Circumcision controversies

Circumcision has been the subject of controversy for thousands of years. The Ancient Greeks and Romans valued the foreskin and were opposed to circumcision. Traditional Judaism and Islam have advocated male circumcision as a religious obligation.

From the mid 19th century, there has been advocacy in Anglophone countries on medical grounds while opponents of routine circumcision often question its effectiveness in preventing disease.^[1] Modern critics also object to subjecting newborn boys, without their consent, to a procedure they consider to have questionable benefits, significant risks and a potentially negative impact on later sexual enjoyment.

Religious and cultural conflicts

Ancient world

The Bible recounts Abraham and his undergoing circumcision as a radical break with the culture of his times. The Jewish and Islamic traditions both record circumcision used as a way to distinguish a group.^[2]. The bible records the concept of circumcised or un-circumcised as a derogatory reference from an opponent^[3]. From biblical and apocryphal texts it seems that circumcision was practiced only by the Jewish communities of the time and purely as a religious practice.

The Seleucid Empire made laws prohibiting circumcision, affecting the Jews living within the empire. In 167 B.C Antiochus (175–165 B.C.) gave a decree that punished any mother who circumcised their son with death^[4] (according to Tacitus, as quoted by Hodges, Antiochus "endeavoured to abolish Jewish superstition and to introduce Greek civilization."^[5]). See also Antinomianism in the Books of the Maccabees.

In the Roman Empire, the consul Titus Flavius Clemens was condemned to death by the Roman Senate in 95 A.D. for converting to Judaism and becoming circumcised. Hadrian (117-138 A.D.) forbade circumcision. Antoninus Pius (138-161) upheld the decree but around 140 A.D. included an exemption for Jews who circumcised their sons, though not their servants or slaves.^[5]

During these times Jewish response took two forms: circumcisions were secretly performed - even on dead Jews - so that the law of their fathers could be carried out^[4], or efforts were made to alter their circumcision status. The second apparently began during the reign of Antiochus and continued through to the time of Antoninus, when a radical method of circumcision, the periah, was introduced that left the glans totally uncovered, making it almost impossible to restore the foreskin.^[6]

A device called a Pondus Judaeus took advantage of the common form of circumcision among Jews at that time, in which only the distal part of the foreskin was cut off, leaving a short prepuce. It was a special weight made of bronze, copper, or leather, which was fixed to the remant foreskin, pulling it downward. When it was applied for a longer period, the foreskin was lengthened. Martial mentioned the instrument in Epigrammaton Libri 7:35.^[6] The apostle Paul referred to these practices, saying: "Was a man already circumcised when he was called? He should not become uncircumcised." (1 Cor 7:18) But he also explicitly denounced the practice, rejecting and condemning those who promoted circumcision to Gentile Christians, labelling the advocates of circumcision "false brothers". (Gal 2:4)

Under Constantine the two rescripts of Antoninus on circumcision were re-enacted and again in the 6th century under Justinian. These restrictions on circumcision made their way into both secular and canon law and "at least through the Middle Ages, preserved and enhanced laws banning Hebrews from circumcising non-Hebrews and banning Christians or slaves of any religious affiliation from undergoing circumcision for any reason."^[5]

Islam

In the early 7th century, the Prophet Muhummad welded together many Semitic tribes of the Arabian peninsular into the kernel of a rapidly expanding Muslim movement. The one thing that can be said with some certainty is that male and female circumcision was already well established among these tribes, and probably had been for more than a thousand years, most likely as a fertility right. Herodotus had noticed the practice among various Semite nations in the 5th century B.C., and Josephus had specifically mentioned circumcision as a tradition among Arabs in the first century AD.^[7]

The Qur'an does not mention circumcision at all, but there are many hadith (stories about the life and sayings of Muhammad) that do. All endorse circumcision, but like all hadith are open to interpretation by Islamic jurists, which has meant from the outset there have been different views about the status of circumcision, falling into three broad categories: ^[8]

1. Mandatory for both boys and girls
2. Sunna (advisable or recommended) for both sexes
3. Mandatory for boys but sunna or makrumah (honourable) for girls

This has led to widely different practices in different societies, from universal circumcision of all adults in some, to a complete absence of the practice in others. There is also no consensus on when it should be performed (ranging from birth to the onset of puberty), though the eighth day after birth (the Jewish custom) is usually avoided.^[8]

Middle Ages to 19th century

Thomas Aquinas in his Summa Theologica questioned why, if under Jewish doctrine circumcision removed original sin, Jesus was circumcised - as Jesus had no original sin. Steve Jones suggests there is a theological tradition that Jesus regained his foreskin at the Ascension. "Had he failed to do so, the Saved would themselves have to be operated upon in Paradise so as not to be more perfect than their Saviour."^[9]

The Jews were expelled from England by Edward I in 1290, ostensibly over social tensions concerning usury. But the public imagination had been gripped by recurring stories of forced circumcion of Christian boys, often followed by their ritual murder, since at least the 12th century: "So pervasive was the belief that Jews circumcised their victims ... that Menasseh ben Israil, the Dutch Rabbi who sought from Cromwell the readmission of the Jews in 1656, had to dwell at considerable length in his Vindiciae Judaeorum at refuting the claim."^[10]

In 15th century Spain most Jews and Muslims were expelled and the Spanish Inquisition monitored and prosecuted converts to Christianity to ensure they were not secretly consorting with Jews or engaging in Jewish practices such as circumcision.^[11]

In 1521 Cortés defeated the Aztec empire in Mesoamerica, which was followed by a large influx of Spanish clergy, whose writings provide most of information about pre-conquest Aztec life and customs largely assembled from interviews with those who survived the invasion and subsequent epidemics, and their descendents. Diego Durán, a Dominican friar, was convinced that the Aztecs were one of the lost tribes of Israel, with a crucial piece of supporting evidence being that they had practised circumcision.The History of the Indies of New Spain,

So influential was this notion that 300 years later Bancroft in his monumental Native Races^[12] began his discussion of circumcision by writing: "Whether the custom of circumcision, which has been the great prop of argument in favor of the Jewish origin of the Aztecs, really obtained among these people, has been doubted by numerous authors," concluding that it probably existed in a "certain form among some tribes" (p278). The key being "a certain form", since Bancroft makes clear in a footnote that the majority of the sources, including Clavigero, Carbajal Espinosa, Oviedo y Herrera, and especially Acosta, believed Duria and others "confounded the custom of drawing blood from the secret organs with circumcision", and "the incision on the prepuce and ear to have been mistaken for circumcision", adding that this blood-letting rite was "chiefly performed upon sons of great men" (page 279). The case was not helped by the fact no reports of seeing a circumcised adult Aztec existed in the literature. The case for ancient Mayan circumcision was even weaker, based entirely on Brasseur de Bourbourg reporting that he had found "traces" of circumcision in an abridged manuscript written by another cleric, Diego de Landa. But Cogolludo, who had access to the same manuscript and many additional sources, reported that circumcision was unknown to the Indians of Yucatan.(p279)

(Today, although the "lost tribe" theory has receded to the fringes, it is still very common to see the Aztecs (and Mayans) appearing without qualification in the list of pre-modern people who practised circumcision. UNAIDS makes the claim^[13], even though it cites Remondino^[4], who had acknowledged that it was "a matter of controversy" whether the foreskin had actually been removed.)

Countries that do not circumcise have often held antipathy for those that do. Being circumcised was a often seen as a sign of disgrace.^[4] According to Darby, it was also seen as a serious loss of erogenous tissue: "During the Renaissance and 18th century the centrality of the foreskin to male sexual function and the pleasure of both partners was recognised by anatomists Berengario da Carpi, Gabriello Fallopio and William Harvey, in popular sex manuals like Aristotle's master-piece, and by physicians like John Hunter, who also appreciated the importance of the foreskin in providing the slack tissue needed to accommodate an erection."^[14]

In 1650, English physician John Bulwer in his study of body modification, Anthropometamorphosis: Man Transform’d, or the Artificial Changeling, wrote of the loss in sexual pleasure resulting from circumcision: "the part which hangeth over the end of the foreskin, is moved up and down in coition, that in this attrition it might gather more heat, and increase the pleasure of the other sexe; a contentation of which they [the circumcised] are defrauded by this injurious invention. For, the shortnesse of the prepuce is reckoned among the organical defects of the yard, … yet circumcision detracts somewhat from the delight of women, by lessening their titillation." The English historian Edward Gibbon, author of The History of the Decline and Fall of the Roman Empire, referred to the practice as "a painful and often dangerous rite", and a "singular mutilation" practiced only by Jews and Turks.

The first formal objection to circumcision within Judaism occurred in 1843 in Frankfurt. The Society for the Friends of Reform, a group that attacked traditional Jewish practices, said that brit milah was not a mitzvah but an outworn legacy from Israel's earlier phases, an obsolete throwback to primitive religion.^[15] With the expanding role of medicine came further opposition; certain aspects of Jewish circumcision such as periah and metzitzah (drawing the blood from the circumcision wound through sucking or a cloth) were deemed unhygienic. Later evidence that syphilis and tuberculosis— two of the most feared infectious diseases in the nineteenth century — were spread by mohels, caused various rabbis to advocate metzitzah to be done using a sponge or a tube.^[16] (Today, the Rabbinical Council of America, the largest group of Modern Orthodox rabbis, endorses using a glass tube.^[17])

Ephron reports that Gentiles and also some Jewish reformers in early 19th century Germany had criticized ritual circumcision as "barbaric" and that Jewish doctors responded to these criticisms with defences of the ritual or proposals for modification or reform. By the late 19th century some German Jewish doctors defended circumcision by claiming it had health advantages.^[18]

Modern debates

Medical advocacy and opposition

A protest against non-therapeutic infant circumcision in connection with the annual meeting of the American Academy of Pediatrics at Washington Convention Center

Circumcision spread in several English-speaking nations from the late nineteenth century. Doctors such as Sir Jonathan Hutchinson in England wrote articles in favour of the procedure.^[19] Peter Charles Remondino, a San Diego physician, wrote a History of Circumcision from the Earliest Times to the Present: Moral and Physical Reasons for Its Performance (1891), to promote circumcision.^[20] Lewis Sayre, a prominent orthopedic surgeon at the time, was another early American advocate.^[20] However, the theories on which many early claims were made, such as the reflex theory of disease and the alleged harmful effects of masturbation, have long since been abandoned by the medical profession.^[20]

Dr. John Harvey Kellogg recommended circumcision of boys caught masturbating, writing: "A remedy for masturbation which is almost always successful in small boys is circumcision, especially when there is any degree of phimosis. The operation should be performed by a surgeon without administering anaesthetic, as the pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment." (page 295) But he was opposed to routine circumcision of infants: "It is doubtful, however, whether as much harm as good does not result from circumcision, since it has been shown by extensive observation among the Jews that very great contraction of the meatus, or external orifice of the urethra, is exceedingly common among them, being undoubtedly the result of the prolonged irritation and subsequent cicatricial contraction resulting from circumcision in infancy." (page 107)^[21]

An early British opponent of circumcision was Herbert Snow, who wrote a short book called The barbarity of circumcision as a remedy for congenital abnormality in 1890.^[22] But as late as 1936, L. E. Holt, an author of pediatric textbooks, advocated male and female circumcision as a treatment for masturbation.^[23]

The first serious questioning of the practice did not occur until late 1949 when Gairdner published The Fate of the Foreskin in the British Medical Journal; according to Wallerstein this began to affect the practice of circumcision in Britain.^[1] In the 60 years since, rates of infant circumcision have fallen, often sharply, in all Anglophone countries, with the exception of the United States, where a majority of male newborns are still circumcised. (See Prevalence of circumcision)

According to Darby and Cox, the persistence of circumcision in the USA has led to more vigorous protest movements.^[24] The National Organization of Circumcision Information Resource Centers (NOCIRC), was formed by Marilyn Milos, R.N., in 1985.^[25] The organization's stated objective is to secure the birthright of male, female, and intersex children and babies to keep their sex organs intact. Protest rallies have been held in the USA and other areas. NOCIRC have consistently criticised the American medical community's circumcision guidelines.^[25] According to Milos and Donna Macris, "The need to defend the baby's right to a peaceful beginning was brought to light by Dr. Frederick Leboyer in his landmark work, Birth Without Violence".^[25]

This period also saw the formation of anti-circumcision organizations in Australia, Canada, the United Kingdom and South Africa. Activists began creating websites in the mid-1990s, and this process has continued. One such organization distributed questionnaires to circumcised men. The complaints included prominent scarring (33%), insufficient penile skin for comfortable erection (27%), erectile curvature from uneven skin loss (16%), and pain and bleeding upon erection/manipulation (17%). Psychological complaints included feelings of mutilation (60%), low self esteem/inferiority to intact men (50%), genital dysmorphia (55%), rage (52%), resentment/depression (59%), violation (46%), or parental betrayal (30%). Many respondents reported that their physical/emotional suffering impeded emotional intimacy with their partner(s), resulting in sexual dysfunction.^[26] Prominent men known to be unhappy about being circumcised include A E Houseman, W.H. Auden, Geoffrey Keynes and his brother John Maynard Keynes, the famous economist.^[24] In 1996 the British Medical Journal published a letter by 20 men saying that "we have been harmed by circumcision in childhood"; they argued that "it cannot be ethical for a doctor to amputate normal tissue from a normal child".^[24] Dr. Benjamin Spock (d. 1998), who originally supported circumcision, changed his mind near the end of his life.^[27]

Prominent American advocates for infant circumcision include Dr. Thomas Wiswell, who began publishing research on the relative incidence of urinary tract infections in the mid 1980s;^[28] Dr. Edgar Schoen, (b. 1925) former chair of the American Academy of Pediatrics' Task Force on Circumcision, who maintains a web site promoting circumcision^[29] and claims physical benefits in sexual performance in addition to medical arguments; and Aaron J. Fink, M.D. (d. 1990), who self-published Circumcision: A Parent's Decision for Life to promote his ideas.

In Australia, Professor Brian Morris, author of In Favour of Circumcision, asserts that circumcision confers many medical benefits including reduced risk of UTIs, penile cancer, HIV, balanitis, posthitis, phimosis, and prostate cancer and argues that circumcision has sexual benefits.^[30] However, Morris's views have been strongly criticised by Professor Basil Donovan.^[31] David Forbes, chair of the pediatrics and child health policy and advocacy committee of the Royal Australasian College of Physicians has stated that Morris has not been asked to review the college's circumcision policy and is not a member of the college.^{[32] [33]}

The American Academy of Pediatrics (AAP) circumcision policy has been criticised, both by those who believe that it is too negative about the practice^[34], and those who believe that it is too positive.^[35] Hill has also criticised the Academy's circumcision information brochure for parents, arguing that the brochure is inadequate to persuade parents to avoid circumcision.^[36]

The WHO and UNAIDS recommend male circumcision as a means of reducing the rate of HIV infection,^[37] but this has also proved controversial, with doubts raised about the efficacy of mass circumcision campaigns in sub-Saharan Africa.^{[38] [39]}

Another area of continuing dispute is the effect of circumcision on penile sensitivity. In April 2007, the British Journal of Urology published a study (Sorrells et al., 2007) that stated it "conclusively shows that circumcised males have a significant penile sensory deficit as compared with non-circumcised intact men" and that "the most sensitive regions in the uncircumcised penis are those removed by circumcision."[7] But in June 2007, the BJU published a letter in reponse by Waskett and Morris, which concluded that "despite a poorly representative sample and a methodology prone to exaggerating the sensitivity of the prepuce, NOCIRC's claims remain unproven. When the authors' data are analysed properly, no significant differences exist. Thus the claim that circumcision adversely affects penile sensitivity is poorly supported, and this study provides no evidence for the belief that circumcision adversely affects sexual pleasure."[8] Hugh Young, a critic of circumcision, responded to this, stating that Waskett and Morris "critique the finding of Sorrells et al. that 'circumcision ablates [removes] the most sensitive part of the penis' by excluding that part from consideration... That the foreskin itself has a sexual function was well-known for centuries before secular circumcision became widespread. What would need to be proved rigorously is that cutting a significant part of the distal penis off does not diminish sexual pleasure." [9]

Genital integrity

Many opponents of circumcision see infant circumcision as unnecessary, harmful and unethical;^[40] some want the procedures prohibited.^[41] Boyle et al. suggest that "As we enter the 21st century, appropriate legal action must be taken to safeguard the physical genital integrity of male children."^[42]

Hammond asserts that every person has a right to a whole and intact body and that, where minors are concerned, "the unnecessary removal of a functioning body organ in the name of tradition, custom or any other non-disease related cause should never be acceptable to the health profession." He says that such interventions are violations of individual bodily rights and "a breach of fundamental medical ethics principles".^[26] Others also see the genital cutting of children as a human rights issue, ^[43] opposing the genital modification and mutilation of children, including circumcision and female genital cutting. Several anti-circumcision organizations also oppose the sexual-reassignment surgery of infants with ambiguous genitalia.^{[41][44][45][46]}

Current laws in many countries, and laws in several U.S. states, prohibit the genital modification and mutilation of female minors, with some exceptions based on medical need. Opponents of male circumcision assert that laws against genital modification and mutilation of minors should apply equally to males and females. Many anti-circumcision groups have joined the International Coalition for Genital Integrity [10] and endorsed its declaration[11], which was adopted by the First International Symposium on Circumcision, on March 3, 1989, at Anaheim, California. (There have been nine such further symposia held since, with the proceedings of several subsequently published in book form.)^[47]

However, linking male circumcision to female genital cutting is itself highly controversial. Organisations actually involved in combatting FGC have been at considerable pains to distinguish the two, as this UNICEF document explains: "When the practice first came to be known beyond the societies in which it was traditionally carried out, it was generally referred to as “female circumcision”. This term, however, draws a direct parallel with male circumcision and, as a result, creates confusion between these two distinct practices."[12]

This stance has been largely echoed by Western medical and political authorities. The Australian Medical Association states: "The AMA rejects the euphemism "female circumcision", sometimes used to describe the various forms of female genital mutilation, because the use of this phrase trivialises the severe and often irreparable physical and psychological damage occasioned to girls and women by these practices."[13] In the United States, the organization MGMbill.org sent a proposed bill to the US Congress and 15 state legislatures between 2004 and 2007 to extend the prohibition on genital modification and mutilation of minors to include male and intersex children.^[41] But the proposed bill has not been endorsed by any member of Congress.^[48]

Other contemporary controversies

While circumcision debates are often dominated by the concerns of Anglophone countries, very different controversies over the procedure regularly erupt in other cultural contexts. In South Asia, Pakistan has long used circumcision status as a definitive marker of Indian covert involvement in its internal affairs. But this assumption was thrown into confusion when it was discovered that large segments of its own Muslim male population, specifically from western tribal areas, were themselves uncircumcised.^[49][50].

Opposition to circumcision exists among Jews in Israel. Even though there is often pressure from family to circumcise their sons, a small but growing number of Jews are choosing to forgo the procedure.^[51] Islamic anti-circumcision groups, such as Qur'an Alone, have also emerged, arguing among other things that routine circumcision is an insult to Allah since it tries to improve on his perfect creation.[14]

Northern Europe, which has no tradition of routine circumcision, has been struggling with the challenges of its Jewish and Muslim minorities. Finland is considering legislation to legalise male circumcision.^[52] Sweden in 2001 passed a law requiring traditional circumcisers to be certified and for the infants to be given a medically administered anaesthetic. The World Jewish Congress responded strongly: "This is the first legal restriction placed on a Jewish rite in Europe since the Nazi era."^[53]

In the Xhosa areas of South Africa, the large death toll from traditional circumcision provide a constant source of friction between traditional leaders, who oppose medicalised procedures, and health authorities. In 2009 in Eastern Cape Province alone, 80 boys died and hundreds were hospitalised after attending initiation schools.^[54]

See also

• History of circumcision
• Ethics of circumcision
• Human rights
• Reproductive rights
• Ridged band
• Female genital cutting
• Gliding action
• Foreskin
• Medical analysis of circumcision
• Penis

References

Further reading

• Robert Darby, "A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain, Chicago, University of Chicago Press, 2005. (ISBN 0-226-13645-0)
• Leonard B. Glick, "Marked in Your Flesh: Circumcision from Ancient Judea to Modern America", New York, Oxford University Press, 2005
• David A. Gollaher, Circumcision: A History of the World's Most Controversial Surgery. New York: Basic Books, 2000. 253 pages. (ISBN 0-465-04397-6)
• Peter Charles Remondino. History of Circumcision from the Earliest Times to the Present. Philadelphia and London; F. A. Davis; 1891.
• Edward Wallerstein, Circumcision: An American Health Fallacy. New York: Springer Publishing Co. 1980.
• Ritual Circumcisionist's Kit, 1950s URL: http://americanhistory.si.edu/toolbox/ritual.html
• David L. Gollaher, Circumcision: A history of the world's most controversial surgery, New York, Basic Books, 2000, ISBN 0-465-04397-6, hardback
• Dunsmuir WD, Gordon EM. The history of circumcision. BJU Int 1999;83 Suppl. 1:1-12. URL: http://www.cirp.org/library/history/dunsmuir1/

External links

Opposition to circumcision

• The Circumcision Information and Resource Pages
• National Organization of Circumcision Information Resource Centers (NOCIRC)
• MGMbill.org
• Doctors Opposing Circumcision
• Circumstitions has links to many genital integrity resources

Criticism of opposition to circumcision

• "Anti-Circumcision Lobby Groups"
• "Myths, Lies and Half-Truths About Male Circumcision

Circumcision advocates

• The Benefits of Male Circumcision by Dr David Hawker, General Practitioner, UK
• Medical Benefits of Circumcision by Professor Brian Morris, Australia
• Circumcision: a lifetime of medical benefits by Dr. Edgar J. Schoen, USA
• Circlist Revamped site for circumcision enthusiasts

Critics of circumcision advocacy

• Myths about circumcision
• Circumcision Positions of Advocates and Critics
• Circumcision: The Step to Becoming a REAL Man