Nedarim 31b ~ Great is Milah

נדרים לא, ב

רבי ישמעאל אומר: גדולה מילה שנכרתו עליה שלש עשרה בריתות. רבי יוסי אומר: גדולה מילה שדוחה את השבת חמורה. רבי יהושע בן קרחה אומר: גדולה מילה שלא נתלה לו למשה הצדיק עליה מלא שעה. רבי נחמיה אומר: גדולה מילה שדוחה את הנגעים. רבי אומר: גדולה מילה שכל המצות שעשה אברהם אבינו לא נקרא שלם עד שמל שנאמר "התהלך לפני והיה תמים" דבר אחר גדולה מילה שאלמלא היא לא ברא הקב"ה את עולמו שנאמר כה אמר ה' אם לא בריתי יומם ולילה חקות שמים וארץ לא שמתי

R. Ishmael said, great is [the precept] of Milah (circumcision), Since thirteen covenants were made concerning it.  R. Jose said, circumcision is a great precept, for it overrides the strict laws of  Shabbat. R. Joshua b. Karha said: great is [the precept of] circumcision. For [neglecting] which Moses did not have [his punishment] suspended even for a single hour. R. Nehemiah said, great is [the precept of] circumcision, since it supersedes the laws of Nega'im. Rabbi said, great is circumcision, for in spite of all the commands that Abraham fulfilled, he was not called complete until he circumcised himself, as it is written, “walk before me, and be complete.” Another explanation: great is circumcision, since but for that, the Holy One, Blessed be he, would not have created the universe, as it is written, “but for my covenant (בריתי) by day and night, the laws of Heaven and Earth I would not have established." (Nedarim 31b).

Non-Religiously Motivated Circumcision

Medical circumcision is widely practiced in the US where the rate of male newborn circumcision is about 55%, down from a high of about 62% in 1999. (This change may be due to an increase in the Hispanic population, which is traditionally non-circumcising.) In Europe the rate varies greatly by country. In Britain about 16% of male babies are circumcised; in Denmark, the figure is less than 2%. Worldwide, about one-third of all male boys are circumcised by the age of fifteen.

In 2012 the Task Force on Circumcision of American Academy of Pediatrics reviewed the scientific literature about the health benefits of male circumcision.  The Task Force concluded that “the preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure.”  However, these health benefits were not enough for them to recommend circumcision as a routine procedure for all male newborns - and this position is also held by Britain's National Health Service.  What then, are the health benefits of male circumcision?

Global prevalence of male circumcision.  From  Male circumcision: global trends and determinants of prevalence, safety and acceptability .  World Health Organizations and the Joint United Nations Program on HIV/AIDS, 2007. 

Global prevalence of male circumcision. From Male circumcision: global trends and determinants of prevalence, safety and acceptability. World Health Organizations and the Joint United Nations Program on HIV/AIDS, 2007. 

In the pluralistic society of the United States, where parents are afforded wide authority for determining what constitutes appropriate child-rearing and child welfare, it is legitimate for the parents to take into account their own cultural, religious, and ethnic traditions, in addition to medical factors, when making this choice.
— Technical Report: Male Circumcision. American Academy of Pediatrics. Pediatrics 2012; 130 (3): e756-785.


Sexually Transmitted Diseases – including HIV

In 2005 the first study on the role of circumcision in protecting against HIV infection was published. The study was run in South Africa, where over 3,200 men were randomized to circumcision or no-circumcision. The study was stopped early when an interim analysis showed that HIV infection was 60% lower in the circumcision group. Male circumcision prevented six out of ten potential HIV infections. This was a remarkable finding.  In fact the study team commented that male circumcision provided an equivalent degree of protection against acquiring HIV infection “to what a vaccine of high efficacy would have achieved.”

And male circumcision is not just protective against HIV. It decreases the transmission rates for human papilloma virus (HPV) and herpes simplex virus 2 (HSV-2) in female partners, and the balance of evidence suggests that it also protective against syphilis. (But it doesn’t seem to protect against the two most common sexually transmitted diseases in the US – chlamydia and gonorrhea.) A team from John Hopkins University School of Public Health predicted that if neonatal circumcision rates in the US would fall to European levels of about 10%, the result would be an additional $500 million in healthcare costs. Over a ten year period, there would be more than 4,000 new HIV infections in men and more than 125,000 new herpes simplex infections.

With an estimated cost per infection averted in the range of $150 to $900 over a 10-year period (depending on the local incidence of HIV infection), male circumcision appears to be one of the most cost-effective preventive approaches, requiring only a one-time intervention.
— Piot and Quinn. Response to the AIDS Pandemic - A Global Health Model.New England Journal of Medicine 2013. 368;23. 2210-2218

Urinary Tract Infections and Phimosis

Male circumcision also protects against urinary tract infections – but according to the Task Force you’d have to circumcise about 100 babies to prevent one such infection. Phimosis (an inability to retract the foreskin) and other inflammatory problems of the penis are either absent or much reduced in circumcised boys:  “From ages 1 through 8 years, the rates were 6.5 penile problems per 100 circumcised boys over the study period, compared with 17.2 penile problems per 100 uncircumcised boys.”

Penile and Cervical Cancer

Penile cancer is rare, but cervical cancer is not.  Male circumcision reduces the risk of penile cancer by about 50%, and it seems that it also reduces the odds of cervical cancer in the man’s partner (especially if he has had six or more lifetime sexual partners.)

The Risks from Male Circumcision

There are of course risks associated with the procedure of male circumcision itself, but these are rare.  A recent study reviewed 1.4 million male circumcisions and found only 16 cases in which an adverse event occurred, although ten of these were serious.  Overall, the procedure is very safe when properly performed in the first year of life, but complications rise up to twenty-fold if the procedure is performed after infancy. (It goes without saying that the dangerous practice of metzizah  be-peh should never be performed.)

What about life after a safely performed circumcision? Does that change? One recent Belgium study of more than 1,000 men,  “circumcised men reported decreased sexual pleasure and lower orgasm intensity. They also stated more effort was required to achieve orgasm, and a higher percentage of them experienced unusual sensations (burning, prickling, itching, or tingling and numbness of the glans penis).” A Danish study found a similar result: “circumcised men …were more likely to report frequent orgasm difficulties…and women with circumcised spouses more often reported incomplete sexual needs fulfillment.” These were however, individual studies, and in 2013, the Journal of Sexual Medicine published an exhaustive meta-analysis of 36 publications describing the effects of male circumcision on aspects of male sexual function. It found no evidence overall "for any significant difference in components of sexual function, sensitivity, sexual sensation, or sexual pleasure in men who are circumcised and men who are not." Furthermore, it examined several studies of men circumcised in adulthood, which are of particular research interest since these men serve as their own control.  In this group too, the meta-analysis failed to find any adverse effect of circumcision on the parameters examined. 

The Costly Investment of Brit Milah

The medical benefits of male circumcision are well documented, and its risks are small. But none of these benefits were known to those who first introduced the ritual, and anthropologists wonder why circumcision, and other painful and irrevocable rites of passage, should be so common across cultures.  One possible answer comes from the theory of costly investment.

This is based on the finding that religious, ethnic and tribal groups that demand more from their members do better in the long run than those that demand less. These groups have to insure that all members contribute equally, and that there are no “free-riders” – those who are taking from the group but not giving back. One way to weed out the free-riders is to demand a costly and irrevocable investment in order to join the group – and that investment might be circumcision, tattooing or scarification, all of which are used as a means to induct new members. Once the costly investment is made, a person will be less likely to leave the group. Joseph Henrich (from the departments of Psychology and Economics at the University of British Columbia) has a term for these investmentscredibility enhancing displays (CREDs):

Participation in rituals involving costly acts will elevate people's degree of belief commitment. If the professed beliefs involve group commitment, cooperation toward fellow in- group members, or the hatred of out-groups, then ritual attendees will trust, identify and cooperate with in-group members more than non attendees.
...In learning how to behave and what to believe, learners give weight to both prestige and CREDs, among other things. Thus, successful cultural forms, especially those involving deep commitment to counterintuitive beliefs, will tend to begin with and be sustained by prestigious individuals performing CREDs. Cues of prestige influence who people pay attention to for learning, while CREDs convince them that the prestigious model really believes (is committed to) his or her professed beliefs. The “virtuous- ness” arises from these prestigious individuals' role as models. CGS [Cultural Group Selection] will favor, over long swaths of historical time, religions with role models who effectively transmit beliefs and practices that strengthen in-group cooperation, promote intra-group harmony and increase competitiveness against out-groups. 
From Henrich, J. The evolution of costly displays, cooperation and religion: credibility enhancing displays and their implications for cultural evolution.   Evolution and Human Behavior   2009; 30: 244-260.

From Henrich, J. The evolution of costly displays, cooperation and religion: credibility enhancing displays and their implications for cultural evolution. Evolution and Human Behavior 2009; 30: 244-260.

Nelson Mandela's Ritual Circumcision

Whether or not Brit Milah is just another credibility enhancing display, it is a very widely practiced ritual- and extends far beyond the Jewish and Muslim communities.  Nelson Mandela recalled his own circumcision (at the age of 16!) in his autobiography

When I was sixteen, the regent decided that it was time I became a man. In Xhosa tradition this is achieved through one means only: circumcision.  In my tradition, an uncircumcised male cannot be heir to his father's wealth, cannot marry or officiate at tribal rituals. An uncircumcised Xhosa man is a contradiction in terms, for he is not considered a man at all, but a boy...
The night before the circumcision there was a ceremony near our huts with singing and dancing. Women came from the nearby villages, and we danced to their singing and clapping...At dawn, when the stars  were still in the sky...we were escorted to the river to bath in its cold waters, a ritual that signified our purification before the ceremony...We were clad only in our blankets, and as the  ceremony began, with drums pounding, we were ordered to sit on a blanket n the ground with our legs spread out in front of us...I could see a thin elderly man emerged from a tent and knee in front of the first boy...The old man was a famous ingcibi, ad circumcision expert...
Suddenly, I heard the first boy cry out: "Ndyindoda!"   (I am a man!), which we were trained to say at the moment of circumcision...before I new it, the old man was kneeling in from of me...without a word he took my foreskin, pulled it forward, and then, in a single motion, brought down his assegai...I felt fire shooting through my veins; the pain was so intense that I buried my chin into my chest. Many seconds seemed to pass before I remembered the cry, and then I recovered and called out, "Ndiyindoda"...A boy may cry; a man conceals his pain...I was given my circumcision name, Dalibunga, meaning "Founder of the Bunga,"...

Jewish Criticism of Milah

Among the most vocal critics of the practice today are those who are born Jewish. But circumcision has been criticized for as long as it has been practiced, and these self-criticisms are not new.  In the 1780s, a British Jew (who wrote anonymously) published a pamphlet called A Peep into the Synagogue, in which he was critical of many Jewish practices.  And his most scathing words were those he penned about circumcision:

In the extravagant Catalogue of Jewish absurdities, there is not one more shameful than that of Circumsition [sic], it is a barbarous violation of the principles of Nature,  For what can be more unhuman, than to punish an Infant by a cruel operation on a part of its body, done by a bungling Butcher of a Priest! Or what can be more insulting to all-wise Creator, than for a stupid Fool of a Fellow, to presume to correct His workmanship, by finding one superfluous part, and taking that away to reduce the subject to perfection. (Anonymous. A Peep into the Synagogue, or A Letter to the Jews. London, undated.) 

The Joy of Milah

Although it is under attack in Europe and is less popular than it has been US, circumcision remains a time for joy for the many faith communities in which it is practiced. The ritual is often accompanied by feasting and gift-giving, whether it is performed in Muslim or Jewish communities, or by members of African tribes.  The Talmud explains why, for Jews, the ritual is one that is associated with so much joy. It is an explanation that is as simple as it is profound:

שבת קל, א

 תניא רשב"ג אומר כל מצוה שקיבלו עליהם בשמחה כגון מילה דכתיב "שש אנכי על אמרתך כמוצא שלל רב" עדיין עושין אותה בשמחה

It was taught in a Baraisa: Rabban Shimon ben Gamliel says: Any commandment that the Jewish people accepted with joy - like circumcision, as it it written: "I rejoice over your word like one who finds great spoils" [Ps. 119:162]  - they still perform with joy...(Shabbat 130b.)

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