My thoughts about male genital mutilation.
(Notice to reader: The following article reflects the views and biases of the author. Unbiased articles are boring, and besides, what’s the use of having a blog if you can’t say what you want. I have made every attempt, however, to base my statements on verifiable fact. If there is any part of this article you do not agree with, say so.)
"Custom will reconcile people to any atrocity."
George Bernard Shaw
My father refused to have me circumcised and for this I remain eternally grateful. He was an enlightened, well-informed man and even in 1953 when routine infant circumcision was more the rule than the exception, he considered the procedure an abomination. If he were alive today, he would no doubt be proud that I am writing on this, the topic of numerous discussions between us and one about which he never softened his stance (…sorry).
My interest in circumcision has been rekindled primarily by the recent media coverage female genital mutilation has attracted. This latter practice, based as it is in ignorance and superstition, no doubt deserves all the attention it has garnered and no clear-thinking or fair-minded person can but vociferously support its complete abolition. What puzzles me though is that among these clear-thinking and fair-mined individuals are those who would, as they decry female genital mutilation, show not one bit of hesitation at having their male children so mutilated. Granted, the female version of this assault, and assault it is, I assure you, is much more harmful and disfiguring for the victim. However, I intend to make the case that male infant circumcision, unless performed for true therapeutic indications, is nothing short of medical assault, constitutes a serious abuse of the infant’s human rights, has no place in an enlightened society and should rightly be referred to as male genital mutilation.
I will deal first with the origins of male circumcision, a topic about which there is little consensus. We know from Egyptian hieroglyphs that circumcision has been practiced for more than 5,000 years. According the anthropologist Desmond Morris, the practice may have arisen from an Egyptian cult of snake worship and the belief that as with the snake that sheds its skin and undergoes a rebirth, so can the penis through circumcision. Ashley Montagu, on the other hand, suggests that Egyptian circumcision represented a sign of affiliation to the cult of the sun god Amon-Re. The Egyptian myth suggests that Amon-Re mutilated his genitals in some way. Circumcision was also common among ancient Semitic peoples who themselves may have borrowed it from the Egyptians. From Wikipedia: The Book of Jeremiah, written in the sixth century BCE, lists the Egyptians, Jews, Edomites, Ammonites, and Moabites as circumcising cultures. Herodotus, writing in the fifth century BCE, would add the Colchians, Ethiopians, Phoenicians, and Syrians to that list. Male circumcision has variously been used as a right of passage, a religious dedication, an in-group mark, an out-group mark, a mark of superiority, a mark of inferiority or slavery or a manipulation of sexual aesthetics.
According to the Old Testament (Genesis, chapter 17, verses 9 – 14) God commanded Abraham to circumcise himself, his offspring and his slaves. Thus, the ceremony of Brit milah, the ritual circumcision on the 8th day after birth, is obligatory for all males under Jewish religious law although there is some disagreement on this point among Jewish scholars (The Torah forbids the torture or causing of pain to any living creature, especially physically assaulting or harming another person (Exodus 21:18-27). Jewish law specifically forbids body modification, including the cutting or marking of the human body (Lev. 19:28). Jews are also required to help those who are helpless, such as newborn infants, and are exempt from performing religious duties that would cause harm to others.). The oral sucking of the bleeding penis (metzitzah b'peh) by the one who performs the cutting is now the subject of considerable controversy and is probably performed only among ultra orthodox Jews. Furthermore, more liberal Jews are questioning the very need for circumcision.
More interesting, though, is the origin of non-religious circumcision of males in the United States. Since the beginning of the twentieth century, neonatal circumcision has been the most frequently performed surgery in the US. That American attitudes to issues of sexuality are often puzzling is, in my mind, a given. When Janet Jackson’s right nipple, a very lovely one at that, I might add, was exposed to millions of innocent Americans during Superbowl XXXVIII, America was thrown into crisis. As an amused and somewhat perplexed world looked on, America writhed in moral indignation as it tallied up the damage that had been perpetrated on its young minds and souls. I mention the Janet Jackson incident simply to prime you for what follows.
The practice of non-religious male circumcision in America started in the mid-1800’s as a means of preventing masturbation. I kid you not. Masturbation was not only considered sinful but was also said to cause blindness, weakening of the mind, tuberculosis, warts, epilepsy as well as a variety of other ailments. It was viewed as the most dangerous form of sexuality. Furthermore, Americans of this era were very conscious of the recently popularized “germ theory of disease” and as a consequence had a great disdain for dirt and body secretions. It is no surprise that smegma (from the Greek word for soap), a normal and essential secretion under the male prepuce, was viewed as unhealthy and its elimination by circumcision seen as essential.
One of the most influential proponents of circumcision in mid-1800’s America was a physician named John Harvey Kellogg (his brother Will Keith Kellogg invented Corn Flakes). Dr. Kellogg certainly had unusual ideas about nutrition and health. Consider his approach to good health (from Wikipedia): “Kellogg made sure that the bowel of each and every patient was plied with water, from above and below. His favorite device was an enema machine ("just like one I saw in Germany") that could run fifteen gallons of water through an unfortunate bowel in a matter of seconds. Every water enema was followed by a pint of yogurt -- half was eaten, the other half was administered by enema "thus planting the protective germs where they are most needed and may render most effective service." The yogurt served to replace "the intestinal flora" of the bowel, creating what Kellogg claimed was a squeaky clean intestine.” Gulp! (See the film THE ROAD TO WELLVILLE staring Anthony Hopkins as Dr. Kellogg)
With regard to circumcision, he wrote in his Treatment for Self-Abuse and its Effects: “ A remedy for masturbation which is almost always successful in small boys is circumcision. The operation should be performed by a surgeon without administering an anesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment. In females, the author has found the application of pure carbolic acid to the clitoris an excellent means of allaying the abnormal excitement.”
Many other factors contributed to the rise in popularity of neonatal circumcision but only a couple more will be mentioned here. A very popular parenting book, All About the Baby, published around 1890 strongly recommended infant circumcision to prevent the vice of masturbation. It is also around this time that women of the wealthier classes started having their deliveries in hospitals and consequently having their infants circumcised there as well. Circumcision thus became a class marker of those wealthy enough to afford a hospital birth.
I would recommend highly the following article entitled Porn Flakes: Kellogg, Graham and the Crusade for Moral Fiber by Carrie McLaren. In it, the author serves up Kellogg’s Corn Flakes, Graham Crackers, Granola, Shredded Wheat, Post Toasties and Post Grapenuts followed by a large cup of Postum. This entertaining, well-written piece is sure to add valuable insight into your understanding of the rise of both circumcision and breakfast cereal in America.
Routine infant circumcision saw a steady rise in popularity in English speaking countries such as the US, Canada, Australia, New Zealand and the UK. One source estimates that the rate of infant circumcision in the US was 30% in 1900, 55% in 1925 and 72% in 1950. Since 1950, the US infant circumcision rate has remained fairly steady save for a slight decline to about 55% in the last few decades. Except for groups such as followers of the Jewish and Islamic faiths who practice circumcision for religious and cultural reasons, infant circumcision is uncommon in Asia, South America, Central America, and most of Europe. One notable exception is South Korea where circumcision was virtually unknown before the US trusteeship (1945 – 1948) and US involvement in the Korean War (1950 – 1953) but which now boasts a neonatal circumcision rate of over 95%! It is a nearly inescapable conclusion that this custom, like blue jeans, is a direct result of US cultural influences. Furthermore, surveys show that it is widely believed by South Koreans that circumcision is universal and compulsory in the world. Interesting. For a less narrow-minded view of the incidence and distribution of circumcision in the world, have a look at this website.
What reasons do parents give for having their children circumcised? The one I hear most often is cleanliness or genital hygiene. Yes, I agree that it’s probably easier to keep that little penis smegma-free if there’s no foreskin for it to hide under. But wait a minute! Aren’t there other areas on our bodies that accumulate unwanted stuff? What about the lint and dirt in the belly button; maybe we should start surgically obliterating belly buttons. How about those nasty boogers in your nostrils; nasal ablation would solve the problem, right? Wax and dirt buildup in the external auditory canal and ear; lop the ear off and problem solved. Now I know I’m getting a bit silly here but stay with me. The point is this: you do not surgically excise perfectly normal and functional body parts merely for ease of grooming…without the consent of the recipient to boot (More on this later.).
The other reason parents have their children circumcised is for the health benefits. They argue that many conditions such as urinary tract infections, ballanitis and phemosis are less common in circumcised males. I won’t go into these conditions in detail except to say that they are uncommon, benign and preventable by a whole variety of non-disfiguring treatments. Even if, for the sake of argument, circumcision does decrease the incidence of these benign conditions, it is not justified. If it was, we would then be compelled, no obligated, to perform prophylactic mastectomies on all our female infants as 1 in every 8 women will develop invasive breast cancer, an often fatal condition, in her lifetime.
A more recent justification for male circumcision is the prevention of infection by the AIDS virus. A recent study by the National Institutes of Health has concluded that medically performed adult circumcision significantly reduces a man's risk of acquiring HIV through heterosexual intercourse. The trial in Kenya showed a 53% reduction of HIV acquisition in circumcised men relative to uncircumcised men, while a trial in Uganda showed that HIV acquisition was reduced by 48% in circumcised men. The official NIH press release can be found here and the WHO press release here. Now, these are impressive findings and represent a major step in the fight against HIV transmission. The reason for the greater risk of HIV transmission in uncircumcised males is believed to be that intact foreskin contains Langerhans cells. These cells are part of our immune system and are active in capture, uptake and processing of antigens and are therefore felt to be the primary point of viral entry.
Do the promising results of this study justify male infant circumcision? Absolutely not. First and foremost, both the NIH and the WHO point out that the individual’s human rights must be respected and that medical circumcision requires consent. Second, the protection afforded by circumcision does not replace the other known effective prevention methods and should always be considered as part of a comprehensive prevention package, which includes correct and consistent use of male or female condoms, reduction in the number of sexual partners, delaying the onset of sexual relations, and HIV testing and counseling. Third, medical circumcision is a surgical procedure and as such is associated with a number of known complications. Finally, there exists the risk that performing medical circumcision has the potential to undermine existing protective behaviors and prevention strategies that reduce the risk of HIV infection by giving the individual a false sense of protection.
KEEP THE TIP
What’s so important about the foreskin anyway? Circumcision only removes a few millimeters of skin so what’s the big deal? Well the big deal is that the foreskin is a normal, functioning and important part of male anatomy. It is not a vestigial organ and it certainly is not just an extra piece of overhanging skin. The foreskin forms the protective covering over the head or glans of the penis. It is rich in sensory nerve fibers and movement of the foreskin back and forth over the shaft and glans provides much of the pleasurable sensation experienced during sex. The inner foreskin layer is not just "skin," but mucocutaneous tissue of a unique type found nowhere else on the body. The nerve endings in the foreskin are called Meissner's corpuscles and are similar to those found in the fingertips and lips, parts of our body that respond in a fraction of a second to light touch. In an average circumcised adult man, the area of skin that is missing because of the surgery would, when erect and unfolded, measure approximately 50 - 100 cm2 or about ½ the total surface of the penis. Males who were circumcised as infants do not usually report sexual problems linked with their circumcision, perhaps because they have never experienced sexual sensation with a foreskin. However, men circumcised as sexually active adults quite frequently complain of sexual problems arising from either reduced or altered penile sensation. (By the way, in the course of my reading, I came across the statement that the glans is insensitive to pinprick, an observation I am quite willing to accept without proof.)
To continue on this painful topic, it is very important to understand that the circumcised penis loses sensitivity in three ways (Sorry for the lengthy explanation but this is important.):
1. Loss of the foreskin nerves themselves. It has been shown that the inner foreskin possesses a greater density of nerve endings. It is thought to be more erogenous than even the glans. There is no question that the foreskin is a highly erogenous tissue. This tremendous amount of sensitivity is lost completely when the forefold of the skin system is amputated. In addition to this, the most sensitive part of the penis, the frenulum of the foreskin, is either partially or totally removed in most infant circumcisions. The frenulum is the continuation of the inner foreskin, which attaches to the underside (ventral part) of the glans. Thus, a significant percentage, if not the majority, of erogenous nerve supply to the penis is removed in circumcision at birth.
2. Damage to the glans. The erogenous sensitivity that remains after circumcision is primarily in the glans. This is further reduced by removal of the protective foreskin which leaves the glans permanently exposed. Unlike the shaft of the penis, and most of the rest of the body, the head of the penis, does not posses its own attached skin. This structure, like the eye ball and the gums of the mouth, is a somewhat naked structure. Its surface is non-keratinized, like that of the gums, the eye ball, and the clitoris in women. That means that it does not posses a protective thick layer like the keratinized skin of the outer penile skin system. Like the gums and the eye ball, the glans of the intact penis has a retractable skin covering. The skin covering of the glans is the foreskin. The eyelid is very similar in architecture to the foreskin. If the eyelid were removed and the eyeball were to become keratinized, you'd have a much harder time seeing. The same is true of the glans. It becomes artificially keratinized (dry, hardened, discolored, and wrinkled) as a result of permanent exposure, and thus less sensitive. Because most American men are circumcised and have a glans of this nature, it is harder to notice the abnormality. But just compare the glans of an intact man with that of a circumcised man next to each other and you'll notice a big difference. Thus, in addition to removing lots of erogenous nerve endings in the inner foreskin and frenulum, circumcision further desensitizes the remaining sensitivity of the glans by leaving it exposed.
3. Loss of skin mobility. The nerve endings in the glans are predominantly complex touch receptors also known as mechanoreceptors. This is different from the light touch receptors of the skin which detect surface friction. The mechanoreceptors are best stimulated by massage action rather than surface friction. Thus, the glans is best stimulated to feel pleasure by a rolling massage action. With an ample and highly mobile skin system that rolls over the glans with pressure from the opposing surface, this optimal stimulation of the glans is achieved while avoiding direct friction of the delicate glans surface. Direct friction tends to fire off pain receptors causing irritation and also causes further keratinization of the glans. With the skin system of the penis significantly reduced by circumcision, the mobility is essentially gone and now the penis is a static mass with no dynamic self-stimulation mechanism. Now, it must be rubbed. Direct friction is now the primary form of stimulation. So then circumcision further reduces erogenous sensitivity in the penis by reducing skin mobility and thus the ability to use the foreskin to massage the glans. The combination of foreskin and glans in concert results in an even higher level of stimulation which is unknown to the circumcised male.
All surgical procedures have a certain risk of complication and circumcision is no exception. The exact incidence of complications is difficult to gage exactly and varies depending on the definitions used. The American Medical Association and the American Academy of Pediatrics both estimate the rate of complications at 0.2% - 0.6%; the American Academy of Family Physicians places it at 0.1% - 35%; the Royal Australasian College of Physicians and the Canadian Pediatric Society give an estimate of 0.6% - 55%. Bleeding and infection are the most common complications in the short term. The long term complications include urinary fistulas, chordee, cysts, lymphedema, ulceration of the glans, necrosis of all or part of the penis, hypospadias, epispadias, impotence and removal of too much tissue, sometimes causing secondary phimosis. The fatality rate is estimated at 1 in 500,000.
Recently, 3 infants in NYC and 8 in Israel contracted herpes after metzizah b’peh (see above). The virus was presumably acquired from the mohel’s (Rabbi specializing in the rituals and technique of circumcision) mouth.
Circumcision is one of the most horrifying procedures I have ever witnessed in my medical career. The 4 or 5 circumcisions I attended were during my medical school years and none of them were performed with anesthesia. The memory of those infant boys strapped to the molded plastic frame screaming and writhing in pain as the Gomco clamp was tightened down around the foreskin will forever remain with me. Anyone who chooses to have his or her infant circumcised should be forced to attend the procedure. There is no longer any doubt that infants feel pain and there is increasing evidence that the pain of circumcision can leave lasting psychological effects.
LEGAL AND ETHICAL CONSIDERATIONS
With regard to the legal and ethical aspects of circumcisions, I respectfully defer to Dr. Margaret Somerville, one of the world’s best-known medical ethicists. She is the founding director of the Centre for Medicine, Ethics and Law at McGill University, where she holds the Samuel Gale Chair in the Faculty of Law and is a professor in the Faculty of Medicine; she has worked with the World Health Organization, the United Nations High Commissioner for Human Rights and UNESCO.
Dr. Somerville has advanced the opinion that infant male circumcision undertaken for non-medical reasons is “technically criminal assault” (under the Canadian Criminal Code). In her own words, “All wounding of one person by another person is prima facie criminal assault (indeed, aggravated criminal assault), but it can become justified—that is, not illegal, not a crime—on certain conditions. The most common and important situation in which wounding is not a criminal assault, is when it is indicated as medically required surgery and it is undertaken with the informed consent of the person on whom it is carried out or, if this person is incompetent, of their legal representative (in the case of children, the parents). The difficulty with infant male circumcision is that when it is not medically indicated, medical justification is not present and, although adults can consent to have a non-therapeutic intervention carried out on themselves provided the intervention is not considered to be contrary to public policy, in general, they may not consent to having such interventions carried out on their children. The exception to this is if the intervention is considered to be what the law calls de minimis, that is, a trifle of which the law will not take notice. Arguably, ear piercing, especially as it is reversible, falls within this category. However, even the rabbis with whom I talked agreed that male infant circumcision is not de minimis” This legal argument places a heavy burden of the treating physician to justify as “medically indicated” any procedure he intends to carry out on a patient lest the wounding be considered assault.
Male circumcision is the only medically unnecessary surgery in the USA that is performed without obtaining consent from the patient. In law, parental rights are derived from parental duty and exist only so long as they are needed for the protection of the person and property of the child. Giving consent to medical treatment of a child is a clear incident of parental responsibility arising from the duty to protect the child. This duty is clearly breached when the procedure in question is non-therapeutic, ablative and irreversible. Furthermore, the UN Convention on the Rights of the Child
is explicit in Article 24.3: "States Parties shall take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children."
There you have it, my thoughts on circumcision. More than ever, I am of the view that non-therapeutic infant circumcision is nothing less than an act of male genital mutilation, a failure of society to protect the male child against assault, a breach of basic human rights and an abrogation of parental duties and responsibilities. Furthermore, religious, tribal or other cultural justification for circumcision is, in my view, no longer tenable in the context of modern medical knowledge and universal social jurisprudence.
Finally, my dear reader, I leave you with the following quote from one of the keenest observers of the naked ape:
“These, then, are the human genitals. Considering their great delicacy, complexity and sensitivity, one might imagine that an intelligent species like man would leave them alone. Sadly, this has never been the case. For thousands of years, in many different cultures, the genitals have fallen victim to an amazing variety of mutilations and restrictions. For organs that are capable of giving us an immense amount of pleasure, they have been given an inordinate amount of pain.”-- Desmond Morris.