Circumcision
Volume 2, Number 1
June 1997 (posted Sept 1997)
TABLE OF CONTENTS
EDITORIAL
Surfers Beware!
By Robert S. Van Howe, M.D.
A recent commentary in the Journal of the American Medical Association warned of the consistency of the quality of medical information available on the Internet. To put it in terms that surfers can understand, the waves may be big, but the water can be dangerously shallow. CIRCUMCISION is part of the World Wide Web medical milieu that needs to assert its credibility. To that end, I have tried to reference my comments in the Abstracts and Analysis section to help those who are interested in pursuing the topics further. The issue of infant circumcision evokes passions seldom seen with other medical topics. In an attempt to help the surfer put the information regarding male circumcision on the Internet into perspective, I will be reviewing several of the web sites and documents that have come to my attention. If you find something of interest on the Internet please feel free to let me know about it.
Several of the web sites are extremely well done and documented, while some are long on hyperbole and short on documentation. Over the next several issues, I will try to look at several of these.
In this issue I publish an article I have written, but which has been approved by our reviewers. I feel uneasy doing this, but the article did receive positive feedback. There are also a couple of reprinted articles that should provoke discussion. There are several book reviews, but the number of abstracts that demanded attention since the last issue has exploded, which is responsible for the delay in the release of this issue.
Robert S. Van Howe, M.D. F.A.A.P.
Clinical Instructor
Medical College of Wisconsin
Department of Pediatrics
Marshfield Clinic - Lakeland Center
Minocqua, Wisconsin 54548
ORIGINAL ARTICLE
Meatal Stenosis with Bladder Distention
by Robert S. Van Howe, M.D., FAAP
ABSTRACT
Meatal stenosis is the most common serious complication of penile circumcision. The stenosis may result from injury to the frenular artery with an incidence of 2% to 11%. Because of this high incidence, the risk of developing meatal stenosis needs to be included in any discussion of the risks of penile circumcision. When surgical treatment of phimosis is considered, preservation of the frenular artery or the use of an alternative procedure, such as preputial plasty, is advised.INTRODUCTION
Meatal stenosis may be the most common serious complication of penile circumcision. Stenosis of the meatus can lead to obstructive symptoms, including obstructive uropathy.CASE REPORT
A six-year-old male awoke at 0430 with abdominal pain, and complaining that his "privates hurt." His father, fearing that he might be developing gastroenteritis, gave him two 355 ml cans of a carbonated beverage because he was not voiding. His abdominal pain persisted. He was brought to the physician's office where at 1030 he voided an extreme amount of urine before being examined. He was examined less than 30 minutes later. On physical examination he weighed 18.6 kg, was afebrile with normal vital signs. He had tenderness over the suprapubic area and a bladder that percussed to the level of the umbilicus. Genitalia revealed a Tanner I circumcised male with meatal opening of 1-2 mm with a skin tag over the ventral aspect. Urinalysis was normal. After voiding his bladder could not be palpated or percussed.At the time of urethral meatotomy his meatal opening was 4 French. After surgery his symptoms resolved, and he remains symptom free.DISCUSSION
The association between circumcision and meatal stenosis has long been recognized. An article in The Annals of Anatomy and Surgery in 1881 mentions that meatotomy was so prevalent among Jewish males that it had been designated by Jewish men as their "Second Circumcision."[1] A 1935 Lancet article also noted the association between circumcision and meatal stenosis.[2]The cardinal symptoms of meatal stenosis are penile pain at the initiation of micturition, narrow high velocity stream, and the need to sit or to stand back from the toilet bowl to urinate.[3]
In the 1950s, Berry and Cross demonstrated that circumcised men have smaller meatal openings than men with foreskins (mean diameter (French) 22.7 13.6 versus 19.9 1 4.3, Z = 5.05, p < 0.000004) and are more likely to have meatal openings 18 French or smaller (odds ratio = 6.07, 95% confidence interval = 2.90 - 12.67). Likewise in children, boys with foreskins had larger meatal openings (mean diameter (French) 13.3 1 1.6 versus 12.6 1 1.6, Z = 2.79, p = 0.0026), while circumcised boys were more likely to have a meatal opening 12 French or smaller (odds ratio = 2.44, 95% confidence interval = 1.36 - 4.41).[4]
Meatal size increases with age,[5] and although Berry and Cross do not provide an age analysis of their pediatric subjects, their selection process should not have produced an age bias.
One would expect the small difference in mean meatal opening to have limited clinical significance, but meatal stenosis occurs almost exclusively in the circumcised penis. Traumatic meatitis of the unprotected post-circumcision urethral meatus and/or meatal ischemia following damage to the frenular artery at circumcision have been cited as possible etiologic factors.[3] Some have speculated that the polyacrylate in super-absorbent diapers may be a factor,[6] while the "ammoniacal diaper" has traditionally been blamed for meatal problems in the circumcised penis.[7]
Meatal ulceration is common following neonatal circumcision, affecting as many as 20% of circumcised boys.[8] This irritation is believed to lead to scarring that leads to narrowing of the meatus. The number of circumcised boys who develop meatal stenosis is unknown. A recent report of 58 urethral meatotomies performed on circumcised boys on an outpatient basis in one year's time in a single practice[6] suggests that urethral meatotomy is a very common procedure in the United States.
Leitch found 8 cases of meatal ulcers and 3 cases of meatal stenosis in the 200 circumcisions he studied.[9] In the 100 neonatal circumcisions followed by Patel, 31 had meatal ulcers and 8 developed meatal stenosis.[10] In one prospective study of 140 elective circumcisions, 4 (2.8%) developed meatal stenosis requiring formal meatotomy,[11] while a second study of 117 circumcisions had 13 (11.1%) boys develop meatal stenosis necessitating meatotomy.[12] In the three year period studied by Persad et al., 88 circumcisions and 91 preputial plasties were performed. Seven (8%) of the circumcision patients and none of the preputial plasty patients developed meatal stenosis (odd ratio = 16.84, 95% confidence interval = 0.94 - 299.49, p = 0.0061).[3]
Most of these studies looked at circumcisions performed after the neonatal period, but Barry and Cross found that the timing of circumcision did not significantly influence the size of the meatal opening in circumcised adult men (Z = 0.99, p = 0.1587).[4]
Despite the consistently strong association between circumcision and meatal stenosis, the 1989 statement of the American Academy of Pediatrics Task Force on Circumcision has led to some confusion and misrepresentation of the scientific data. After acknowledging that meatitis is more common in the circumcised penis, the report erroneously states, without reference, that, "there is no evidence that meatitis leads to stenosis of the urethral meatus."[13]
Even though meatal stenosis is fairly common in the circumcised penis, studies of the cost-utility of neonatal circumcision have not considered the cost of meatotomy in their calculations.[14, 15]
To avoid meatal stenosis when surgery is unavoidable, preservation of the frenular artery or the use of less drastic prepuce-sparing procedures is advised.[16] If this is not possible, the risk of developing meatal stenosis needs to be included in any discussion of the risks of penile circumcision.
References
- Mastin WM. Infantile circumcision a cause of contraction of the external urethral meatus.
- Ann Anat Surg 1881; 4:123-128.
- Thompson AR. Stricture of the external urinary meatus. Lancet 1935; 1:1373-7.
- Persad R, Sharma S, McTavish J, Imber C, Mouriquand PD. Clinical presentation and pathophysiology of meatal stenosis following circumcision. Br J Urol 1995; 75:91-93.
- Berry CD Jr, Cross RR Jr. Urethral meatal caliber in circumcised and uncircumcised males.
- Am J Dis Child 1956; 92:621.
- Morton HG. Meatus sized in 1,000 circumcised children from two weeks to sixteen years of age.
- J Florida Med Assoc 1963; 50: 137-138.
- Cartwright PC, Snow BW, McNees DC. Urethral meatotomy in the office using topical EMLA cream for anesthesia. J Urol 1996; 156:857-859.
- Brennemann J. The ulcerated meatus in the circumcised child. Am J Dis Child 1921; 21:38-47.
- MacKenzie AR. Meatal ulceration following neonatal circumcision.
- Obstet Gynecol 1966; 28: 221-223.
- Leitch IO. Circumcision. A continuing enigma. Aust Paediatr J 1970; 6:59-65.
- Patel H. The problem of routine circumcision. Can Med Assoc J 1966; 95:576-581.
- Griffiths DM, Atwell JD, Freeman NV. A prospective survey of the indications and morbidity of circumcision in children.
- Eur Urol 1985; 11:184-187.
- Stenram A, Malmfors G, Okmian L. Circumcision for phimosis--indications and results. Acta Paediatr Scand 1986; 75:321-323.
- American Academy of Pediatrics:
- Report of the Task Force on Circumcision.
- Pediatrics 1989; 84: 388-391.
- Ganiats TG, Humphrey JB, Taras HL, Kaplan RM. Routine neonatal circumcision: a cost-utility analysis. Med Dis Making 1991; 11:282-93.
- Lawler FH, Bisonni RS, Holtgrave DR. Circumcision: a decision analysis of its medical value. Fam Med 1991; 23:587-93.
- Cuckow PM, Rix G, Mouriquand PDE. Preputial plasty: a good alternative to circumcision.
- J Pediatr Sur 1994; 29:561-3.
Statement to the United Kingdom Law Commission In response to request for commentary re: ConsultationPaper
No. 139 20November 1996by Mr Brian Levitt
San Francisco, California USAI am a Jewish man, and I was circumcised ritually on the eighth day of life in accordance with Jewish custom. I am writing to the Law Commission to testify in no uncertain terms how I feel that this surgery has mutilated and harmed me. In my opinion, this surgery (non-therapeutic infant circumcision) violates every ethical notion of informed consent, it does indeed harm the development of the penis throughout childhood and the function of the penis in adulthood, and it absolutely should not be considered lawful in either a ritual or medical context. Superstition or faith is not an adequate defense for performing cosmetic genital surgery on the healthy, functional body parts of a healthy infant. What surgeries an adult might elect relative to his own penis must be considered separately.
Aside from the physical harm of circumcision, several aspects of this procedure are troubling when carried out in a ritual setting. This invasive surgery, involving on average the excision of half of the skin and mucosa of the penis, is not generally carried out by a qualified surgeon. Given the relatively high rate of complications from this surgery, even when performed by licensed physicians, this situation is clearly unacceptable.
Until now, inadequate inquiries have been made into the physical and psychological harms of infant circumcision, in part because custom and superstition have discouraged impartial scrutiny and investigation. However, in recent years a substantial body of scholarly evidence has clearly proven that the male foreskin has highly evolved, specialized functions throughout life. Moreover, the speculative medical benefits of infant circumcision have been almost completely disproven. Finally, there now exists a body of medical documentation of the vast categories of complications from the surgery (up to and including death), extended psychological impact and response to the pain of the procedure, and growing anger and resentment by adult men toward their involuntary infant circumcisions. This last point cannot be emphasized too strongly : circumcision is by no means universally welcomed by those upon whom it has been visited in infancy, regardless of whether performed in a medical or ritual setting.
It is the duty of society, through its laws, to protect those without capacity to consent from bodily scarring in the name of anything other than necessary medical intervention. This is the standard which the Law Commission recognizes in tattooing, and must logically be applied to the far more damaging and permanent example of genital surgery.
Ironically, it is precisely in the interest of preserving freedom of religion that government must prevent ritual infant or childhood mutilations of either gender. The act of marking a child with a ritual mutilation, especially upon the genitals, takes away that individual's right to a whole, functional body and his right to choose whether to be marked with the scars of that particular religion.
I urge the Law Commission not to shy away from close scrutiny of the ritual practice of infant circumcision within Judaism. It will learn that over the millennia, the Jewish practice of circumcision has changed radically before becoming the deeply intrusive surgery we see today. Numerous times circumcision has fallen into complete discontinuance by the Jews, only to be resurrected in times of oppression. Moreover, the circumcision of biblical times, a small cut of the preputial tissue that overhangs the infant glans, was replaced by the year 140 AD with the radical circumcision performed by today's mohels. This latter, significant surgery may have become traditional, but it is not the circumcision commanded by God in Genesis 17. Nor should it enjoy any special protection whatsoever by government and its laws.
To varying degrees, circumcision is a law or commandment of the branches of Judaism, but it is not definitive of membership in the Jewish religion. It is accepted that he that is not circumcised, but is the son of a Jewish mother, is a Jew. Numerous scholars of Judaism have clearly pointed out that this damaging surgical ritual is inconsistent with all other tenets of the Jewish religion to protect the integrity of the individual and do no harm to another person. The Law Commission would be doing all Jews great service, in fact, to finally recognize the universal harm, the permanence, and the impossibility of informed consent of non-therapeutic circumcision on any infant boy, regardless of religion. To fail to do so, to create a "special exception" for Jewish boys, would be tantamount to governmental discrimination against infants born into the Jewish faith by assuming that their pain is less (it is not) and that they will simply learn to accept their harm. Our pain is real, we are part of the larger society, and we need and expect full protection under the law.
Low-ranking Soldier
To the Editor:
I am writing to thank you for your web page on circumcision. I am a new intern in the departments of medicine and pediatrics at the University of California San Diego. As part of my pediatrics training I have been on a rotation at the Navy hospital in San Diego. Performing circumcision in the newborn nursery has been one of my responsibilities. I have precise instructions to obtain "informed consent" for the procedure by telling the parents that our babies almost never bleed, that we reduce the risk of infection with sterile technique, and that circumcision decreases the incidence of urinary tract infection in boys, penile cancer in old men, and cervical cancer in the partners of men who have been circumcised. I was told that these benefits were shown by Dr. Wiswell to be both medically important and statistically significant. Given this information, the parents are then left to make their own decision without our persuasion or input.Well sir, I may not have been the brightest medical student in my class, but I do remember the distinctions between odds ratios, relative risks, associations and causal relationships. To honestly tell a patient that removal of their son's foreskin has medical benefit we would need a prospective, randomized, double-blinded clinical trial with a measure of long term morbidity and mortality outcomes. Where I went to medical school (UCSF), retrospective, case-control studies of non-randomized populations were considered to have built-in biases and not reliable for evidence of causal relationships.
To tell parents that there is scientific evidence of medical benefit to circumcision is therefore a misrepresentation of Dr. Wiswell's work. Since most of our patients have not had formal training in the interpretation of statistical data, they rely on us as physicians to do the interpreting for them. When we misrepresent the medical literature to our patients, it is worse than giving them our personal bias, because it gives them a persuasion against which they have no defense. Therefore, I thank you for your lengthy criticism of the research that has supported the practice of male genital mutilation.
Of course, this whole debate is moot because obtaining parental consent for circumcision of a child falls outside the boundaries of medical ethics, another course I took in medical school. We were taught to hold autonomy and self-determination as the first principle of ethics to be upheld, overridden only in time of medical expediency, and then only when the patient's incompetence to make decisions has been demonstrated. Why don't these rules apply to the practice of circumcision?
I feel like a low-ranking nazi soldier, lacking the moral fortitude to refuse doing what I know is wrong. Ken Brady, M.D. University of California San Diego
Did the New England Journal of Medicine Circumcise Medical Information?
To the Editor:
The New England Journal of Medicine(NEJM) printed a strongly pro-circumcision (anti-normal anatomy) editorial by Dr. Thomas Wiswell,[1] but did not print the pro-normal anatomy alternative opinion.[see Abstracts & Analysis] When misinformation in Wiswell's editorial was brought to the attention of the editor, there was no attempt to correct Wiswell's exaggerated benefit claims. Strangely enough, the NEJM printed a Sounding Board discussion of circumcision in 1990 examining the purported advantages and disadvantages of circumcision[2,3].What has happened in the last seven years to make circumcision less controversial? Why does the NEJM only present the purported benefits of circumcision? Why did the NEJM fail to print any letters critical of this pro-circumcision agenda? Let's recap some of the research that they overlooked.
Circumcision is losing popularity in the United States and has been discredited by the Canadian Pediatric Society[4] and the Australasian Pediatric Surgeons[5] in 1996 position papers. Taylor described the unique innervation of the preputial mucosa in 1996, and its loss to circumcision.[6] Taddio et al showed that circumcision with and without local anesthesia (EMLA) resulted in negative behavioral changes in a child's' response to pain.[7]Laumann has shown that circumcision causes sexual behavior changes and an apparent increased risk of many venereal diseases in adult men.[8] Price has questioned whether parents can ethically changes their child's genitalia.[9] The editorial staff at NEJM could not have missed these advances. So why did they not present another Sounding Board article, and instead chose to present only a pro-circumcision editorial by Wiswell?
In a previous article in the NEJM, Royce et al, insinuated that the prepuce may be a risk factor for HIV infections.[10] This factually inaccurate article was referenced in a letter to the editor as proof that circumcision protects an individual from HIV infections.[11] Fortunately, Laumann pointed out the fallacy of this logic. "The lack of rigorous, systematic controls for co-factors relevant to the particularities of the African context, the prophylactic status of the presence or absence of the foreskin remains an open question."[12] But thefact that the NEJM failed to print our letter of criticism, [see Abstracts & Analysis] suggests that the NEJM only prints material that supports neonatal circumcision.
Beyond Wiswell's proclamation of the benefits of circumcision, the research presented by Taddio et al[13] was proclaimed as a major advance. When the limitations of this form of local anesthesia was brought to the attention of the editors, they failed to print the criticism.[see Abstracts & Analysis] They failed to point out that this form of local anesthesia (EMLA) did not prevent the long term negative behavioral response to pain previously reported in the Lancet![7]
Interestingly, the lack of effects of EMLA on long term negative behavioral changes caused by circumcision were printed in a British medical journal. Presumably, Taddio is smart enough to submit negative studies to European medical journals,[7,14] and luke-warm studies to American medical journals.[13]
Certainly, over the last seven years, the NEJM has shifted from a balanced approach, to a one-sided, pro-circumcision stance, even though the lion's share of the medical literature would encourage a shift in the opposite direction. It is hoped that in the near future, the NEJM will have the courage to confront the ethical problems, and medical complications associated with circumcision. Maybe then, it will be acceptable for a physician to tell the parents of a newborn child: "Your baby has normal anatomy, so there is no need to charge you money to surgically alter this child's genital anatomy. If your son or daughter wants to change their genital anatomy, they are free to after age 18, when they can make an informed decision." Physicians will then be able to teach parents not to fear normal anatomy.
Normal anatomy is not as dirty and dangerous as once thought. Regardless if a part of the body is malformed, diseased, or carries some risk, an individual must retain the right to refuse surgery. Prophylactic removal of normal anatomy to please parents, or to produce income for the physician is unethical. I hope the NEJM can temper its pro-circumcision agenda. Circumcision of the medical knowledge and information is more dangerous than amputating part of the penis from a restrained, non-consenting baby.
Christopher J. Cold, MD
Department of Pathology
Marshfield ClinicReferences
- Wiswell TE. Circumcision circumspection. N Engl J Med 1997; 336:1244-5.
- Schoen EJ. The status of circumcision of newborns. N Engl J Med 1990; 322:1308-12.
- Poland RL. The question of routine neonatal circumcision. N Engl J Med. 1990; 322:1312-5.
- Fetus and Newborn Committee, Canadian Paediatric Society. Neonatal circumcision revisited.
- Can Med Assoc J 1996; 154:769-80.
- Australasian Association of Paediatric Surgeons. Guidelines for circumcision. April 1996.
- Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996; 77:291-95.
- Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination.
- Lancet 1997; 349:599-603.
- Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States: prevalence, prophylactic effects, and sexual practices, and sexual practice.
- JAMA 1997; 277:1052-7.
- Price (Bull. Medical Ethics).
- Royce RA, Sena A, Cates W Jr, Cohen MS. Sexual transmission of HIV.
- N Engl J M ed 1997; 336:1072-1078.
- JAMA 1997; 278(3):201
- Laumann EO. JAMA 1997; 278(3):203
- Taddio A, Stevens B, Craig K, Rastogi P, Ben-David S, Shennan A, Mulligan P, Koren G. Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision.
- N Engl J Med 1997; 336:1197-1201.
- Taddio A, Goldbach M, Ipp M, Stevens B, Koren G Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet 1995; 345:291-2.
BOOK REVIEWS:Circumcision:The Hidden Trauma
How an American Cultural Practice Affects Infants and Ultimately Us AllRonald Goldman, Ph.D.
Vanguard Publications, 302 pp, Boston (C)1997
Introduction: Controversial Questions
- Infant Development and Response to Circumcision
- Why Parents and Physicians Choose to Circumcise Infants
- Social and Cultural Factors Perpetuating Circumcision in America
- Long-Term Psychological Effects of Circumcision: I. Early Trauma and Memory
- Long-Term Psychological Effects of Circumcision: II. Adult Emotional Impact
- Circumcision and Mother-Child Relationship
- The Impact of Circumcision on American Society
- The Lesson of Circumcision
While it could be easy to dismiss Circumcision, The Hidden Trauma as the unsupportible rantings of an anti-circumcision fanatic, Goldman never allows the reader the opportunity to do so. He begins by describing the fragile psychological state of the newborn. This in-depth portrayal leaves little doubt that surgical alteration of the genitalia is an unwelcomed intervention. Goldman utilizes the diagnosis of post-traumatic stress disorder as the context in which to understand the impact of neonatal circumcision on the individual male. The information that is currently known supports such a thesis, but what is not known could fill volumes. This is where Goldman's investigation is disadvantaged, through no fault of his own, and he is the first to admit it. He adroitly points out what direction future research should take to validate or nullify his hypothesis.
In one of the most insightful portions of the book, Goldman gives the reasons why this research has not taken place, and may never take place. Simply put, the medical profession does not want to know what harm neonatal circumcision has wrought on our society. Although this may sound like a superficial accusation, this quest for ignorance is deeply rooted.
A newborn's whole world is his mother. She is the source of comfort, warmth, food, and protection. Neonatal circumcision disrupts this essential bond of trust between the newborn and his mother.
Perhaps the strongest section of the book questions the effect of neonatal circumcision on society as a whole. Using the Karl Menninger quote , "What's done to children, they will do to society," the author plays out the logical consequences of neonatal circumcision on all of society. While a newcomer to this issue may find some of the speculation far-fetched, when thought is given to the assertions and questions raised in this section, the issue implodes on the individual reader and explodes on all of us.
So why do Americans continue to circumcise? Goldman offers: "Parents do not know what they are choosing, and physicians do not feel what they are doing. The separation of the decision maker from the decision implementer helps to perpetuate the pain." A vicious circle of ignorance and denial is firmly entrenched. This book takes a huge step in pulling back the veil of ignorance.
The book is extremely well written in a very engaging manner; however, as compelling as the topic is, the fundamental nature of neonatal circumcision, exposed for what it is by the author, is fairly gruesome. The reader can easily be caught in the dialect of wanting to know more, but not wanting to know more.
This book is easily the best source of information on the psychological impacts of neonatal circumcision and should be required reading for any physician before performing the surgery.
Circumcision: The Hidden Trauma
Ronald Goldman, Ph.D
A "circumcised" version of the following review appeared in The Compleat Mother. The full text appears here.
This is one book I had trouble putting down and picking up. 'Putting down' because it was extremely insightful and well crafted--riveting, in fact. 'Picking up' because of the painful and complex social implications--and the guilt.
This book is an unsettling account of what our society does to infant males in the form of a cultural medical procedure, ie. circumcision, and how that initial trauma continues to alter our society in ways few of us can comprehend or wish to acknowledge.
As a physician who has performed circumcisions (and hated every second), and as a mother of three intact children (two boys and one girl), I found myself thankful that I had the courage to stop performing circumcisions and that I had left my boys intact. But I also became despondent as I suddenly became aware of how our medical system and society has failed our children in so many ways. I realized that I had fallen prey to many of our societal and medical games/expectations and had not nurtured my children as I should have. Reading this book has permanently changed my perspectives on our society,and therefore, on my practice of medicine.
This book is profoundly fascinating and disturbing. It is not for the weak and insecure. It is extremely well-written and well-researched. I highly recommend it.
Michelle R. Storms, M.D.
Family Practice
Minocqua, Wisconsin
Questioning Circumcision: A Jewish Perspective
Ronald Goldman, PhD
Vangard Publications, 132 pp, Boston, 1998Forward by Rabbi Raymond Singer, PhD
Introduction
1. Origins and Background
2. Assumed Benefits
3. Risks: Opinions versus Research
4. Unrecognized Consequences
5. Personal Experiences
6. Conflicts and Questions
7. Preventing More Pain
Appendix A. My Experience with Circumcision
Appendix B. One Woman's Learning Process
Appendix C. Discussion following "The Circumcision Debate"
Appendix D. A Response to Traditionalists
Appendix E. Circumcision and Anti-Semitism
Appendix F. Precaustions for Parents of Intact Boys
Appendix G. Alternative RitualsThis book is a revision of an early work by Ronald Goldman that I had not read previously. As readable as Circumcision The Hidden Trauma was, Questioning Circumcision is even more approachable for the lay reader. It is a quick read that aptly covers most of the bases.
The thrust of the book is to bring the religious issue of circumcision into an open debate. For too long discussion of circumcision in Jewish circles has not taken place. Goldman demonstrates that there is an undercurrent in Reform Judaism that questions the practice. Questioning everything is the cornerstone of Reform Judaism, so why has circumcision been exempt?
The book is directed at Reform Jews and hits the mark directly without wandering off subject. The text is easy to read and understand, while the questions the book raises are clear and concise. The only thing missing from the book is the Orthodox perspective defending the practice. The enumeration of abandoned punishments for the Torah and the principles of Judaism that circumcision violates is powerful; however, there are times that the penalty of death for children who defy their parents looks inviting.
This book should be read by all Jewish parents before considering having children. If they decide to proceed with the Bris Milah, they will do so fully informed.
Circumcision: A Guide to a Decision
by Dr John Smith
Edited and revised by Geoffrey Francis
1996 HTML Edition by Vernon Quaintance
http://www.users.dircon.co.uk/~vernon/Guide_to_Decision/index.htmlThis 8,300 word booklet was first published in 1979 by Dr. John Smith (a pseudonym) and has been revised in its present form and posted on the world wide web. The booklet was intended to present "both sides of the argument," but after reading only a few paragraphs it becomes abundantly clear that theintention is to promote circumcision at all ages possible. With a careful reading I found 89 statements that were either blatantly false or completely fabricated. This is a lie or mistruth for every 100 words. Several of the statement border on the ridulous and even more cross over the line. Some examples:
"Phimosis also makes sexual intercourse unsatisfactory and low deposition of semen in the vagina due to poor penetration may causeinfertility."
"It is not generally known that the tendency to penis troubles is inherited so if a man has trouble with his prepuce or frenulum he should seriously consider having his sons circumcised at birth as a preventative measure."
"Merchant seamen, particularly engine-room staff, are also at risk and although circumcision is not a condition of employment it is a sensible precaution and advised by some firms. Whilst one cannot predict that anyone will have trouble abroad or at sea, it is probably better to lose a normal prepuce at a suitable time under optimum conditions in the U.K. than find that the operation has become necessary when conditions are primitive, the time is inconvenient, the foreskin is inflamed and medical aid is not readily available."
"Chefs and other kitchen workers are a further example of those at risk - with the added complication that food hygiene can be compromised if one is constantly rubbing at the irritated foreskin." So much for eating at French restaurants.
"A long prepuce may be an anatomical cause of premature or early ejaculation . . . "
"The troubles which may be associated with a rather long foreskin suggest that it is a redundant or unwanted piece of skin and it would be better to complete the development process by shortening it surgically."
"Having shown that a tight prepuce is a definite indication for circumcision one would expect that a rather loose one would be an advantage. A loose, short foreskin usually causes no trouble during sexual intercourse but it may ride to-and-fro during everyday activities trapping pubic hairs. A long, loose foreskin may be a nuisance if it will not remain retracted as a collar behind the glans during sexual intercourse but tends to slip forward re-covering the glans. The man virtually masturbates inside his foreskin during intercourse and his partner complains of lack of stimulation."
"Circumcision renders the penis permanently clean and avoids the washing and inspection which may draw unnecessary attention to his penis at an early age."
"The glans without its masking foreskin tends to produce a more prominent bulge in tight clothing which some females find sexually stimulating."
"Whilst there is no exact relationship between stature and the size of the penis there is a general tendency for the shorter man to have a smaller penis."
"The importance of penis size as a factor in sexual adequacy has been exaggerated but it must be apparent that to give the same amount of stimulation the man with a short penis must insert a greater proportion of his organ than his better endowed neighbour. A limiting factor in penetration is how far a prepuce can be drawn back without causing discomfort. The size of the penis cannot be increased but circumcising a small organ may be a useful measure in enabling a man to give greater satisfaction to his partner."
"The resulting psychological disturbance can lead to various problems including enuresis (bed-wetting)."
"Similarly if one son needs a circumcision for medical reasons then his parents may want to consider having all his brothers, both younger and older, circumcised at the same time to keep them alike and avoid possible future problems."
"On the other hand feelings of regret or resentment are not engendered in men who are coerced into having the operation when it is not essential (e.g. going to sea or request of fiancee) and they are just as pleased as those who are done for say phimosis."
"A number of men complain that a loss of sensitivity or dryness of the glans following circumcision has spoiled their sex lives. At the other extreme are those who seek the operation to achieve these changes in the glans to enhance their sex lives. These complaints are similar to the mutilation obsession because men with naturally short foreskins are not troubled by having the glans exposed."
"The fear that an erection after the operation will tear the stitches is of course quite unwarranted." In truth the penis is so painful, erections are nearly impossible.
"If one ignores the extremists who would either forbid circumcision by law or seek to impose it upon everyone, then the evidence does suggest that the advantages do outweigh the disadvantages."
"'Ballooning' or swelling of the foreskin when passing water is an absolute indication for circumcision at any age." (Ballooning is normal.)
The absurdity of most of these statements speak for themselves.
One of the more distressing elements of the booklet is a section entitled "Circumcision is Essential." According to the booklet circumcision is essential for religion, upon parental request, upon patient request, a tight foreskin, inflammation of the foreskin, or a torn or tight frenulum. Actually none of these are true. When Reformed Judaism emerged over a century ago, ritual circumcision was one of the first tenets to be dropped (it was later readopted). If the procedure was essential, then the physician would have the obligation to perform the procedure. This is clearly not the case for a procedure requested for cosmetic reasons. Physicians have always had the option of not performing a cosmetic surgery. It is now known that "a tight foreskin" is normal to a certain age and can be treated with topical steroids or preputial plasty. Inflammation is readily treatable with topical therapy, and most cases are non-infectious but rather a form of eczema. Frenular problems, which can sometimes be serious, can easily be treated by less drastic measures.
When I completed the booklet it reminded me of the 1975 book, Surgery of Love, by James C. Burt, M.D., of Dayton, Ohio. Burt became notorious 10 years later when it was discovered that he was altering the genitalia of his female patients without their knowledge or consent. He truly believed he was doing them a favor. In a like vein, I'm sure Dr Smith truly believed he was doing his male patients a huge favor by surgically amputating the most neurologically complex portion of the penis. Interestingly, the booklet does not contain any medical references, making it impossible for the reader to sift the rare true claim from the abundant bogus claims.
Dr John Smith claims to have used a psuedonym because, "In Britain a doctor may not advertise his practise or specialties." There is a huge difference between an information booklet and promotional material urging patients and parents to consider unwarranted surgery. It appears as though this booklet is clearly the latter. If the intention was the former, he should have had the courage to stand by his claims by affixing his name to the booklet.
INTERNET REVIEWS:Medical Benefits from Circumcision
Brian J. Morris, PhD DSc
University Academic (in medical sciences)
http://www.physiol.usyd.edu.au/brianm/circumcision.htm
Email: brianm@physiol.usyd.edu.auAbout a year ago Gerald Weiss MD asked me to look at this web site and would I consider publishing its contents in CIRCUMCISION. After reading Mr Morris's web page I quickly decided that it would require a lot of work before I would consider publishing it. Even though the article tried to advocate an extreme position, that does not grant the author license to misquote the facts from the articles he cites. I found a number of factual inaccuracies in the article. A number of findings asserted as factual were attributed to opinion pieces rather than primary research. It is also best to steer away from quoting inflammatory letters with unsubstantiated accusations. Merely quoting the opinion of someone like-minded has no power or credibility. It is better to clearly demonstrate the primary research basis from which conclusions can be drawn. The cardinal rule of any form of writing is show don't tell.
Mr. Morris needs to be congratulated for finding the 62 medical references that support his position, and he even accurately reports the contents of most of them, but what about the thousands of medical references that are contrary to his bias?
When it comes to the body of literature that fails to confirm or directly refutes the author's position, he has one of two options. One is to ignore it completely (which is what the author has done), or acknowledge the existence of this body of knowledge and refute its content (which is far more difficult). By taking the former course, the article can be more easily dismissed and makes it far more difficult for the author to be taken seriously. If I were reviewing this article for publication my comment would be "Has the author adequately researched the topic?" It doesn't appear so. Weiss's article in CLINICAL PEDIATRICS is much tighter. He brought the reader to his conclusion, rather than telling him/her what to think. Unfortunately, Weiss did not acknowledge or address the body of literature that is contrary to its position.
Mr. Morris's only acknowledgment of any alternative to his bias appeared in a recent letter in which he states: "There are lobby groups who[sic] oppose circumcision and these have been very active in trying to pursued[sic] health care providers of their views. However, their arguments are philisophical[sic] and based on conjecture, distortions, anecdotes, testimonials and emotion, rather than a proper evaluation of the numerous scientific studies published in international peer-reviewed journal." I have two suggestions for Mr. Morris: read the studies before getting back to us and get a spell checker.
Since this review has been written, Mr. Morris has revised his web site. He has expanded the bibliography to 104 references. Most of his unreferenced statements are either speculation or fabrication. The new version has a number of internal inconsistencies. For example the risk of UTI is from 12 to 20 times higher and incidence of UTI varies from 1 in 20 to 1 in 25. In truth, the risk of UTI is 4 to 5 times higher and the incidence is 1 in 100 to 1 in 10,000. He does acknowledge a few studies that disagree with his premise, and has moved to a more neutral position on some issues. He has added an unenlightened discussion of the validity of substitute consent given by parents.
A Dilemma in Infant Research: Can it be ethical to have a treatment group in which pain is not treated?
Barbara Brady-Fryer, RN, MN Coordinator, Research, University of Alberta Hospital
The Bioethics Bulletins
March 1995, Volume 7, Number 1
http://gpu.srv.ualberta.ca/~ethics/bb7-1dil.htm TThis article provides an excellent discussion of the competing issues involved in performing research on neonatal circumcision pain relief. The current standard of care is no anesthetic, but ethical review boar ds have rightly determined that including this as part of a research protocol violates ethical standards. So how is one to compare new therapy to current therapy when current therapy is "unethical"?
The discussion represents both the ethical and practical issues. The medical establishment has trouble finding a way of justifying a stone-age blood ritual in an era of cost-restraints, outcome based research, protection of animal rights, modern pain relief, and effective non-surgical therapies. The author's frustration with these issues comes through as does her desire to do what is right for the child. I highly recommend finding and reading this essay.
Male Circumcision: an ethical and legal affront
By Christopher Price M.A.(Oxon)
Bulletin of Medical Ethics;May 1997, 128:13-19
Introduction
The origins of circumcision are lost in antiquity. Male circumcision is depicted in Egyptian tombs 5,000 years ago, while Gairdner [1] refers to evidence that it originated in prehistory up to 15,000 years ago. Well before it acquired its religious overtones, it was clearly sacrificial, demanding the loss of something of great value.
The words of Rabbi Maimonides [2] from the 12th century support this view of the losses: "As regards circumcision, I think that one of its objects is to limit sexual intercourse, and to weaken the organ of generation as far as possible, and thus cause man to be moderate....This commandment has not been enjoined as a complement to a deficient physical creation, but as a means for perfecting man's moral shortcomings. The bodily injury caused to that organ is exactly that which is desired; it does not interrupt any vital function, nor does it destroy the power of generation. Circumcision simply counteracts excessive lust; for there is no doubt that circumcision weakens the power of sexual excitement, and sometimes lessens the natural enjoyment...."
In the 19th century circumcision was advanced, in Britain and other English-speaking countries, as a preventive for masturbation and the ills believed to be caused by masturbation, and was labelled as 'hygienic', a misdescription which persists. Thereafter it became a procedure credited with a wide range of supposed benefits. Even today the prepuce is popularly seen as no more than a piece of vestigial skin of no, or minimal, function and whose removal causes no real pain, involves few or no risks and produces no short or long-term harm. It is usually claimed that when done in infancy itconfers benefits. The practice is still widespread in the USA where currently 60% (down from 90% in the 1970s) of male neonates are circumcised; the increasingly bizarre attempts to justify this routine mutilation[3] only raise questions as to the psychopathology of the procedure.
From the perception of harmlessness flows the belief that it represents a cheap, easy and appropriate solution to medical problems with the prepuce, and that its removal for ritual, cultural or social reasons is ethical and legal, giving rise to neither criminal nor civil liability since the operator may rely on parental consent to the procedure.
Brazier[4] encapsulates the misconceived discussion of the medical facts and legal issues that is common: "Medical opinion on male circumcision is divided. Until recently many doctors regarded it as rarely medically indicated. Now it seems circumcision provides some protection against venereal disease, at any rate for the circumcised man's partner! Male circumcision is a matter of medical debate. For Jewish and Muslim parents it is an article of faith. The child suffers momentary pain. Although medical opinion may not necessarily regard it as positively beneficial, it is in no way medically harmful if properly performed. The community as a whole regards it as a decision for the infant's parents."
Even the more thoughtful view of Poulter[5] errs: "The basic right to bodily integrity which everyone possesses under the English common law means that any interference with this right amounts to an assault or battery... The question raised in cases of circumcision, excision or infibulation is whether the operation can be justified as constituting lawful as opposed to unlawful interference with this right... Although there are no precedents in this field there would appear to be three possible grounds upon which a defence of lawfulness might succeed at common law. The first is that the procedure is therapeutic. If this can be established a parent can validly consent to it on behalf of a child who is too young to understand what is being done. It would appear unlikely that this defence could generally succeed other than in comparatively rare instances of physical defect or abnormality. Second... it seems that a parent may equally validly authorise a non-therapeutic operation, provided it is not actively against his child's interests. This would appear to be the basis upon which the vast majority of male infants have been circumcised in this country with impunity from time immemorial. There is no need under this heading for the parent to establish that the operation is positively beneficial for the child, merely that he was acting reasonably in authorising it. Third, it has been tentatively suggested that a parent may even authorise something that is against his child's interests if it is compensated by sufficient advantage to others and is not seriously detrimental to the child... It seems extremely unlikely that it could justify the more remote and controversial benefit of satisfying a deeply-felt community attachment to traditional customs."
Poulter concludes that male circumcision is lawful. This can only be so if he is correct both in his analysis of the legal right of a parent to assent to an assault on his child for non-therapeutic reasons (i.e. his grounds 2 and 3), and in the view that male circumcision is harmless and not to be equated with female circumcision. His view of parental consent is open to doubt; but even if correct, the evidence of harm would defeat his conclusion on 'ground' 2, and more so for 'ground' 3. I shall not attempt to review here all the medical studies on the adverse effects of circumcision, nor the issues raised when doctors perform circumcision to treat a medical condition, for which a less invasive treatment would have been effective. There is however an extensive literature.[6]
This paper proceeds from the basis that circumcision incontrovertibly:
- inflicts severe pain, and that anaesthetics if used to manage that pain are themselves risky;
- carries significant risks;
- produces short and long-term harm and diminution in sexual function;
- and has no medical benefits.[7]
Since it is clear that 'traditional' thinking as to the supposed legality of the procedure for non-therapeutic reasons is predicated on conventional beliefs about the nature of circumcision, this paper examines the consequences that flow from a recognition of the harmfulness of circumcision.
Assault
In Collins v. Wilcock [8] Robert Goff LJ said: "the fundamental principle, plain and incontestable, is that every person's body is inviolate. It has long been established that any touching of another person, however slight, may amount to a battery.....As Blackstone wrote in his Commentaries, 17th ed.(1830)vol. 3, p 120: 'the law cannot draw the line between different degrees of violence, and therefore totally prohibits the first and lowest stage of it; every man's person being sacred, and no other having a right to meddle with it, in even the slightest manner.' The effect is that everybody is protected not only against physical injury but against any form of physical molestation. But so widely drawn a principle must inevitably be subject to exceptions."
Lord Lane CJ [9] has said that:
"...Nothing we have said is intended to cast doubt upon the accepted legality of properly conducted games and sports, lawful chastisement or correction, reasonable surgical interference, dangerous exhibitions, etc. These apparent exceptions can be justified as involving the exercise of a legal right, in the case of chastisement or correction, or as needed in the public interest, in the other cases."Although earlier cases[10] indicated common law exceptions to the general rule thatit was not permissible to inflict injury even with the victim's consent, circumcision was not mentioned as one. The first specific mention of it arose in the prosecution of a mother for scarifying the cheeks of her sons in accordance with tribal custom.[11] Judge King-Hamilton QC said that the potential for serious injury was great because the slightest movement might lead to an eye injury; in distinction, he considered, from the 'accepted practices of ear-piercing and ritual circumcision'. But there is an obvious difference between piercing an ear-lobe and amputating a prepuce; and even in 1974 there was enough evidence of the harm from neonatal circumcision. Indeed, unattractive as ritual scarification of a child's body might be (it clearly was to Judge King-Hamilton), it is far less unacceptable than ritual circumcision. It amputates no flesh and causes no loss of function.
Lord Templeman said in R v. Brown :[12] "In some circumstances violence is not punishable under the criminal law... Surgery involves intentional violence resulting in actual or sometimes serious bodily harm but surgery is a lawful activity. Other activities carried on with consent by or on behalf of the injured person have been accepted as lawful notwithstanding that they involve actual bodily harm. Ritual circumcision, tattooing, ear-piercing and violent sports.. are lawful activities." The express inclusion of circumcision as lawful was not essential to the finding of the majority of the law lords that consensual sado-masochistic injuries were criminal. Further, as Lord Templeman observed, some activities, once thought of as legal, were no longer regarded as such: "In earlier days other forms of violence were lawful... when they ceased to be lawful they were tolerated until well into the 19th century. Duelling and fighting were at first lawful and then tolerated provided the protagonists were voluntary participants".
Lord Templeman's view clearly depended on a perception that the harm caused by circumcision was minimal, that parental consent sufficed and, it would seem, on a tacit belief that religious and/or multicultural tolerance demanded its continuing acceptance; he was bolstered no doubt by doctors whose readiness to circumcise for spurious reasons provided a misplaced respectability.
His remarks, both about ritual circumcision per se and as contrasted with the sado-masochistic practises in Brown, were made without regard to the ordinary law of assault to the person, to the criminal offence of wilful harm to children (Children and Young Persons Act 1933) or to the limits on parental consent implicit in the duty to treat the child's welfare as paramount(Children Act 1989).
The Law Commission,[13] in its consultation paper on consent in the criminal law, asserts that "Male circumcision is lawful under English common law.. It is generally accepted that the removal of the foreskin of the penis has little, if any, effect on a man's ability to enjoy sexual intercourse, and this act is not, therefore, regarded as mutilation".
Male circumcision was also considered by the Queensland Law Reform Commission [14] (QLRC) - a common law jurisdiction. QLRC made no claim for its legality at common law. In Queensland a person can consent to what would otherwise be a simple assault, but consent does not remove criminal responsibility for more serious injuries such as wounding. QLRC stated that: "In the absence of 'real' consent, circumcision of male infants would fall within the definition of assault under s.245 of the Queensland Criminal Code. It might also be an offence endangering life or health. A number of criminal offences may be committed depending on the circumstances."
QLRC concluded: "Whether or not circumcision would be for the benefit of the particular child and whether or not it would be reasonable having regard to the child's state at the time and to all the circumstances of the case would need to be assessed on a case-by-case basis". It appears to have based the permissibility of male circumcision on the exemption given by law to medical procedures, rather than on some general rule of common law that it is an exception to the general prohibition on consensual infliction of injury.
QLRC also discussed the limits on parental consent: "The common law operating in Queensland appears to be that if a young person is unable, through lack of maturity or other disability, to give effective consent to a proposed procedure and if the nature of the proposed treatment is invasive, irreversible and major surgery and for non-therapeutic purposes, then court approval is required before such treatment can proceed. The court will not approve the treatment unless it is necessary and in the young person's best interests... The basis of this attitude is the respect which must be paid to an individual's bodily integrity...Unless there are immediate health benefits to a particular child from circumcision, it is unlikely that the procedure itself could be considered as therapeutic... The circumcision is invasive, irreversible and major. It involves the removal of an otherwise healthy organ part. It has serious attendant risks... On a strict interpretation of the assault provisions of the Queensland Criminal Code, routine circumcision of a male infant could be regarded as a criminal act. Further, consent by parents to the procedure being performed may be invalid in the light of the common law's restrictions on the ability of parents to consent to the non-therapeutic treatment of children". It is clear that the QLRC believes non-therapeutic circumcision to be unlawful.
Parental consent and child welfare
The law recognises limits on the parental discharge of responsibilities for children. First, the law sees parents as having duties (from which flow rights in order to discharge those duties). As Lord Scarman says in Gillick:[15] "The principle of the law, as I shall endeavour to show, is that 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."
Professor Dwyer[16] convincingly argues that the view that parents have rights over their children is incorrect and untenable: the rights reside in the children with the parents acting as agents for the children to enforce those rights. Dwyer writes from a culture and constitution (that of the US) which sets great store on freedom from state interference and on religious freedom, to the point that the correct position has been blurred. Dwyer echoes English law as to the nature of the parent-child relationship.
Approaches to medical interventions involving children are discussed also by Linda Delany.[17] Those who would apply to all non-therapeutic circumcisions a different and/or lower level of protection of the child than either of those identified by Delany must clearly articulate this, demonstrating why such a differing approach would be necessary, proper and justified against general legal principles and civilised legal norms.
The factual situation discussed by Delany is the practice of requiring a child to donate an organ or bodily material for the benefit of another, such as a seriously-ill sibling; whilst these procedures may often involve reduction in function (at least potentially, as when a kidney is donated), they may also merely involve the loss of body fluids which the donor will restore naturally. One approach, wholly consistent with the Children Act 1989, is that of the House of Lords in Gillick, permitting a medical procedure only if it serves the best interests of the child who undergoes it. The second, stemming from S v. S, W v. Official Solicitor,[18] accepts that parents can give valid consent to treatments which are not "against the interests of the child".
Applying either approach to non-therapeutic circumcision (where the loss and risks are significant, there is no recipient to benefit and, at best, the 'benefit' to the victim is an intangible cultural identity) leads to the conclusion that a parent cannot give a valid consent to a non-therapeutic circumcision.
The law has for many years also recognised the need to protect children from the wilful infliction of harm by parents, guardians or those in loco parentis. Thus, under section 1(1) of the Children and Young Persons Act 1933, a person who 'wilfully assaults' a child or 'causes or procures him to be assaulted..... in a manner likely to cause him unnecessary suffering or injury to health' commits an offence. As Brigman [19] has observed, routine circumcision is child abuse.
It is hard to see why criminal liability should not properly attach to all those complicit in the non-therapeutic circumcision of a boy, including the consenting parent, as well as the circumciser, since the parent "causes or procures him to be assaulted". Irrespective of any criminal liability the circumcised child would seem to have a strong claim for substantial damages against all those involved in his mutilation.
The defence of necessity
Doctors who perform ritual circumcisions usually plead 'necessity': in its least repellent form the argument runs that since boys will be ritually circumcised anyway, it is 'better' that this be done by doctors in a clinical setting; alternatively that it is a 'service' to the community which 'ought to be made available'. The Bradford Royal Infirmary provides such a service, with the knowledge and, seemingly, encouragement of the NHS Executive.
Quite where the interests of the child-patient figure in this, and how this approach is compatible with the ethical principle that the doctor owes his duty solely to his patient - the child - and not to a parent and/or some religious behest, is hard to see.
Even the American Academy of Pediatrics in guidance on treating children [20] has said:
"Thus 'proxy consent' poses serious problems for pediatric health care providers. Such providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses... the pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent."
Those who advance the plea of necessity and/ or expediency might wish to consider how they would rebut comparison with unethical behaviour by other doctors, such as those involved in torture, who also use such excuses. They might also explain why abusive behaviour towards a child is less abusive when performed by a doctor.
Perhaps the antiquity and religious overtones of the procedure, coupled with the continuing unease at masturbation that provided the 19th Century arguments for routine circumcision in the name of 'hygiene', provide the oil for this 'slippery slope' where the interests of the patient are subordinated to demands of the State, religion, or parents. Thus we should be alarmed but not surprised that "the Royal College of Physicians requires as a condition of admission to fellowship the completion of a 'form of faith' in which the doctor promises to 'do everything... to the honour of the College and welfare of the State' without mention of responsibilities to individual patients."[21]
Discrimination
Discrimination against boys in permitting inevitably damaging mutilation of their genitals, whilst enacting legislation[22] to criminalise a similar procedure when done to girls, is as offensive as any other expression of discrimination. Kluge[23] compares female with male circumcision and, expressing similar views on both, writes: "To argue differently is to be guilty of discrimination on the basis of sex...Both involve what in other contexts would be called nonconsensual mutilation of a minor for nonmedical reasons". Circumcision further discriminates - between those boys who, because of an accident of birth, face non-therapeutic circumcision and those more fortunate boys who do not.
Rejoicing in our multicultural society does not mean that we should be blind to practices, whatever their source and motive, which are themselves abusive and discriminatory of others, directly and inevitably diminishing the freedoms, human rights, integrity and dignity of others.
International law
Certain rights are recognised as so fundamental that they are part of customary international law, as well as being found in a host of international conventions on human rights: these include the right to bodily integrity, freedom from cruel and inhuman treatment (which would include circumcision once its harmful effects were recognised), and freedom from discrimination on a variety of grounds including birth, sex, race, creed.[24]
The UN Convention on the Rights of the Child makes the position clearer in respect to circumcision. Article 24(3) provides: "States Parties shall take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children." Some have sought to argue that this provision was only aimed at female circumcision; but this argument cannot hold when the Convention is read with the interpretative provisions of the Vienna Convention on the Law of Treaties 1969.[25]
"God commands it"
Since the Holocaust it has been regarded as virtually impossible to criticise any Jewish practice, or even ritual circumcision by the two main religions that perform it (Judaism and Islam). Any such criticism is seen as essentially racist and/or a denial of religious freedom. But it is not. Rather it is an assertion of the rights of the individual over the perceived rights of others to behave towards that individual in any way that they think fit.
Customary international law provides that an individual's exercise of his freedoms can legitimately be restrained when so to exercise them is to damage or deny those freedoms to another. Thus Article 9(2) of the European Convention on Human Rights provides:
"Freedom to manifest one's religion or beliefs shall be subject only to such limitations as are prescribed by law and are necessary in a democratic society in the interests of public safety, for the protection of public order, health or morals, or for the protection of the rights and freedoms of others". The Convention thus distinguishes between the unfettered right to freedom of thought, and the more restricted right to manifest one's religion.
As Dwyer[26] says: "... even if it does on the whole further parents' interests to possess rights to direct their children's lives in ways that are harmful to the children, the state should deem such interests illegitimate and refuse to give them precedence over the interests of children. The problem with such 'interests' is that they entail treating children instrumentally, using children in ways that sacrifice their welfare interests in order to further the ulterior interests of parents....This is true whether the parents' motives are self-regarding or solely concerned with the well-being of the child (e.g. if the parents believe they are sacrificing the child's temporal interests in order to further the child's spiritual interests)....The reluctance of liberals in particular to take a stand against religiously motivated parenting of which they personally disapprove is, I believe, due largely to their believing that liberal values of tolerance and respect for diverse ideological views require the state to defer to the viewpoint of the parents in determining whether particular parenting practices should be permissible. This might be a defensible position from which to determine the permissibility of what individuals do to themselves or what consenting adults do to each other. However, it is a mistake in the case of children, who are not the same persons as their parents, nor, in general, consenting participants in the religious practices of their parents."
Conclusion
At a time when society is wrestling with legal and ethical issues such as those of conception for infertile couples, xenotransplants and animal cloning, it may seem trivial to look critically at male circumcision. But so to look (combining the state of medical knowledge of the inevitable harm of the procedure, and the absence of benefits from non-therapeutic circumcision, with a return to a critical examination of the law and ethical principles in the light of the known medical position) reveals current attitudes which do no credit either to doctors, lawyers or ethicists. The BMA guidance on circumcision, published in September 1996 by its Medical Ethics Committee, and the recent GMC guidelines, are but examples of shabby and sectionalist attempts by the medical profession to pander to the ritual circumcisers, at the expense of the child-patient. Non-therapeutic circumcision is clearly discriminatory, unethical and illegal. Its pre-historic origins, and its kinship with subincision and other forms of penile mutilation, show its essential barbarity. It should no longer be tolerated, despite its religious overtones.
References
- Gairdner D. The fate of the foreskin: A study of circumcision. BMJ (1949) ii, 1433-37.
- Rabbi Maimonides. A guide for the perplexed (trans. M. Friedlander). Dover, New York, 1956.
- Mutilation: 'Disfigurement or injury by removal or destruction of any conspicuous or essential part of the body.' Stedman's Medical Dictionary (26th Edition) 1995.
- Brazier M. Medicine, Patients and the Law. Penguin, Harmondsworth, 1992.
- Poulter D. English law and ethnic minority customs. Butterworths, London, 1986.
- A useful starting-point would be: Williams N, Kapila L, Complications of circumcision. Br J Surg (1993) 80:1231-36.
Taylor R, Lockwood AP and Taylor AJ: The prepuce:specialized mucosa of the penis and its loss to circumcision. Br J Urol (1996) 77:291-295.
Anon. Personal View. BMJ (1994) 309:676.
Warren J, Bigelow J. The case against circumcision. Br J Sexual Med (1994) 24:6-8.
- "...we would like to discourage the American Academy of Pediatrics from promoting routine circumcision as a preventative measure for penile and cervical cancer. Research suggesting a pattern in the circumcision status of partners of women with cervical cancer is methodologically flawed, outdated, and has not been taken seriously in the medical community for decades. Penile cancer rates in countries which do not practice circumcision are lower than those found in the United States. Fatalities caused by circumcision accidents may approximate the mortality rate from penile cancer." (Letter from American Cancer Society to American Academy of Pediatrics, 16 Feb 1996).
- Collins v. Wilcock (1984) 1 WLR 1172,1177.
- Attorney-General's Reference (No 6 of 80) [1981] QB 715.
- R v Coney (1882) 8 QBD 534 and R v Donovan [1934] 2 KB 498.
- R v Adesanya. The Times, July 1974, 16-17.
- R v Brown 1994 1 AC 212.
- Law Commission. Consent in the Criminal Law: Consultation Paper No. 139, 1996.
- Queensland Law Reform Commission. Research paper: circumcision of male infants. QLRC, Brisbane, 1993.
- Gillick v West Norfolk and Wisbech Area Health Authority [1985] 3 All ER 402.
- Dwyer JG. Parents' religion and children's welfare: debunking the doctrine of parents' rights: California Law Review (1994) 82(6):1371-1447.
- Delany L. Altruism by proxy: volunteering children for bone marrow donation. BMJ (1996) 312:240.
- S v. S, W v. Official Solicitor [1970] 3 All ER, 107. See also Skegg, Consent to medical procedures on minors in 36 MLR 370-381, where he argues that this second approach is relevant to any medical intervention carried out on children purely for other people's benefit.
- Brigman, WE. Circumcision as child abuse: the legal and constitutional issues. J Family Law (Univ. Louisville) (1984-85) 23(3):337-57.
- American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics (1995) 95:314-17.
- Nicholson G. College oath requires physicians to do everything for the welfare of the state (letter). BMJ (1997) 314:439.
- Prohibition of Female Circumcision Act 1985.
- Kluge E. Female circumcision: when medical ethics confronts cultural values. CMA Journal (1993)148:288-9.
- See also Universal Declaration of Human Rights, Art. 30; International Covenant on Civil and Political Rights, Art 5 and Art 18(3) "Freedom to >manifest one's religion or beliefs may be subject only to such limitations as are prescribed by law and are necessary to protect... the fundamental rights and freedoms of others".
- By virtue of Article 31 the words of treaty provisions must be given their ordinary meaning; and by Article 32,recourse may not be had to the traveaux préparatoire unless the meaning of the treaty provisions is on the face of it unclear, or possibly, where all the parties are in agreement so to refer.
- Dwyer JG. The children we abandon: religious exemptions to child welfare and education laws as denials of equal protection to children of religious objectors. North Carolina Law Review (1996) 74(5), 1323-1478.
For reasons of space, the following sources were not included in the article as published but are given here for further reading:
- 1. "There can be no doubt of [masturbation's] injurious effect, and of the proneness to practice it on the part of children with defective brains. Circumcision should always be practiced. It may be necessary to make the genitals so sore by blistering fluids that pain results from attempts to rub the parts."
Angel Money. Treatment Of Disease In Children. Philadelphia: P. Blakiston. 1887. p. 421.That it causes loss was as well known in the 19th and the first part of the 20th C, as it was to Maimonides, but today vehemently denied, is shown by:
- 2. "In consequence of circumcision the epithelial covering of the glans becomes dry, hard, less liable to excoriation and inflammation, and less pervious to venereal viruses. The sensibility of the glans is diminished, but not sufficiently to interfere with the copulative function of the organ or to constitute an objection...It is well authenticated that the foreskin...is a fruitful cause of the habit of masturbation in children... I conclude that the foreskin is detrimental to health, and that circumcision is a wise measure of hygiene."
Jefferson C. Crossland, MD, "The Hygiene of Circumcision," New York Medical Journal, 1891; 53:484-485- 3. Mutilate:
- To deprive (a person or animal) of a limb or some principal organ of the body; to cut off or otherwise destroy the use of (a limb or organ)
- To render (a thing, esp. a record, book etc.) imperfect by cutting off or destroying a part.
Oxford English Dictionary 1971.'Implies the cutting off or removal of a part essential to completeness, not only of a person but also of a thing, and to his or its perfection, beauty, entirety or fulfilment of function.'
Webster's New Dictionary of Synonyms: a Dictionary of Discriminated Synonyms and Analogous and Contrasted Words (1968)Mutilation:
- The action of depriving (a person or animal ) of a limb or of the use of a limb; the excision or maiming (of a limb or bodily organ).
- The action of rendering (a thing) imperfect by excision or destruction of one or more of its parts.
Oxford English Dictionary 1971.'Disfigurement or injury by removal or destruction of any conspicuous or essential part of the body.'
Stedman's Medical Dictionary (26th Edition) 1995'The act of depriving an individual of a limb, member, or any other important part; deprival of an organ; severe disfigurement.'
Dorland's Illus. Medical Dictionary (28th Ed) 1994- 4. "We may circumcise the male patient with present and probably with future advantage; the operation, too, should not be performed under chloroform, so that the pain experienced may be associated with the habit we wish to eradicate." Athol A.W. Johnson, On An Injurious Habit Occasionally Met with in Infancy and Early Childhood,
The Lancet, vol. 1 (April 7, 1860)pp.344-345."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 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..."
John Harvey Kellogg, MD. Treatment for Self-Abuse and Its Effects, Plain Facts for Old and Young. Burlington, Iowa: F. Segner & Co. 1888. p. 295."Measures more radical than circumcision would, if public opinion permitted their adoption, be a true kindness to many patients of both sexes."
Jonathan Hutchinson, "On Circumcision as Preventive of Masturbation," Arch of Surgery 1891;2:267-268"Clarence B. was addicted to the secret vice practiced among boys. I performed an orificial operation, consisting of circumcision...He needed the rightful punishment of cutting pains after his illicit pleasures."
N. Bergman, MD. "Report of a Few Cases of Circumcision," Journal of Orificial Surgery 1898;7:249-251 5."Finally, circumcision probably tends to increase the power of sexual control. The only physiological advantage which the prepuce can be supposed to confer is that of 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 in the present state of society can well be spared. If in their loss increase in sexual control should result, one should be thankful."
Jonathan Hutchinson. "Our London Letter." Medical News 1900; 77:707-708"It has been urged as an argument against the universal adoption of circumcision that the removal of the protective covering of the glans tends to dull the sensibility of that exquisitely sensitive structure and thereby diminishes sexual appetite and the pleasurable effects of coitus. Granted that this be true, my answer is that, whatever may have been the case in days gone be, sensuality in our time needs neither whip nor spur, but would be all the better for a little more judicious use of curb and bearing-rein."
E. Harding Freeland. "Circumcision as a Preventive of Syphilis and Other Disorders,"The Lancet (December 29, 1900):1869-1871."I suggest that all male children should be circumcised. This is "against nature," but that is exactly the reason why it should be done. Nature intends that the adolescent male shall copulate as often and as promiscuously as possible, and to that end covers the sensitive glans so that it shall be ever ready to receive stimuli. Civilization, on the contrary, requires chastity, and the glans of the circumcised rapidly assumes a leathery texture less sensitive than skin. Thus the adolescent has his attention drawn to his penis much less often. I am convinced that masturbation is much less common in the circumcised. With these considerations in view it does not seem apt to argue that "God knows best how to make little boys."
R.W. Cockshut. "Circumcision,"British Medical Journal (1935) 2:764.- Wiswell's purported findings for UTIs have also been dismissed by the AAP as "methodologically flawed."
"There are no valid medical indications for circumcision in the neonatal period."
Committee On Fetus And Newborn. Standards and Recommendations for Hospital Care of Newborn Infants, 5th Ed. Evanston:American Academy of Pediatrics. 1971, 110.- Secretary, Dept. of Health and Community Services v. JWB and SMB: 1992 175 CLR 218 [Marion's Case]
- The Universal Declaration of Human Rights provides in Article 2 that:
'Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as: race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status.'In the UN Convention on the Right of the Child, Art. 2 provides:
- "States Parties shall respect and ensure the rights set forth in the present Convention to each child within their jurisdiction without discrimination of any kind, irrespective of the child's or his or her parent's or legal guardian's race, colour, sex, language, religion, political or other opinion, national, ethnic or social origin, property, disability, birth or other status."
- "States Parties shall take all appropriate measures to ensure that the child is protected against all forms of discrimination or punishment on the basis of the status, activities, expressed opinions, or beliefs of the child's parents, legal guardians, or family members."
- "Circumcision causes pain, trauma, and a permanent loss of protective and erogenous tissue...Removing normal, healthy, functioning tissue for no medical reason has ethical implications: circumcision violates the United Nations' Universal Declaration of Human Rights (Article 5) and the United Nations' Convention on the Rights of the Child (Article 13).
Leo Sorger, MD. To AGOC: Stop Circumcisions, OB.GYN. NEWS (November 1, 1994): p. 8"Despite the obviously irrational cruelty of circumcision, the profit incentive in American medical practice is unlikely to allow science or human rights principles to interrupt the highly lucrative American circumcision industry. It is now time for European medical associations loudly to condemn the North American medical community for participating in and profiting from what is by any standard a senseless and barbaric sexual mutilation of innocent children."
Paul M. Fleiss, MD, MPH. Circumcision Lancet, 1995;345:927.
World-Renowned French Sexologist Censored over Anti-Circumcision Speech!
Faits & Documents (April 15, 1997); page 9.
Circumcision is Politically Correct
Renowned as an authority in his field and an author of many sexological textbooks, the sexologist Gerard Zwang, who, in February, 1996, participated in a symposium entitled, "Ethics, Religion, Law and Reproduction," --organized by the Committee for the Research and Study of Fertility (Groupe de Recherches et d'Etudes sur la Fertilite - G.R.E.F.) -- was just informed by its organisers that the book reproducing the presentations given at the symposium has been subjected to the amputation of his presentation, which was entitled "Male Circumcision: The Medical Point of View." This decision was made at the insistence of the Schering and Theramex Laboratories who financed the printing of the book. Dr. Zwang send the president of the Physicians Council (Conseil de l'Ordre des Medecins) a letter concerning the censure of which he was the object "from the confessional milieux represented by two laboratories." "Everyone," he writes, "has always supported the denonciation of female sexual mutilation. The joint denunciation of ritual circumcision has always been part of my publications, and until now contemporary scientific publications have always accepted them. This time, the attack on freedom of expression is caracteristic."
G.R.E.F.'s letter to Dr. Zwang
G.R.E.F
Groupe de Recherche et D'Etude sur la FertiliteAssociation Loi 1901
Paris, 6 March 1997
Docteur G. ZWANGMy dear Colleague,
On the occasion of our 3rd annual meeting on 4 March, the organization committee discussed the problem created by the text of your presentation.
In order to recognize the conflicting interests of everyone, the signatories of this letter agreed that the following propositions would be acceptable:
The book version of the presentations given at the symposium "Ethics, Religion, Law and Reproduction," of 20 February 1996 will be published without your presentation, "Male Circumcision: The Medical Point of View." In actual fact, our partners in the pharmaceutical industry do not wish, for reasons of their own, to be associated with such a position. For, in the agreement we have with the Schering and Theramex laboratories, the distribution of the book of presentations, likely to be distributed by the medical examiners of these two companies, is part of its specifications. We cannot, therefore, go against their wishes without violating our contract.
Dr. Zwang's reply to G.R.E.F
12 March 1997
Professor MadelenatMy dear Colleague,
I apparently no longer exist, I never went to the Palais des Congres on 20 February 1996, I never gave a speech, and one cannot publish a presentation that I never gave.
My generation has already experienced the difficulties of legalizing contraception and the medicalization of abortion in spite of the French Episcopate and pressure from the Vatican. In our supposedly Christian county, it seems even more difficult to go up against the circumcisers' lobby united with the rabbinate and the imamate. They seem to hold the financial power in the two laboratories that sponsored your symposium, namely Schering and Theramex.
In order not to embarrass you further, I accept your decision, thanking once again Jean Cohen for his tolerance and courage.
Of course, as far as I am concerned, I will not stop there. I have resolved to denounce by every means in my possession this manifestation of militant religious obscurantism that revives the practice of anti-scientific censorship that I had thought died out in the Middle Ages.
Cordially,
Gerard Zwang
From Genetic Cosmology to Genital Cosmetics:Origin Theories of the Righting Rites of Male Circumcision
Copyright, 1997, Duane Voskuil, Ph.D.
Philosopher, former Chair,
Department of Philosophy,
University of North DakotaAbstract
Man's preconscious envy of woman's power to reproduce and interpret cosmic order may underlie male genital cosmetics. Humanity began its quest to understand, as is still the case, by using metaphors. Early in human history the world was compared to the order of a woman's body: Her control of her body and her body's control of her, with its blood and milk flows, birthing and death, was the basis for the first metaphors to explain cosmic forces. This identification was facilitated by the moon's cycles mirroring her life stages and her monthly bleeding. The sympathetic magical effect of body-modifying cosmetics enhanced this cosmic tie. For men to be brought into this female-focused cosmology, required men adopt a menstrual mind-set. Male genital cosmetic surgery imprinted the cosmic female cycles into men's minds by altering their bodies and, therefore, their brains and minds, to reflect female patterns. Male genital blood-letting is man's way of being "on guard" or "AWARE" of female-type forces that make and control our bodies and the universe. These ancient mind-setting rituals, possibly furthered by envy of youth's virility, maintain the "righting" rite even though more male-oriented cosmologies have usurped much of the sacredness of goddess-oriented cultures and have cast male gender as life's central theme. Yet, men do not feel secure with this worldview since the persistence of ancient, ingrained patterns conflict with male-gendered rituals. The conclusion is that gendered cosmologies, be they female or male, always cause divisiveness and neurotic behavior. One such behavior, plaguing us yet today, is the routine doctoring of the normal genitals of children to make them more appropriate, for example, "cleaner" or better, for the disturbed values of our society.
Contents
- I. Becoming AWARE
- Of buttons and bows.
- Two purposes presented.
- Pain and AWAREness.
- AWARE and beware.
- AWAREness always partial.
- Proposals for circumcision origin.
- Pre-patriarchal origin.
- Blood-letting and creation.
- Circumcision indispensable.
- II. Evolution and Meaning.
- Physiology, Sex and gender.
- Nature, culture and patrism.
- Metaphor and myth.
- Religion and culture.
- Gender superficial but influential.
- III. Origin Metaphors Based in Menstruation.
- Female perspective.
- Genetic cosmology.
- Menstrual blood unavoidable.
- Blood and predators.
- Blood as life.
- Appropriate behavior as ritual.
- Menstrual isolation.
- Menstruation and the moon.
- Moon people, moon cognates.
- Coincidence as control.
- Body as microcosm.
- Gaining control of self and cosmos.
- Success and celebration.
- IV. Man's Place in a Woman's World.
- Cosmetics and cosmology.
- Ritual as conceptualization.
- Blood, kin and power.
- Superficial males.
- Male lunatics.
- Cosmetic surgery for cosmological knowledge.
- Circumcision and Menstruation.
- Righting rites of genital blood.
- Male power from female grace.
- Heroic life and sacred king.
- Genital sacrifice as substitute.
- Blessings' trickle-down.
- V. Patriarchal Modifications.
- Male separatism.
- Hierarchical abusers.
- Male re-birthing.
- Domination and womb envy.
- Ritual hunting, war and sports.
- Gender and materialism.
- VI. Summary.
- The flow-er.
- The prick-er
- Genderless cosmic subject
- Selected Bibliography
From Genetic Cosmology to Genital Cosmetics:Origin Theories of the Righting Rites of Male Circumcision [1, Endnote]
I. Becoming AWARE.
Of buttons and bows.
In North Dakota one can still find an abandoned farm with a barn and its make-shift stanchions, a granary with oft-repaired mouse holes and a cast-out radio, a garage studded with nails hung with gaskets and license plates, a two-holer too far from the house to use on a subzero winter's night, and a house with its cut-glass window over-looking over-grown lilacs and a weed-filled driveway. Inside one such lonely house, among scattered clothes, boxes of personal papers and calendars dating to my youth, among accumulated years of thin phone books with names marked out or penciled in, is a brown paper bag half full of buttons in one corner of a vanity drawer. I put the buttons in a bubbled-glass mason jar, turn it around like a kaleidoscope and meditate on the lives whose fingers fingered the endless variety of these cosmic shapes that helped alter bodies and minds with their cosmetic purpose.For years I have turned off highways onto numerous byways looking for a stack of letters tied up with a faded ribbon or handwriting on a cellar wall that would tell me why people with flintstone knives, stingray spines or sharp fingernails began to attack our body's pleasure center. I wish I could say I've found the philosopher's stone in some crumbling foundation wall or a talking burning bush. I haven't.
But I have found enough buttons, enough pieces of cloth and tattered letters to have a good hunch. So with a broken Philco radio sitting on the mantel like an oracle skull, I've laid out the pieces on a worn floor, filled in the largest holes with the most likely cloth and stitching, and listened for the spirits to speak. They whispered, but this is what I heard them say:
Two purposes presented.
(1) The origin of the cosmos, like our human origin and all gendered life-forms, came from the creative power of a female. As a whole worldview developed around female physiology, men likely acquired a deepening sense of anxiety and inferiority. Men's bodies did not flow, create nor nurture new lives. Men were hard-pressed to identify with a culture based on such bodily functions. Genital surgery was the male "fix," a fix so powerful it continues even though men have wrested social power and philosophical explanations from women.As I sat there, I also heard (2) how insidious every gender-based philosophy must be. Genital mutilations would never have occurred had our cosmologies been genderless. The origin of violence on male genitals was founded on a view of reality that devalued men. The sacred, life-giving blood did not clot within male genitals to create new life, nor flow from them in harmony with the universe. As horrendous as men's backlash towards women has been, men still hear a voice telling them, "Fear women!" If the voice were clearer and more focused, it might say, "Fear female-based philosophical cosmogonies." This voice may be right, but we are exploring a time where buttons are hard to find.
Pain and AWAREness.
I'm no longer AWARE when I first became AWARE of what a foreskin was or when I heard foreskins are routinely cut off. I do remember as a preschooler having recurring nightmares of men going from house to house knocking on doors and asking parents to give them their boys so they could be officially castrated. I can still feel the panic I had 50 years ago as the official crew came closer to my house and I realized my parents would tell them where I was hiding. I still feel the agony that eventually shocked me awake, screaming, as I sought to find safety in some dark closet. I was not AWARE then that many humans are castrated like male pigs on the farm. I was not AWARE then that many of us had already been mutilated. Each time I hear of another kind of assault on male or female genitals, I want to wake up.AWARE and beware.
I've been driven by a hope genital mutilations would stop if we could became more AWARE of the reasons they started. As I was regretting that these reasons seem lost in a time before possible documentation, it occurred to me to reflect on the meaning of "AWAREness"itself, since language often maintains meanings below our AWAREness.In the Oxford English Dictionary I found the word "AWARE" once meant "to be wary," or "to be on guard" before it came to mean "enlightenment" or "consciousness." The word itself carries with it how AWAREness develops, that is, from concrete physical experiences to an abstract and general concept.
Perhaps being AWARE of how AWAREness evolved can help us be more AWARE why circumcision started, or at least help recognize the more likely theories.
Originally, looking out for our physical safety must have been one and the same as looking out for the safety of our conceptual life, our fundamental belief structure. We all live our lives in a fog of cause and effect. Though we may not be able to isolate the exact causes for an event, we refuse to believe things happen for no reason. Where true cause and effect cannot be established, superstition or sympathetic magic steps in.
Maintaining a split between mind and matter, physical and conceptual, already requires a highly evolved, sophisticated concept. Feelings and meanings do not begin in AWAREness. Life is first physical feeling and action. Successful actions are repeated. Repeated action is the beginning of ritual which embodies our first symbols. Symbols, in turn, then come to control action, often with little AWAREness of the purpose for the control.
AWAREness always partial.
Most of my life I never asked why circumcision began. Like a Fargo businessman who, when asked whether he was circumcised, answered, "I don't know," I didn't know enough to ask the question. The ability to ask a question is already a state of AWAREness.We will have little success discovering why circumcision started by asking people why they amputate parts of their children's genitals. Most people do not know or are unAWARE why they do it. If someone does give a reason, it will likely be a rationalization for continuing the practice, not why it began (ERE 664). Explanations are necessarily given within a philosophical context, a substratum of beliefs that defines the culture, and these beliefs are never fully articulated.
Proposals for circumcision origin.
Evidence is increasing that the metaphors used to explain origins at the time circumcisions began were significantly different from those we use today. This must be kept in mind when evaluationg the following reasons often given for the origin of male genital mutilation: An act of consecration, a sacrifice, a tribal mark, a blood-charm, for hygiene, to remove phimosis, protection against sexual dangers, a test of courage, to increase reproduction, a hallowing of the sexual life, an intensification of sexual pleasure, a diminishment of sexual pleasure, an expression of the belief in resurrections, to be more like a woman, and to be less like a woman (ERE, B, W 265-266). [2] The last two, which find the reason for circumcision in men's physical difference from women, I think come closest. If circumcision has a pre-patriarchal origin, being like a woman would seem to make sense as a motivation. If circumcision is a patriarchal invention, being less like a woman could be a reason. But patriarchal circumcision, from all indications, is an adaptation of a ritual already well-established before the rise of male-dominated societies.Pre-patriarchal origin.
We know circumcisions were being done at the time writing was invented (TS 4). Patriarchal patterns began to take over as a cultural norm 5,000 to 6,000 years ago, becoming fully instituted in Europe and America only after the witch burnings and, some would argue, not until the 19th century. [3] Circumcision may continue as an expression of hierarchical control by dominant males or their gods, [4] but it is not likely to have started in such an environment. We don't mutilate what we truly love and admire. The original mutilation must have been seen as an improvement of the male genitals, as many see it yet today.Blood-letting and creation.
Perhaps, circumcision did begin as a male bonding rite, but not as a bonding among males. The bond was likely a bonding of males to a female-gendered AWAREness, to a cultural philosophy dominated by female metaphors. Male genital blood-letting is man's way of being "on guard" or "AWARE" of female-type forces that make and control our bodies and the universe. It is his way of fitting in and righting nature's wrong. Nature's mistake is not the prepuce nor any particular part of his genitals. The mistake is the failure of male genitals to bleed which denies them the power of creation (GJ).Circumcision indispensable.
Certainly, circumcision was thought to be an indispensable ritual, important for the survival of the group, not the thoughtless mutilation many claim it has become. The anti-circumcision movement stirs up so many "irrational" and strong emotions because, unarticulated as they are, these reasons, once believed to be a matter of life and death, still motivate genital blood-letting. Vachel Lindsay's poem The Congo has the haunting refrain, "the Mumbo Jumbo will hoo-doo you." Who can doubt the Mumbo Jumbo hoo-doos us as we watch our entranced shamans in their white robes and sterile inner sanctums wielding their knives in the indispensable genital righting rite?II. Evolution and Meaning.
Physiology, sex and gender.
Humans have evolved through several stages, physically and conceptually. Earlier stages are nearly always carried along in some way into later stages. We came, for example, from organisms that developed not only sex, but gendered sex, which is not necessary for life (MS). Without gender, circumcision would have lain in the infinity of unactualized possibilities.The popular view, that males controlled human evolution and developed human culture out of their needs, particularly as hunters, does not stand up to scrutiny. The evidence seems to indicate our hominid ancestors were mainly plant gatherers. Meat scavenging from carnivore kills supplied about 15% of their opportunistic diet. Those in the lineage from which we evolved probably began their theorizing and ritualistic behavior while they were less than a hundred pounds as adults. Evidence of ancient bone finds suggests large cats dragged hominids up into trees to eat them (J). Rather than being hunters, early people were hunted themselves by large carnivores.
Nature, culture and patrism.
When we differentiated from other primates, we were small bipeds, then, who survived by gathering plants and scavenging. The move from opportunistic dependence on nature, to some control of nature in significant and predictable ways, is the beginning of culture. It is second only to our biological inheritance in influencing the way we think and behave. A third important development is the change within cultures from prominent female to dominant male metaphors and control.Marija Gimbutas makes a strong case for a Neolithic culture in Europe whose dominant cultural metaphors were female (G1, G2). Female anatomy was the main source of the first metaphors used to explain reality. I am inclined to believe these metaphors, at some level of AWAREness, have a very long past, tens, if not hundreds, of thousands of years.
Metaphor and myth.
What mainly distinguishes humans from other creatures is our ability to theorize. Yet animal behavior exhibits some ability to draw conclusions or connections between things, so there is no point at which hominids began to theorize. Origin myths and psychological archetypes reveal something universal about human experience and theorizing that may also say something universal about non-human reality.Philosophy, as any intellectual discipline, seeks to find metaphors that explain something about life. What distinguishes philosophical from other kinds of explanation is its scope. Metaphors that are, or are assumed to be, universal or to apply everywhere at all times are philosophical. But what is taken to be universal depends on one's ability to generalize, that is, on one's AWAREness. To a child in the womb, the womb is all there is. "Mother" is always there, even though not conceptualized as such.
Religion and culture.
A metaphor is a comparison of something familiar to something less familiar. If philosophy seeks the most general metaphors, then religion seeks to ritually weave these metaphors into the fabric of our daily activity. These cultural insights, carried more or less unconsciously by the ritual, continue to shape our mental and physical existence for better or worse. Circumcision, often denied to be a religious ritual by many, is a ritual that cuts deeper than any named religion. [5] The term "cultural tradition" is often used to refer to this deeper level.Just as our physiology developed as a means to survive in the environment we found ourselves millions of years ago, so too human culture began and evolved out of beliefs that certain rituals are essential for survival. The feeling that life has purpose or meaning is far more a function of ritualized social behavior than the conceptual AWAREness intellectuals are inclined to deify. So even when one is conceptually faced with self-destructive behavior, the ritual may not change, as any anti-circumcision activist will attest.
Gender superficial but influential.
One characteristic found in all early theories of reality and nearly universal yet today, is the role of gender. Even though gender, from a sophisticated philosophical point of view, is a superficial aspect of existence, people have taken it to be a universal part of reality as far back as archeological evidence gives clues to the human mind. Most things in human experience, including humans themselves, were male or female. Generalizing on this experience, gender was applied to things not obviously gendered, like mountains, bodies of water and ships upon that water.III. Origin Metaphors Based in Menstruation.
Female perspective.
What might have been those earliest ritualized metaphors that gave a sense of order, purpose and understanding to creatures hundreds of thousands, perhaps more than a million, years ago? What environmental forces were so unavoidably familiar and startling they ritualized behavior long before that behavior was in AWAREness? The wealth of recent scholarship emphasizing the female role in human development has brought a new perspective to such questions.We must be wary of sentimentalizing the female metaphors used before the age of patriarchy. Rituals like circumcision and human sacrifice developed before patriarchal societies. After all, Skadi, the Queen of the Shades, had to be propitiated every year by a human stand-in for Loki whose testicles were ripped out of his body to land in her loins bathing them in blood. If she smiled, spring would return. [6] She, like other death goddesses, collected the severed penises of her emasculated heroes. (W 941). Echoes of this practice can be heard in David's collection of two hundred enemy foreskins (probably attached to the penises) as a sign of his worthiness to marry a princess (I Sam. 16-18). [7]
Genetic cosmology.
A culture which worships female functions projects these functions onto natural events. When theory begins to explain not only our human origin and structure but all of reality, cosmology begins. Cosmology finds order and purpose in previously uninterpreted experiences of the world, or at least in a larger world than our "on guard" stance had previously considered. The first stories of cosmic genesis were birth stories, that is, genetic or genital cosmologies. Why did our first philosophical cosmogonies reflect major episodes in women's physiology?Menstrual blood unavoidable.
Judy Grahn points out that blood may have been the most important and also the most dangerous substance people faced(GJ). And face it we must, and especially, face it she must. Women bleed. Women bleed naturally. Their blood flows from their genitals. A woman is a flow-er. This unavoidable biological fact and its inevitable consequences are the basis for the best and the worst in human culture, for the origin of human culture itself, if Grahn's provocative thesis is true.Blood and predators.
Myths often combine the origin of menstruation and the world by saying a canine or feline predator was responsible for both. The Maya had their Jaguar; North American Indians their Coyote; the ancient Egyptians their Jackal. They rip flesh, draw blood. Predators are in stories that relate birth and its fluids to menstrual blood. They also make solid ground as Coyote did by bringing dirt up from beneath the primeval waters (EO 88).Blood as life.
The origin of our fixation on blood is not so much related to the kill of the hunt as it is with blood we involuntarily shed, either naturally with no loss or threat to life, or traumatically when wounded or killed. Eventually, natural bleeding was discovered to be necessary for life. Blood was even said to be the stuff of life, since retained menstrual blood was believed to coagulate into the fetus itself, just as the heavenly bodies were curds and clots of mother nature's milk and blood.More likely, however, we first became AWARE of the power of blood as a major threat to our life. To lose much blood is to die, except when the flowing blood is the cyclical bleeding of the moonlike menses. But blood also attracts predators. The menstruating woman's life was more endangered because she left a scent trail of blood. Anyone around her was also at risk. Hatred of the wolf might come from competition for some of the same resources, but Little Red Riding Hood's fear of the wolf likely stems from its role as a predator attracted to her red blood. Blood was wondrous, but dangerous. [8]
Appropriate behavior as ritual.
Those who changed their behavior, instinctually or culturally, to minimize the danger reproduced more than those who didn't. Ritual is simply appropriate behavior or behavior believed to be appropriate. Inappropriate behavior is not just dissocial, irreligious, or naughty. Originally it was life-threatening. When individuals presented a danger to their group, such behavior, even when it was biologically necessary, had to be severely controlled. A person endangering the group can either be ostracized or confined and controlled within the group in order to protect the group. Learning self-control through ritual stands at the divide between instinct and AWAREness, just as the meaning of "AWAREness" itself divides between physical and conceptual concern.Menstrual isolation.
For everyone's protection, the menstruating female had to be either isolated outside the group in some place less accessible or obvious to predators or isolated within the group. Her isolation was in a protective sanctuary, or menstrual hut, which is still a major part of many initiation rites and may have developed into our temples (B144, T100, GJ243).[9]Menstruation and the moon.
Not only did our ancestors discover a connection between predation and menstruation, but also between menstruation and the cyclical rhythms of the sky. Ancient peoples were obsessed with astronomical measurements. Among the daily rhythms and the yearly cycles, among the random events of sunshine and storm, was the moon's regular waxing and waning coincident with female menstrual cycles.Moon people, moon cognates. "Moon," "month," "mother," "mouth," "menstruation," "measurement" "math," "matter," "mammaries," and even "man" which is still pronounced more like "moon" in some dialects, are linguistic cognates testifying to a common source. Humans first defined themselves as "moon people," as creatures who saw in the moon a basic metaphor defining who they were. The linkage of these words presents the metaphorical link between human physiology and cosmogony. If menstrual blood and birth are linked, then when menstrual blood and moon are linked, cosmic origin and birth are linked. Birth, an exclusively female function, gives life to us and the cosmos.
Coincidence as control.
Coincidence is never mere coincidence to the emerging superstitious mind. The menstruating female was not just coincidentally in step with the rhythms of the world. She and the world were in reciprocal control. Since woman's blood was powerful, she was powerful, powerful enough to alter nature's course. Power is dangerous as well as wondrous. Everything about her was charged. Her body became a metaphor for the world (GJ).Body as microcosm.
Her actions were mirrored in the world, as the world was mirrored in her. Her body fluids, tears, spit, milk, blood and urine, were the fluids of the world. We are affected by things around us, but those most powerful among us can cause things in the world to change.The effect the menstruant could have on the world was probably felt to be at first, like all superstitions or sympathetic magic, just the way the world works. We just "know" that stepping on cracks breaks backs; we don't need a theory as to how or why. No cosmic gods or goddesses need exist to please or to anger, though they have been feared now for millennia. Causality in reality was seen as a two-way street. Storms affect us, but combing her hair could cause storms, a superstition believed by clergy into the 17th century (W 368).
Gaining control of self and cosmos.
Grahn and Bryk marshal evidence from anthropology and mythology to show how cultures have treated the menstruant, especially during her first bleedings. Since her skin was the earth's surface, a surface all too unstable, as those who live in earthquake zones know too well, she could not be allowed to scratch herself. To scratch open her skin would cause the earth to open. Neither could she look at the light nor touch the ground so she was elevated on a chair, bed or platform shoes. She could only drink water from a straw, and could not even move for days or weeks. She could not touch her blood to clean herself. She might be whipped with nettles. All this suffering she had to endure for the welfare of the clan. She was put through a ritual she could never forget. She was made AWARE.These behaviors reflect the extreme of not wanting to step on the crack that breaks MOTHER's back. Mother is the mother of all life, the collective cosmic mother who is both caring and threatening. She gives birth to her children from the blood-water of her womb, nurtures reality with the various saps from her breast and takes us back (despite our wishes) into her dark, but regenerating tomb-womb.
Success and celebration.
At the end of the menstruant's seclusion, when the danger was less, she was washed, coifed, draped and pampered in ways that continue to protect her and the group from negative influences. Her clothes and eye make-up protected the clan members from overpowering direct contact with the charged person. [10] Jewelry distracted negative spirits and plugged body openings preventing these spirits from entering her body. A celebration ensued because once again the world had not collapsed, the flood of unAWAREness had once more been held at bay. The group once again had been brought into a state of AWAREness, had been put on guard.But the price to be paid for AWAREness is blood. The blood price, according to one mythology, [11] is first paid by a willing female, Inanna, as she hangs for three days on the peg (the dark moon) before being killed and resurrected (to start fresh after her bleeding) (GJ 212). Payment for the menstrual AWAREness is passed in a later myth to an unwilling male victim, Dumuzi, which begins the transfer from female-centered mythologies to male-centered ones that ends with Christ's willing sacrifice for his father, and Mithras' heroic acts glorifying his father without self-sacrifice (U).
The "world" saved from the flood, refers to the conceptual scheme generated to understand our place in the world, our ultimate orientation or "east-bearing." Our conceptual insights are always in danger of being lost in the flood of unconsciousness. But Innana's Boat of Heaven (also known as "her well-praised vulva," and the crescent moon) rides out the high water. She keeps her orientation since she possesses the menstrual laws, the basic insights needed to understand and orient life, and delivers to her people her cargo of laws that hold heaven and earth together (WK, GJ 214). The world, apart from a philosophy, is mere chaos. It is the dream-time (as Indians say) before the beginning.
IV. Man's Place in a Woman's World.
Cosmetics and cosmology.
These behaviors, focused around the female's blood flow and its dangers, were the beginnings of cosmetics. Altering our body affects the world around us. The prostitute, originally a fu