery?

Dr Malik describes circumcision surgery as a minor operation that involves the removal of the foreskin from the penis. He explains that the method used to perform circumcision is usually different for adults and babies. Methods used for adults include:

The forceps method - more common in UK

This is one of the more common methods used for adults in the UK. The foreskin is pulled in front of the glans - the tip of the penis. Forceps are applied to hold the foreskin, which is then removed with a scalpel. The smooth surface of the forceps helps assist with a clean smooth cut, and there is minimal bleeding, if any.

The sleeve resection method - more common in US

"Here, a double-sided circumcision clamp is applied horizontally across the foreskin, crushing the tissue. A scalpel is used to remove the foreskin above the clamp. Blood vessels are heated with an electrocautery device to stop bleeding and prevent infection. The skin edges are then stitched back together," says Dr Malik.

The freehand method

This involves the foreskin being cut without the assistance of tools to secure the skin and help with precision. This will only be offered in certain circumstances where forceps and clamps aren't suitable. The cosmetic outcome can still be good, but make sure you choose a reputable surgeon who you trust.

What are the risks of circumcision surgery?  

As with all surgeries, there are some risks involved. However, the chances of a problem arising are low. The circumcision surgeon says: "proper surgical techniques and sterile conditions reduce the chances of complications. Overall, in expert hands, it is a quick and safe procedure."  

Problems linked to circumcision surgery include:  

• Bleeding. 

• Infection. 

• Pain. 

• Inflammation. 

• A poor cosmetic outcome - how the finished result looks. 

The risks are slightly higher with adult circumcision, occurring in up to 3.8% of cases, compared to 0.6% of cases with infant circumcision⁵. Nonetheless, these complications are usually mild and easily treated⁵.  

Being circumcised is a highly personal decision. There are a few things to consider, and the best thing you can do is to speak to your doctor, ask lots of questions, and become informed on all the facts before deciding.

How long does it take to recover from circumcision?  

Adult circumcision surgery takes around an hour to complete. It may take you around three weeks to fully recover, and in the first few days it's important to take things slowly. This means resting, taking pain medicines and antibiotics as instructed by your doctor, and avoiding any heavy lifting.  

Drink plenty of water, especially in the first 24 hours after the surgery. Wearing loose, comfortable underwear will also help the healing process. Make sure you keep the dressing over the area until your doctor says you can take it off. 

Further reading 

1. Morris et al: Estimation of country-specific and global prevalence of male circumcision.  

2. Data Pandas: Circumcision by country.  

3. Johansen et al: Urogenital infections and inflammations.  

4. World Health Organization: Preventing HIV through safe voluntary medical male circumcision for adolescent boys and men in generalized HIV epidemics.  

5. Morris et al: A 'snip' in time: what is the best age to circumcise?