“Fate of the Foreskin: A Study of Circumcision” (1949) by Douglas Gairdner

In 1949, Douglas Gairdner, a pediatrician in Cambridge, England, published “Fate of the Foreskin: A Study of Circumcision,” hereafter, “Fate of the Foreskin,” in the British Medical Journal. In the article, Gairdner highlights what he saw as a seriously understudied topic, the natural development of the foreskin in males. Although physicians were then circumcising tens of thousands of male infants annually in England, data on the normal anatomy and function of the foreskin were scarce. In “Fate of the Foreskin,” Gairdner assembles those data and uses them to argue against performing circumcision to treat conditions like phimosis. Phimosis is when the foreskin tightly encases the glans, or head, of the penis and cannot retract. Gairdner finds that an unretractable foreskin is actually the normal state for newborn males, and that the foreskin will become retractable on its own over a period of months to years. By showing that phimosis is not a pathological condition, “Fate of the Foreskin” questioned the legitimacy of routine circumcision, and ultimately led to a steep decline of the practice in England.

Medical Context

At the time he wrote “Fate of the Foreskin,” Gairdner was a pediatrician affiliated with United Cambridge Hospitals and a lecturer in pediatrics at Cambridge University. He was then thirty-nine years old. Gairdner earned his undergraduate degree in chemistry in 1936 from Trinity College Oxford, England. He then switched to medicine and received his clinical training at Middlesex Hospital Medical School in London, England. He arrived at Addenbrooke’s Hospital in 1948 in Cambridge, after having done his residency in pediatrics at The Hospital for Sick Children in London during the late 1930s, a fellowship at Bellevue Hospital in New York City, New York, in 1939, and a five-year stint in the Royal Army Medical Corps during World War Two. Later in his career, he served for fifteen years as editor of the Recent Advances in Pediatrics and coeditor of Archives of Disease in Childhood until 1979. As a hospital pediatrician in England, Gairdner was familiar with the surgical procedure of circumcision, the reasons that doctors gave for performing it, and the complications that sometimes occur. He also had access to pathology facilities for examining tissue specimens and includes several tissue images in the article. He was, therefore, in a position to evaluate the relevant evidence.

In 1949, the year Gairdner published “Fate of the Foreskin,” the practice of circumcising newborns and young boys in England and Wales was common. Gairdner states that a conservative estimate of the number of boys circumcised every year in England and Wales at that time was 90,000 boys. For a summary of the reasons that doctors performed circumcision, Gairdner points readers to a long correspondence in the British Medical Journal that took place between August 1935 and November 1935. Reasons cited include the prevention of bed wetting, masturbation, hernia, venereal diseases, and cancer, and the treatment of phimosis. Not all of those who participated in that correspondence supported routine infantile circumcision, but those who did indicated that they viewed phimosis as a pathological and dangerous condition that needed a remedy.

“Fate of the Foreskin” was among the first medical publications to describe the typical development of the foreskin over time, and its findings influenced the English medical profession’s view of the procedure. By looking at data from several hundred infants and young males, Gairdner found that it could take anywhere from birth to more than five years for the separation between the glans and foreskin to occur. Gairdner reported that those findings indicated that phimosis as a rationale for performing circumcision on infants and young males was unjustified. Moreover, “Fate of the Foreskin” entered the medical literature around the time that England was formulating its mandatory national health insurance plan, the National Health Service, or NHS. According to David Gollaher, author of Circumcision: A History of the World’s Most Controversial Surgery (2000), “Fate of the Foreskin” was likely one of the influences behind the decision of the NHS to not include circumcision among insured procedures. Consequently, rates of circumcision in Britain plummeted from perhaps fifty percent of all newborn males born into the working class each year to less than one percent by the early 1960s.

“Fate of the Foreskin”: A Roadmap

“Fate of the Foreskin” is divided into eleven sections, including an unlabeled introduction followed by ten labeled body sections. In the introduction, Gairdner establishes the need for his study, namely the lack of readily available data describing the normal anatomy and function of the foreskin. Three of the next ten sections describe the origins of circumcision as a cultural practice, its incidence among nations around the world, and the frequency of complications resulting from the surgery. Among Western nations, Gairdner notes, circumcision of infants is common only in English-speaking countries. Another three sections describe the development, anatomy, and function of the foreskin. Gairdner notes that, at birth, the foreskin typically completely covers the glans and is adhered to it. Gradually, the foreskin will separate from the glans and become retractable, a process that can take up to five years or longer. Two sections describe the supposedly pathological conditions for which circumcision is indicated, mainly phimosis, and the conditions that are supposedly prevented by the procedure, including venereal disease, penile cancer in men, and cervical cancer in women. Gairdner discounts nearly all of those rationales for performing circumcision on newborns. In a conclusion section and a summary section, Gairdner reiterates his major findings that a foreskin that adheres to the glans is a normal feature of newborn males, and that strong evidence does not support most reasons why doctors perform circumcision on infants.

In the introduction of “Fate of the Foreskin,” Gairdner draws attention to the fact that circumcision is one of the most commonly performed surgeries in Britain, and yet data on the normal development, anatomy, and function of the foreskin are not readily available to those performing the procedure. Without those data, he notes, doctors lack the information necessary to weigh the pros and cons of circumcision. And yet, as Gairdner points out, doctors were at that time circumcising tens of thousands of infants in Britain every year.

Following that brief introduction, Gairdner reviews available evidence for the origins and prevalence of circumcision in his next section, “Origins of Circumcision.” He notes that approximately one-sixth of people around the globe practice circumcision, including many Jews and Muslims. He states that the origins of circumcision, whether as a religious sacrifice or something else, are obscure, though the practice is clearly very old. Gairdner cites evidence that Egyptian mummies dating from 2300 BC were apparently circumcised and that ancient wall artwork shows that Egyptians were practicing circumcision thousands of years before that. Whether circumcision had a single origin or evolved in different cultures independently, no one can say, according to Gairdner.

Gairdner turns in his second section, “Development of the Prepuce,” to existing knowledge about the development of the foreskin, starting from the time it forms at around eight weeks of fetal development to birth and beyond. For that information he relies mostly on previously published reports. He explains how the foreskin begins as a thickened ring of skin that grows up and over the glans, more rapidly on the upper surface than the lower surface of the penis. By about sixteen weeks of gestation, the foreskin has grown to the tip of the glans. At that stage, the foreskin is completely fused to the underlying glans. Eventually, a space between the glans and foreskin forms and grows until the two surfaces are completely separated, but that process of separation has usually only just started by birth. In the article, Figure 1, a series of drawings, helps the reader visualize the developmental stages.

Next, in a third section called “Anatomy of the Prepuce,” Gairdner reports that most young newborn males do not have a fully retractable prepuce, which is another name for foreskin. He comes to that conclusion after examining foreskin separation in a group of one hundred male newborns, two hundred boys up to age five, and two hundred boys ages five to thirteen. He found that only four percent of males have a fully retractable foreskin at birth. By six months, twenty percent of boys have complete foreskin retractability. The rate of complete retractability rises to eighty percent by two years and ninety percent by three years. Six percent of boys ages five to thirteen still have a foreskin that is non-retractable, according to Gairdner’s numbers. Gairdner makes the further point that doctors’ use of the word “adhesions” to describe the state of the unseparated foreskin and glans, as they commonly did when recommending circumcision to treat phimosis, is inappropriate because it suggests that the foreskin and the glans were previously separate structures. The “Anatomy of the Prepuce” section is also accompanied by Figure 5, a bar graph showing the percentage of males with retractable foreskin from birth to age five.

In a short fourth section, “Function of the Prepuce,” Gairdner notes that many people have speculated that the foreskin is a structure with no function, but Gairdner argues that the foreskin plays a protective function. He points out, for example, that circumcised penises are much more likely to become irritated from the ammonia in the urine of a wet diaper, so the foreskin may help protect younger males from such irritation.

In its fifth section, “Incidence of Circumcision,” Gairdner shifts to a discussion of the higher percentage of circumcisions in certain areas in England in males especially from more prestigious areas. Gairdner notes that, among Western countries, neonatal circumcision is common only in English-speaking countries. Scientists rarely practiced circumcision in the countries of continental Europe, Scandinavia, or South America. Using data submitted from colleagues, Gairdner provides statistics for the varying prevalence of circumcision around England and to draw some conclusions about its relationship to social class. To show the variance by region, Gairdner points out that in Newcastle-upon-Tyne, England, scientists circumcised twelve percent of 500 male infants by age twelve months, whereas in Cambridge, scientists circumcised thirty-one percent of eighty-nine male infants by twelve months. Regarding circumcision’s relationship to class, Gairdner cites figures from a colleague showing that eighty-four percent of university students coming from more-prestigious schools are circumcised whereas only fifty percent of boys coming from less-prestigious schools are circumcised. Citing a conservative estimate of twenty percent for the incidence of circumcision in England and Wales, Gairdner estimates that 90,000 male infants are circumcised annually.

In a sixth section called “Mortality and Sequelae of Circumcision,” Gairdner turns to a discussion of the complications that can arise from circumcision, including blood loss, infection, and even death. Reviewing data from public health records, Gairdner finds that an average of sixteen children under five die each year from complications of circumcision, including from blood loss, infection, and reactions to anesthesia. Gairdner states that, based on his own experience, two percent of children circumcised as outpatients will be admitted to the hospital on account of surgical complications such as blood hemorrhage. The author includes a table detailing deaths from 1942 to 1947 connected to circumcisions in children in England and Wales up to five years.

The seventh and largest section of the article, titled “Pathological Conditions of Prepuce for which Circumcision is Performed,” evaluates each of the commonly stated reasons for circumcising boys, with a particular focus on phimosis, and finds that the evidence supporting them is weak. Given the data on normal development of the foreskin and the time it takes for the foreskin to naturally separate from the glans, Gairdner underscores that the diagnosis of phimosis cannot properly be applied to an infant. Moreover, forcing retraction of the foreskin at that stage is likely to be painful and traumatic, he states. Gairdner notes that he has seen several cases where parents or nurses of an infant have forced retraction, with the result that the foreskin cannot be re-extended over the glans, a painful condition called paraphimosis. He attributes that practice to ignorance of the normal anatomy and function of the foreskin.

Continuing in that same section, Gairdner next turns to question the legitimacy of performing circumcision due to inflammation of the foreskin, another reason that physicians commonly cited for performing circumcision. Gairdner discounts that reason as valid, stating that in young males, inflammation of the foreskin is likely a result of ammonia from urine that has accumulated in a diaper rather than something pathological about the foreskin itself. In circumcised infants, ammonia is likely to lead to inflammation of the glans, and potentially to a meatal ulcer, where a sore forms on the opening to the urethra. Thus, circumcision is likely to make matters worse because the glans will be more exposed to that irritating liquid.

In the last part of the same section, Gairdner mentions several less commonly cited reasons for performing circumcision including bed wetting, masturbation, twitches and spasms, night terrors, and convulsions. He concludes that there is no evidence linking a non-retractable foreskin to any of those symptoms.

In its eighth section, “Conditions Prevented by Circumcision,” Gairdner takes up the issue of circumcision used as a means of disease prevention and concludes the evidence in those cases is similarly weak. While some doctors had argued that circumcision prevents paraphimosis, Gairdner points out that that condition only ever arises when someone tries to forcibly retract the foreskin. Therefore, the solution is not to circumcise, but to educate parents about the dangers of forcibly retracting the foreskin in young males. Another commonly stated reason for performing circumcision is to prevent future venereal disease, particularly syphilis. Gairdner cites evidence from three separate studies, one published in 1934 and two published in 1947, and concludes that circumcision is not an effective means of preventing the contraction of venereal diseases. One of the studies from 1947 found that hospitalized patients reported a history of venereal disease in approximately equal proportions whether they were circumcised or not. A second study from 1947 of Canadian soldiers visiting a base clinic for treatment of a venereal disease found that the proportion of uncircumcised soldiers who contracted venereal disease was actually higher than intact soldiers, seventy-seven percent versus fifty-two. However, Gardiner states that the difference in percentages may be due to the uncircumcised males coming from a lower social class and therefore likely to expose themselves to an infection. A third reason that doctors commonly give for performing circumcision is preventing penile cancer, which Gairdner states is one of the only reasons for performing circumcision that is potentially valid. Removing the foreskin prior to five years of age does indeed prevent penile cancer in old age. However, he acknowledges that the reason is unknown. Nevertheless, he points out that there are likely other ways to prevent the development of penile cancer, including practicing better hygiene.

Continuing in that section, Gairdner criticizes a fourth reason doctors sometimes give for circumcision, namely, preventing cervical cancer in women, likely on the basis of a 1947 study finding a lower incidence of cervical cancer among Jewish women, whose husbands are likely circumcised. Because of potentially confounding factors, however, Gairdner recommends a more direct test of that hypothesis by comparing whether husbands of women with cervical cancer are more likely to have been circumcised. Without that evidence, Gairdner concludes that it would be premature to recommend universal circumcision of infants. As to the question of whether circumcision makes cleaning and hygiene easier, or whether circumcised penises are aesthetically more appealing or more erotically satisfying, Gairdner points to anecdotal evidence. Among the parents of several hundred infants referred for circumcision, Gairdner states that only one father wanted his son circumcised to avoid the disagreeable experience he had with his own foreskin. He further states that, in his experience, when the question of sexual pleasure comes up in conversation, uncircumcised men often claim that they have an advantage over their circumcised peers.

In the last two sections, “Conclusions” and “Summary,” Gairdner reiterates that the foreskin is rarely retractable at birth, and again urges against using circumcision to prevent conditions like phimosis. According to the figures he assembled in “Fate of the Foreskin,” roughly ninety percent of infants will develop foreskin retractability by age three, though doctors learned later that it can sometimes take much longer than that. Gairdner concludes that during the first years of life when the child is incontinent, the foreskin plays a protective role, for instance against ammonia. And he stresses that none of the reasons commonly given for routine circumcision are convincing, based on his analysis. Though circumcision might prevent penile cancer much later in life, Gairdner suggests that better hygiene could be a less invasive way to achieve the same ends. If they did so, they would prevent roughly sixteen child deaths per year.

Reception and Impact

“Fate of the Foreskin” was one of the first academic articles to examine the normal anatomy of the foreskin and, on that basis, to question the legitimacy of routine infant circumcision. The article generated a fair amount of discussion at the time, as reflected in the correspondence section of the British Medical Journal, where “Fate of the Foreskin” appeared. As of 2025, over 700 articles have cited and more than a dozen doctors wrote in to comment on Gairdner’s article, beginning shortly after the article’s publication. Of those, the majority were in support of Gairdner’s position and opposed routine circumcision. Of those who supported Gairdner’s position, most agreed that circumcision was medically unnecessary, and several pointed to the risks of the procedure, including disfigurement of the penis and even death. Of those who were critical of Gairdner’s position, most reiterated their belief in the dangers of phimosis, including a future risk of cancer, and some blamed the risk of complications on unskilled practitioners rather than the procedure itself. A decade later, in 1959, the writers of the British Medical Journal responded to the general public’s question about the need for circumcision in infants. The writers noted that circumcision had fallen in popularity from before WWII, when a majority of male infants were circumcised, to 1959, when only a minority underwent the procedure. The team that answered stated that Gairdner’s article had a great deal to do with influencing opinion against routine circumcision.

Since “Fate of the Foreskin” was published in 1949, larger studies have confirmed a number of Gairdner’s basic findings, including about the development of the foreskin. Studies of Danish boys by Jakob Oster and of Japanese boys by Hiroyuki Kayaba found that it is normal for the foreskin to remain attached to the glans at birth. “Fate of the Foreskin” has little to say about sexual pleasure, but studies in the late 1950s showed that the foreskin has a cluster of fine-tuned nerve endings that are exquisitely sensitive to touch, which researchers took to mean the foreskin was highly involved in sexual pleasure. Since the publication of “Fate of the Foreskin,” doctors have also learned more about the causes of both penile cancer and cervical cancer. In both cases, the cause is human papillomavirus, or HPV, for which there are now, in 2025, vaccines. Furthermore, epidemiological studies have found that the rates of penile cancer are actually lower in countries like Denmark and Finland, where circumcision is not common, compared to rates in the US, but genital hygiene is emphasized, according to Kayaba. Such findings have undercut the argument for circumcision as a means to reduce cancer risk.

According to Gollaher, Gairdner wrote “Fate of the Foreskin” in the context of economic pressures to reduce the cost of healthcare and the national health insurance in Britain. After WWII, England began designing its mandatory national health insurance plan, the National Health Service, and its architects were increasingly looking to weigh costs and benefits of medical procedures they planned to reimburse citizens for in order to contain costs. Gollaher suggests that Gairdner was motivated by the idea that if circumcision was deemed unnecessary, Britain could shift resources to other things, though Gairdner himself makes no mention of economic concerns in his paper. Regardless, the NHS did indeed decide not to reimburse circumcision except in cases of true disease and rates predictably plummeted in England. A 2005 study found the rate of neonatal circumcision in England is between five and six percent.

Gollaher claims that doctors in the US seem to have ignored “Fate of the Foreskin” due to the system of private insurance. Rates of circumcision in the US continued to rise even after the publication of Gairdner’s article. Gollaher notes that mainstream journals in the US did not critique circumcision until the 1960s. Several authors put the rate of neonatal circumcision at around eighty percent by the 1960s. According to the US Centers for Disease Control and Prevention, as of 2010, the most recent date for which data are available, doctors circumcise more than half of all newborn males born in the US.

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