“we are all apt to accept a historical myth where we cannot rely on historical knowledge. Where history is lacking, mythology takes its place, and those who disdain history are among the foremost victims of mythology.”
— Owsei Temkin (1)
Although many nineteenth century misconceptions about the foreskin have been dispelled since Douglas Gairdner showed that infantile phimosis was not an abnormality, other old ideas have proved more persistent. Three of these are the proposition that ritual or religious circumcision arose as a hygiene measure; the view of the foreskin as a “cesspool”; and the assertion that circumcision makes no difference to sexual response. It is suggested that the first idea should be dismissed as a myth; that the second is a reflection of religious ideology and medical misunderstanding; and that the third is contradicted by centuries of medical opinion and has been seriously questioned by modern research.
* * * * * * *
Although much progress has been made since 1949 in dispelling nineteenth century myths about the male foreskin (for example, that infantile phimosis was a pathological abnormality (2), that circumcised men were immune to syphilis (3, 4), and that circumcised boys did not masturbate), other myths have proved more persistent. Among these are the idea that ritual circumcision as practised by certain tribal peoples arose as a hygiene or sanitary measure, particularly as a precaution against sand or dust in desert environments (5); the description of the foreskin as a “harbour for filth” or “cesspool”; and the assertion that the removal of the foreskin makes no difference to sexual function.
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.
Many of the cultures which practised male circumcision also enforced various forms of female genital mutilation (14, 15), but western doctors today are horrified by this sort of surgery, do not seek evidence that it might be beneficial to women’s health and do not suggest that it originated as a means of preventing sand from irritating the clitoral hood or labia. It was a different story in the 1850s and 60s, and it remains different in the cultures which continue to practise female circumcision. In the 1850s and 60s many English doctors believed that clitoridectomy was as valuable as male circumcision in treating nervous diseases like epilepsy, hysteria and masturbation (as well as their sequelae in madness) and pushed the therapy on women with little attempt to gain consent (16, 17). Egyptian and other Islamic physicians today insist on the hygienic value of female circumcision as a preventive of both organic disease and sexual promiscuity (18).
The notion of the foreskin as inherently dirty and disease-promoting has been revived in recent times by several advocates of routine circumcision. The American G.N. Weiss states that “over the millennia the male’s preputial cavity has acted as a cesspool for infectious agents transmitting disease” (19), while Australia’s Brian Morris quotes both this remark and a reference by the Brisbane GP Terry Russell to “pathogenic organisms multiplying in the warm, moist environment under the prepuce”. Morris adds that the “stench” of the foreskin means that uncircumcised men need three showers a day (20). The origins of these scientifically baseless assertions lie partly in ancient Judaic theology, which designated many natural phenomena as unclean in a spiritual or religious sense, and partly in the late nineteenth century century’s limited understanding of epidemiology. Bacteriological causation of disease was not fully understood at that time, visible “filth” alone was thought to be capable of generating disease (21), and neither the anatomy nor the functions of the foreskin had been studied. In the 1890s another advocate of universal circumcision, Jonathan Hutchinson (one of England’s most distinguished surgeons), described the foreskin as a “harbour for filth” (22). Modern research, however, has shown these beliefs to be without foundation: far from being unhygienic, the infant foreskin promotes the cleanliness of the penis by acting as a valve to let urine out while blocking the entry of foreign matter. It also protects the glans from dirt and abrasion and keeps it moist in much the same way as the eyelid lubricates the eye. In adults the sub-preputial moisture is not merely harmless, but is a useful moisturiser and may have anti-bacterial and anti-fungal properties (23-26).
A striking omission from many discussions of the risks and benefits of circumcision is a consideration of the value of the foreskin and the corresponding disadvantages of being obliged to live without one. Much of the past argument as to the health benefits of circumcision has rested on the assumption that the foreskin was useless flap of skin, with the result that the loss of this complex and versatile structure was never factored into such cost-benefit analyses of the procedure as have been attempted. Most have these have ignored the value of the lost tissue and focused exclusively on the additional risks of the operation (bleeding, infection etc). If the foreskin performs valuable functions, or even if it is no more than a desirable adornment, the equation changes sharply: even if circumcision offered real health benefits, they must be set against the costs of losing that part of the body. Although most medical discussions ignore it (5), there is a vast medical literature on the significance of the foreskin, stretching from the ancient Greeks, who regarded the foreskin as the most beautiful part of the male genitals, to the contemporary Canadian and New Zealand researchers who have identified the complex innervation of the penis, the frenular delta and the ridged bands of the foreskin, as well as its relevance to the experience of female partners (27-30).
In the Graeco-Roman world doctors considered the foreskin so important that they devised treatments to lengthen those which did not provide generous coverage of the glans (31). During the Renaissance the centrality of the foreskin to male sexual function and the pleasure of both partners was recognised by Berengario da Carpi (32), Gabriele Falloppio (33) and William Harvey (34). In the eighteenth century male folklore held that the foreskin was “the best of your property” (35), and a similar outlook was expressed in popular sex manuals like Aristotle’s Master-Piece (36) and by physicians such as Robert James (37) and John Hunter, who also appreciated the importance of the foreskin in providing the slack tissue needed to accommodate erection:
The prepuce is … a doubling of the skin of the penis when not erected … by which provision the glans is covered and preserved when not necessary to be used, whereby its feelings are probably more acute. When the penis becomes erect it in general fills the whole skin, by which the doubling forming the prepuce in the non-erect state is unfolded, and is employed in covering the body of the penis (38).
There is a puzzle in the fact that while circumcision advocates today assure parents that circumcision makes no difference to the experience of sex, their counterparts a century ago insisted that it made a major difference and that this was the most important reason for doing it. In the nineteenth century the erotic role of the foreskin was well understood by surgeons, who wanted to cut it off precisely because its tactile responsiveness (“irritability”, as they complained) was a major factor leading boys to masturbation: William Acton damned the foreskin as “a source of serious mischief” (39), and most of his contemporaries concurred (40, 41). Both opponents and supporters of circumcision agreed that the significant role the foreskin played in sexual response was the main reason why it should be left in place or removed. In the USA William Hammond commented that “circumcision, when performed in early life, generally lessens the voluptuous sensations of sexual intercourse”, and that even those who had it done later reported that “the operation had very decidedly diminished the voluptuous feelings afterwards experienced” (42). Both he and Acton considered the foreskin necessary for optimal sexual function, especially in old age. Jonathan Hutchinson, an ardent supporter of universal infant circumcision, thought this was the most important reason why it should be excised:
The only physiological advantage which the prepuce … confer[s] is … maintaining the penis in a condition susceptible to more acute sensation than would otherwise exist. It may increase the pleasure of coition and the impulse to it: but these are advantages which … we can well be spared. If in their loss increase in sexual control should result, one should be thankful (43).
Similar comments were made by dozens of British and American medical men from the 1840s to the 1930s. In 1874 a correspondent to the Lancet signing himself “a Jewish surgeon” stated that “the removal of the prepuce reduces to an extraordinary degree the sensitiveness of the glans penis” and expressed his belief that “the intention of the rite was to enhance and advance as far as possible the chastity of the race by blunting mechanically the sensibility of the organ of sexual appetite” (44). In this view he was following the great Jewish physician and philosopher Maimonides, who had written that the reason for circumcision was “the desire to bring about a decrease in sexual intercourse and a weakening of the organ” (45). In 1915 a doctor in the USA similarly commented:
Circumcision not only reduces the irritability of the child’s penis, but also the so-called passion of which so many married men are so extremely proud, to the detriment of their wives and their married life. Many youthful rapes could be prevented, many separations, and divorces also, and many an unhappy marriage improved, if this unnatural passion was cut down by a timely circumcision (46).
The phrasing used by many made it clear that a word like hygienic had a moral as well as a physical connotation. In his article “The hygiene of circumcision”, another US physician stressed the value of the operation in diminishing the sensibility of the penis and discouraging masturbation (47). In his book Sex hygiene for the male (1912), G. Frank Lydston wrote:
Circumcision promotes cleanliness, prevents disease, and by reducing over-sensitiveness of the parts tends to relieve sexual irritability, thus correcting any tendency which may exist to improper manipulations of the genital organs and the consequent acquirement [sic] of evil sexual habits, such as masturbation (48).
A modern American physician who had himself circumcised in the 1970s was so pleased with the result that he wrote an article urging everybody else to have it done, but even he acknowledged the loss of sexual sensation:
The change in sensation during intercourse a few weeks later was surprising. The sharp pleasurable sensation was noticeably lessened, as it is when topical anaesthetics are used to delay ejaculation. … The overpowering erotic sensation has been dulled, and with it some of the immediate pleasurable sensation. Initial excitement has decreased. … [When fully erect the penis presents] a smooth shaft with a piston-in-cylinder-like action during coition. Friction and therefore sensation are diminished (49).
It is difficult to put numbers on so subjective an experience as sexual satisfaction, but the research of Cold and Taylor has provided scientific confirmation of the eighteenth century folklore that a man’s foreskin was “the best of your property”. Valentine left a hostage to fortune which merits the attention of doctors and parents today. Regardless of the disease prevention/risk of harm calculus, “If it [the foreskin] does have a function, its routine removal in newborns cannot be justified. Perhaps the foreskin does have a rationale that has been ignored or not recognised” (50).
As much as recognising the rationale, it is a matter of remembering the medical knowledge already accumulated before the masturbation phobia of the nineteenth century and the circumcision mania of the twentieth century consigned it to the archives. Referring to the sorry results of forgetting the cure for scurvy discovered by John Woodall in the 1630s, Sir Geoffrey Keynes remarks that it was an example of “how easily important facts may be forgotten through failure to consult the history of medicine” (51). If researchers today paid more attention to medical history they might be saved from errors like the myth of desert hygiene and find themselves able to make a stronger case that optimal male health and happiness required doctors to protect the foreskin instead of seeking excuses to destroy it.
1. Temkin O. “The usefulness of medical history for medicine”, in The double face of Janus and other essays, Baltimore, Johns Hopkins University Press, 1977, 68-100, here 69
2. Gairdner D. “The fate of the foreskin: A study of circumcision”, British Medical Journal, 24 December 1949, 1433-7
3. Gilman S. Freud, race and gender, Princeton University Press, 1993, ch. 2
4. Darby R. “Where doctors differ: The debate on circumcision as a preventive of syphilis 1855-1914”, Social History of Medicine, March 2003 (forthcoming)
5. Paediatric and Child Health Division, Royal Australasian College of Physicians, Policy statement on circumcision, RACP, Sydney, September 2002: http://www.racp.edu.au/hpu/paed/circumcision/index.htm
6. Gollaher D.L. Circumcision: A history of the world’s most controversial surgery, New York, Basic Books, 2000, ch. 3
7. Loeb E.M. “The blood sacrifice complex”, in Memoirs of the American Anthropological Association, No. 23, 1923, repr. New York, Kraus Reprint, 1974
8. Ngxamngxa A.N.N. “The function of circumcision among the Xhosa-spe tribes in historical perspective”, in E.J. de Jager (ed.), Man: Anthropological essays presented to O.F. Raum, Capetown, Struik, 1971, 183-204
9. Thesiger W. The marsh Arabs, London 1964, 101-2
10. Hoffman L.W. Covenant of blood: Circumcision and gender in rabbinic Judaism, University of Chicago Press, 1996
11. Aldeeb Abu-Sahlieh S.A. Male and female circumcision among Jews, Christians and Muslims: Religious, medical, social and legal debate, Warren PA, Shangri-La Publications (Marco Polo Monographs, No. 5), 2001
12. Remondino P.C. History of circumcision from the earliest times to the present: Moral and physical reasons for its performance, Philadelphia and London, F.A. Davis, 1891
13. Davidson A. “Genital irritation in boys”, The Practitioner (London), Vol. 42, 1889, 350-56, here 356
14. Roles N.C. “Tribal surgery in East Africa during the XIXth century: Part 1 – Ritual operations”, East African Medical Journal, Vol. 43, 1966, 579-94
15. Scheper-Hughes N. “Virgin territory: The male discovers the clitoris”, Medical Anthropology Quarterly, Vol. 5, 1991, 25-8
16. Moscucci O. “Clitoridectomy, circumcision and the politics of sexual pleasure in mid-Victorian Britain”, in Andrew H. Miller and James Eli Adams (eds), Sexualities in Victorian Britain, Bloomington, Indiana University Press, 1996
17. Fleming J.B. “Clitoridectomy: The disastrous downfall of Isaac Baker Brown FRCS (1867)”, Journal of Obstetrics and Gynaecology of the British Empire, Vol. 67, 1960, 1017-34
18. Gollaher D.L. Circumcision: A history of the world’s most controversial surgery, New York, Basic Books, 2000, ch. 8
19. Weiss G.N. “Prophylactic neonatal surgery and infectious diseases”, Pediatric Infectious Diseases Journal, Vol. 16, 1997, 727-34
20. Morris B. In favour of circumcision, Sydney, New South Wales University Press, 1999, 30
21. Worboys M. Spreading germs: Disease theories and medical practice in Britain 1865-1900, Cambridge University Press, 2000
22. Hutchinson J. “A plea for circumcision”, Archives of Surgery, Vol. 2, 1890, 15
23. Van Howe R.S. “Circumcision and infectious diseases revisited”, Pediatric Infectious Diseases Journal, Vol. 17, 1998, 1-6
24. Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Inf 1998;74:364-367
25. Prakash [sic, Parkash] S, Raghuram R, Venkatesan, et al. Sub-preputial wetness - Its nature. Ann Nat Med Sci (India) 1982; 18(3): 109-112
26. Lee-Huang S, Huang PL, Sun Y, et al. Lysozyme and RNases as anti-HIV components in beta-core preparations of human chorionic gonadotropin. Proc Natl Acad Sci USA 1999;96(6):2678-81
27. Taylor J.R. Lockwood A.P. and Taylor A.J. “The prepuce: Specialised mucosa of the penis and its loss to circumcision”, British Journal of Urology, Vol. 77, 1996, 291-5
28. Cold C.J. and Taylor J.R. “The prepuce”, BJU International, Vol. 83, Supplement 1, January 1999, 34–44
29. Cold C.J. and McGrath K.A. “Anatomy and histology of the penile and clitoral prepuce in primates: Evolutionary perspective of specialised sensory tissue of the external genitalia”, in George C. Denniston, Frederick Hodges and Marilyn Milos (eds), Male and female circumcision: Medical, legal and ethical considerations in pediatric practice, New York, Kluwer Academic/Plenum Publishers, 1999
30. O’Hara K. and O’Hara J. “The effect of male circumcision on the sexual enjoyment of the female partner”, BJU International 1999;83 Suppl 1, 79-84.
31. Hodges, F. “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, Vol. 75, 2001, pp. 375-405
32. da Carpi, Jacopo Berengario. A short introduction to anatomy, translated by L.R. Lind, University of Chicago Press, 1959, 72-3
33. Quoted in Alex Comfort, The anxiety makers: Some curious preoccupations of the medical profession, London, Nelson, 1967, 17; and in Thomas Laqueur, Making sex: Body and gender from the Greeks to Freud, Cambridge, Mass., Harvard University Press, 1991, 271, fn. 75
34. Harvey, W. The anatomical lectures of William Harvey, ed. and trans Gweneth Whitteridge, Edinburgh, E. & S. Livingstone, 1964, 213
35. Wolper, R.S. “Circumcision as polemic in the Jew Bill of 1753: The cutter cut?”, Eighteenth Century Life, Vol. 7, 1982, 24-36
36. Aristotle’s complete masterpiece, in three parts, displaying the secrets of nature in the generation of man, London, 1749, facsimile reprint, New York, Garland, 1986, 13
37. James R. A medicinal dictionary: including physic, surgery, anatomy, chymistry, and botany, in all their branches relative to medicine, 3 vols, London, 1743-45, Vol. II, entry for “Generatio”
38. Hunter J. A treatise on the venereal disease, London 1786, 221
39. Acton W. The functions and disorders of the reproductive organs in childhood, youth, adult age and advanced life, 3rd London edition, Philadelphia, Lindsay and Blakiston, 1865, 22
40. Parsons G.P. “Equal treatment for all: American medical remedies for male sexual problems, 1850-1900”, Journal of the History of Medicine, Vol. 32, 1977, 55-71
41. Darby R. “Circumcision as a preventive of masturbation: A review of the secondary historical literature”, Journal of Social History, Spring 2003, forthcoming
42. Hammond W.A. Sexual impotence in the male and female, Detroit, 1887, facsimile reprint, New York, Arno, 1974, 272-3
43. Hutchinson J. “The advantages of circumcision”, Medical Review, Vol. 3, 1900, 641-2
44. “Circumcision”, Lancet, 12 December 1874, 856
45. Moses Maimonides. Guide for the perplexed, trans. M. Friedlander, New York, Dover Publications, 1956, 378
46. Wuesthoff L.W. “Benefits of circumcision”, Medical World, Vol. 33, 1915, 434
47. Crossland J.C. “The hygiene of circumcision”, New York Medical Journal, Vol. 53, 1891, 484-5
48. Wolbarst A. “Universal circumcision as a sanitary measure”, Journal of the American Medical Association, Vol. 62, 1914, 95 (cited)
49. Valentine R.J. “Adult circumcision: A personal report”, Medical Aspects of Human Sexuality, Vol. 8, January 1974, 31-42, 48, here 32-3
50. Valentine R.J. “Adult circumcision: A personal report”, Medical Aspects of Human Sexuality, Vol. 8, January 1974, 32-3
51. Keynes G. The gates of memory, Oxford, Clarendon Press, 1981, 360
NOTE: This paper was originally written in 2002. A shorter version was published in the Medical Journal of Australia as "Medical history and medical practice: Persistent myths about the foreskin", Medical Journal of Australia, Vol. 178, 17 February 2003.