Circumcision: A History of the World's Most Controversial Surgery
David L. Gollaher, Basic Books, pp. 253, $26.00
Reviewed by Hanoch Ben-Yami
Translated by Steven Cohen
"As the history of female circumcision suggests, if male circumcision were confined to developing countries, it would, by now, have emerged as an international cause celebre, stirring passionate opposition from feminists, physicians, politicians and the global human rights community. If routine medical circumcision didn't exist today, no one would dare to invent it. Yet it does exist. And owing to a long and curious history, it is so deeply embedded in certain cultures and worldviews that it is hard to recognize for what it is."
This is how Dr. David Gollaher, president of the California Healthcare Institute and recipient of the Avery O. Craven award of the Organization of American Historians, ends the preface to his book on the history of circumcision. In his work, Gollaher presents: the history of circumcision and the attitudes toward it in Judaism, Christianity and Islam - from their beginnings and up until today; the findings of anthropological studies into male and female circumcision; the entrenchment of the practice of circumcision in the modern-day United States; and the developments in physiological knowledge with regard to the foreskin and sexual organs in general. Gollaher also presents and evaluates current studies into the link between circumcision and health; he deals with the history of the anti-circumcision movement in the U.S.; and ends with a modern history of female circumcision. The conclusions of his levelheaded, comprehensive research are quoted above.
The first chapter of the book deals with the Jewish tradition of circumcision. The source of Jewish circumcision lies in Egyptian culture, which had a strong influence on the Hebrew culture at the time of the First Temple. Hellenic culture abhorred circumcision, leading the Hebrews who were assimilated into the Greek culture to try and reconstruct their foreskins by stretching them. In order to prevent this, the custom, which up until then had only entailed the removal of the tip of the foreskin, was radicalized to include the periah - the separation of the remains of the foreskin from the glans, which the mohel performs with his fingernails.
I believe this change to be a very significant one from a number of aspects. The fact that Jewish religious law altered the circumcision rite over time opens the door for future changes to the custom within the same framework. Perhaps, in particular, it would be possible to do away with periah, which is the most painful and dangerous part of circumcision. Why shouldn't the covenant be restored to the original covenant of Abraham?
Throughout history, rabbis and others have tried to explain the reason for the commandment. The most common justification is that circumcision diminishes the sexual pleasure of both the circumcised individual and his partner and thereby bridles sexual urges and desires. This argument is propagated in the teachings of the Jewish sages of old, Philo of Alexandria, Maimonides, Rabbi Nachman of Bratslav and others. Christian culture of old also believed circumcision to lessen sexual pleasure and this was one of the principal reasons why the practice became so widespread in Puritan America, around 1900.
Modern-day studies support the opinion that circumcision diminishes the sexual pleasure of a man and his partner. Circumcision affects the nervous system of the penis, thereby causing the organ to be less sensitive; because, among other reasons, of the important role of the foreskin in intercourse, circumcision also results in a change in the dynamics of the act. This belief is backed up by a statistical study of the opinions of women who had experienced sex with both circumcised and uncircumcised men.
The second chapter of the book presents a history of circumcision from a Christian and Islamic point of view.
St. Paul was responsible for Christianity's rejection of circumcision, together with other Jewish customs. Throughout the Middle Ages and through to the outset of the modern era, Christianity regarded circumcision as a dark custom, spreading a number of malicious rumors about the alleged kidnapping and circumcising of Christian children.
On the other hand, circumcision took up an important place in Islamic culture - no less important than its status in Judaism - and it has maintained this position up until today. For example, when, in 1992, a Libyan lawyer published a book questioning the legitimacy of the custom in Islam, he was severely censured by the press and religious figures, including from the Mosque of the Prophet in Medina, who called for the issuing of a death sentence against the man if he refused to retract his opinions. The books were recalled from the stores and libraries, and burnt.
Chapter three presents an anthropological study into circumcision. Many tribes in Africa, Indonesia and among the Aborigines of Australia practice various forms of male circumcision. The theories that attempted to find a universal reason for circumcision failed, and it now appears that the custom emerged in different places for different reasons. The justifications for circumcision differ from place to place, but there is one justification - a relatively popular one repeated by various cultures - that is, perhaps, of particular interest. Various tribes believe that the clitoris, which is a miniature, male-like sexual organ, causes a woman to exhibit a masculine side; whereas the foreskin, which causes the male penis to resemble the female sexual organ, gives a man a feminine side. Male and female circumcision does away with this duality and makes the circumcised individual unmistakably female or masculine, as the case may be.
The parallel between male and female circumcision, which we perceive as totally different, is repeated in various forms throughout the book, helping to undermine and shake our prejudices with regard to the two customs.
The United States is the only country in the world in which more than 50 percent of the male population undergoes circumcision for reasons other than religious ones. Chapter four of the book deals with the entrenchment of the custom in the U.S. In the 1870s, one of the most important physicians of the 19th century, Lewis Sayre, successfully used circumcision to treat a number of incidences of genital infections among children - infections that had caused partial paralysis in their victims.
Sayre was very pleased with his discovery and believed he could use circumcision to treat epilepsy, hernias and various mental disorders. Due to the high regard in which Sayre was held, the custom of circumcision began to spread through the U.S. Numerous mental disorders were attributed to "irritations" of the sexual organs and circumcision became one of a group of treatments for these and other problems. Among other practices, the treatments also included the administering of electric shocks by attaching electrodes to the anus and the urethra. During the same period, clitoral amputation also became a standard method of treating mental disorders attributed to the same causes.
In the 1870s and 1880s, medical studies began to reveal micro-organisms to be the causes of infectious diseases and immediately, it became fashionable for doctors and scientists to discover sources of infection everywhere. During this period, and without conducting any research into the matter, smegma - a sebaceous secretion found between the foreskin and the glans - was declared "an infectious substance." Many still believe this to be true, despite the fact that smegma has been shown to contain anti-bacterial and anti-viral substances and that the micro-organisms that exist between the foreskin and the glans are no different to those that exist in a woman's vagina.
In any event, doctors in the late 1800s believed they had discovered a source of infectious diseases - a belief that was reinforced by the fact that some of the diseases appeared less frequently among the Jewish population. These reasons for circumcision were supplemented by the belief that the circumcision diminished sexual pleasures and urges and reduced the chances that young circumcised boys would masturbate - as aforesaid, these beliefs earned circumcision points during the Victorian period. Furthermore, the technical developments in the field of surgery at the time reduced the risks involved in circumcision.
And so, without any proper scientific foundation, and supported by sexual inhibitions, the routine circumcision of infants spread among the upper-class sectors of American society. The custom became a status symbol, thereby continuing to spread among wider and wider circles (even today, circumcision in the U.S. is more common among the upper classes.), finally entrenching itself as routine surgery for newborns and often performed without requesting the consent of the parents.
As aforementioned, circumcision of newborn males took hold in the U.S. without any proper knowledge about the foreskin and its function. During the 20th century, the foreskin was often thought of as a piece of skin and that's all. In addition, the proper condition of the foreskin in babies was considered identical to that in adults. The fifth chapter of the book relates to these two completely mistaken determinations and the history of their refutation.
Let me begin with the second determination. The proper condition in an adult is one in which the foreskin can be pulled back over the glans, in the same manner that it is drawn back when the penis is erect. The condition in which drawing back the foreskin is impossible due to a narrowing of its opening is called phimosis.
On the other hand, in babies, the foreskin is attached to the glans and the two form a single, continuous tissue. The opening of the foreskin might also be too narrow to allow it to be pulled back. The organ is, therefore, naturally protected from the accumulation of secretions around the urethra. During the initial years of the child's life, the foreskin is gradually and independently detached from the glans.
Ignorance with regard to this condition often led doctors to diagnose phimosis or "adhesions" of the foreskin to the glans in babies. In light of such diagnoses, circumcision was often the recommended treatment; either that or the "adhesions" were treated by separating the foreskin manually and forcefully from the glans (often causing injury and infection). Doctors also recommended - unadvisedly so - that parents clean under the foreskin of their baby by drawing the skin back over the glans, while, in actual fact, it should be left untouched. Because of the mistaken beliefs that are so entrenched in the U.S. today, the American Academy of Pediatrics still has to distribute instructions and explanations on how to care for an uncircumcised organ.
Allow me now to return to the first determination. Studies into the physiology of the foreskin have shown it to be a very complex organ. While the exterior of the foreskin resembles the skin that covers the shaft of the penis, its interior resembles the skin found inside the mouth or in a woman's vagina. It comprises a dense accumulation of nerves and nerve endings and is more sensitive to touch, heat and cold than the glans itself. It has strips of muscle that give it flexibility and shape it. The strip of muscle at the opening of the foreskin, on its interior, also comprises nerve endings similar to those found at the tips of one's fingers and on one's lips, making this part of the foreskin particularly sensitive. The uncircumcised penis secretes smegma between the foreskin and the glans. This liquid serves to lubricate the organ during intercourse and to provide protection from infections and friction. It's also worth noting that a removed foreskin can be used to cultivate skin tissue that can be grafted onto different people, without the problem of it being rejected by the body's immune system. Why the foreskin, in particular, contains these unique skin cells remains a mystery.
Despite having only partial knowledge about the foreskin, it is clear that it is a complex organ with a wide range of functions, very few of which have already been discovered and researched. With the circumcision of the penis, this complexity disappears - never to return.
Over the years, researchers have tried to establish a foundation for the medical justification that is offered with regard to the routine circumcision of infants. The sixth chapter of the book evaluates the existing evidence regarding the alleged link between circumcision and health. During the course of the 20th century, American doctors promoted circumcision as protection against a wide range of diseases, including penile cancer, sexually-transmitted diseases (STDs), urinary tract infections and, more recently, AIDS. Because this review does not have room for a satisfactory report on all the relevant studies, I will concentrate on AIDS.
An article published in Scientific American in 1996, showed - based on prior studies - that south of the Sahara Desert in Africa, there is a significant correlation between areas in which circumcision is not commonplace and areas in which AIDS is widespread. This correlation led the writers of the article to wonder whether an uncircumcised individual is particularly susceptible to the disease. Other publications have even offered a number of explanations for this sensitivity. For example, it is argued that perhaps the HIV virus can survive under the foreskin for a longer period of time, therefore increasing the chances of infection with the disease.
These statistics and arguments are, however, far from satisfactory. If we examine the correlation between circumcision and the prevalence of AIDS in developed countries, rather than in central and southern Africa, we will find the reverse situation. The U.S. is the Western country in which circumcision is most popular, but it is also the Western country with the highest incidence of AIDS. On the other hand, in some countries in which circumcision is almost non-existent - Japan, for example - AIDS is very rare too. If such correlation were to serve as causal evidence, we would have to conclude that in developed countries, circumcision increases one's chances of being infected with AIDS.
The principal problem of the studies that showed a negative correlation between circumcision and AIDS is that circumcision is not an independent variable. Circumcised individuals come from societies that are different to those of the uncircumcised individuals; and circumcision is, therefore, evidence of cultural differences and, hence, possible differences with regard to personal hygiene, sexual practices and more. In addition, some of the studies that were conducted in Africa itself found the opposite relationship: For example, a study conducted among 12,534 Tanzanian men in 1995 showed that the HIV virus was actually more prevalent among circumcised individuals.
To Gollaher's criticism, we can add the following: None of the possible mechanisms that allegedly make the uncircumcised penis more susceptible to infection has been clinically tested and it is very easy to propose mechanisms that have the reverse effect. For example, there is more friction between the sexual organs during intercourse with a circumcised man and, therefore, the circumcised man runs more of a risk of bleeding and contracting an infection. This is, of course, only a hypothesis, but it demonstrates that prior to clinical testing of the hypotheses on either side of the argument, none can be assumed to hold true.
Furthermore, the assumption that the AIDS virus can, perhaps, survive for a longer period of time between the foreskin and the glans, is evidence of nothing apart from prejudices concerning the infectious nature of the foreskin. In fact, already in 1982, the anti-bacterial enzyme, lysozyme, was found to be present under the foreskin; in 1999, lysozyme was revealed to be an effective agent for killing HIV in vitro. In 1998, it was also reported that an intact foreskin is impermeable to the HIV virus. These facts cannot, of course, be seen as proof that the foreskin provides protection against AIDS, but the findings certainly show that the foreskin cannot be deemed the source of infection before additional studies are conducted into the matter.
Returning to the link between circumcision and culture, we find that some of the societies south of the Sahara in which circumcision is customary are Islamic, with far less permissive sexual practices than those of the majority of the other societies in the region; and, after all, it is well known that sexual permissiveness increase the risk of being infected with AIDS. In addition, the custom of "dry sex" - in which the woman dries her vagina, using leaves and powders, in order to heighten sexual pleasure - is common practice south of the Sahara. "Dry sex" is known to increase the risk of contracting AIDS because of the greater danger of causing injuries to the sexual organs. Thus far, none of the research into the relationship between circumcision and AIDS has considered the prevalence of "dry sex" as a factor causing statistical deviations. These studies have also failed to properly consider other hindering factors such as the existence among the subjects of open wounds as a result of other STDs or female circumcision. Despite the fact that some 40 studies have been conducted into the link between AIDS and male circumcision, there has not been a single study into its connection with female circumcision.
It is also worth noting that most of the studies that showed the HIV virus to be more widespread among uncircumcised men examined selected populations that constituted high-risk groups - visitors to STD clinics, frequenters of brothels and others. On the other hand, most of the studies in which subjects were randomly selected from whole populations yielded contrasting findings: The HIV virus appeared more frequently among circumcised men. Furthermore, North American researchers tended to report more on the protective effect of circumcision than did their counterparts from Europe, where circumcision is not commonplace. An analysis of all the literature on the subject up until 1999 reveals that circumcised men run more of a risk of contracting the HIV virus.
Where does this leave us with regard to the question of the relationship between circumcision and susceptibility to AIDS? The truth is that today, we don't know if there is a connection between the two at all or what it may be. There is certainly not enough evidence to support the claim that circumcision provides protection from AIDS. Moreover, the fact that the U.S. - where circumcision is widespread - is the Western country with the highest incidence of AIDS shows that one cannot depend on the protective effect of circumcision and that other means of protection are far more effective. The same holds true for Israel: The Jewish sector of the population that has the highest incidence of AIDS, is no different - from the point of view of circumcision - to other Jewish populations.
In any event, even if it emerges that circumcision offers a certain protective effect against AIDS, this effect would only be significant once the circumcised individual begins to have sex and does not justify the circumcision of babies. Why not wait till the teenage years and then include the individual in the decision?
A summary of the medical research with regard to the contribution of circumcision to health in general shows that today, the pediatric medicine associations of Britain, Australia, Canada and the U.S. hold the view that there is no health justification for performing routine circumcisions on infants.
The seventh chapter of Gollaher's book is dedicated to the movement against circumcision in the U.S. I assume that readers in Israel will have less of an interest in this chapter, but at least they will learn that even in the U.S. - the only country in the world in which most men are circumcised for reasons other than religious ones - circumcision has come under a spirited, powerful attack by various groups for close to 20 years.
The book ends with a chapter about female circumcision. As aforesaid, in contrast to the prevailing view in the developed countries of today, in most cultures in which female circumcision is currently performed, the attitude to the practice is on a par with the attitude toward male circumcision. These cultures see the male and female sexual organs as analogous. In general, the two forms of circumcision are performed in the framework of ceremonies that symbolize a transition into maturity; both are considered to have aesthetic value; the most common justification for both is the suppression of the sexual urges of the circumcised individual; and more.
In most cultures in which female circumcision is practiced, the attitude of the women to the custom is positive: They see it as a sign of belonging to the community and do not consider it harmful from other aspects. Furthermore, these cultures repeatedly attribute the following medical value to circumcision: It reduces the risk of contracting diseases of the urinary tract, the HIV virus and more.
As is the case with male circumcision, the manner in which female circumcision is performed differs from place to place. The repercussions of radical circumcision techniques among women are more serious than those of male circumcision, but these radical techniques are not the norm. For example, and contrary to the prevailing belief in Israel, female circumcision among the Bedouin is no more than a small scratch on the hood or foreskin of the clitoris. Such a scratch is less painful and less dangerous and has far less of an effect on sexuality than does male circumcision among Jews.
Conditioning and prejudices alone cause us to view male circumcision is such a different light to female circumcision - so much so that while we consider the painful inflicting of a deformity on a male baby a cause for celebration, we are repulsed by the corresponding practice among females, deeming it a barbaric ritual that grossly violates fundamental human rights. Even if there are elements of Judaism of which we should be proud, circumcision is certainly not among them.
Gollaher's book should be translated into Hebrew. It could teach both the Jewish and Muslim populations of Israel some important facts about themselves. Such a translation would undoubtedly be a thorn in the flesh of a number of politically-influential elements, but perhaps there's a publisher out there who won't be deterred by them.
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