Neonatal Circumcision Reconsidered

Psychological trauma is an affliction of the powerless. At the moment of trauma, the victim is rendered helpless by overwhelming force. When the force is that of nature, we speak of disasters. When the force is that of other human beings, we speak of atrocities. Traumatic events overwhelm the ordinary systems of care that give people a sense of control, connection, and meaning. (Herman, 1992, p. 33)

Male circumcision involves the surgical removal of the penile foreskin, a fold of skin and mucous membrane that normally covers the head or glans of the penis. Routine neonatal circumcision is usually done from one to three days after birth, while Jewish ritual circumcision is performed on the eighth day after birth.

Postnatal circumcision is still frequently performed in the United States, the only industrialized nation to continue this practice for non-religious reasons on a majority of newborn male babies--about 60 percent according to the National Center for Health Statistics. Estimating from this figure, doctors continue to circumcise over one million baby boys a year, an average of 3,500 a day or one every 25 seconds. Circumcisions performed on Jewish newborns by a trained religious person called a mohel (ritual circumciser) account for less than 4% of this number.

Controversy continues regarding the practice of newborn male circumcision. A variety of reasons are put forward both for and against the procedure, but recent information using reliable sources is often not well known to the general public or to health care professionals. My purpose in writing this article is to present what I found in my client population regarding the lifelong effects of this procedure. It is my hope that this will stimulate further thought and therapeutic exploration of this issue.

Clinical reports
The psychotherapeutic approach I use when working with early trauma resolution involves a guided associative process that follows my client's flow of thoughts, memories, images, and body sensations. This is intertwined with a sensitive repatterning of memories of traumatic events and is more fully described in my article Touching and Holding During Regressive Therapy (Rhinehart, 1998).

Many men who were circumcised as neonates consider it a nonissue because they cannot remember anything about it. In my psychotherapeutic work with men, however, it is clear that the memory is there. Since the event occurred at a very early preverbal level, it is most often experienced as a body or somatic memory rather than as a more familiar verbal memory. Various disturbing mental images and intense feelings often accompany the reemergence of this body memory, including the feel of sharp metallic instruments cutting into one's flesh (anesthesia is normally not used in circumcision), the sense of being overpowered by big people, being alone and helpless, feelings of terror, and a sense of paralysis and immobilization.

Case examples
The following four examples show the long-term effects of circumcision trauma, effects I have found typical among my clients.

ST is a 44-year-old man whose adult life is filled with a seemingly nameless terror. This feeling was most intense when he had to relate to people in other than a superficial manner. At those times has body might start shaking uncontrollably. He would look away, withdraw inwardly, and experience a high level of embarrassment. During our therapeutic work, as he reexperienced the terror, his trembling hands went automatically to his groin to cover his genitals in a protective way. He felt that he was reliving the time of his neonatal circumcision. He was in physical and emotional terror as he rocked back and forth, feeling completely powerless, betrayed and alone. He did not have words for this experience, which had been forgotten until we began our work--just moans and groans of agony and helplessness. In his view, his circumcision was one of the most important experiences underlying his early decision that people were unsafe and dangerous. This decision expressed itself in his lifelong sense of fear around other people, especially those in positions of authority. The circumcision experience, bad enough in itself was made more severe by his mother's inability to offer him comfort at the time. This greatly reinforced the degree of his trauma and the resulting negative decisions he made about the safety of his world and the people in it. At present, the trauma has been largely resolved and his neurologic circuitry repatterned, thus eliminating the terror and trembling.

BJ, 52 years old, came into therapy because he experienced early issues coming up and polluting my life. During a particular session he kept using the term cut off in relation to family and other life issues. These issues had been triggered by his attending the bris (Jewish ritual circumcision) for a friend's newborn son. He heard the baby screaming and, much to his surprise, felt extremely uncomfortable, sweaty, dizzy, and aware that his genitals felt like they had suddenly been plunged into ice water and were shrinking. Following this, he felt rage welling up at the idea that something was being taken from the baby--that he was being overpowered, reduced, and diminished against his will. BJ felt that this clearly related to his own neonatal circumcision. He was born three weeks before term weighing five pounds. He believes that he was not comforted or touched much after his premature birth or the circumcision which was performed on the third day in spite of his low birth weight. As we worked together, BJ made connections--cognitively, emotionally, and physically--between his early experience and his lifelong sense of anger, powerlessness, diminishment as a male, and underlying generalized ominous feeling that he was somehow going to be punished for being male. In photographs of himself as a young boy he noticed that he frequently had both hands covering his genitals. What also surfaced from a very young place was an incredulous How can you do this to me--I can't trust you anymore, which reflected his feeling as an adult that people are untrustworthy. Connected with these was the belief that he was not supposed to cry or get mad as a result of what was done to him. Releasing and repatterning his feelings around his circumcision led to a significant increase in self-confidence, clarity in his relationships, and freedom to be the creative male person that he is without holding back because of fear of retaliation.

RJ is in his early sixties. He had a lifelong fear of any sharp metal instruments. When preparing food, he had to use knives as sparingly as possible, and he could not stand to have them lying out. When he did use a knife, he had to clean and put it away immediately. In therapy, the connection of this became clear to him. The body memory that he experienced was an excruciating feeling in his penis of a sharp steely knife (a scapel-like instrument) cutting his foreskin away. New he finds it increasingly easy to be around knives, and he has a new sense of freedom in the world.

WK is in his mid-forties and has experienced anxiety and panic all his life. As a child he described himself as being on edge constantly and unable to perform well in almost everything he tried. He felt particularly inadequate and worthless in academic and occupational settings--that is, around authority figures. During the initial part of our therapy, we made some progress through the effects of his father's frequent shaming behavior toward him as he grew up; this behavior created and reinforced feelings of powerlessness and hopelessness in WK. During therapy, we identified and worked with residues of birth trauma as well as residues of his mother's (and father's) unresolved depression and fear related to the SIDS death at six weeks of an older sister, which occurred about a year before his conception. However, the ease with which his anxiety and panic reactions could be triggered--particularly in relation to authority figures at work--persisted. It was not until he came on pictures of a neonatal circumcision that he became aware of the extreme trauma associated with his own experience. As the memory surfaced, his body suddenly became stiff, numb, and filled with terror, and his mind went blank (cortical shock)--typical of what happens when experiencing this level of traumatic response). As an adult, any situation in which he felt vulnerable triggered this flooding reaction in his body/mind. It was as if his mind was operating on the basis of a very early decision that big people were dangerous and might attack him at any time. This early decision, then, had to do with maintaining a somatic state of hypervigilance and tension. While his rational mind could be clear that this was not necessary, his body maintained this stance anyway. This early decision had made intimate relationships difficult as an adult.

Later-Life Symptoms of Circumcision
Other men with whom I have worked have also made causal connections between present-day problems--such as a sense of defeat, shyness, anger, or fear--and their neonatal circumcision experiences. I have developed a list of symptoms and behaviors that appear to have been caused or significantly conditioned by these neonatal experiences. Since these symptoms and behaviors can result from other traumatic experiences as well, this list should not be used as a diagnostic checklist to identify circumcision trauma; however, they may suggest its presence. These symptoms include

• a sense of personal powerlessness
• fears of being overpowered and victimized by others
• lack of trust in others and life
• a sense of vulnerability to violent attack by others
• guardedness in relationships
• reluctance to be in relationships with women
• defensiveness
• diminished sense of maleness
• feeling damaged, especially in the presence of surgical complications such as skin tags, penile curvature due to uneven foreskin removal, partial ablation of edges of the glans and so on
• sense of reduced penile size, a part cut off or amputated
• low self-esteem
• shame about not measuring up
• anger and violence toward women
• irrational rage reactions
• addictions and dependencies
• difficulties in establishing intimate relationships
• emotional numbing
• need for more intensity in sexual experience.
• sexual callousness
• decreased tenderness in intimacy
• decreased ability to communicate
• feelings of not being understood

Discussion
The idea that circumcision may cause problems in later life is not new. Freud (1916-1917/1933) suggested, in his discussion of anxiety and instinctual life (pp. 86-87), that there could be a connection between castration fears, neuroses, and circumcision:

It is our suspicion that during the human family's primaeval period castration used actually to be carried out by a jealous and cruel father upon growing boys, and that circumcision, which so frequently plays a part in puberty rites among primitive peoples, is a clearly recognizable relic of it, ...We must hold fast to the view that fear of castration is one of the commonest and strongest motives for repression and thus for the formation of neuroses. The analysis of cases in which circumcision, though not, it is true, castration has been carried out on boys as a cure or punishment for masturbation (a far from rare occurrence in Anglo-American society) has given our conviction a last degree of certainty.
~ pp. 86-87

Freud's thinking, advanced for its time, was in contrast to the more prevalent idea of his era that neonates are very little more intelligent than a vegetable … not directly conscious of anything (Goldman, 1997, p.7). This was the opinion of a renowned infant specialist at the University of Pennsylvania in 1895. Even fifty years later, newborn infants were [still] believed to be incapable of anything except eating, moving, crying, and sleeping. (Spock, 1946, cited in Goldman, 1997, p.7).

While Freud's thinking was focused on the formation of neuroses, perhaps a more accurate way of thinking about circumcision today is in relation to trauma, which we now know much more about. We also know that the neonate is highly intelligent even though he or she is, most likely, not in a position to differentiate circumcision from castration.

In her model of human responses to trauma, Pomeroy (1995) brings together what we know about what trauma is, how it happens, and what our psychic responses to traumatic events. She describes three inborn levels or lines of defense for dealing with a threatening experience: (1) relational resources, consisting of boundaries and safe, trustworthy individual and communal connections; (2) fight, flight, and freeze defenses from the brains limbic system; and (3) shock defenses, also from the limbic system, but without emotional control (pp. 90-93). She points out that when an overwhelming threat alarm is signaled by the emotional brain, the emotional brain's defenses take over. The emotional brain responds at the level of fight-flight freeze (active defenses) or shock defenses (passive reflexes) (p. 92).

In the case of circumcision, relational resources are unavailable to the neonate. The next level of fight-flight-freeze also does not serve him since he is easily trapped and overpowered by those performing the procedure. All he has left, therefore is the level of shock defense, which consists of central nervous system flooding by terror, rage, and finally numbing, paralysis, and dissociation; this his his last chance to control the high level of central nervous system activation, which might otherwise result in death. Watchinig videotapes of neonates being circumcised portrays this clearly to the aware eye. The so-called quiet after circumcision is more likely a state of dissociation in response to the overwhelming pain and terror than it is a state of peaceful relaxation.

Van Howe (1996), reporting on his clinical study, writes, Newborn males respond to circumcision with a marked reduction in oxygenation during the procedure, a cortisol surge [indicating strong adrenal arousal], decreased wakefulness, increased vagal tone, and less interactions with their environment following the procedure. All of these hinder the maternal-infant bonding experience that makes breastfeeding possible (p. 431).

In translating this level of experience to adult life, Emerson (1991), a pioneer in healing pre- and perinatal trauma in infants and children, has said that perinatal trauma (such as circumcision) results in anger and rage [that] are inexplicably intertwined with low self-esteem, shame, guilt, violence, and disempowerment.

Relevance to Transactional Analysis
In an earlier article (Rhinehart, 1998), p. 58) I noted that in the October 1995 TAJ, which was a memorial to Robert Goulding, he is quoted as talking about somatic redecision (Blackstone, 1995, p. 345). This concept arose during discussion of a group therapy session in which a client made a decision, during her work, to allow herself to reach out and be cuddled tightly by another woman, whom she had chosen as her therapist. This somatic redecision was felt to be a shift within the Child in the present  (p. 345). From this we might infer that here was an earlier somatic decision in the Child of the past not to allow this type of cuddling.

Steiner (1979) talked about the somatic component [of a script decision] which bodily reflects the decision (p. 109). Later he wrote, The somatic component refers to the fact that a person who has made a decision invariably brings certain aspects of her anatomy into play, especially the musculature (p. 111).

Eskine (1980) described the three aspects of script that must be dealt with to achieve cure: behavioral, intrapsychic, and somatic (p. 103). He underlined that the somatic aspects of script need to be an important focus of script cure (p. 105) and that with each scripting decision or script reaction I think that there is always a corresponding physiological inhibition or restriction within the body. The younger the child or more severe the trauma, the greater is the physiological reaction (p. 105).

For a neonate undergoing circumcision, perhaps it would be accurate to say that his decision is primarily somatic and derives from the defensive patterning of his shock experience. Because of its content and context, circumcision sets in place an automatic central nervous system and generalized somatic reaction to interpersonal experience from that point on. Some males will experience continuing vigilance, some a readiness to fight, flee, or freeze; and other will jump to rage, terror, or disconnection. It is helpful to note that, in considering the levels of defense, whenever the two earlier levels (relational and fight or flight) are experienced by the mind as ineffective, the mind tends not to use them later. This means that a mind patterned in this way jumps right to terror, rage and/or dissociation when confronted with situations that are interpreted as threatening, even though to the rational mind or cortex these situations may not be significant. In other words, when an event occurs in a man's life that resembles any aspect of the original circumcision experience, the chances that the extreme forms of panic, rage, violence, or dissociation might result are much more likely--just as they are in any other posttraumatic stress situation.

The feelings and behaviors my clients experienced fit precisely unto what Herman (1992) called complex posttraumatic stress reaction (p. 121). They are no different from the experience of rape victims, combat veterans, female circumcision victims, and survivors of natural disasters. She also indicated that the common factor underlying the effects of trauma is the experience of violence and powerlessness (p. 33)--made worse if it is inflicted by other human beings in contrast to a natural disaster. Both are dramatically present in the procedure of neonatal circumcision.

Stern (1985) pointed out that the trauma disrupts the ability to cope with and assimilate information and also that if the empathic failures of parents are too large, the sense of a cohesive self will be thrown too far off balance (p. 245) Since intense affective states act as cardinal organizing elements (p. 245) in the personality, they leave lasting impressions.

Although good experiences immediately following routine circumcision--such as parental holding, nursing, soothing, and comforting--may mitigate the intensity of the traumatic experience, my experience with clients confirms that circumcision registers in the body-mind in myriad ways, direct and indirect, throughout the man's life.

 Hammond (1999), in his survey of men circumcised in infancy or childhood, outlines the physical, sexual, and psychological consequences experienced by 546 men. The leading physical and sexual consequences were prominent scarring of the penis (33%), insufficient penile skin for a comfortable erection (27%) (neonatal circumcisions remove what would grow to be come 51% of the adult penile covering, and progressive sensory deficit in the glans (61%) leading to compensations such as compulsive sexual behaviors that offer more intense kinds of stimulation to a sensorily dulled glans, As to the psychological consequences, respondents described:

It is important to note that the problematic symptoms and behaviors that my clients experienced and expressed as adults might not initially lead a therapist to suspect such an early causal origin. Instead, they may seem more closely related to a highly stressful lifestyle, and it is true that it is in stressful times that such symptoms tend to surface. In most of my clients, negative experiences that occurred at older ages, while often significant in themselves, were actually layered on earlier traumatic experiences such as circumcision, trauma that had set up abasic mode of reaction to perceived threat. Therefore, in cases in which working therapeutically at older levels does not resolve a problem over the long term, it is important to look at earlier layers.

Two other important considerations involving the transactions between parents, doctors, nurses, and the newborn are discounting and scripting.

Discounting: Given that the neonate is a fully aware, perceptive, and responsive sentient being, circumcision discounts his experience in at least five areas:

1. Pain: His physical pain is ignored.
2. Separation/abandonment: The terror of separation from mother and being immoblized in the circumstraint board is ignored.
3. Violence: The significance and memory for him is ignored or rationalized.
4. Protection: His cries of protest are not heard or respected.
5. Objectification: The decision to circumcise is made by others as if he were an object and his experience did not exist or matter. This is perhaps not much different than decisions made about the fate of concentration camp internees by camp commanders; they too had their rationalizations.

Scripting: The circumcision experience for the neonate centers around abandonment, helplessness, pain, and violence. The neonate is uniquely vulnerable and responsive to these experiences, which is why he needs protection rather than abandonment as he integrates his birth experience and attempts to establish his bonding connection with his parents in the outside world. In my client population, because they were not protected from injury by those who were responsible for this function, decisions were made and beliefs created or reinforced that supported fear of , indifference to, and violence toward other human beings. These decisions and beliefs evolved into life scripts expressed over time. Power became identified with violence so that perpetrators and victims become the fare of life.

Porter-Steele (1998) suggests that even a little violence is too much, and our world has a tremendous amount of violence. … We [transactional analysts] recognize cultural and individual scripts that support violence instead of workable, compassionate problem solving (p. 15). Perhaps routine neonatal circumcision is exactly this kind of culturally and individually determined scripting, and it can be stopped very simply, thus eliminating major discounting and victimization for millions of newborn males.

Finally, another provocative possibility is mentioned by Taoist Master Mantak Chia in his book Taoist Secrets of Love: Cultivating Male Sexual Energy (Chia with Winn, 1984, p. 243). He describes how the spot on a man's penis that is sexually assaulted during circumcision is reflexively connected to his heart and lung energies. This suggests that, in addition to the effects described in the article, circumcision may have a negative effect on the more subtle energy fields in a man's body around heart and lung function.

Both the history of circumcision and more current research regarding what the newborn male experiences are extensively presented in books such as Goldman's (1997) Circumcision: The Hidden Trauma and Questioning Circumcision--A Jewish Perspective (1998), Brigg's (1985) Circumcision: What Every Parent Should Know, Ritter and Denniston's (1992) Say No to Circumcision and Denniston and Milo's (1997) Sexual Mutilations: A Human Tragedy.

Summary
Circumcision of the newborn male child consists of removal of the penile foreskin, a normal, functional part of the child's body. The United States is now the only industrialized country in the world that continues to circumcise the majority of its newborn male children for non-religious reasons. In my client population of adult men, serious and sometimes disabling lifelong consequences appear to have resulted from this procedure, and long-term psychotherapy focusing on early trauma resolution appears to be effective in dealing with these consequences. Early prevention by eliminating the practice of routine circumcision is seen as desirable. The author welcomes sharing of readers' reactions and experiences via letter or email.

John W. Rhinehart, M.D. is a practicing psychiatrist and psychotherapist and director of Deep Brook Center, a holistic center for innovative psychotherapies and nutrition in Newtown, Connecticut. Send comments and reprint requests to 46 West Street, Newtown CT 06470 or call (203) 426-4553, or email to DEEPBROOKCTR1@webtv.net

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