Regardless of pediatricians' attempts to negate routine newborn circumcision, U.S. circumcision rates remain constant. This study hypothesized that, because circumcision is usually a maternal choice and the circumcised penises are perceived by young women as more attractive, most women prefer circumcision for sexual reasons.

Of 145 new mothers of sons responding to this survey, 71-83% preferred circumcised penises for each sexual activity listed.

Visual appeal and sexual hygiene were predominate reasons for favoring circumcised sexual partners. Even among women having sexual experience only with uncircumcised partners, only half preferred uncircumcised penises for sexual partners. Eighty-nine percent of the sample had had their sons circumcised. This study furthers debate over whether circumcision decisions should be based solely on medical considerations limited to the newborn period.

In spite of recent attempt by the American Academy of Pediatrics and other organizations to persuade the public to abandon the practice of routine newborn circumcision, new parents have continued to request the procedure at the same high rates. In the United States, approximately 75-90% of newborn males are circumcised, compared to only 10% of Europeans and 20% of males in general worldwide.

One survey of 200 women concerning their maternal attitudes circumcision revealed that mothers were not giving medically valid reasons for having their sons circumcised, and the authors concluded that health care providers needed to do a better job of educating parents about the medical risks and benefits of the procedure.

Even after other researchers launched extensive programs to inform prospective parents about the lack of "absolute medical indication" for circumcision, no significant change in the rate of newborn circumcisions could be observed in targeted samples. Parents within the United States who do not have their sons circumcised report the main reason is cultural. That is, most are a part of a subgroup, often Hispanic, that traditionally does not circumcise.

Only 10% of the subjects who choose to leave their sons uncircumcised cite being convinced on the basis of reading or on physician's advice.

It has been demonstrated that mothers more than fathers usually decide whether to have their sons circumcised. Although informed consent for circumcision now includes information on how easy it can be to give proper penile hygiene to an uncircumcised baby, mothers persist in their desire to have their male infants circumcised. This trend is particularly noteworthy within the current financial context in which many third party payers deny coverage for newborn circumcisions.

Review of the Literature and Conceptual Framework

Controversy characterized the history of circumcision.

Circumcision has existed since the Stone Age for unknown reasons. In earliest written records documenting its use, religious beliefs required that the male foreskin be removed as an outward display of faith and membership in the group.

In some cultures, circumcision signified a boy's entrance into manhood. In whatever setting, the uncircumcised were looked down upon for being pagan or unmasculine.

Later, the European elite class made circumcision exclusive privilege in the Victorian era. This notion persisted even into the early twentieth century as evidence that a man had been born into a situation where the luxury of circumcision could be afforded.

Circumcision has not solely been a status symbol, however. Within certain circumstances it was a necessity. Entire armies found themselves immobilized by balanitis, a painful inflammation under the foreskin due primarily to lack of access to bathing facilities. Societies that live in arid, sandy environments where water is precious learned long ago about the merits of circumcision.

Even today, hygiene can be so difficult within some segments of the health care system, such as in institutions for the elderly or the mentally handicapped where patients may resist personal hygiene care, that circumcision eventually has to be performed to prevent infections or other complications of the foreskin.

Inadequate penile hygiene, which is more likely in uncircumcised men, is resurfacing again as a predictor of carcinoma of the penis. After the proclamation by the American Academy of Pediatrics against circumcision, studies have since begun reporting a relationship between uncircumcision and the incidence of urinary tract infection in male children.

Other complications, especially balanitis, bring about significantly more medical visits for uncircumcised boys than for penile problems in circumcised boys. Good hygiene, which itself can be difficult for even the best intentioned parents, does not entirely eliminate these problems.

It is argued, therefore, that pediatricians have an incomplete perspective in the current debate over whether circumcision for newborns is necessary. Furthermore, medical indications and contradictions aside, insight into the cultural and sexual rationale for why the American public and American women in particular prefer circumcision is missing. Social reasons for circumcision, when conceded at all, are dismissed by medical personnel as being unjustifiable existing "scientific" proof.

In addition, arguments that cite historical fallacies about circumcision fail tests of logic when posing as premises for concluding that circumcision for any reason is wrong.

The debate on medical grounds seems to miss a major portion of the reasoning, though. In the face of the current campaign against circumcision, why is it still requested at such high rates? What motivations do American women have for wanting American males to be circumcised?

In a study by Bean and Egelhoff of 277 new mothers of sons, 78% reported favoring circumcision even before becoming pregnant and having to make a conscious choice affecting a son, and 91% ultimately decide to have their newborn son circumcised. Even those woman whose husbands were uncircumcised overwhelmingly opted for circumcision.

The reason must seem important enough to woman for them to withstand pressure from physicians and others who oppose circumcision. Brown & Brown go as far as to say that "the circumcision decision of the United States is emerging as a cultural ritual rather than the result of medical misunderstanding among parents".

One idea that has been overlooked is that the penis is a sexual instrument, not just a passageway for urination. For example, circumcision at puberty in nonliterate cultures is in some ways a sexual recognition of the emerging man. The permanent exposure of the glans of the penis renders it a sexual tool.

Most research conducted previously on the reasons newborn males are circumcised fails to include a reference to the perceived sexual appeal of a circumcised penis over an uncircumcised one.

Typical lists of reasons from which the subjects could choose offered only hygiene, religion, father's or sibling's circumcision status, and other traditional explanations. At the most, an "Other" category included in some surveys caught untold thoughts on the perceived advantage of circumcision. Without the inclusion of sexual attitudes toward penis type on such a list, respondents would typically hesitate to spontaneously present sexual rationale favoring circumcision, particularly in reference to a newborn penis.

Admitting to sexual desires and preferences is difficult enough for subjects even in straightforward studies. Without the researcher conceding the possibility, it is not likely a mother would volunteer information about her hopes for her son's future sexual attractiveness.

It was not until a study on cultural values associated with the decision to circumcise, in which Harris used unstructured interviews, that the sexual overtones of newborn circumcision were explicitly reported. One of her findings was that a circumcised penis has a certain "cosmetic appeal," that in America the exposed glans is more pleasing aesthetically.

She concluded that circumcision could be an acceptable practice based on cultural values, and that the health care delivery system could be a more "perceptive cultural broker" with regard to honoring a society's view of beauty.

In asking various groups about why circumcision may be indicated, a few surveys have included a response category labeled "cultural," which may have been construed by some subjects to include sexual attitudes.

One such study found that significantly more obstetricians than pediatricians believed that the culture was a valid reason for neonatal circumcision.

What the concept of culture means, though, is that to many Americans circumcision seems to be normal because that is what they are accustomed to seeing. This could certainly be true, in that what people are used to is what they prefer.

This cultural perspective brings circumcision into a new arena, one in which the rigidity by some health professionals fosters alienation and resistance. Some go so far as to say that opting for circumcision indicates an emotional response that is not based on rational decision making.

A study of female preference for certain male body parts showed that 89% of woman students at a southern college preferred pictures of circumcised penises over uncircumcised ones.

This is as close as the literature comes to facing the persistent preference by American women for circumcision, as best displayed by new mothers of male infants. To date, no study has explored the possible sexual motivations behind circumcision, however.

It was the purpose of this investigation, therefore, to determine if women, particularly mothers who recently made a decision about circumcision of their newborn sons, do indeed prefer circumcised sexual partners, and if so, for what reasons. This study hypothesized that most American woman prefer circumcised penises in their sexual relations, a factor unrelated to the purported lack of medical indications for the procedure.

Women 18 years of age and older who delivered full-term healthy sons within the previous month at a major midwest medical center comprised the targeted sample. Candidates for the study were chosen during a 6-month period based upon their willingness to participate in an earlier study that dealt with who and what influenced their decisions to circumcise or not circumcise their babies. The sample had been randomly selected and 85% made up the group to whom questionnaires were mailed for this study.

Of the 269 women who received the questionnaire, 148 returned their forms yielding a response rate of 55%. Three were unusable, yielding a final sample of 145. Due to the explicit sexual nature of the questions, this rate compares favorably to the other research studies investigating such personal sexual issues.

Because there had been no previous data collection tool seeking this type of information, it is necessary to first confirm the content validity through it's review by several experts. The survey instrument was tested on a pilot group of women who gave subsequent feedback about its clarity and the completeness of the response options available from which to choose. By comparing the outcome of this questionnaire to certain items on the previously conducted study on the group of 269, it was also possible to establish the reliability of the individual subject's responses over a period of time.

The survey was highly personal, asking the women about their own sexual experiences with men and about their preferences for circumcised or uncircumcised penises for various sexual activities. No reference was made to the women's decision to circumcise their own sons or not.

This survey dealt entirely with adult sexual experiences and preferences in order to distinguish the two issues and allow for correlational tests between their choices as parents and their attitudes as sexual adult women.

Each subject had received a thorough review of circumcision at the hospital when deciding about their son's candidacy for the procedure. Each was also shown drawings of both uncircumcised and circumcised penises. It was assumed, therefore, that the subjects knew what circumcision meant and what types of penises their sexual partners had. Lay terminology was used in each question. Prior to implementation of the study, all procedures and tools received approval by a human research subjects' rights board. Confidentiality was guaranteed to the subjects and was maintained throughout the study.

Results

Most of the newborn sons of mothers in the sample had been circumcised (89%). This percent is similar to the circumcision rate prevailing in the geographic area at the time of data collection.

Of the women in the sample, 83.7% were married, 12.8% were single, and 3.5% were separated, divorced, or widowed.

By race, 97.9% were Caucasian, 1.4% were black, and 0.7% were Hispanic. Another characteristic consistent with the midwest population generally was religion: 46.1% were Protestant, 21.3% were Catholic, 29.1% claimed no religion, 0.7% were Jewish, and the remaining 2.8% listed other religions.

The group was well educated. All but 12.7% had finished high school and 25.3% had at least some higher education. Fourteen percent had finished college. There was a weak correlation between higher education and the choice to circumcise the newborn (rpb =3D 0.27).

In response to the question "With which penis types have you had sexual experience?", 16.5% revealed that they had had sexual contract with both circumcised and uncircumcised men. Only 5.5% had sexual experience exclusively with uncircumcised sexual partners, and the remainder of the sample was sexually experienced only with circumcised men.

The responses to "If you could choose anyone for your ideal male sex partner, which circumcision type would you prefer he have for the following activities?" as shown in Table 1. There was a strong correlation between the circumcision status of her newborn son and a woman's ideal male partner's status for the purpose of intercourse (phi =3D 0.86)m, and a moderate correlation for visual appeal (phi =3D 0.50).

To investigate any possible relationship between the circumcision status of one's father or brothers and the preferred type of ideal sexual partner, correlational tests were made on those subjects who knew whether these family members were circumcised. No similarities were found that could be attributed to childhood exposed to penises of either type (phi =3D 0.12 for fathers and 0.06 for brothers).

It was interesting to note that 22% of the sample did not know whether their fathers were circumcised and of those who had brothers, 9% did not know whether they were circumcised.

TABLE ONE

71 6 23

Looking at to Achieve sexual arousal

Giving manual

penile stimulation

Giving Fellatio

It could be surmised that some women prefer circumcised penises because that their sole experience in sexual contacts.

However, of the group with dual experience (N =3D 24), two-thirds favored circumcision exclusively and a significantly greater proportion preferred circumcised partners for all the sexual activities listed in Table 1 (p < 0.01).

Among those women who had sexual experience only with uncircumcised partners (N =3D 8), their past was more clearly correlated to their preferences. For each of the sexual activities presented, approximately half of this sub-group desired an uncircumcised penis and the other half said that penis type did not matter.

Evidently, almost any sexual exposure to a circumcised swayed women to sexually prefer circumcision. That is only 1% of the entire sample consistently preferred uncircumcised partners for all sexual activities, and those subjects came entirely from the group which had had sexual experience only with uncircumcised penises.

When asked "Why do you prefer one penis type over another for sex?", subjects were instructed to mark all options that applied to them.

Among those preferring a circumcised penis, the reasons they indicated appeared in the following ranked order from most frequent to least:

Stays cleaner (92 %)

Looks sexier (90%)

Feels nicer to touch (85%)

Seems more natural (77%)

Smells more pleasant (55%)

Stays softer (54%)

It was fascinating to find that so many women thought a circumcised penis seemed more natural, probably meaning to them "familiar" within the American cultural context.

Among those preferring an uncircumcised penis, most also stated that to them it looked more natural, but no one in the entire study thought that an uncircumcised

Among those preferring an uncircumcised penis, most also stated that to them it looked more natural, but no one in the entire study thought that an uncircumcised penis looked sexier.

Overall, the factor correlating most strongly with whether the newborn son was circumcised was the subject's favorite penis type for sexual intercourse. There was little or no correlation between the newborn circumcision decision and demographic factors including race, upbringing, or sexual experiences.

Conclusions

This study clearly support the hypothesis that American women prefer circumcision for sexual reasons. The preference for circumcision does not necessarily come out of ignorance nor from lack of exposure to uncircumcised men.

Even when women grow up with uncircumcised fathers and brothers, or have uncircumcised sexual partners, the majority of such a group still prefer circumcised sexual partners.

Women state a preference for circumcised penises particularly for sexual activities like fellatio, but also for intercourse, manual stimulation, and visual appeal.

They say that this is primarily due to circumcised penises being cleaner and looking sexier.

The cleanliness of circumcised penises within the sexual context means something different from cleanliness as a hygiene factor to prevent balanitis and other complications.

To a sexual partner, cleanliness is important because the penis tastes, smells, and looks more appealing. Spontaneous sexual activity is more likely to be enjoyable with a man who is circumcised, because bathing efforts last for longer periods of time. For the uncircumcised, washing under the foreskin must be attended to frequently to prevent the accumulation of any smegma, whereas in the circumcised male, the constant exposure or the coronal ring and the glans to air prevents the build up of odors and secretions.

Of almost equal importance to cleanliness of the penis for sexual activities is the visual attractiveness of a circumcised penis. What is sexier about a circumcised penis?

Perhaps visualizing the glans, the urinary meatus, and the corona without them being hidden under a foreskin is arousing. After all, such is the appearance of an erect penis, and sexual imagery of the erect penis involves exposure of the glans.

While the foreskin of an uncircumcised penis can be retracted, the circumcised penis exists in exposed beauty whether flaccid or erect. Furthermore, in some uncircumcised men the foreskin can actually detract from the visual appeal of the penis. American producer of erotic films and publishers of photographic literature are careful, for example, on those rare occasions when uncircumcised models or actors are used, to select penises with foreskins that are smooth and free from extra wrinkled skin. Particularly to the unaccustomed eye, a puckered or wrinkled foreskin can lack sexual appeal.

These findings suggest that the decision to have a new-born son circumcised may not be significantly affected by increasing the already rigorous efforts to explain the supposed lack of medical indications. While many mothers may not consciously view their sons as sexual beings, many may opt for circumcision with the belief that the son will be more sexually attractive to his future sexual partners, based on how they themselves feel. Future research can address this issue within a different cultural setting where most males are uncircumcised.

Newborn circumcision need no longer be performed without local anesthesia, silencing the outcry against circumcision as a form of "barbarism". Removal of the foreskin may be viewed as preventive care, not unlike procedures done in other areas of health care (such as the extraction of asymptomatic wisdom teeth).

The opponents of circumcision argue in return against the imposition of such a decision without the affected newborn male's consent. In response, those favoring circumcision point out that the many men who later want or need to be circumcised face a major surgical procedure that would have presented only a minor inconvenience if done as an infant.

Circumcision has, therefore, now become a much broader issue than one that can be dismissed on such narrow grounds as those proposed by the American Academy of Pediatrics. Not least among the considerations is the worth of sexual preference for male circumcision within the American culture as a valid reason for continuing the practice.