The Summer 2007 edition of The Skeptic magazine (Australia) included an article by Brian Morris on the medical benefits of routine circumcision. In the course of this rather aggressive excursus he defended old claims that the origins of ritual circumcision among certain ancient Middle Eastern tribes lay in health problems caused by the accumulation of sand and dust under the foreskin. Attacking an earlier article by David Vernon, he writes:
“In attempting to ridicule the notion that circumcision arose in the Middle East to solve problems caused by ‘sand and dust’, Vernon cites an article by Robert Darby, an anti-circ activist. Darby’s claims stemming from ‘medical records’ ‘he analyzed’ are false. Infections, initiated by the aggravation of dirt and sand, are not uncommon under desert conditions, and have even crippled whole armies of uncircumcised soldiers. It is difficult to achieve sanitation during prolonged battle. To contradict Darby, and thus Vernon, a US Army report by General Patton stated that in World War II 150,000 soldiers were hospitalised for foreskin problems due to inadequate hygiene. (28) To quote: “Time and money could have been saved had prophylactic circumcision been performed before the men were shipped overseas” and “Because keeping the foreskin clean was very difficult in the field, many soldiers with only a minimal tendency toward phimosis were likely to develop balanoposthitis”. (28) The story was similar in Iraq during ‘Desert Storm’ in the early 1990s. (29,30) In the Vietnam War men requested circumcision to avoid “jungle rot”. [1]
It might seem rather late in the day to offer a response, but since Professor Morris makes an ad hominem attack on me and suggests that my scholarship is spurious, I hope that I may be permitted a reply in which I shall show that his own respect for evidence is not all that it should be. Describing me as “an anti-circ activist” is an ad hominem device to suggest that because I am sceptical of the value and ethics of routine circumcision anything I say on the subject must be rubbish. I have indeed published extensively on circumcision issues, [2] but if that makes me an anti-circumcision activist, Morris can only be described as an anti-foreskin activist whose views demand to be treated with equal skepticism. [3] Referring to my article as cited by Vernon, he places “medical records” and “he analyzed” in inverted commas, insinuating that the records are somehow unreliable and that my analysis is faulty or even dishonest, leading to his triumphant conclusion that my refutation of this claim must be false.
Morris does not identify the article, however, which was a peer-reviewed paper published in the New Zealand Medical Journal [4] – precisely an instance of those “good research studies published in reputable international journals” that Morris says Vernon should have cited. My paper relied on scholarly anthropological sources to show that ritual circumcision arose for cultural/religious, not health reasons; and on the medical volumes of the official histories of Australia and New Zealand in the Second World War to prove that balanitis caused by sand under the foreskin was not a problem in the North African campaign, and that, contrary to the “sand myth”, there were no mass circumcision drives to cure it. Does Professor Morris suggest that the authors of the official histories, in which none of the words “balanitis,” “circumcision,” or “foreskin” make a single appearance, were “anti-circ activists” or (horror of horrors) actually uncircumcised men themselves?
But what of Professor Morris’s own scholarly standards?
Attempting to refute my argument he cites “a US Army report by General Patton”, and lists a series of pages that are supposed to back up his claim. But when you actually check those pages you find that they have nothing to do with sand under the foreskin and fail to provide any support for the argument that Morris wishes to make. For a start he gets the details of the book wrong. It is not a “report by General Patton”, but a multi-author volume in the official history of U.S. medical services in World War 2, edited by John F. Patton MD. [5] Secondly, there are only two occurrences of the word sand in the entire volume (pages 221 and 447), neither of which has anything to do with foreskins or circumcision. The volume scarcely deals with the Middle Eastern or North African (desert) combat theatres, but mostly with the South-East Asian and Pacific theatres, characterized by dense jungles and wet, humid conditions that posed many intractable health problems, affecting many parts of the body, not just the penis. But in those conditions sand and dust were not an issue. There is not the slightest support for his hyperbolic claim that “Infections, initiated by the aggravation of dirt and sand, are not uncommon under desert conditions, and have even crippled whole armies of uncircumcised soldiers.”
As for the pages nominated by Morris, let us see what they actually say:
Chapter 4, Venereal Disease (John F. Patton)
On page 52, in the section on chancroid, Patton notes that “any penile lesion in the presence of a redundant prepuce may present a problem and also invites secondary infection. Phimosis was a common complication of chancroid, and dorsal slits were often necessary, followed by circumcision after the local infection subsided.” He adds that “Higher headquarters sometimes questioned the number of circumcisions performed in the theater,” but insists that “all were performed from medical necessity, and none were done electively.” In other words, Patton was a fervent believer in circumcision and operated whether the soldiers liked it or not. In those days, in the absence of appropriate antibiotics, circumcision might well have been the only possible response to infections of this type.
On page 64 Patton simply notes that in the Mediterranean theatre of Operations circumcision was a common treatment for venereal disease and associated phimosis and inflammation (balanitis).
Chapter 6: Infections and Related Conditions (Charles Montgomery Stewart)
On page 100 under the heading “Balanoposthitis” (inflammation of glans and foreskin) Stewart notes that lack of cleanliness can lead to irritation, ulcers, and infections. “Treatment requires prompt, regular, strict personal cleanliness and local hygiene. Irrigations of the preputial sac are necessary if the foreskin cannot be retracted. Early inflammation promptly treated subsides rapidly.” He goes on to suggest that in order “to prevent recurrence, circumcision should be mandatory when the local infection and inflammation have cleared”, but does not report that this was actually done.
On page 102, under the heading “Balanitis: Preventive Measures”, Montgomery notes that “During the years 1942-1945, inclusive, 22,709 patients were admitted to Army hospitals for balanitis”. Although this was remarkably small proportion of the 13 million men enlisted in the U.S. army during World War 2, he went on to recommend routine circumcision as a prophylactic measure – though it is not clear whether he meant army personnel only, or the entire population.
On page 105, Montgomery discusses phimosis (“a congenital or acquired narrowing of the opening of the prepuce”) and notes that “Eventually, the treatment is circumcision,” but warns that “Circumcision in the adult is not the benign procedure it appears to be. These patients are incapacitated from returning to full duty for a minimum of 10 days postoperatively.” He then gives instructions on circumcision technique, warning that “extreme care must be exercised to avoid removal of too much skin. Carelessness may result in partial denudation of the penile shaft. Sufficient preputial skin edge must be left to cover the sensitive papillae of the corona.” In other words, for all his belief in circumcision, Montgomery recognised that because excision of the foreskin could damage the penis you must not remove too much tissue.
On page 106 Montgomery notes that during the entire war 110,562 men were admitted to army hospitals for paraphimosis and phimosis and repeats his view that these figures are “so startling” that they “would justify routine prophylactic circumcision.”
On page 120 Montgomery discusses venereal warts, discusses topical treatment and notes that “circumcision may be necessary to obtain a permanent cure.”
On page 145-6 he continues his discussion of genital warts, and maintains his rage against the foreskin: “Armed forces urological historians should be impressed with the fact that the redundant prepuce again can be pronounced guilty as a consistent contributor to the etiology and high incidence of this disease. Hospital admissions for paraphimosis, phimosis, balanitis, and condyloma acuminatum during the 1942-1945 period totaled 146,793. Had these patients be circumcised before induction, this total would be probably have been close to zero.” As I point out in the discussion below, he provides no evidence that uncircumcised men were significantly more subject to these conditions. His last comment is the fallacy of prediction in hindsight.
In Chapter 8, “Genitourinary Neoplasms” (cancer), under the heading “Neoplastic Diseases of the Penis”, Vincent Vermooten notes (page 183): “Carcinomas are so rare in this age group that they call for no comment.” This is also where Morris gets one of his money quotes: “Because keeping the foreskin clean was very difficult in the field [South-East Asia], many soldiers with only a minimal tendency toward phimosis were likely to develop balanoposthitis, and in the presence of venereal warts, inflammation would almost certainly develop,” but the author added that “the use of estrogenic hormone in plastic operations on the penis aided in the prompt recovery of these patients.”
Chapter 18, “Reflections” by Ormond S. Culp and John F. Patton, is where Morris finds his other money quote: “During 1942-1945 almost 150,000 soldiers were hospitalized for medical reasons with phimosis, paraphimosis, and/or balanitis; they were unable to maintain adequate local hygiene under combat conditions. The man-hours lost as a result of circumcisions and adjuvant therapy were costly to the war effort and exasperated the commanding officers. Time and money would have been saved had prophylactic circumcision been performed before the men were shipped overseas.”
Comment and analysis
It is obvious that the pages cited by Morris, although they contain many hostile references to the foreskin, have no bearing on the origins of circumcision in the Middle East, nor to balanitis or other inflammations among Australian or New Zealand soldiers in North Africa. There is no mention of sand at all. Most of the data comes from South-East Asia, where humidity and jungle parasites certainly were major problems; but if they were problems that especially afflicted the foreskins of the U.S. troops, one wonders how the Japanese coped, not to mention the Thais, Vietnamese and Melanesians, none of whom have ever practised circumcision.
How significant are the statistics? A total of 13,104,355 men served in the U.S. military in World War 2. If we assume that half were uncircumcised, the number who experienced problems is small: 22,709 cases of balanitis would affect 0.35% and the number needed to treat would be 288.5. If all the venereal warts were in uncircumcised men (13,522 cases) then only 0.21% would get infected, and the number needed to treat would be 484.6. Phimosis and paraphimosis hospitalizations (110,562) account for only 1.69%, with a number needed to treat of 59.3. In the broad scheme of things, these numbers are trivial, and on a cost/benefit calculation alone would certainly not justify general routine circumcision in advance. [6]
It is significant that the volume discussed here was published in 1987, and written by American medical doctors who had clearly been acculturated into America’s post-war love affair with circumcision. There is no detailed study of the history of circumcision in the United States, but several studies have suggested that the practice was already popular in the 1930s, became even more deeply embedded in the 1950s-60s, and that the influence of the U.S. Military was a significant factor in this development. [7] The passages quoted above are riddled with speculative assertions about what would or would not have happened if the men experiencing penis problems had been circumcised in advance. But since there are no comparative figures on the incidence of warts, balanitis or venereal infections in circumcised as compared with uncircumcised men, how can we be sure that the latter were disproportionately affected? The British army surgeon Sir Daniel Whiddon asserted that in the Middle East campaigns it was the circumcised men who were more affected by venereal disease: “The shaky science of the arguments in favour of wholesale infant circumcision is often supported by the statement, itself unsupported by any by any scientific evidence, that the circumcised are less liable to disease, particularly that they are less likely to get venereal disease and cancer. The first statement is untrue. You were long enough in the Middle East to know that our circumcised allies were the most enthusiastic supporters of the VD departments.” [8]
Of course you cannot experience phimosis if you lack a foreskin with which to experience it, but then, without testicles or a prostate you won’t be at risk of testicular or prostate cancer. The definitions of phimosis given in these passages are very loose, and seem to based on the outdated Edwardian idea that a non-retractile foreskin was in itself pathological, rather than on the scientific understanding that developed in the wake of Douglas Gairdner’s research. [9] As soon as penicillin became available, most venereal diseases were routed away from urology; in those primitive days doctors circumcised for many conditions that would now be treated topically with antibiotics or other medications. The medical history volumes of the Australian official history do not mention problems caused by “lack of circumcision” in the jungles of New Guinea, and if more recent evidence is sought, there is significantly no mention of foreskin problems or circumcision in relation to control of venereal disease, balanitis or any other health issue in Ian Howie-Willis’s biography of Major-General Sir Samuel Burston, the officer in charge of Australian army medical services throughout the Pacific campaign. [10] In response to an inquiry from me, Dr Willis replied: “If circumcision had been practised as widely as your ‘urban myth’ would have it, I’d also expect that it would have been the subject of one of the many ‘technical bulletins’ issued to Medical Corps staff by the successive Directors General of Medical Services. I’ve seen most of these bulletins but certainly didn’t see one dealing with circumcision either in the context of VD or balanitis. Similarly, this is a topic which is never mentioned in any of Burston’s official or personal correspondence, which I’ve read thoroughly. … The reason that circumcision doesn’t appear in my book is that I never encountered its occurrence during my research.” (Email, 1 August 2012) Among the Australian military, it would seem that the foreskin was not seen as some sort of rogue organ and circumcision not hailed as the solution.
Accordingly, one suspects that the problems identified so readily by American medical personnel had more to do with their pre-existing animus against the foreskin than with an objective appraisal of the issues. What so many of the comments (Montgomery’s especially) embody is the post-war consensus that baby boys should be circumcised as a matter of course. Worth noting is the admission that military headquarters questioned the need for so many circumcisions, suggesting that the field medical corps had a basic anti-foreskin attitude, and operated whenever there was the slightest excuse.
So much for Morris’s use of Dr (not General) Patton. His other references are equally dodgy. The claim about Desert Storm relies on unsourced allegations by Edgar Schoen, an even more vigorous anti-foreskin activist than Morris himself, [11] and on the very article by Gardiner that I refute in my paper in the NZ Medical Journal. Morris is rightly critical of anecdotal evidence, but one of Gardiner’s key pieces of evidence for the “sand problem” was his claim that “a German surgeon” had told him that German Africa Corps troops had “suffered in the same way”, and had similarly been circumcised. But as I remark in my paper, the proposition that a German under the rule of Nazism would have submitted to an operation that could have identified him as a Jew, or that anybody in authority would have recommended such a course, is implausible. To make sure, Mr Hugh Young questioned Manfred Rommel, son of the German commander, who replied: “I have never heard that soldiers in the Africa Corps were circumcised. The veterans I could contact have not either.”
Morris’s final claim, that “in the Vietnam War men requested circumcision to avoid ‘jungle rot,’” is backed up by no reference at all; but I am willing to concede that in humid, jungle conditions fungal and related conditions would have been a much greater problem than in the dry heat of the desert – tinea and worse between the toes and under the arms, for example. But we do not hear of doctors recommending amputation of the toes as a cure, or prophylactic digitectomy as prophylaxis. In short, for all Professor Morris’s huffing and puffing, there remains no evidence that ritual circumcision in the Middle East arose from hygienic/medical considerations, nor that troops engaged in the North African campaigns suffered epidemics of balanitis and other inflammations caused by sand and dust under their foreskin. As I concluded in my paper, such assertions are medical urban myths.
NOTES and REFERENCES
1. Brian Morris, Circumcision facts trump anti-circ fiction. Australian Skeptic 27 (4) Summer 2007, 57.
2. Most recently, The child’s right to an open future: Is the principle applicable to non-therapeutic circumcision? Journal of Medical Ethics 39 (July 2013).
3. Professor Basil Donovan has described him as “a man on a mission to rid the world of the male foreskin”: review of Morris, In Favour of Circumcision, in Venereology 12, 1999, 68-9. Text available at History of Circumcision
4. Robert Darby, The riddle of the sands: Circumcision, history and myth. New Zealand Medical Journal 118, 15 July 2005.
5. The correct citation is Medical Department, United States Army. Surgery in World War II. UROLOGY. Edited by John F. Patton MD. (Washington: Office of the Surgeon General and Center of Military History, United States Army, 1987) Online at: http://babel.hathitrust.org/cgi/pt?id=mdp.39015026943020
6. Figures calculated by Dr Robert Van Howe, Department of Pediatrics, Central Michigan University.
7. Edward Wallerstein. Circumcision: An American Health Fallacy. New York: Springer, 1980; Frederick Hodges. “A short history of the institutionalization of involuntary sexual mutilation in the United States”, in George C. Denniston and Marilyn Milos (eds), Sexual Mutilations: A Human Tragedy, New York: Plenum Press, 1997; Robert Darby. The Sorcerer’s Apprentice: Why Can’t the United States Stop Circumcising Boys? e-book, Amazon, 2013.
8. Whiddon D. The Widdicombe file. Lancet 1953;ii (15 Aug):337-8.
9. Gairdner D. The fate of the foreskin: A study of circumcision. Br Med J 1949;2:1433-7. For a listing of recent studies see collection at CIRP.
10. Ian Howie-Willis. A Medical Emergency: Major-General ‘Ginger’ Burston and the Army Medical Service in World War II. Newport, NSW: Big Sky Publishing, 2012.
11. And one whose own use of evidence sometimes has its shortcomings: see Robert Darby and John Cozijn, The British Royal Family’s Circumcision Tradition: Genesis and Evolution of a Contemporary Legend. Sage Open, 16 October 2013.
See also "He might have to fight in the desert" at Circumstitions.
NOTE: This reply was submitted to The Skeptic magazine, but was refused publication.