Although this topic deviates from the original focus of this book, the general ignorance about circumcision seems to warrant a more detailed description.
I initially considered the concept of circumcision as one of the normal life experiences in the male infant. Yet, on further thought, I realized that the majority of men in the world are not circumcised. The questions arose: who, where, when, and why? Estimates are that about 85 percent of the men in the world are not circumcised. The country with the highest percentage of men who have had this procedure is the United States. It is the most common surgery performed in this country.
Circumcision is one of the oldest surgical procedures known. It has been practiced for more than 6,000 years. One suggestion is that it was present 15,000 years ago in primitive cultures. In the Stone Age, the procedure was performed with flint knives. It is thought that the bleeding that resulted in men simulated the monthly bleeding in women and was part of a ritual.
There is evidence that circumcision was practiced in ancient Egypt, especially among the caste of priests. A drawing on the wall of an Egyptian tomb dated 2400 BC demonstrates the procedure. The ancient Egyptian mummies were circumcised. The practice seems to have arisen independently in various primitive tribes, e.g., some tribes in Africa, many natives in early America, and the Australian Aborigines.
Circumcision is a religious ritual for Jews and Muslims. It comes from Abraham’s covenant with God (Genesis 17:9–14) in which the procedure was described. In Judaism, circumcision is a symbolic token, a physical distinguishing mark of Jewishness. It is performed on the eighth day after birth as indicated in the Bible, the Mosaic practice. In biblical times in Egypt, many Jews were not circumcised in order to imitate the Egyptians. Only the Egyptian high priests were relieved of their foreskin. Later, in order for the Jews to enter Palestine, their entry was contingent on their being circumcised. If necessary, circumcision was performed at the border.
The traditional pattern for both Jews and Muslims is to circumcise at a similar time, six to eight days after birth. It has been pointed out that Mohammed never told his followers to be circumcised.
It is generally unknown that circumcision was promoted in the United States in the late nineteenth century as a cure for masturbation. Masturbation was considered to be a cause of many illnesses: madness, idiocy, epilepsy, spinal paralysis and convulsions, a form of insanity, priapism (constant erection), insomnia, blindness, consumption, heart disease, memory loss, and adult suicidal tendencies. It was thought that removal of the foreskin would diminish the pruriency of sexual appetite and result in its cessation. There were tortuous methods of preventing masturbation such as tying the hands, immobilizing the child’s body, and other ways to prevent the male child from reaching his penis. In that Victorian time, there was much hysteria about the evils of masturbation.
At about the same time (1870–1890), there were claims from the medical profession that circumcision was a cure for paralysis, serious orthopedic disease, epilepsy, hernia, and lunacy. These were thought to be a result of the nervous consequences of genital irritation by an adherent or constricted foreskin (prepuce). This was a time of surgical experimentation on the genitalia of both sexes to relieve reflex neuroses. (Note: this was also a period of “normal ovariectomy” in women to relieve symptoms ranging from hysteria and neurasthenia to backache.)
Once the circumcision procedure had been established, in the early twentieth century it became a sanitary measure. The concept of personal cleanliness had expanded in the late nineteenth century. Cleanliness became an essential criterion of social respectability. Dirt was seen as a moral and social hazard. Thus circumcision replaced soap and water as a daily routine. New claims were made for the value of removing the foreskin in males. It was said to be a cure for fecal incontinence and constipation. It was considered a safeguard against malignancies such as cancer and syphilis and a prophylactic for impotence.
In the twentieth century, circumcision became a standard practice—a sanitary measure and prophylactic against venereal disease. It became a mark of class distinction as the foreskin came to signify ignorance, neglect, and poverty. Since many of the doctors were Jewish, they tended to encourage the procedure. In time the white, middle-class gentiles accepted the idea and the cost, leaving the recent immigrants, the African Americans, and the poor with foreskins as a mark of lower class and inferiority. The penis began to be considered “dirty.” During World War I (and World War II) circumcision was considered necessary for “hygienic reasons.” Some soldiers who refused were disciplined and/or dishonorably discharged. Medical textbooks began showing the circumcised penis.
These concepts spread to the English-speaking countries—England, Canada, Australia, and New Zealand. In 1945, however, the British dropped circumcision from the list of medically insured services and the number of circumcised infants quickly dropped. By 1949, there was a virtual cessation of medically motivated circumcision in Canada, Australia, and New Zealand.
In the U.S., although routine hysterectomies, tonsillectomies, and gall bladder removals decreased, circumcision increased. It reached its peak in the 1960s and ’70s when 85–90 percent of the male children were circumcised. The benefits of this routine procedure began to be questioned in the 1960s. Could circumcision be a beautification comparable to rhinoplasty? In the early 1970s, the American Academy of Pediatrics concluded that there were no medical grounds for routine infant circumcision when comparing the “potential” medical benefits with “inherent” risks and disadvantages. This statement was for the most part ignored by the general medical profession.
Today in many U.S. hospitals, removal of the foreskin on the third or fourth day after birth is routine. The practice appears to be local and regional. In California the number of circumcisions is decreasing. When asked, many parents say they choose the procedure for social reasons—so the son will be like the father and his peers and not subject to ridicule.
There seems to be no question that foreskin removal is accompanied by pain. This has been measured by increased heart rate, increased respiratory rate, and intensity of crying. There is a plethora of literature on studies to reduce the pain of the procedure. General anesthetic is not considered by most to be appropriate since it could result in the death of the child. A dorsal penile nerve block (local anesthetic) is said to be the most effective despite adverse local and systemic reactions. Other methods that have been tried (classical music, intrauterine sounds, sucrose-coated pacifier) have been shown to have no effect on pain reduction.
The literature on the pros and cons of circumcision is filled with emotional debate. Many conclusions have been drawn from incomplete or biased data. The controversy over the value of the foreskin (prepuce) involves medical aspects, religion, esthetics, sexuality, cultural sensitivity, social engineering, psychology, ethics, constitutional rights of the newborn, and cosmology.
The advocates of circumcision present it as a precautionary deterrent to various conditions and diseases. The rationalizations in the Jewish faith are sanitation, an aid to procreation, and a deterrent to sex crimes and intermarriage; the real purpose remains obscure. In the medical rationale, it is accepted (but not proven) that there is a somewhat higher incidence of urinary tract disease in non-circumcised boys the first year. There are some indications that it may be a little higher in circumcised boys after that time. In both situations, the incidence of the disease is relatively rare.
Conditions considered to be prevented by circumcision are: pathological constriction of the foreskin over the glans (head) of the penis [phimosis]; inflammation of the tip of the glans and the foreskin [posthitis]; painful constriction of the glans (head) of the penis by the retraction of tight foreskin behind the head [paraphimosis]; susceptibility to venereal disease; and cancer of the penis in older men. Again, these conditions are rare.
Those in opposition to the procedure make the analogy that circumcision to prevent these conditions is like pulling teeth to prevent cavities. The constriction of the prepuce can be alleviated by making a small slit in the tissue to relieve pressure. Most conditions are considered to be preventable by better education in hygiene. The major complication to the surgery is possible hemorrhage and infection, which if excessive could lead to loss of the tip or entire penis, or to death. Although extremely rare, such disasters have been reported. A condition that has been reported from circumcision is a narrowing of the urinary opening (meatal stenosis), which is a result of ulcerations at the opening of the head of the penis caused by removal of the foreskin.
The foreskin appears in the fetus at two months of pregnancy as a thickened ring of epithelium growing forward over the glans of the penis. By four months, this foreskin has grown over the entire glans, forming a continuous layer adhering to the epithelial covering of the head (Fig. 3-1). The formation of the space between the layers of the foreskin and the head is rarely complete at birth or in the first six months after birth. The foreskin may be non retractable up to three years of age. When this is the case, the suggestion is not to force the foreskin back over the glans until it is structurally ready to do so. It is thought that the foreskin protects the glans from urine and feces. The inner surface of the prepuce is a mucous membrane richly supplied with blood vessels, sensory nerves, and stretch receptors.
In the original description of the procedure as practiced by the Jews, only the outer foreskin, the tip, was removed, preserving the inner lining (bris milah). The practice today by the medical profession is generally more extreme. It starts with breaking the “adhesions” and then applying either a clamp or other device to crush and then excise the tissue of the prepuce. In most cases, the foreskin is removed down to the base of the glans. The baby is restrained and often the face is covered.
Those practitioners who advocate birth without violence strongly oppose circumcision. They consider the practice to be torture, emotional and physical abuse, and sexual abuse. They believe it causes a change in the brain’s stress response system. It may cause bonding impairment in the first years of life especially from the pain in the raw penis rubbing against the mother’s body while breast feeding.
The following is a distribution of attitudes about circumcision in different countries and parts of the world. These have been accumulated by literature search and personal interviews. As indicated previously, circumcision was a common practice in the English-speaking countries until recent years. The United States now is considered to have one of the highest rates. Circumcision is not generally seen in continental Europe, Scandinavia, Japan, or South America. In Spain, I am told, it will happen only if the doctor recommends it, which also seems to be the case in Mexico. In northern Africa, Turkey, and the Near East where the population is mostly Arab (Muslim), it is the general practice. The Muslims are circumcised in India, while the Buddhists and Sikhs are not. In China, circumcision is not generally known except in the province just north of Tibet, where the inhabitants are Muslim.
Figure 3-1
Stages in the development of male genitalia
Approximate stages of pregnancy: (A) 7th week; (B) 10th week; (C) 12th week; (D) near term (photo credit 3.1)
My information from Argentina is that the church is officially against circumcision and can make it difficult to have the procedure done. In Brazil, there seems to be a class difference, especially in Rio de Janeiro where they try to be more American than the Americans. In central Africa, there is a variation from tribe to tribe. Some tribes have circumcision at puberty as a “rite of manhood.” Among some Arab peoples, circumcision is done immediately before marriage. In native Samoa, the boys are circumcised at any age from three to twenty. The followers of Taoism and Buddhism in the Far East rejoice in the intact body.
There is obviously little agreement on the advantages or disadvantages of circumcision. I have talked to a number of men who were circumcised as adults. They are very positive about the results from both a sanitary and cosmetic point of view. On the other hand, there are cases of prepuce reconstruction in circumcised men who felt they had been deprived of a body part without their consent.
The subject is controversial even among adult individuals. Many women and gay men are biased to the point of precluding sexual relations with one or the other (circumcised or uncircumcised men). In the end, the old adage remains true: beauty is in the eye of the beholder.