Considering the similarities between the male and female genitals, the nature of the surgery, the justifications offered, and the support (in Western societies) for the principle that the genders should be treated equally, it may at first seem surprising that male and female circumcision enjoy such strikingly different reputations, at least in Anglophone countries. The first is regarded as a mild and harmless adjustment that should be tolerated, if not actively promoted, the second as a cruel abomination that must be stopped by law, no matter how culturally significant to its practitioners. Although the term “genital cutting” has been introduced in the hope of calming the debate, and while some culture-focused feminist critics have sought to “challenge western polemics,” [1] it is still generally true that not to call circumcision of women or girls female genital mutilation results in accusations of trivializing the offence, but to call circumcision of boys male genital mutilation is likely to elicit accusations of emotionalism, even by those who agree that routine circumcision of males is unnecessary and should generally not be performed. [2]
While the World Health Organization (WHO), the United Nations and other international agencies devote substantial resources on programs to eradicate female genital cutting (FGC), they have been conspicuously silent about the circumcision of boys. Indeed, WHO shows acute schizophrenia on the issue, since it funds expensive programs to eradicate FGC while simultaneously funding even more expensive programs to promote and enforce male circumcision. For all the rhetoric about the science behind such programs, it is really no more than an expression of the nineteenth century assumption that circumcision of boys is health-giving while circumcision of girls or women in a mutilation. It was only in the current decade that male circumcision has been raised as a human rights issue at the United Nations, and to date no serious discussion of the topic has occurred, let alone any action. [3] Double standards reign.
It might be thought that the reason for this double standard lies in the greater physical severity of FGC, but this is to confuse cause with effect. On the contrary, it is the tolerant or positive attitude toward male circumcision and the rarity of female circumcision in Western societies that promote the illusion that the operation is necessarily more sexually disabling, and without benefit to health, when performed on girls or women. A second reason for the double standard is that, while circumcision of males is mistakenly thought to designate a single surgical procedure, the term “female circumcision” is expansive, referring to any one or more of several different procedures.
These procedures have been defined by the WHO (1996) as follows:
Type 1: Excision of the prepuce with or without excision of part or all of the clitoris;
Type 2: Excision of the clitoris together with partial or total excision of the labia minora;
Type 3: Excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation);
Type 4: Unclassified (includes a wide variety of mutilations not falling into Types 1 through 3).
This classification has been modified since 1996 but still retains the basic division into four types, as set out in a WHO “Fact Sheet” of May 2008:
Female genital mutilation is classified into four major types:
See WHO Fact Sheet 241, May 2008
The severity of female circumcision depends on which of, as well as how crudely, these operations are performed, and it is true that the most extreme forms (involving the amputation of the external genitalia, with or without infibulation) are significantly worse than even the most radical foreskin amputation. But it should be remembered that the most extreme forms of female circumcision are comparatively rare, and that male circumcision in general is far more common on a world scale than female: about 13 million boys, compared with two million girls annually. [4] Quantity is not the whole story, but the vigorous efforts to protect the two million girls contrast sharply with the absence of interest in protecting the larger number of boys.
But the effects of male genital cutting (MGC) are also highly unpredictable, depending on how much penile tissue is removed, on the skill of the surgeon, on the precise configuration of penile blood vessels and nerve networks, on the genetically determined length of the foreskin, and on the eventual size attained by the penis at puberty and maturity. The more tissue excised, the greater the damage to the penis and the greater the effect on sexual functioning and capability. Although equivalent quantities of tissue may be lost, outcomes will be worse in cases where the penis grows larger in maturity, where the infant or boy has only a short foreskin, or where the unpredictable locations of blood vessels and nerves mean that important connections are severed. Because the slack (“redundant”) surface tissue is needed to accommodate the enlarged penis when tumescent, a severe circumcision will render erections painful or even impossible. [5] A further common outcome among boys circumcised in infancy, especially when the operation excises a large quantity of penile shaft skin (as is the American norm, particularly when the Gomco clamp is used), is that scrotal skin gets pulled up onto the penis shaft as the wound heals, and even more when the penis enlarges at puberty. Such men often present both sebaceous glands and pubic hair on their penis, sometimes growing as far up as the line of the former frenulum. [6]
Selecting appropriate terminology to discuss genital alteration may at first appear a straightforward task, but, while much effort has gone into categorizing the types of female genital alteration, surgeries on the penis are classified by a single term. Because MGC, even when non-therapeutic, is construed as harmless, there have been few efforts to provide male circumcision with a classification system similar to that constructed for female circumcision; yet in principle such a project should be no more difficult than devising a scale to measure damage to female genitals. Some attempts have already been made: Hanny Lightfoot-Klein (1989) has set out the similarities, and Swiss/Palestinian authority Dr Sami Aldeeb has offered the following:
Type 1: This type consists of cutting away in part or in totality the skin of the penis that extends beyond the glans. This skin is called foreskin or prepuce.
Type 2: This type is practiced mainly by Jews. The circumciser takes a firm grip of the foreskin with his left hand. Having determined the amount to be removed, he clamps a shield on it to protect the glans from injury. The knife is then taken in the right hand and the foreskin is amputated with one sweep along the shield. This part of the operation is called the milah. It reveals the mucous membrane (inner lining of the foreskin), the edge of which is then grasped firmly between the thumbnail and index finger of each hand, and is torn down the center as far as the corona. This second part of the operation is called periah. It is traditionally performed by the circumciser with his sharpened fingernails.
Type 3: This type involves completely peeling the skin of the penis and sometimes the skin of the scrotum and pubis. It existed (and probably continues to exist) among some tribes of South Arabia. Jacques Lantier describes a similar practice in black Africa, in the Namshi tribe.
Type 4: This type consists in a slitting open of the urinary tube from the scrotum to the glans, creating in this way an opening that looks like the female vagina. Called subincision, this type of circumcision is still performed by some Australian aborigines. [7]
Dr. Aldeeb deserves credit for venturing into terra incognita, but such a mixture of broad and specific categories fails to include the full range and variety of circumcision procedures, yet also identifies operations that are vanishingly rare. The vast majority of circumcision procedures today, especially those performed in hospitals and clinics, fall under none of these headings, while Types 3 and 4 are confined to a very few traditional (tribal) societies and are little more than anthropological curiosities. If the intention was to include all types of penile mutilation, mention should have been made of infibulation, piercing and the various “enhancements” found in southeast Asia. [8]
The classification also leaves out the relatively mild forms of penile mutilation, such as slitting of the foreskin without excision of tissue, that are (or were) found in the Philippines [9] and certain Pacific islands, such as Samoa and Fiji. We write “were found” because as these procedures are medicalized (no longer performed as a traditional rite, but as minor surgery in a clinic by trained medical personnel), it is apparent that they are becoming more severe: no longer a mere dorsal slit, but a full-scale foreskin amputation on the United States model – that is, tearing or otherwise separating the foreskin from the glans, stretching it to a lesser or greater degree, and cutting roughly at the line of the corona. Although the setting may be more hygienic and complications such as bleeding and infection reduced, the effect of medicalization is a more damaging surgical outcome. In the developed world, the great diversity in surgical outcomes is the result of the differing techniques applied, the instruments used and the preferences of the surgeon or other operator.
More seriously, Aldeeb’s classification neglects the vital fact that there is no precise definition of the foreskin and thus no precise definition of what is removed by MGC. The foreskin is not a discrete organ like a finger or pancreas, but a double-layered extension of the surface tissue of the penis; where the foreskin starts and the rest of the penis ends is a matter for judgment. The foreskin is generally described as a cap that fits over the glans, but the foreskin often extends beyond the glans (always in juveniles), and the point at which the doubling of the tissue begins can be anywhere along the penis shaft and shifts according to the degree of tumescence. On average, the doubling of tissue begins well beyond the corona of the glans, as the position of the circumcision scar on cut men (usually seen at about half an inch to an inch below the glans) testifies. Moreover, the length of the foreskin varies enormously from one individual to another, meaning that the same “standard” cut will be more severe on a boy with a short foreskin than on one who had more tissue to begin with. Since the severity and harm of the surgery depends primarily on how much of the loose penile tissue is removed, and whether it is mainly the outer (skin) layer or the inner (mucous membrane) layer, MGC Types 1 and 2 listed above can easily be broken down into an indefinite number of divisions (10, 20, 30 per cent, etc., of the foreskin), with both the visible damage and the impact on sexual sensation and sexual function increasing at each step.
The severity of the operation is also affected by whether it removes the frenulum, the sensitive “bridle” on the underside of the penis, adjoining the cleft in the glans. This is now known as the frenular delta and is understood to support one of the body’s densest concentrations of fine-touch nerve receptors, whose specific function is to detect and transmit pleasurable touch. [10]Because the ridged band is also uniquely ridged or corrugated, retraction and stretching of this accordion-like structure may play an important role in penile reflexes, including urination, erection, and ejaculation. [11] Where the foreskin is still adherent, as it is in nearly all infants and commonly in boys up to the age of about eight, forcibly tearing it from the glans adds a further dimension of both pain and injury (including skin bridges and adhesions). The damage often extends to the parts of the penis that remain, and the pain is severe. [12] Nor is it just a matter of losing nerve endings: the destruction of the sliding mechanism of the foreskin back and forth over the glans, and thus of the stimulation and lubrication it affords, is another serious effect of MGC. Yet it is a harm that cannot be picked up by the sort of “sensitivity studies” that have appeared in the wake of Masters and Johnson’s much cited but deeply flawed study (1966). [13]
In order to assist the development of an objective measuring stick for MGC damage we suggest the following provisional five-point scale:
Type 1: A nick to or slitting of the foreskin; or premature or forcible separation of the prepuce from the glans, without amputation of tissue.
Type 2: Amputation of the portion of the foreskin extending beyond the glans.
Type 3: Amputation of the foreskin at a point partway along the glans; some foreskin and all of the frenulum left; some sliding functionality retained.
Type 4: Amputation of the foreskin at or below the corona of the glans.
Type 5: Other forms of penis mutilation, including meatotomy, subincision, infibulation, piercing and implants.
Type 2 corresponds to the original Judaic operation of bris (before the institution of periah — tearing the foreskin from the glans — in the Hellenic period) [14] ; most of the foreskin and all of the frenulum left; a fair degree of sliding functionality retained. When this procedure is performed after infancy, after separation of prepuce from glans, more of the preputial tissue and some of the frenular tissue tends to be cut.
Because there is no agreed understanding of circumcision and the results are highly variable, depending on the quantity of tissue removed, the degree to which the foreskin is stretched during the operation, and the instruments used, it is useful to break Type 4 into three subtypes.
Type 4A: Amputation of the foreskin at the corona of the glans, leaving glans fully exposed, but retaining frenulum; little or no sliding functionality; frenular nerves retained.
Type 4B: Amputation of the foreskin at the corona of the glans, also excising frenulum; little or no sliding functionality; no frenular nerves left.
Type 4C: Amputation of the foreskin beyond the corona of the glans, at any point along the penis shaft; all foreskin and variable quantities of shaft skin excised; all frenular nerves lost; zero sliding functionality; high risk of insufficient slack tissue for accommodating tumescence.
It would be interesting to know the proportion of MGC operations falling into each of these categories. The vast majority would probably be the most severe, Type 4, and possibly Types 4B and 4C, particularly in the United States, where the ‘high and tight’ look is favored by the obstetricians and urologists who perform most of the procedures, and whose preference is facilitated by the infamous Gomco clamp, a device that ensures maximum loss of tissue, as well as a slow and painful operation. [15]
With respect to FGC, it is also possible to break the WHO’s definition down more precisely into at least seven procedures: a nick to the clitoris; separation of the clitoral hood or prepuce, without amputation of tissue; removal of the clitoral hood; excision of part or all of the labia minora; excision of part or all of the labia majora; excision of part or all of the clitoris; stitching up the vaginal orifice. The main difference between female and male genital cutting can now be seen to consist in the fact that the severity of FGC increases as the number of procedures rises, thus bringing more parts of the genitals under the knife; while the severity of MGC primarily depends on how much of a single element of the genitals is amputated. It is the variety of the procedures constituting FGC, in contrast with the unitary nature of MGC, which promotes the illusion that the first is a cruel and injurious form of torture called mutilation, while the second is a mild surgical adjustment called circumcision.
1. Stanlie M. James and Claire C. Robertson, eds., Genital Cutting and Transnational Sisterhood: Disputing U.S. Polemics (Chicago: University of Illinois Press, 2002).
2. Robert Nye, “Review of Robert Darby, A Surgical Temptation,” Journal of the American Medical Association 294 (7 Dec. 2005):2771–2772
3. See J. Steven Svoboda, “Male Circumcision,” Paper submitted to the Sub-Commission for the Promotion and Protection of Human Rights, August 9, 2001, United Nations Document No. E/CN.4/Sub.2/2002/1 (March 23, 2002); and “Educating the United Nations about Male Circumcision,” in Flesh and Blood: Perspectives on the Problem of Circumcision in Contemporary Society, ed. G. C. Denniston, M. F. Milos, and F. M. Hodges (New York: Kluwer Academic/Plenum Publishers, 2004).
4. George C. Denniston, Frederick Hodges, and Marilyn Milos, eds., Understanding Circumcision: A Multi-disciplinary Approach to a Multi-dimensional Problem (London: Kluwer Academic/Plenum Press, 2001), p. v. Since accurate statistics on circumcision are not kept, these figures are the roughest of estimates, though it can be said that the vast majority of these boys are from Muslim families, most of whom probably undergo the operation between the ages of four and eight.
5. J. G. Boyle, R. Goldman, and J. Steven Svoboda, “Male Circumcision: Pain, Trauma and Psychosexual Sequelae,” Journal of Health Psychology 7: 3 (2002):329–343; Tim Hammond, “A Preliminary Poll of Men Circumcised in Infancy or Childhood,” BJU International 83 (Suppl. 1, January 1999):85–92; Shane Peterson. “Assaulted and Mutilated: A Personal Account of Circumcision Trauma,” in Denniston, Hodges, and Milos (eds), op. cit., pp. 271–290; John Warren, et al, “Circumcision of Children,” British Medical Journal 312 (1996):37; N. Williams and L. Kapila, “Complications of Circumcision,” British Journal of Surgery 80 (1993):1231–1236.
6. Such men experience further discomfort with erections and find particular difficulty using condoms. The hair can also inflict abrasion and discomfort on sexual partners. For graphic illustrations of just how much damage routinely circumcised penises commonly sustain, and how different they look from uncircumcised penises, see the images of damage and difference at Circumstitions. If a man presented at his GP with these sorts of injuries – scarring, granulated tissue, skin bridges where raw tissue surfaces have fused, distortion – on any part of his body other than his penis, he would be referred, urgently, to a plastic surgeon. But so normal are these results that many of the images have been taken from pornographic magazines and personal ads on sexual contact websites. See C.J. Cold and J. R. Taylor, “The Prepuce,” BJU International 83 (Suppl. 1, January 1999):34–44; John Money and Jackie Davison, “Adult Penile Circumcision: Erotosexual and Cosmetic Sequelae,” Journal of Sex Research 19 (1983):289–292; J. R. Taylor, A. P. Lockwood, and A. J. Taylor, “The Prepuce: Specialized Mucosa of the Penis and Its Loss to Circumcision,” British Journal of Urology 7 (1996):291–295; G. Zwang, “Functional and Erotic Consequences of Sexual Mutilations,” in Sexual Mutilations: A Human Tragedy, eds. G. C. Denniston and M.F. Milos (New York: PlenumPress,1997).
7. Sami A. Aldeeb Abu-Sahlieh, Male and Female Circumcision among Jews, Christians and Muslims: Religious, Medical, Social and Legal Debate (Warren, PA: Shangri-La Publications, 2001), p. 9; full text available from FGM Network; Sami A. Aldeeb Abu-Sahlieh, “Male and Female Circumcision: The Myth of the Difference,” in Rogaia Mustafa Abusharaf (ed.) Female Circumcision: Multicultural Perspectives. (Philadelphia: University of Pennsylvania Press, 2006), pp. 60-61.
8. See Terence Hull and Meiwita Budiharsana, “Male Circumcision and Penis Enhancement in Southeast Asia: Matters of Pain and Pleasure,” Reproductive Health Matters 9 (2001):60-67. It is an interesting sidelight on Anglophone attitudes that while anthropologists have devoted much time and ink to the origins and meaning of genital cutting rites, they have neglected the equally (and possibly more) numerous societies that practiced various forms of foreskin elongation or otherwise sought to conceal rather than uncover the glans – anything from the penis sheaths and gourds of New Guinea and Melanesia to the infibulation of slaves in classical Rome and the modesty-preserving kynodesme in ancient Greece. See Eric Dingwall, Male Infibulation (London: John Bale, 1925); and Frederick Hodges, “The Ideal Prepuce in Ancient Greece and Rome: Male Genital Aesthetics and their Relation to Lipodermos, Circumcision, Foreskin Restoration and the Kinodesme,” Bulletin of the History of Medicine 75 (2001): 375-405.
9. Romeo B. Lee “Filipino Experience of Ritual Male Circumcision: Knowledge and Insights for Anti-circumcision Advocacy.” Culture, Health & Sexuality 8:3 (2006): 225–234.
10. See C. J. Cold and J. R. Taylor, “The Prepuce,” BJU International 83 (Suppl. 1, January 1999); Ken McGrath, “The Frenular Delta: A New Preputial Structure,” in Denniston, Hodges, and Milos, eds. Understanding Circumcision, op. cit., 199-206; and J. R. Taylor, A. P. Lockwood, and A. J. Taylor, “The Prepuce: Specialized Mucosa of the Penis and Its Loss to Circumcision.” British Journal of Urology 7 (1996):291–295.
11. See J. R.Taylor, “The Forgotten Foreskin and its Ridged Band.” Journal of Sexual Medicine 4 (2007):1516.
12. See A. Taddio, J. Katz, A. L. Ilersich, and G. Koren. “Effect of Neonatal Circumcision on Pain Response during Subsequent Routine Vaccination.” Lancet 1997 349:9052: 599–603.
13. For critiques of Masters and Johnson, see John M.Foley, The Practice of Circumcision: A Revaluation (New York: Materia Medica, 1966); Frederick Hodges and Paul Fleiss, “Letter,” Pediatrics 105:3, Part 1 (2000):683–684; available on Quotes page; M. L. Sorrells, J. L. Snyder, M. D. Reiss, et al., “Fine-Touch Pressure Thresholds in the Adult Penis,” BJU International 99 (2007):864–869, and the incisive deconstruction by Hugh Young, The Foreskin, Circumcision and Sexuality.
14. See Leonard Glick, Marked in Your Flesh: Circumcision from Ancient Judea to Modern America (New York: Oxford University Press, 2005), p. 31 & pp. 43–45.
15. See Leonard Glick, Marked in Your Flesh, op. cit., 196–197; R. L. Miller and D.C. Snyder, “Immediate Circumcision of the Newborn Male,” American Journal of Obstetrics and Gynaecology 65 (1953):1–11; and Julian Wan, “Gomco Circumcision Clamp: An Enduring and Unexpected Success.” Urology 59 (2002):790–794. Further information on Gomco clamp.