Research published in biomedical and social science journals are strongly focused on numbers because quantifiable data can be subjected to a variety of statistical manipulations and are assumed to be objective. This approach works well when you are dealing with discrete, objective entities, such as barrels of oil, correlations between variables or the number of people with particular demographic characteristics who believe x or y. The approach may not be so useful when trying to reach conclusions about people’s subjective feelings and emotions, particularly in the sexual arena, where people are notoriously reluctant to report their real feelings and may be confused or uncertain as to what they really think and want. Recent research into men’s feelings about their penis and, more especially, their circumcision status, have tended to emphasise the apparent conclusion that most men are reasonably happy with their condition, whatever it happens to be, and therefore that there is not really any great problem. But are mere numbers the only important consideration?
The most recent study by Bossio and Pukall found that men circumcised as adults were significantly more content with their situation than men circumcised as infants or children, concluding that age of circumcision was an important factor in their level of satisfaction. But it is equally likely that the age at which the operation is performed is actually a proxy, standing in for other factors, such as consent and whether the patient was conscious at the time and thus can remember the procedure.
In the following discussion I consider, first, the question of numbers, and secondly outline a hypothesis that four key factors are involved in a male’s level of satisfaction or dissatisfaction with his circumcision status.
It is widely assumed that unless large numbers of men are resentful of or upset about having been circumcised there is really no need for concern or any moves to regulate or restrict circumcision. But are numbers really so important? How many women in regions or cultures that practise female genial cutting (FGC) feel or say they are harmed? Governments did not feel it necessary to prove the harm of FGC or calculate the number of women who felt harmed or otherwise upset or resentful before criminalising it: Third World countries agreed after Western pressure, developed countries acted out of a sense of general repugnance.
What is remarkable about the United States is that, in a society of such genital conformity that the circumcised penis is seen as the American norm and parents cut baby boys in order to make sure that they are not teased in the proverbial locker room, any men at all feel resentful rather than grateful at having been circumcised. The anti-circumcision movement arose in the 1980s, a decade when the vast majority of adult men were circumcised, and the incidence of infant circumcision was more than 80%.
A more significant metric is the number of adult men who seek circumcision for themselves. In the USA this number is hard to obtain, but there seems to be general agreement that it is very small – as you would expect, given that most adult men are already circumcised, and few have the option. At the same time, there is evidence that plenty of men who have not been circumcised like it that way, and that some who bow to pressure later regret their decision.
Figures from Australia give a more accurate picture. According to Medicare statistics, from 2009 to 2016 the number of circumcisions of boys under 6 months of age fell from 20246 to 14880. In the same period, the number of circumcisions among males aged 10 years and over increased from 3039 to 3205. Some of these are probably the result of a wrongful diagnosis of phimosis, but most would have been done with at least a degree of consent, even for boys under 18, as few parents could force a boy older than 10 years to get circumcised if he really did not want to be. Since Medicare does not give a more detailed breakdown by age, it is not possible to know the number of men over the age of 18 who elect circumcision for themselves; but it is likely that most of the cases in the over 10 years of age category occur before age 18, in order to deal with foreskin tightness problems arising when the penis enlarges at puberty. Even without this detail, and considering that the current male birthrate in Australia is about 160,000 per year, it is clear that the number of competent males electing circumcision for themselves in a society where the majority of men are not circumcised, and the rate of infant circumcision (under 6 months of age) is less than 10%, is miniscule – good evidence that most men like and appreciate their foreskins.
One curious piece of evidence is a recent survey of “genital dissatisfaction” by Gaither et al.** They surveyed a sample of about 4000 American men and found that only 62 per cent were “satisfied” with their circumcision status, 35 per cent were “neutral” and 7 per cent were “dissatisfied”. Unfortunately, the researchers failed to ask the respondents to state whether they were circumcised or not, so it is impossible to know how many of the “satisfied” customers were happy because they had not been circumcised or because they had been, and the same uncertainty applies to the “unsatisfied” and “neutral” categories. What is striking about the survey is (1) the low level of satisfaction overall: the highest score was only 64 per cent, relating to the shape of the glans; and (2) the high level of a “neutral” response, suggesting that a high proportion of American men are pretty fatalistic about these matters. From the point of view of assessing attitudes to circumcision, however, the survey tells us almost nothing.
** Thomas W. Gaither et al. Characterization of Genital Dissatisfaction in a National Sample of U.S. Men. Archives of Sexual Behaviour 46 (2017): 2123-2130.
I think the truth of the matter is that most men are reasonably content with whatever fate has dealt them, or at least resigned to their situation, and I suspect that many of the uncircumcised men who seek circumcision in adulthood are the very ones who would have embarked on foreskin restoration had they been circumcised in childhood. For some men, the grass is always greener in the next paddock. But the situation is not symmetrical: a male who has not been circumcised can always get himself circumcised if that is what he desires; a male who has been circumcised in infancy or childhood does not have the option of getting his foreskin back.
There is also the question of the intensity of feeling. Suppose that in a sample of 100 circumcised men 90 expressed themselves content with their state, while 10 reported discontent or resentment. It looks as though most men are pretty happy, but these raw figures take no account of the intensity of the feelings: it may be that the feelings of the 10 who resent having been circumcised are much stronger than the feelings of satisfaction expressed by the contented majority. If their feelings were, say, 10 times stronger, the overall level of dissatisfaction or resentment would exceed the level of satisfaction. The problem is that intensity of feeling is not a variable that can easily be quantified, so most researchers make little serious attempt to include it in their studies; yet without an accurate assessment of intensity, definite conclusions about the degree of satisfaction or dissatisfaction cannot be reached.
Similar considerations apply to the degree of strictly physical harm. At one end of the spectrum there are mild and average circumcision procedures; at the other end the severe penile injuries sustained by Xhosa teenagers in their bush initiation, or by children in clinical settings who suffer excessive tissue removal or loss of their glans or entire penis, not to mention opportunistic infections, bleeding and other adverse side-effects, sometimes causing death. When reaching overall conclusions about the incidence of what are euphemistically called “complications”, it is necessary to factor in the severity of the damage, not merely the raw number of incidents. I do not pretend that it is easy to do this, and if it proves to be impossible then medical authorities should be up-front and admit that the real risks of circumcision complications cannot be quantified - as the American Academy of Pediatrics actually conceded in their 2012 policy. But if the mere physical risks cannot be quantified (let alone ethical, psychological and other factors), perhaps (as Dritsas argued long ago) there should be a moratorium on non-therapeutic circumcision procedures until we have this information.
While the subjectivities are important (and cut both ways), I think that circumcision is objectively harmful insofar as it involves cutting of flesh, inflicting injury and removing a normal body part, even if men do not think, or do not say, that they have been harmed. There are certain analogies with slavery and women’s subordination. Slaves endured their servitude, and women their subordination, for centuries without making much of a fuss. It was only when a few agitators, influenced by the development of the concept of human rights in the eighteenth century Enlightenment, started to raise their consciousness that they began to regard themselves as harmed by their condition. Even in the American Civil War the lead in the fight against slavery was taken by northern liberals, not the slaves.
Even if circumcision did not cause significant harm it would not amount to a reason why it should performed: for circumcision to be legitimately done, there must be compelling arguments as to why it is significantly better to be circumcised. If it does not make much difference, given the risks and costs, the best (least risk and least cost) course is not to do it. It should not, therefore, be necessary to prove that circumcision is harmful for it not to be performed, merely that it does not do significant net good. I concede that if it is to be legally prohibited, it is necessary to prove harm (on the principle that the role of the law is to prevent persons from harming others), but this rule applies as much to FGC as to MGC. Personally, I have never argued that circumcision should be criminalised, and do not believe that it should be; at the same time, I believe that governments should make more effort to discourage the practice, rather than allowing the open slather that prevails in most places at present. For some of my ideas, see my submission to the Tasmania Law Reform Institute inquiry.
It is often asserted that claims by men that they have been harmed by circumcision are worthless because they are merely anecdotal evidence. In fact, most claims of harm are not anecdotal at all, but personal testimony: men who have been circumcised reporting their own experience. Anecdotal evidence is properly hearsay – what somebody heard reported about somebody else. Personal testimony is usually reliable evidence: if it is enough to get somebody convicted of a capital offence in a court of law it ought to be enough to persuade an impartial judge or jury that the complainants have suffered harm.
“Botched circumcision” is a misleading expression that ought not to be used. It suggests that circumcision normally gives what is glibly referred to as “an excellent cosmetic result”, and that something goes wrong in only a very few cases – though sufficiently numerous to drive the Mogen Clamp company out of business as a result of lawsuits. What “botched circumcision” seems to designate are cases where the damage extends beyond the foreskin, such as clipping off portions of the glans, or ripping the body of the penis shaft. I would define it as damage beyond what was intended – but exactly what anatomical result is intended by circumcision is variable and rarely specified.
Some writers suggest that excessive skin removal should be regarded as a botched circumcision, but “excessive” is a matter of arbitrary and subjective judgement. In fact, the removal of so much skin that erections at puberty become painful or difficult is quite common and not regarded as a disability by most doctors in places where circumcision is (or was) normative. Shane Peterson had such a severe circumcision that his erections at puberty were both painful and restricted, and he actually considered sexual reassignment surgery and made a suicide attempt. When he sought help from doctors and psychologists they told him that his circumcision was perfectly normal and that the problem was entirely in his head. I have heard (in person or by correspondence) many similar reports from other circumcised men.
The question of when skin removal is excessive raises the question of the purpose of circumcision. Is it simply to ensure that the glans is permanently bared, or is to remove as much loose tissue as possible? The Victorian anti-masturbation campaigners wanted to prevent the gliding action that facilitated bad habits, while the anti-syphilis crusaders wanted to ensure that the glans became dry and hardened and thus impermeable (as they thought) to the syphilis microbes. Circumcision does make the glans go dry and hard, but there has never been any proof that circumcised men were less susceptible to infection with syphilis. In the case of HIV, if (as is claimed) the mucosa of the foreskin is the principal Trojan Horse for entry of the virus, it follows that the circumcision procedure should be as radical as possible.
Like excessive skin removal, the definition of the extent of the foreskin is a matter for judgement because there is no clearly demarcated point where the foreskin ends and the rest of the penis begins. The penis is an integrated structure, not one composed of detachable modules – as illustrated vividly in discussions of its embryology. The Renaissance anatomists described the frenulum as the “bridle” that tethered the foreskin and ensured that it rolled back into place when not in use. They also noted that it was highly sensitive to both pain and pleasure. It is of interest that the ancient Greeks had no separate word for foreskin: posthe was penis, and akroposthion (often translated as foreskin) designated the top, or tip or peak of the penis; they evidently saw the penis as a unitary structure.
While circumcision is often likened to snipping off the end of an asparagus stalk, it is really more like tearing the sepals off a rosebud. (This image might be regarded as too emotive; but at least in the case of roses the difference between the petals and the sepals is pretty clear; no such sharp demarcation can be found between the foreskin and the rest of the penis.) These points are illustrated in this description of a circumcision procedure by a Victorian doctor who sought “an improved method of circumcision” because it was difficult “to separate the inner layer [of the foreskin] from the tiny glans, wet and slippery with blood” as it usually was. The virtue of MacLeod’s proposed technique was that it made it easier for doctors to see what they were doing and thus limit damage to what they intended:
“The last case operated on, in a child of two years, scarcely admitted the point of a probe through the orifice of the prepuce, but by dilating this orifice forcibly with “sinus forceps”, and the addition of a few tiny snips with scissors round the margin … the foreskin could be drawn back until the point of the glans showed itself. Further retraction was prevented by the adhesions … but these were easily broken down by means of a probe passed between the prepuce and the glans, and this done until the corona glandis was exposed.” (Macleod, Neil (1883), “An improved method of circumcision for congenital phimosis”, Edinburgh Medical Journal, Vol. 28, pp. 807-8)
Only then was it possible to start cutting the foreskin off.
Whether the frenulum is regarded as part of the foreskin or not, it is nearly always removed in circumcision procedures these days, as even the most cursory survey of internet porn sites will reveal. I have noticed that the penises of Muslim men seem to be particularly severely denuded, but the typical American penis is similar. (Check out some of the tumblr.com accounts if you need visual evidence, especially those specialising in circumcised penises.)
Information in anatomy texts is useful, but textbooks are often out of date, as they tend to repeat old information from one edition to the next, and they leave the issue at an abstract level. We are dealing here with flesh and blood, and an organ that is the most loaded and contested site on the human body. There is really no substitute for close visual and tactile examination of the parts in question, not merely in a state of rest, but in actual operation. For this reason, I would give the reports of men who have sex with men (MSM) at least as much credence as those of most medical personnel, especially urologists – who only see people with problems and thus tend to develop a jaundiced view of the body. Most MSM have extensive experience of penises, not merely as objects to look at, but as functioning organs. My impression from internet dating sites is that MSM have a strong preference for the uncut penis, suggesting that in their experience it makes for a more satisfying sexual experience.
In our paper, Circumcision sexual experience and harm, Brian Earp and I argued that inadequate information on the harms of nontherapeutic circumcision is a reason for leaving the choice to male minors when they are old enough to make an autonomous choice for themselves. An even more important reason is because it is impossible to predict how a boy will react to discovering that he has been circumcised and what he will feel about it later – happy, indifferent, resentful, suicidal? Not circumcising is simply the least-risk option.
Hypothesis: Age is not the key factor, but usually a proxy for more important variables, namely:
• Autonomy: Elected, consented or coerced
• Conformity: Circumcision status of peers
• Consciousness: Whether aware at the time
• Rationale: Whether therapeutic or non-therapeutic
For the purposes of this typology I assume that circumcision can be elected or consented to after puberty or from age 16 (whichever comes later). Procedures before then are characterised as coerced, even where children have requested them, agreed or not expressed objections.
Likelihood of satisfaction and absence of resentment – sliding scale from most satisfaction and least resentment to least satisfaction and most resentment.
1. Elected therapeutic or non-therapeutic circumcision (a) where peers mostly circumcised; (b) where peers mostly not circumcised.
Non-therapeutic here could mean cultural/religious, cosmetic, conformist, sexual fetish or any other non-medical reason. Therapeutic means correcting a foreskin problem that is causing discomfort, inconvenience or other medical or sexual dysfunction.
2. Infant circumcision (not aware at time) where peers mostly circumcised.
Lack of awareness that anything was taken away and absence of experience of possessing a foreskin would be predicted to increase satisfaction and reduce resentment; and the converse applies. This category includes Jewish circumcision and routine circumcision in USA, and expresses the relatively high level of satisfaction and low level of resentment in these groups.
3. Childhood therapeutic circumcision (aware at time) (a) where peers are mostly circumcised; (b) where peers are mostly not circumcised.
4. Childhood non-therapeutic circumcision (aware at time) where peers mostly circumcised.
This includes most cultural/religious procedures, notably Muslim and many tribal
5. Infant circumcision (not aware at time) where peers mostly not circumcised.
6. Coerced adult (age 14-plus) circumcision (a) where peers mostly circumcised; (b) where peers mostly not circumcised.
Further refinements are possible, such as the difference between actively elected and passively consented to; and it would be possible to give greater weight to the conformity factor (circumcision status of peers).
There is a case for switching items 3 and 4, but I have categorised childhood cultural/religious circumcision as likely to generate more resentment and less satisfaction because there are many more of them, so more scope for a range of subjective responses; and because a (genuinely) therapeutic circumcision would remove a source of discomfort and contribute to well-being. There is a Turkish study** showing that a high percentage of boys find their circumcision rite a terrifying and painful ordeal; and any number of videos available on Youtube will confirm this impression.
** Sahin F, Beyazova U, Akturk A. “Attitudes and practices regarding circumcision in Turkey.” Child Care Health and Development 29 (2003): 275-280. Abstract at cirp.org.
The second variable above (condition of peers) could be framed more broadly as degree of knowledge that the penis can come with foreskin intact. Such awareness is more likely to the extent that males in that society are not circumcised and less likely to the extent that they are, but knowledge through other means (books, magazines, contact with other places, internet) can also be significant. What is remarkable about the United States is not the fact that most circumcised men seem to accept their condition without complaint, but that any men at all resent their situation. It cannot be an accident that the rise of a community-based anti-circumcision movement developed at precisely the same time as growing awareness that the uncircumcised penis was a viable option and the normal thing on a world scale.
Such knowledge came in a variety of forms: increasing international travel, exposure to classical and Renaissance art (especially ancient Greek and Roman sculpture) and – perhaps most importantly – the availability of visual pornography that showed human genitals in explicit detail. This latter resource exploded with the rise of the Internet, which has always been awash with images of human genitalia, including penises. It may reasonably be hypothesised that such exposure to the intact penis, particularly on the bodies of the attractive, athletic men that are typically displayed in pornographic material would be likely to have two effects: (1) to attract women who, as mothers, would then be less likely to seek circumcision for their own sons; and (2) to arouse feelings of envy and inadequacy among men who had been circumcised in infancy or childhood.
On top of all this, the development of an anti-circumcision movement led to a public debate that brought the issue into the open and made an immense wealth of alternative information available, particularly through dedicated websites available to anybody with internet access. It has been the ready availability of such alternative sources of information that led to a significant decline in the incidence of routine circumcision in South Korea.
By contrast, in closed monocultural societies lacking any contact with other cultures, and where all males are circumcised in infancy or childhood, there will never be any opportunity for comparison, and it is thus unlikely that many people (or any people) will suppose that it is possible not to be circumcised, or even capable of imagining such a state. In societies of universal infant circumcision, nobody will even know what a normal adult penis looks like, let alone whether it functions differently. In this situation there is unlikely to be any noticeable discontent; in Jewish communities, for example, there has been strong evidence of dissent from the circumcision rule only during periods when Jewish people were seeking integration into the wider society, notably the Hellenistic period of the ancient Mediterranean; nineteenth century Germany; and the contemporary world. (See The Forgotten Critics for details.)
In today’s increasingly globalised, multi-inter-connected world, where even the most poverty-stricken village in darkest Africa has access to television, smart phones and the internet, closed societies of this old type can scarcely exist. In this situation we can expect the strengthening of two opposed trends: increasing opposition to circumcision from young people in cultures where it remains normative; and increasingly desperate efforts on the part of cultural and medical conservatives to preserve the practice.
Written for Circumcision Information Australia by Dr Robert Darby