Controversy and debate: The everlasting circumcision experiment

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Circumcision has always been a controversial, and on a world scale, a minority practice. Even among societies where it was commonly performed, as with the ancient Hebrews, there were always critics who asked why would would parents do to babies things that no rational adult would ever do to himself. Medically rationalised circumcision has been controversial from the outset, and in its place of origin (Britain) never affected more than a third of boys. Even then it was subject to constant doubt and criticism: as early as the 1890s one doctor attacked the practice as "barbarity". The practice never spread beyond the English-speaking world, and only in the United States did it (briefly) become nearly universal.

On the basis of these facts, any reasonable person would have to conclude that as a health precaution, circumcision was nothing more than an inconclusive experiment.

On this page we consider some of the current topics of debate:

Also on this site

Have the circumcision promoters made a convincing case?

Circumcision and public health (2): Is circumcision a biomedical imperative for the 21st century?

Circumcision and "moral hygiene": The 19th Century anti-masturbation crusade

Origins of ritual circumcision

There is no evidence that ritual or religious circumcision first arose as a hygiene measure. Many primitive cultures carried out a variety of mutilating procedures on different parts of the body, including the genitals of both boys and girls, but the origins and rationale of these practices are obscure and contested, as are the environmental conditions prevailing when and where such customs emerged. Past societies also practised cannibalism, human sacrifice, infanticide, widow-burial, foot-binding and many other traditions not endorsed today. It is a delusion of Marxist anthropology to assume that traditional rites must have a materialist and rational explanation; modern anthropology recognises that such customs emerge from the belief structure or cosmology of the cultures which produced them and do not necessarily have practical significance. Many conflicting theories have been advanced to account for the rise of ritual operations on the male and female genitals (6-8), among which are the following:

 

The only point of agreement among proponents of the various theories is that a pragmatic aim like hygiene had nothing to do with it. In the days before aseptic surgery, any cutting of flesh was about the least hygienic thing anybody could do, carrying a high risk of bleeding, infection and death. Travelling in Iraq in the 1930s the English doctor Wilfred Thesiger reported that Arab boys undergoing circumcision:

sometimes took two months to recover, suffering great pain in the meanwhile. One young man came to me for treatment ten days after his circumcision, and … the stench made me retch. His entire penis, his scrotum and the inside of his thighs were a suppurating mess from which the skin was sloughing away, the pus trickling down his legs (9).

None of the ancient cultures which practised circumcision have traditionally claimed that the ritual was introduced as a hygiene measure: African tribes, Arabs, Jews, Moslems and Australian Aboriginals explain it different ways, but divine command, tribal identification, social role, family obligation, respect for ancestors and promotion of chastity figure prominently (10, 11). It was only in the late nineteenth century, when mass circumcision was being introduced for “health” reasons, that doctors sought legitimacy for the new procedure by claiming continuity with the distant past and attempting to explain the origins of circumcision in terms of their own hygienic agenda (12). As a Dr Davidson put it in 1889, “a nation like the Jews, whose ideas of sanitation were so far advanced … adopted the practice as much for its substantial benefits to health as out of regard to religious ceremonial” (13). Moslems enjoying less respect at that time, and little being known about them, the Jews were the preferred model. Nobody has ever suggested that circumcision as performed by the Aboriginals had a hygienic rationale, nor that their custom of knocking out teeth during initiation ceremonies was a precaution against the inconvenience of tooth decay in later life.

For references, see full essay on this site

Further information

History of Circumcision

 

Circumcision Information and Resource Pages

Robert Darby. "The riddle of the sands: Circumcision, history and myth", New Zealand Medical Journal 118, 15 July 2005. Also available from Robert Darby's Academia.edu page

Medical history and medical practice: Three persistent myths about the foreskin

Dr Karl on the origins of circumcision (and Brian Morris's response)

Circumcision and sand revisited: Did sand under the foreskin really cripple armies? Robert Darby replies to Brian Morris

Origins of cultural/religious/ritual circumcision are not related

to hygienic or other practical considerations

 

The following letter from Dr V. Raveenthiran in the Journal of Pediatric Surgery replies to the speculations of a certain Steven Moreton on the supposed “hygienic” or “health” origins of non-therapeutic circumcision.

Dr. Moreton has placed many contentious arguments regarding circumcision. I agree with him that tracing the origins of this ancient procedure is not an easy task; however, the exercise is not completely irrelevant to modern medical practice. Circumcision is the only surgical operation that is either passionately patronized or vehemently condemned — not only by laity but also by medical practitioners [1]. Influence of lobbying groups is such that even the medical literature is more often distorted [2] as it is evident from frequent reversal of policy recommendations by professional bodies such as American Academy of Pediatrics [3]. Dichotomized circumcision politics, which potentially affects millions of children, can be better understood only by studying its historical evolution.

Historically several hypotheses have been proposed regarding the origins and purpose of circumcision [1,4–8]. They include: (1) Religious sacrifice in fulfillment of the covenant with God; (2) Tribal rite of passage into adulthood; (3) Demonstration of leadership qualities such as courage and endurance of pain which are prerequisite of being elected as chieftains; (4) Deterrent of premature indulgence into procreative life; (5) Superstitious act of ensuring or enhancing virility and fertility; (6) Measure of personal hygiene in xeric environments; (7) Symbol of social status (paradoxically both nobility and slavery); (8) Symbolic emasculation – either humiliating or punitive – of war prisoners and slaves; (9) Mark of clan identification especially during exodus and riots; (10) Aesthetic procedure to enhance men's sexual attractiveness; (11) Imitation of a leader's malformation (aposthia) by his followers; (12) Modifier of sexual pleasure (paradoxically both enhancer and suppressor); (13) Dissuader of masturbation and sexual perversions; (14) Magical repellent of demons that were believed to dwell in preputial sac; (15) Castration substitute employed by jealous fathers to discourage sons from having incestuous affair with mothers; (16) Indigenous technique of creating gender awareness and masculine identity; (17) Superstitious act of separating males from androgynous child and (18) Method of oath taking by men enrolled to guard a particular primitive society.

To the aforementioned long list, Moreton adds “his own theory” of ‘prophylactic origins of circumcision’. It is nothing new but a plagiarized version of an archaic concept that was originally expressed by Herodotus when he first saw circumcised Egyptians in circa 450 BCE. Since then this speculation has been repeated in many avatars — the latest of which claims that circumcision was originally intended to avoid irritation of desert sand accumulating underneath the foreskin [9]. However, Darby exposed the fallacies of hygiene theory and firmly laid it to rest [10,11].

Rhetoric on protective health benefits of circumcision has only camouflaged over time to match unconquered diseases of the given era. For example in late 19th century, when infectious and neurological diseases were poorly understood, Merrill Ricketts claimed circumcision to prevent or cure paralysis, neurasthenia, eczema, elephantiasis, tuberculosis, enuresis, impotence, epilepsy, hysteria and even acne [1,12,13].

Although all of them are now disproved, devotees of circumcision have not abandoned the worship; but simply moved on to build newer altars. They now claim circumcision to be preventive of penile cancer, sexually transmitted infections including HIV, cervical carcinoma, and urinary tract infection. Surprisingly, these misleading claims are often included in medical textbooks. It is now emerging that evidences for these claims are scant, invalid, weak and distorted [1–3]. As we snigger today at the impossible list of Merrill Ricketts, so will our successors chuckle at contemporary claims of hygiene and prophylaxis. From Merrill Ricketts to Moreton, misconception of foreskin hygiene is perpetuated by the dogma wherein the smegma is vilified as an irritant. It defies logic as to how a physiological secretion of body can be harmful [1]. Myths surrounding smegma have long been dispelled [14] and hence Moreton is trying to resurrect a buried lie.

Moreton got his anthropological lessons wrong when he stated that this operation must have been adopted by primitive men on seeing the health benefits enjoyed by an occasional child born without prepuce (aposthia). It is widely acknowledged that primitive societies did not consider malformed children as human beings. Even minor anomalies were considered a bad omen and such babies were either killed or allowed to die by abandoning in wilderness [15]. Therefore a child born with aposthia in prehistoric times was unlikely to have survived long enough to demonstrate the benefits of preputial absence.

I maintained that prehistoric men of paleolithic era were unlikely to have inflicted self-injuries as it would have been a survival disadvantage. I also cited Taves’ experiment wherein circumcision was hypothesized to increase glans friction during intromission. Moreton refutes both these assertions by citing tribal rituals and clinical studies finding infrequent coital injuries in circumcised men. Moreton appears to have mistaken ‘prehistoric men’ for ‘tribal men’ and ‘penile intromission’ for ‘sexual intercourse’. For example, intromission is just the act of inserting the penis into the vagina while intercourse is the full range of act that culminates in orgasm (Oxford English Dictionary). Circumcision certainly makes intromission unpleasant which is why it was projected as masturbation dissuader. Sexual pleasure and coital injuries are determined not only by the status of circumcision but by many other factors such as degree of vaginal lubrication, force of pelvic thrust, coexisting diseases, genital malformations, psychological inclination of partners and coital posture. Unfortunately none of the studies cited by Moreton take all these covariables into consideration. Further, an equally good number of “robust” studies published in high impact journals indicate that coital injuries and impaired sexual pleasure are more frequent in circumcised men [16–19]. This is what I dismiss as dichotomized literature.

Moreton asks for more evidences of circumcision originating as a punishment or humiliation of war prisoners. They are plenty to fill an entire issue of the Journal of Pediatric Surgery; suffice I mention a few of them. Diodorus Siculus (circa 100 BC) in his magnum opus Bibliotheca Historica described a bas-relief seen in the Tomb of Ozymandyas (Hellenized name of Rameses II) [20]. The sculpture, probably commemorating the King's victory in the Battle of Kadesh (circa. 1274 BC), was said to depict chain-bound war prisoners registered by a royal scribe in preparation for amputation of right hand or ‘private parts’. A pile of these excised organs was also seen in the foreground [5]. A more explicit description is found in the Old Testament. Saul wanted to avenge both David and Philistines. Hatching a cleaver plan, he asked David to bring 100 foreskins of philistines as dowry to marry his daughter Michal; And David brought 200 of them and took her hands in wedlock (Samuel 18:25–27). In another story, when Shechemraped Jacob’s daughter Dinah, her enraged brothers deceitfully circumcised all their enemies and humiliatingly killed them while they were still recovering from the sore (Genesis 34:1–31). Forced circumcision of enemies is also well documented as late as in British India.

The theory of punitive origin of circumcision is of some practical importance. I have observed that circumcision is more often promoted and defended by those who have undergone the procedure themselves [21]. Psychologically this appears to be a phenomenon of re-enacting the shame and trauma suffered during childhood [22]. In circumcised adults, I have seen this shame being sublimated into pride at some point of life. Perplexed by this paradox I looked into the history. Now, I could see the ‘shame’ in the punishment of captured enemies and the ‘pride’ in the sacrificial rites of Osiris cult. Osiris himself being punished by emasculation and its symbolic emulation by his followers could be the connecting links between the contrasting emotions of shame and pride.

Finally, I wonder if Dr. Moreton's communication suffers from serious conflicts of interest (COI) as he is the editor and contributor of a blog ‘promoting circumcision’. Certainly, I have no prejudice in exploring and writing the history of circumcision

V. Raveenthiran Department of Pediatric Surgery, SRM Medical College, 200, Fifth Street, Viduthalai Nagar, Kovilambakkam, Chennai 600117, India

References

 

[1] Gollaher DL. Circumcision: a history of the world's most controversial surgery. New York: Basic Books; 2000.

[2] Boyle GJ, Hill G. Circumcision-generated emotions bias medical literature. BJU Int 2012;109:E11.

[3] Frisch M, Aigrain Y, Barauskas V, et al. Cultural bias in the AAP's 2012 technical report and policy statement on male circumcision. Pediatrics 2013;131:796–800.

[4] Friedman DM. A mind of its own: a cultural history of the penis. London: Robert Hale; 2001.

[5] Remondino PC. Theories as to the origin of circumcision. History of circumcision from the earliest times to the present. London: FA Davis; 1891. p. 28–33.

[6] Amin Ud Din M. Aposthia — a motive of circumcision origin. Iran J Public Health 2012;41:84.

[7] Charles W. Motives for male circumcision among preliterate and literate peoples. J Sex Res 1966;2:69–88.

[8] Kaicher DC, Swan KG. A cut above: circumcision as an ancient status symbol. Urology 2010;76:18–20.

[9] Hutson JM. Circumcision: a surgeon's perspective. J Med Ethics 2004;30:238–40.

[10] Darby R. The riddle of the sands: circumcision, history, and myth. N Z Med J 2005; 118:U1564.

[11] Darby R. A surgical temptation: the demonization of the foreskin and the rise of circumcision in Great Britain. University of Chicago Press; 2005.

[12] Ricketts BM. The last fifty of a series of two hundred circumcisions. N Y Med J 1894; 59:431–2.

[13] Anonymous. Circumcision for the relief of acne. Hospital (Lond) 1902;31:339.

[14] Van Howe RS, Hodges FM. The carcinogenicity of smegma: debunking a myth. J Eur Acad Dermatol Venereol 2006;20:1046–54.

[15] Nun L. Neonaticide, infanticide and filicide. Israel: BN Publications; 2017.
[16] Bronselaer GA, Schober JM, Meyer-Bahlburg HF, et al. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int 2013;111:820–7.

[17] Masood S, Patel HR, Himpson RC, et al. Penile sensitivity and sexual satisfaction after circumcision: are we informing men correctly? Urol Int 2005;75:62–6.

[18] Fink KS, Carson CC, De Vellis RF. Adult circumcision outcomes study: effect on erectile function, penile sensitivity, sexual activity and satisfaction. J Urol 2002; 167:2113–6.

[19] Boyle GJ. Circumcision of infants and children: short-term trauma and long-term psychosexual harm. Adv Sex Med 2015;5:22–38.

[20] Diodorus Siculus. Bibliotheca Historica (English translation); vol 1, sec 48:2.
Available from http://penelope.uchicago.edu/Thayer/E/Roman/Texts/Diodorus_Siculus/1C*.html, Accessed date: 30 September 2018.

[21] Muller AJ. To cut or not to cut? Personal factors influence primary care physicians’ position on elective circumcision. J Men's Health 2010;7:227–32.

[22] van der Kolk BA. The compulsion to repeat the trauma. Re-enactment, revictimization, and masochism. Psychiatr Clin North Am 1989;12:389–411.

V. Raveenthiran. Reply to letter to the Editor: Tracing the origins of circumcision. Journal of Pediatric Surgery, early view, 2018

Medically rationalised or "health" circumcision

Circumcision of normal male minors as a preventive health precaution became common during the late Victorian period in Britain and the United States and soon spread to other Anglophone communities. The practice was never adopted anywhere else, except in South Korea after 1953 as a consequence of the U.S. occupation following the Korean War. Although circumcision was abandoned in Britain in the 1950s, it remained common in New Zealand until the 1960s, in Australia until the 1970s and in Canada until the 1980s, and it is still widely practised, and obstinately defended, in the United States. The renaissance of circumcision in obscure corners of the underdeveloped world has a lot to do with the fact that the U.S.A. has a huge medical research industry, provides massive health aid to other countries, has a lot of personnel in the health industry who are in love with circumcision, and has a lot of money. [1]

Over the past thirty years Australian medical authorities have consistently sought to discourage the procedure; in policy statements issued in 1971, 1983, 1996, 2002 and 2004 they have stressed that there is no medical indication or need for circumcision as a routine or precautionary procedure, and that serious legal, ethical and human rights concerns hang over the procedure when performed on minors.

The motivations for circumcision of minors fall into four broad categories: religious or cultural (as in Judaism, Islam and a number of tribal societies); customary or social (to look like dad or the neighbours); therapeutic (to correct a deformity, injury or disease); or prophylactic (to reduce the supposed risk of potential health problems or disease in the future). In addition, a very small number of adults seek circumcision for a variety of personal reasons. It is widely accepted that most circumcision procedures in Australia, especially on boys under the age of ten years, are not clinically necessary and are performed either because the parents prefer the boy to have a circumcised penis (“social circumcision”), or because there has been an incorrect, fraudulent or premature diagnosis of phimosis or other foreskin-related problem, and conservative measures have not been given a fair trial. [2] For this reason, public hospitals in most states have deleted circumcision from their schedule of free services. Unfortunately, this decision has opened the field for a few opportunistic GPs who ignore the recommendation against circumcision issued by the Royal Australasian College of Physicians and advertise themselves as “circumcision specialists”. Some even claim to provide a “bloodless and non-surgical procedure”, a deceptive and misleading claim that should be investigated by the Australian Competition and Consumer Commission.

The cat that came back

Following a strong statement from the Australian College of Paediatrics in 1983, the incidence of circumcision [3] in Australia declined rapidly and looked set to disappear. From the mid-1990s, however, a dedicated band of activists in the public health and medical research industries have sought to revive discredited “health” arguments for the procedure and to conduct research aiming to find new justifications. It is largely owing to the efforts of this group (referred to here as circumcision promoters) that circumcision is a controversial issue today, and not a forgotten medical fad such as doses of mercury or frontal lobotomies.

The circumcision promoters speak of male circumcision, but this vague term ignores the fact that circumcision of males and females is performed in a variety of contexts – religious, tribal, customary, therapeutic, prophylactic, and even as a sexual specialism among advanced S&M devotees. [4] It is therefore vital to establish the context in which today’s circumcision promoters are demanding the widespread and, in some cases, the universal and compulsory performance of the procedure.

The context is the precautionary amputation of erogenous tissue from the penis of normal male infants and boys in the belief that this will reduce the risk of their contracting certain diseases to which they may be exposed at some later date. There is no certainty (and an unknowable probability) that they will ever be exposed to such diseases; and no firm quantification as to the extent of risk reduction conferred by circumcision even if they are exposed. The operation is performed in a coercive environment, by adults on minors who have not given (and by definition cannot give) consent; there is no knowing whether, when they reach maturity, they will be resentful, indifferent or pleased about what was done to them at a time when they lacked the capacity to express an opinion or the power to resist.

Not really medical treatment

In this context circumcision is not a normal medical intervention (since there is no pathology to treat), but the precautionary amputation of a normal body part – and not just any body part: the penis (and its foreskin especially) is the most physically, psychologically and culturally sensitive site on the human body. It is also abnormal because it ignores the normal rules of medical ethics (beneficence, non-maleficence, autonomy and justice), and especially the requirement for informed consent, as set out in the classic exposition by T.L. Beauchamp and J.F. Childress Principles of Biomedical Ethics (1979). It is certainly inconsistent with the definition of the duty of doctors as set out in Thomas Faunce's analysis of medical ethics, Pilgrims in Medicine: "the relief of individual patient suffering." ( See review at h-net)

To pretend that cutting off so culturally loaded and physiologically significant an anatomical feature as the foreskin is a neutral and uncontroversial measure of personal or public health, like washing one’s hands or getting a TB shot, is either pathetically naïve or grossly deceptive.

The circumcision promoters wield considerable influence, partly because they are able to associate their cause with the prestige of modern medical science (which indeed has remarkable achievements to its credit), and partly because Australia’s past history of circumcision means that there is a large cohort of circumcised adult men who regard their condition as normal or at least unobjectionable, and even desirable for hygienic or other health-related reasons. Although these form a constituency likely to favour circumcision of their own boys it is an interesting fact that the decline of circumcision in the 1970s-90s was accomplished with remarkably little controversy or fuss, suggesting that the vast majority of circumcised fathers were perfectly happy to let their sons be.

References

  1. David Gollaher, Circumcision: A History of the World’s Most Controversial Surgery (NewYork: Basic Books, 2000); Robert Darby, A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain (Chicago and London: University of Chicago Press, 2005)
  2. Spilsbury K, Semmons JB, Wisniewski ZS, Holman CD. Routine circumcision practice in Western Australia 1981–1999. ANZ J Surg 2003;73(8):610-4; Spilsbury et al, Circumcision for phimosis and other medical indications in Western Australian boys, Medical Journal of Australia 2003;178 (4): 155-158
  3. Unless otherwise specified, the term circumcision means medically unnecessary circumcision of non-consenting male minors at the behest of parents or other adult.
  4. See, for example, www.circlist.com, http://circumsexual.com, and www.bmezine.com

Further information

History of circumcision in Australia

On this site:

Why some mothers are keen to circumcise

The "public health" case for circumcision

The argument for widespread, and ideally universal, circumcision these days relies on the proposition that we are facing a public health crisis to which circumcision is the only answer. One circumcision promoter has gone so far as to describe circumcision as “a biomedical imperative for the 21st century”. [1] Whatever the problems Africa and certain other developing nations may face, there is no evidence that any Western or developed nation, much less Australia, is threatened with any such crisis. Quite apart from its air of unreality, such “ten minutes to midnight” health alarmism ignores of the principles of risk management, which require that a full assessment of risk consequence, likelihood, mitigation strategies and risk tolerance be undertaken before it is possible to reach any conclusions about the degree of risk inherent in taking or not taking certain actions. Individuals have different levels of risk tolerance, and they have the right to develop their own strategies for handling health risks, and striking the appropriate balance between dangers and pleasures. The health industry is not entitled to pre-empt their options.

Today’s circumcision promoters perform what in books on clear thinking is called a logical slide. They present a mass of data and claim that it is evidence (indeed, proof) that parents should circumcise their baby boys; but in fact, even if their data were valid, what it is evidence for is an argument that an adult male should get himself circumcised. And you might expect that a few cautious males would take this advice, especially if they were sexually promiscuous – except that if they were sexually promiscuous they would not be cautious, and it is a strange fact that very few adult men do get themselves circumcised. Most men are understandably reluctant to hurt their own penis, but hurting somebody else’s body is a different matter, especially if it can be done with the conscience-salving rationalisation that it is “for his own good”. The Victorian-Edwardian doctors who wished to introduce widespread and preferably universal circumcision were not able to convince the uncircumcised adults of their day (who were the ones at risk of syphilis) to get themselves circumcised, but they succeeded in persuading the uncircumcised fathers to cut their boys (who, being children, were not at risk).

"Do it to him, not to me"

This has always been the strategy of the circumcision lobby: not to convince men to circumcise themselves, but to convince parents (today, particularly mothers) to circumcise their children. I recall a discussion with an uncircumcised father of young children who said that if it were proved that circumcision gave a man protection against HIV he would get his own boys circumcised. When I suggested that, since he was the sexually active one and they were not at risk, it would be both fairer and more logical to leave the boys alone and get himself circumcised, he looked at me in disbelief and mumbled something to the effect that the operation was too dangerous and painful for adults, and that in any case, he was used to his foreskin and would miss it. Enough said.

The demand for universal routine circumcision has never been justified because its proponents have failed to specify what would have to be established to make their case worth considering. In order to make a convincing case that prophylactic circumcision without consent was justified you would need to prove (a) that the boy had a high risk of contracting a fatal and incurable disease before reaching the age of consent unless he was circumcised; (b) that circumcision would certainly eliminate the risk or reduce it by a degree proportional to the sacrifice of the body part; and (c) that there was no other practical way of reducing the risk by the same degree. No such proof has ever been attempted, let alone achieved.

A century ago E. Harding Freeland urged universal circumcision of young boys as a preventive of the world’s then most feared disease, syphilis. He was, however, less evasive than today’s circumcision promoters, and made no bones about the fact that he was advocating “the universal practice of an operation which has for its object the wholesale removal of a certain healthy structure as a preventive measure”. Unlike today’s circumcision advocates, he admitted that he therefore had to provide “good evidence” that (1) the operation was free from risk; (2) the removal of the foreskin would inflict no physical disability on the individual; and (3) the benefits of the amputation were substantial and commensurate with the sacrifice. He failed dismally to establish any of these, but his counterparts today do not even make the attempt. [2]

The diseases most commonly cited these days as necessitating widespread circumcision are HIV-AIDS and cervical cancer. Both are irrelevant to children, however, because each is a sexually transmitted infection to which children, not being sexually active, are not at risk. The case for cervical cancer is invalid for the additional reason that, as Sarah Waldeck points out, the person bearing the risk and suffering the deprivation is not the person reaping the benefit. [3] There is little enough warrant in Western law or custom to coerce a person for the sake of his own health; there is none at all for the proposition that a person should be forcibly deprived of a functioning body part for the benefit of an unknown third party.

HIV-AIDS

There is evidence from Africa that circumcised men who have frequent unprotected intercourse with infected female partners are less vulnerable to infection with HIV, and world health authorities have recommended circumcision of sexually active adult men as an adjunct to controlling the spread of AIDS in severely affected regions of Africa. There has, however, been no suggestion from responsible authorities that such measures are appropriate in developed nations or in places, such as Australia, with a low incidence of female to male transmission. The Australian Federation of AIDS organization has stated that circumcision has no role in the management of HIV in Australia, where the disease is largely confined to specific sub-cultures. [4] In any case, protection against HIV would not be a justification for circumcising infants or children, since they are not sexually active and thus not at any risk of contracting the disease (unless through surgery itself.)

Even in Africa the recommendations of the World Health Organisation have been contested, and its gung-ho approach to what it calls the circumcision roll-out has been attacked by the South African Medical Journal as costly, ineffective, a violation of accepted principles of bioethics and human rights, culturally insensitive and smacking of medical colonialism. [5] It has also been criticized by child health and human rights experts as neither medically necessary nor ethically permissible. [6] To cite the African data as an argument for circumcision of male infants and boys in Australia would be irresponsible and inappropriate.

Medical ethics and public health

In this context it is useful to recall the framework proposed by Hodges et al for balancing the requirements of human rights with the those of public health. In an important article published in the Journal of Medical Ethics in 2002, they considered prophylactic interventions in children and how conflicts between the demands of public health and human rights might be resolved. Noting that such interventions were traditionally justified on the grounds of “best interests of the child” and/or “public health”, they proposed two sets of criteria which had to be met before an intervention could be accepted as ethical. The criteria for the “best interests of the child” argument were (1) presence of clinically verifiable disease, deformity or injury; (2) least invasive and most conservative treatment option; (3) net benefit to the patient and minimal negative impact on patient’s health; (4) competence to consent to the procedure; (5) standard practice; (6) individual at high risk of developing the disease. The criteria for the “public health benefit” argument were: (1) substantial danger to public health; (2) condition must have serious consequences if transmitted; (3) effectiveness of the intervention; (4) invasiveness of the intervention; (5) whether individual receives an appreciable benefit not dependent on speculation about future behaviour; (6) the health benefit to society must outweigh the human rights cost to the individual. The authors evaluated several interventions against one or other of these sets of criteria, and neonatal circumcision against both of them. They concluded that while immunisation generally satisfied the “best interests” and “public health” justifications, circumcision failed to satisfy either of them. Such an intervention was thus impermissible because it was performed on a minor without consent; the human rights cost to the individual exceeded the proven public health benefit; and the disease could be avoided through appropriate behavioural choices. [7]

There is, in fact, evidence that Australia’s abandonment of circumcision in the 1980s-90s has actually improved child health outcomes. A major study by the Australian Institute of Health and Welfare in 2005 found that there had been a significant improvement in child health outcomes between the early 1980s and 2000 – the very period when routine circumcision disappeared – and no evidence at all of any “explosion of genito-urinary problems” as predicted by certain circumcision promoters. [8] A further study by the AIHW released in 2009 confirmed this picture and noted that the only child health problems that seemed to be getting more serious were diabetes and asthma. [9]

A recent cost utility analysis of neonatal circumcision found that even if the extreme claims of advocates were true, the associated complications and adverse outcomes would cancel out and exceed the benefit to health. [10]

In places such as Australia, with a past history of widespread circumcision, it is common to find misconceptions about the normal development of the penis and the correct care of the natural (uncut) penis, especially in rural areas. Many people, including doctors, continue to believe that the foreskin should be retractable soon after birth, or at 3 or 4 years at the latest, and that it should be forcibly retracted for cleaning purposes as soon as possible. These ideas are incorrect, since it is quite common for the foreskin not to become retractable until puberty; this rarely causes any problems, and no action is needed unless the boy is experiencing pain or discomfort. [11] Premature or forcible retraction is one of the most common causes of foreskin problems and the real source of the urban myth that the normal penis is prone to problems and “difficult to look after”.

It is also often assumed that minor foreskin problems (discomfort arising from tightness, minor skin infections, minor urethral infections, persistent phimosis etc) cannot be cured by conservative treatment but require amputation. The normal rule in modern medical practice is medical treatment first, followed by surgical intervention only if medical treatment fails; this rule has often not been, but should be, applied to the penis as much as to other parts of the body. Most foreskin problems can be successfully treated with conservative measures that do not require surgery, let alone amputation of tissue, and such medical treatments are the preferred approach today.

References

  1. Brian Morris, “Why circumcision is a biomedical imperative for the 21st century”, BioEssays, November 2007
  2. E. Harding Freeland, “Circumcision as a preventive of syphilis and other disorders”, Lancet 1900 (2), 29 December, 1869-71
  3. Sarah Waldeck, Using circumcision to understand social norms as multipliers, University of Cincinnati Law Review, Vol. 72, 2003, 455-526;
  4. Australian Federation of AIDS Organisations, Briefing Paper, 23 July 2007, Male circumcision has no role in the Australian AIDS epidemic.
  5. D. Sidler, J. Smith, H. Rode, “Neonatal circumcision does not reduce HIV/AIDS infection rates”; A. and J. Myers, “Editorial: Rolling out male circumcision as a mass HIV/AIDS intervention seems neither justified nor practicable”, both in South African Medical Journal, Vol. 98, No. 10, October 2008. Both available at CIRP 
  6. Robert Van Howe and J. Steven Svoboda, Neonatal circumcision is neither medically necessary nor ethically permissible: A reply to Clark et al, Medical Science Monitor, Vol. 14, 2008
  7. Hodges FM, Svoboda JS, Van Howe RS. Prophylactic interventions on children: balancing human rights with public health. J Med Ethics 2002;28: 10-16
  8. Australian Institute of Health and Welfare, A Picture of Australia’s Children (Canberra: AIHW 2005).
  9. AIHW, A Picture of Australia’s Children 2009 (Canberra 2009)
  10. Van Howe RS. A cost-utility analysis of neonatal circumcision. Medical Decision Making 2004;24:584-601
  11. Dan Bollinger, “The penis-care information gap: Preventing improper care of intact boys”, THYMOS: Journal of Boyhood Studies, Vol. 1, Fall 2007, 205-219.

Further information

Circumcision and public health (2): Is circumcision a biomedical imperative for the 21st century?

Further information on phimosis

Information on care of the normal penis from CIRP

Foreskin care at Circumstitions

Circumcision and sexuality

Perhaps no issue has been more bitterly or emotionally debated than the question of what difference circumcision makes to the experience of sex. Circumcision promoters insist that it makes no difference or even improves a man's sex life and that women prefer circumcised partners. Critics of circumcision point to a considerable body of evidence that circumcision makes a big difference, that there is no evidence that women in general prefer circumcised partners, and that - on the contrary - women may enjoy sex more with uncircumcised men.

For much of the twentieth century enthusiasts for routine circumcision have echoed the sentiments of the Victorian sexual health expert (and chastity advocate) William Acton:

Although it is possible that it [the foreskin] may increase the pleasure derived from the act of sexual congress, there is no evidence that Jews, and those who have undergone circumcision, do not enjoy as much pleasure in the copulatory act as the uncircumcised; – at any rate, the former do not complain.[1]

The claims are clear: first, that circumcision makes no difference to a male’s experience of sex; second, that even if it did men do not complain about what they are missing. An obvious point to note is that Acton’s first assertion directly contradicts the medical knowledge of his own day; throughout history and up to the end of the nineteenth century it was generally held by authorities on medical and sexual matters that the foreskin made a significant contribution to the sexual pleasure of both men and their partners. Far from there being “no evidence”, there is so much that the problem becomes one of selection: from many possible sources we may cite the early eighteenth century surgeon John Marten as representing the orthodox position:

This Nut is … cover’d with the preputium or Fore-skin, which is of a loose texture, for the better covering of the Nut, and furling itself up behind the Ring or Hoop, to uncover it; therefore serves as a Cap to the Nut, and to enlarge the pleasure that attends Enjoyment, for in the act of Coition it flips backwards and forwards, being tied together with a membranous String call’d the Fraenum or Bridle, and causes the greater pleasure thereby, both to the Man and the Woman … The cutting of this Preputium or Fore-skin, is done by the Jews, and call’d Circumcision; by having of which taken away, ‘tis said those People lose much of the pleasure in the act of Copulation.[2]

Acton’s statement is even inconsistent with the medical wisdom of the Victorian period, since it was precisely the erotic significance of the foreskin that led the physicians of that “anti-sensual age” to urge its removal.[3] As the prominent surgeon Jonathan Hutchinson expressed it:

The only function which the prepuce can be supposed to have is that of maintaining the penis in a condition susceptible of more acute sensation than would otherwise exist. It may be supposed to increase the pleasure of coition and the impulse to it. These are advantages, however, which in the present state of society can well be spared, and if in their loss some degree of increased sexual control should result, one should be thankful.[4]

Acton himself acknowledged the contribution of the foreskin to sexual pleasure when he denounced it as “a source of serious mischief” and a constant threat to the strict continence he regarded as essential to both morals and health.[5]

In the twentieth century the Puritanism of the Victorians gradually softened, and sexual pleasure came to be seen as a good thing, even a human right, rather than a menace to health and virtue.[6] Advocates of routine circumcision thus found it necessary to minimise the adverse effects of such surgery on sexuality and to focus strictly on its benefits for health. For this purpose they have relied heavily on a sloppy and irrelevant piece of research that Masters and Johnson claim to have carried out and published in their much-read book on human sexual response.

References

1. Acton, W. The functions and disorders of the reproductive organs in childhood, youth, adult age and advanced life. 3rd edn. Philadelphia: Lindsay and Blakiston, 1865, p 22

2. Marten, J. Gonosologium novum: Or a new system of all the secret infirmities and diseases natural, accidental and venereal in men and women. London, 1709; Facsimile reprint, New York: Garland Publishing, 1985, p 12

3. Moscucci, O. Clitoridectomy, circumcision and the politics of sexual pleasure in mid-Victorian Britain. In: Miller AH and Adams JE ed. Sexualities in Victorian Britain. Bloomington: Indiana University Press, 1996

4. Hutchinson, J. The advantages of circumcision. Medical Review 1900;3:642

5. Darby, R. A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain. Chicago: University of Chicago Press, 2005. chap 6

6. Cook, H. The long sexual revolution: English women, sex and contraception 1800-1975. London: Oxford University Press, 2004

Three questions

We cannot hope to settle the question here, but three points ought to be made. First, it defies common sense and logic to assume that cutting the part of the penis that contains the vast bulk of the pleasure-sensing nerves could not make a difference to sexual function and sensation. The loss of the mobile sheath of tissue must also make a huge difference.

Secondly, although some men who choose circumcision as adults and say that it improved their sex life, you cannot assume that the effects of circumcision in adulthood are the same as the operation in infancy or childhood. If you cover a baby's eyes at birth he will never learn to see properly because he needs the stimulus of light on the optic nerve to activate the neuronal pathways in the brain that control vision. There is evidence (from studies by Immerman and Mackey - both advocates of circumcision, incidentally) that something similar may occur if the foreskin is removed in infancy. It may well be that circumcision did improve the sex lives of some men, but in most cases this would have been because they had severe phimosis that inhibited any movement of the foreskin. Most such problems these days can be fixed by application of steroid cream.

Thirdly, why should men have to prove to the satisfaction of the circumcision promoters that the foreskin makes a significant difference to sexual experience before they are allowed to keep it? The foreskin is a natural part of normal human anatomy (indeed, of all mammals), and the default position should be that it is a useful, beneficial or at least non-injurious structure. If the foreskin was as malevolent as the circumcision promoters claim, you would think that evolution might have abolished it by now.

New research into nerve structure of penis shows foreskin to be the sexually dynamic element

Ken McGrath, Senior Lecturer in Pathology at the Faculty of Health, Auckland University of Technology and Member of the New Zealand Institute of Medical Laboratory Scientists discusses his research into the neural anatomy of the human penis and the physical damages caused by circumcision. McGrath is author of The Frenular Delta: A New Preputial Structure published in Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem, Proceedings of the Sixth International Symposium on Genital Integrity: Safeguarding Fundamental Human Rights in the 21st Century, held December 7-9, 2000, in Sydney Australia.

Abstract: Textbooks and papers referring to penile function state that the source of penile sensation is solely the glans and often justify the existence of the prepuce by stating it protects the 'sensitive' glans. These statements are contrary to the neuro-anatomical and physiological facts accumulated over more than a century. This study reviews the findings of Taylor, et al., that the prepuce is the primary sensory platform of the penis, and describes a new preputial structure. This interview was taped in Berkeley, California 2010 and from the Global Survey of Circumcision Harm.

Removal of the male foreskin and the female clitoral hood (female foreskin) are anatomically equivalent. However, neurologically speaking, removal of the male foreskin is as destructive to male sexual sensory experience as removal of the clitoris is for females. This video discussion of penile and foreskin neurology explains why.

Contrary to popular Western myth, many circumcised women do report the ability to feel sexual pleasure and to have orgasm, albeit in a compensatory manner that differs from intact women [suggested reading: Prisoners of Ritual by Hanny Lightfoot-Klein]. Similar compensatory behaviours for achieving orgasm are at work among circumcised men, who must rely on the remaining 50% or less of their penile nerve endings. Just as clitoridectomized girls grow up not knowing the levels of pleasure they could have experienced had they been left intact, so too are men circumcised in infancy unaware of the pleasure they could have experienced had they not had 50% of their penile skin removed. The above video also explains what's really behind the erroneous comment made by some circumcised men that they 'couldn't stand being any more sensitive'.

Watch Ken McGrath's lecture on Youtube.

Further information

On this site

Quotes on the foreskin, circumcision and sexual function through the ages

Foreskin is a feminist issue: Why women should be concerned with male circumcision

On other sites

Development of the foreskin

Anatomy of the adult penis

Sexual functions of the foreskin

Critique of Masters and Johnson (and much more) at Circumstitions

Studies by Immerman and Mackey

(Somewhat speculative, but suggestive, especially as they approve of circumcision precisely because it does inhibit sexuality)

A proposed relationship between circumcision and neural reorganization

A biocultural analysis of circumcision

Male circumcision and female sexual pleasure

There is good evidence that male circumcision affects female sexual pleasure - and for the worse, not the better. Circumcision promoters are putting a lot of effort into trying to persuade people that circumcised men make better lovers, or at least that women "prefer" circumcised men.  It may be true that in societies where circumcision is widespread, some women say they prefer what they are accustomed to; but it is equally true that in societies that practise female circumcision, men prefer circumcised women because that is what they are accustomed to. It is also true that some women who experience uncircumcised sex for the first time never want to go back.  In any case, the imagined sexual preferences of adults are not a valid reason for interfering with children's genitals.

Kristen O'Hara (with Jeffrey O'Hara), Sex as Nature Intended It (Hudson USA, Turning Point Publications, 2001)
See Kristen's website:  www.SexAsNatureIntendedIt.com

O'Hara K, O'Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int 1999;83 Suppl 1:79-84.

Bensley GA, Boyle GJ. Effects of male circumcision on female arousal and orgasm. N Z Med J 2003;116(1181):595-6.

Czech women more likely to experience good orgasms than women in the United States

A study published in the Journal of Sexual Medicine has found that Czech women have more a satisfactory experience of sexual intercourse than women in the United States. The researchers conclude that this is because the key factor in whether a woman has an orgasm is the duration of intercourse, and that the average duration intercourse in Czechoslovakia was more than double that in the United States: 16.2 minutes among the Czechs, compared with only 7 minutes among the Americans. As the authors of the study comment, the results could reflect “a greater appreciation of intercourse and sensuality by Europeans than by Americans.” Since Czech men are generally not circumcised and American men are, they may also reflect the harmful effect of male circumcision on women’s sexual enjoyment.T

hese results are in complete contradiction with the story usually told in the popular U.S. media, that circumcised men “can last longer” before climaxing. The study did not consider this factor, but since circumcision is all but known in Czechoslovakia we can be confident that vast majority of the partners of the Czech women were not circumcised. By contrast, given the high incidence of circumcision in the United States, we can also be confident that most of the partners in the U.S. studies were circumcised. The inevitable conclusion is that circumcised men climax sooner, probably because their reduced sensitivity reduces the pleasure they derive from intercourse so severely that the their pleasure is pretty much limited to the orgasm itself. For uncircumcised men, on the other hand, there is as much pleasure in getting there as there is in arriving – a happy situation that clearly benefits women as well.

Source: Petr Weis and Stuart Brody, Women’s partnered orgasm consistency is associated with greater duration of penile-vaginal intercourse but not of foreplay, Journal of Sexual Medicine, Vol 6 (1), January 2009

Recent studies show that circumcision makes a difference

Korea: Worse sex life after circumcision

Two Korean researchers, DaiSik Kim and Myung-Geol Pang, studied 373 sexually active men, of whom 255 were circumcised and 118 were not. They found that circumcision reduced sexual pleasure in most cases and that a significant minority of men reported major injury to their penis, causing bleeding, scarring and chronic pain. Summarizing their results, the authors write:

"There were no significant differences in sexual drive, erection, ejaculation, and ejaculation latency time between circumcised and uncircumcised men. Masturbatory pleasure decreased after circumcision in 48% of the respondents, while 8% reported increased pleasure. Masturbatory difficulty increased after circumcision in 63% of the respondents but was easier in 37%. About 6% answered that their sex lives improved, while 20% reported a worse sex life after circumcision."

Conclusion: There was a decrease in masturbatory pleasure and sexual enjoyment after circumcision, indicating that adult circumcision adversely affects sexual function in many men, possibly because of complications of the surgery and a loss of nerve endings.

DaiSik Kim and Myung-Geol Pang, The effect of male circumcision on sexuality. BJU Int 99(3):619-22

United States: Circumcision cuts sensitivity of penis

Meanwhile, researchers in the United States have found that circumcision removes the most sensitive part of the penis. Researcher Dr Morris Sorrells and others enlisted 159 men from the San Francisco Bay area, 91 of them circumcised, and conducted touch-sensitivity tests, using an instrument that presses with calibrated hairs, on 17-19 different places on their penises. The men could not see where they were being touched.

It was found that the most sensitive part of a circumcised penis was on the scar in the middle underneath. But several places on the foreskin were more sensitive than that while the glans of the uncircumcised penis was more sensitive than in the circumcised. The paper is summarised here:

OBJECTIVE: To map the fine-touch pressure thresholds of the adult penis in circumcised and uncircumcised men, and to compare the two populations.

SUBJECTS AND METHODS: Adult male volunteers with no history of penile pathology or diabetes were evaluated with a Semmes-Weinstein monofilament touch-test to map the fine-touch pressure thresholds of the penis. Circumcised and uncircumcised men were compared using mixed models for repeated data, controlling for age, type of underwear worn, time since last ejaculation, ethnicity, country of birth, and level of education.

RESULTS: The glans of the uncircumcised men had significantly lower mean ( SEM ) pressure thresholds than that of the circumcised men, at 0.161 (0.078) g ( P = 0.040) when controlled for age, location of measurement, type of underwear worn, and ethnicity. There were significant differences in pressure thresholds by location on the penis ( P < 0.001). The most sensitive location on the circumcised penis was the circumcision scar on the ventral surface. Five locations on the uncircumcised penis that are routinely removed at circumcision had lower pressure thresholds than the ventral scar of the circumcised penis.

CONCLUSIONS: The glans of the circumcised penis is less sensitive to fine touch than the glans of the uncircumcised penis. The transitional region from the external to the internal prepuce is the most sensitive region of the uncircumcised penis and more sensitive than the most sensitive region of the circumcised penis. Circumcision ablates the most sensitive parts of the penis.


Sorrells ML, Snyder JL, Reiss MD, et al. Fine-touch pressure thresholds in the adult penis. BJU International 2007;99:864-9

Full text of article from CIRP

Further discussion, with diagrams and illustrations at Circumstitions

See also a revealing article by Paul Festa in Nerve magazine, How insensitive: A new study confirms a long-time fear: Circumcised men are missing out

Denmark study: Circumcision cuts sexual satisfaction in men and partners

Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark.

Frisch M, Lindholm M, Grønbæk M. Male circumcision and sexual function in men and women: A survey-based, cross-sectional study in Denmark, International Journal of Epidemiology 40 (5), October 2011, 1367-1381.

ABSTRACT

BACKGROUND:  One-third of the world's men are circumcised, but little is known about possible sexual consequences of male circumcision. In Denmark (~5% circumcised), we examined associations of male circumcision with a range of sexual measures in both sexes.

METHODS:  Participants in a national health survey (n = 5552) provided information about their own (men) or their spouse's (women) circumcision status and details about their sex lives. Logistic regression-derived odds ratios (ORs) measured associations of circumcision status with sexual experiences and current difficulties with sexual desire, sexual needs fulfilment and sexual functio ning.

RESULTS:  Age at first intercourse, perceived importance of a good sex life and current sexual activity differed little between circumcised and uncircumcised men or between women with circumcised and uncircumcised spouses. However, circumcised men reported more partners and were more likely to report frequent orgasm difficulties after adjustment for potential confounding factors [11 vs 4%, OR(adj) = 3.26; 95% confidence interval (CI) 1.42-7.47], and women with circumcised spouses more often reported incomplete sexual needs fulfilment (38 vs 28%, OR(adj) = 2.09; 95% CI 1.05-4.16) and frequent sexual function difficulties overall (31 vs 22%, OR(adj) = 3.26; 95% CI 1.15-9.27), notably orgasm difficulties (19 vs 14%, OR(adj) = 2.66; 95% CI 1.07-6.66) and dyspareunia [painful intercourse] (12 vs 3%, OR(adj) = 8.45; 95% CI 3.01-23.74). Findings were stable in several robustness analyses, including one restricted to non-Jews and non-Moslems.

CONCLUSIONS:  Circumcision was associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in women, notably orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment. Thorough examination of these matters in areas where male circumcision is more common is warranted.

Abstract of study available here

Report of study with graphic illustrations

Download study in full as pdf file

FOLLOW-UP

This article was stridently attacked in a letter by Brian Morris and two colleagues, published in the International Journal of Epidemiology in February 2012. The detailed reply by Morten Frisch in defence of his study can be found here.

Circumcision: Just like vaccination

On of the silliest arguments of the circumcision promoters is that circumcision is "just like vaccination".  In this comparison they are treading in the footsteps of Dr Remondino and the enthusiasts of the 1890s, who claimed that universal circumcision would control syphilis (and many other diseases) in the same way as compulsory vaccination defeated smallpox. Unfortunately, only the second of these measures had scientific validity. A moment's thought will reveal the absurdity of the vaccination analogy: even blind Freddie could tell the difference between a boy who came back from the doctor after having had an injection and one who came back after having had his foreskin cut off. To mention a few obvious differences:

In Not a surgical vaccine, a paper published in the Australian and New Zealand Journal of Public Health in 2010, the authors criticised the analogy between circumcision and vaccination (so popular with anti-foreskin activists such as Professor Morris) as regrettable and misleading, and concluded that: “The colourful image of circumcision as ‘surgical vaccine’ is a contradiction in terms, on a par with ‘conjectural fact’; such rhetoric has no place in scientific debate.”  Oddly enough, now that there is a vaccine for cervical cancer, circumcision promoters (who pride themselves on their scientific credentials) are going cold on vaccination and warn of terrible side effects and bad reactions. No doubt these do occur in a few cases, but they are nothing like the adverse effects of circumcision. Like the effectiveness of condoms against HIV and other STIs, effective vaccines destroy the argument for circumcision.

Visual evidence

This being a family site, it does not include any pictures of naughty bits. The web is, however, liberally supplied with images of human genitalia, and there is no shortage of photos of penises, cut and uncut, readily available for those who wish to view them.

The following sites feature explicit but non-pornographic images of normal (uncircumcised) penises.

www.foreskin.org

acroposthion.com

Photos of circumcision injury and comparisons between cut and uncut penises can be found these sites.

http://www.circumstitions.com/Botched1.html

http://www.circumstitions.com/botched-multi.html

http://www.circumstitions.com/comparison.html

Photos of infant circumcision procedure here

In memory of the sexually mutilated child

http://www.circumstitions.com/Circ.html

 


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On this page

  1. Origins of ritual circumcision
  2. Circumcision and public health
  3. Circumcision and sexual satisfaction
  4. Female sexual response and male circumcision
  5. Just like vaccination?
  6. Visual evidence