Circumcision: Cultural-Legal Analysis

And ye shall be circumcised in the flesh of your foreskin; and it shall be a token of a covenant betwixt Me and you.¹

INTRODUCTION

Every year, in hospitals across the United States, hundreds of thousands of newborn boys are strapped naked to a board and assaulted in their genitals by ritually attired practitioners known as physicians.² Although the operation is painful, it is performed without anesthetic; the baby's cries are interpreted as signs of healthy lungs, and his subsequent traumatized sleep explained as proof that the operation caused no discomfort.³ Memories of the pain may impair his intellectual or emotional development.⁴ And the procedure, although safe as surgeries go, is not risk-free. Boys experience hemorrhage, infection, and ulceration; the urethral opening narrows due to scarring; and the penis may be bent, deformed, split, perforated, amputated, or burned off.⁵ Even if the operation goes well, the boy ends up with genitals that are structurally altered. Viewed from the perspective of normal human anatomy, he has been mutilated.

Circumcision, considered in this light, might seem like a practice that lawmakers would take seriously and attempt to stop. Yet the law has not intervened. On the contrary, the law affirmatively favors and protects the circumcision of boys.⁶ What explains this phenomenon?

This article explores the legal treatment of male circumcision from the standpoint of cultural-legal analysis.⁷ The paper builds from a model about the relationship of law and culture—a model that sees this relationship as one of identity. Law is part of culture. The gulf between the complex economic and accounting terms of a federal banking agency's capital adequacy regulations and an African village's ritual of animal sacrifice may appear vast. However, the two institutions are more closely related than they appear. While the differences between them are indeed large, they are each means by which human beings organize their social life within the matrix of a shared culture.

To understand the law in its cultural setting, it is necessary to look to information from fields outside the traditional domain of legal studies. Newspapers, situation comedies, marriage rituals, halftime ceremonies, tabloids, coffee room gossip, pop music, medical research, and modern art, among other data, all relate to the law, and can appropriately be considered when we evaluate the meaning of laws and regulations. The expansion of the relevant data set implies that law in its formal aspect—statutes, judicial decisions, administrative regulations, legislative histories and the like—will share the analytical stage n with information not normally associated with law.

Viewed in this fashion, the relevant materials tend to disclose the Operation of certain basic distinctions: polar categories that seem to be used by many cultures, in various forms, as devices for sorting and organizing social reality. Among the most important of these polarities are the following: purity and pollution, health and harm, self and other, natural and unnatural, beauty and deformity, male and female, order and chaos, good and bad, and true and false.⁸ Usually, cultures assign a thing one of the polar values—it is either pure or polluting, for example—but in some cases, a culture admits a neutral category for things that have neither value: they are neither pure nor polluting. For example, traditional Christian culture viewed circumcision as neutral: it was not polluting to be circumcised, although Christians did not engage in the practice, but neither was lack of circumcision purifying.⁹ Overall, these categories define the social world. They are so basic that they tend to disappear from the consciousness of individuals socialized in the culture. They become ground rather than figure.¹⁰ Their operation becomes more apparent, however, when we view cultures different from our own, or when we observe fluctuations in the assignment of values within a given culture over a period of time.

These polarities offer a potentially useful tool for understanding the relationship between law and culture. It is a tool, however, that must be used with caution. Concepts such as purity and pollution are abstract representations. While they serve to elucidate aspects of social reality, they are far from complete descriptions. These polarities do not fully account for the multifaceted, complex, ambivalent, and contested nature of many human institutions. Moreover, to the extent these categories are used to compare different cultures, or features of a single culture over time, they risk obscuring the particular factors that uniquely condition and define the phenomena under examination. Even within a culture at a given time, these categories are not easily separated from one another. Something that is categorized as pure rather than polluting is also likely to be assigned values of being good, true, healthful, beautiful, and familiar. It is possible, indeed, that these polarities reflect different aspects of a single overarching social filter that separates what is to be brought close from what is to be cast out. Subject to these caveats, however, there is value to a cultural-legal analysis based on how a system defines its reality along basic polarities of social meaning. By applying these concepts, with due attention to their analytical limitations, we can identify aspects of social attitudes, values and beliefs that would otherwise be obscured, and can relate these aspects to one another in a more coherent fashion. By this method, we can draw out the cultural substrate of laws, and thus can offer a deeper and more nuanced interpretation of legal institutions than would be possible if we restricted the field of analysis to categories of information traditionally deemed relevant to legal studies.

Applying cultural-legal analysis, this article divides Western, and specifically American, attitudes towards circumcision into three periods. For many centuries prior to the late nineteenth century, few Christian boys were circumcised, and prophylactic neonatal circumcision was unknown.¹¹ Circumcision of boys was limited principally to Jews, whose traditions were usually respected but were viewed with suspicion and kept at a distance by the broader Christian society. Christian society's response to circumcision during this period was ambivalent, reflecting the compromise within the early Christian church that established circumcision of the flesh as meaningless.¹² The neutrality of circumcision in Christian doctrine had important consequences for the categories that define and enforce cultural attitudes. Male circumcision was viewed as neither pure nor polluting, neither good nor bad, and neither true nor false. On the other hand, some cultural polarities worked against the adoption of circumcision among Christians. Because Christians did not circumcise their children, and Jews did, the state of being circumcised was classified within the dominant Christian culture as alien and unnatural. Likewise, Christian culture defined the uncircumcised phallus as aesthetically normative.¹³ And because of its unfamiliarity, the operation of circumcision was seen as chaotic rather than orderly. These cultural values gave inertia to the tradition of not circumcising males.

During the last decades of the nineteenth and the first decades of the twentieth centuries, a remarkable shift occurred in the English-speaking world.¹⁴ Physicians acting as norm entrepreneurs reconceived the phallus.¹⁵ They portrayed the uncircumcised penis as polluted, unnatural, harmful, alien, effeminized and disfigured, and depicted circumcision as true, orderly, and good. In a remarkably brief period of time, circumcision became ubiquitous: first as a remedy for disease, and later as a prophylactic procedure administered within a few days of birth.¹⁶ American society reached a tipping point, at which the movement towards circumcision gained momentum and became nearly universal.¹⁷ In 1977, circumcision was the most common operation performed on males in the United States.¹⁸ It is still performed on approximately six out of every ten infant boys in this country.¹⁹ The triumph of circumcision continued even after its original rationales—deterring masturbation and spermatorrhoea (wet dreams) and treating miscellaneous other disorders—were discredited.²⁰ Other purposes were supplied to make up for the deficit: circumcision was said to protect against penile cancer and urinary tract infections, and, lately, to reduce the risk of HIV infection.²¹

Despite continuing, although weakening, medical support, a grassroots movement against male circumcision developed during the 1980s and 1990s.²² Through persistent lobbying and publicity, these activists began to undermine the American social consensus. Like the physicians of the nineteenth century who promoted circumcision by manipulating cultural meanings, the anti-circumcision groups, acting as norm entrepreneurs, are now rehabilitating the prepuce by re-conceptualizing its place in the category system that defines our social reality. They promote the uncircumcised penis as pure, healthy, masculine, attractive, familiar, and natural, and portray circumcision as chaotic, false, and bad.²³

These arguments against circumcision have taken root in several English-speaking countries.²⁴ To date, American culture has not followed suit, although rates have dropped even here.²⁵ Circumcision of boys remains normative, and the cultural revisionism of anti-circumcision norm entrepreneurs remains at the fringes of American public discourse. The persistence of the operation in the United States may be due to the insularity of a continent-sized country, to the influence of large Jewish and Muslim populations, or to other factors. Yet even the United States is again approaching a tipping point when circumcision rates fall precipitously as parents come to believe that their children will not suffer a stigma if uncircumcised.²⁶ A generation from now, it is probable that only a minority of American newborn boys will be circumcised.

Even as circumcision practices and attitudes in the United States change, it is unlikely that culture will move to the point of condemning the procedure out of hand. Efforts by contemporary norm entrepreneurs to stigmatize circumcision are met with powerful opposition. Jews and Muslims may well feel uncomfortable with efforts to denigrate a precious religious heritage. Feminists, public health officials, and human rights advocates who oppose female genital mutilation in Africa may seek to avoid being linked with anti-circumcision advocates at home for different reasons. If male and female genital surgeries are seen as morally or physiologically equivalent, then people who support male circumcision in the United States might rethink their opposition to female genital mutilation abroad. Moreover, any identification between the male and female procedures would tend to undermine a core feminist belief about female genital mutilation, namely that it is an operation that embodies and enforces male domination of women's sexuality.²⁷ Opposition from these groups makes it unlikely that the normative image now being promoted by anti-circumcision advocates will receive full acceptance in American culture. More likely, the culture will revert to the condition it occupied before the nineteenth century revolution in attitudes towards circumcision. Circumcision will not be practiced by most Americans, but the procedure will not be stigmatized.

Such a moderate change in cultural attitudes should stimulate limited changes in the law. Given that powerful groups oppose the outright stigmatization of circumcision, it is unlikely that the law will prohibit the practice, even when conducted for non-religious reasons. Changes will probably take place at the margin, however. As cultural attitudes shift, courts may demand a higher level of informed consent to the operation, and may be more willing to impose liability on physicians or hospitals that circumcise people by surprise or against their (or their parents') wishes. States may refuse to reimburse for circumcisions under Medicaid programs. Courts and juries may look with greater favor on plaintiffs who claim injuries from botched circumcisions. Furthermore, the law is likely to penalize physicians or hospitals for performing circumcision without anesthesia, or for failing to inform patients or their guardians that pain-reducing medication is available. In other words, the law is likely to evolve along with changes in social attitudes, but because the attitudinal changes are likely to be moderate, the legal response can be expected to be limited as well. This article proceeds as follows. Section I addresses the legal treatment of circumcision in the United States. Section II describes cultural attitudes in Western society prior to the end of the nineteenth century. Section III covers the rapid realignment of attitudes that occurred during and after the Victorian era. Section IV describes contemporary efforts to eradicate routine neonatal circumcision. Section V discusses prospects for the future, followed by a brief conclusion.

I. LEGAL TREATMENT OF MALE CIRCUMCISION

At present, no law in the United States prohibits circumcision of males. Indeed, U.S. law favors circumcision, providing special exemptions and dispensations that are not available for other medical procedures. Several states specifically exempt circumcision from the ambit of laws prohibiting ritual abuse,²⁸ and rules regulating the unauthorized practice ofmedicine exempt Jewish ritual circumcisers (mohelim).²⁹ Both ritual and medical circumcisions, in short, are freely available under American law.

Tort law does provide a remedy if a circumcision is botched.³⁰ However, the tort regime is not particularly effective as a means of regulating the procedure. Because circumcision only occasionally results in outcomes bad enough to generate a lawsuit, the vast majority of complications from circumcision are not compensated, even when liability may be established.³¹ Moreover, because complications can follow properly performed circumcisions, establishing liability is difficult even when the outcome is more serious. The doctrine of res ipsa loquitur is not available to establish liability from bad results.³² In addition, the patient may not discover or come to appreciate the full harm from the procedure until a substantial period of time has elapsed, resulting in the loss of rights under the statute of limitations.³³

The law provides a remedy, in theory, for unauthorized circumcisions: a patient or his representative may be able to sue for battery if the operation is performed without informed consent.³⁴ But this rule does nothing to protect the persons on whom the procedure is actually performed, who are nearly always children below the age of consent. The child's parents consent to the procedure.³⁵ When these children grow up, they may decide that they would rather not be circumcised, but by then it is too late. Further, the informed consent requirement is not always effective to provide a remedy against unauthorized circumcisions. In Banks v. Wright, for example, the patient was admitted to the hospital for a heart bypass operation and awoke to find himself circumcised.³⁶ A Louisiana appeals court held that although there had been no consent, the operation did not constitute a battery.³⁷ The physician's liability could only be based, if at all, on a theory of negligent failure to disclose risks that could have influenced a reasonable person's decision whether to go forward with the procedure.³⁸ In East v. United States, the court held that no breach of the duty to provide informed consent existed, even though the patient was never advised that a circumcision might be performed during penile implant surgery.³⁹ The patient failed to demonstrate that the circumcision was unnecessary and did not establish that he would have refused consent if properly informed.⁴⁰ Likewise, the court in Kalina v. General Hospital of Syracuse held that a hospital was not liable to the parents for circumcising their child when the parents had specifically informed the hospital that they wished to perform a ritual circumcision away from the hospital setting.⁴¹ The thrust of these and other cases is that circumcision is a harmless and, in fact, a generally helpful operation that should not be placed under excessive legal regulation.⁴²

The rather laissez-faire approach to male circumcision contrasts markedly with the legal treatment of female genital mutilation. At least nine U.S. states have adopted laws prohibiting genital mutilation of girls and imposing criminal sanctions for violations: Delaware (1996),⁴³ Illinois (1998),⁴⁴ Maryland (1998),⁴⁵ Minnesota (1994),⁴⁶ North Dakota (1995),⁴⁷ New York(1997),⁴⁸ Rhode Island (1996),⁴⁹ Tennessee (1996),⁵⁰ and Wisconsin (1997).⁵¹ At the federal level, female genital mutilation is prohibited by the Federal Prohibition of Female Genital Mutilation Act, enacted in 1996.⁵² Federal immigration law is also used in the campaign against female genital mutilation. Several African women have sought asylum in the United States on the ground that they or their daughters faced a threat of genital mutilation if they returned home.⁵³ These women have occasionally succeeded. In one highly publicized case from 1996, the United States Board of Immigration Appeals granted asylum to a woman who claimed she was fleeing the threat of genital mutilation in her home country.⁵⁴

Given the contrast between the treatment of male and female genital surgeries, we might expect to see the disparate treatment challenged as inappropriate or even unconstitutional. A few commentators advocate this reasoning. William E. Brigman, in a 1984-85 paper in the Journal of Family Law, observed that a form of cultural astigmatism prevents Americans from perceiving that routine neonatal circumcision of males in the United States is the most widespread form of child abuse in society today.⁵⁵ Similarly, Abbie J. Chessler concludes that male circumcision is just as barbaric and unjustifiable as female circumcision.⁵⁶ Chessler condemns the failure to equate the procedures as hypocritical. She argues that the double standard which accepts and condones male circumcision but condemns female circumcision makes the concept of human rights meaningless.⁵⁷ In her 1999 book, The Whole Woman, Germaine Greer also suggests that circumcision and female genital mutilation can be compared.⁵⁸ A student note by Shea Lita Bond, published in 1999, takes the same position.⁵⁹

Opponents of male circumcision have also attempted, albeit ineffectually, to challenge the procedure in court on grounds of sex discrimination. The plaintiffs in Fishbeck v. North Dakota claimed that a state's female genital mutilation law deprived males of the equal protection of the law because it did not impose similar sanctions for male circumcision.⁶⁰ The federal courts managed to drop this hot potato by holding that the plaintiffs lacked standing to contest the alleged disparity in treatment.⁶¹ As of yet there has been no ruling on the merits of a gender discrimination challenge to male circumcision.

These commentators and activists are in the distinct minority. For Western observers generally, female genital mutilation and male circumcision are fundamentally different—so different that it is wrong to consider them in the same category. Most observers simply ignore the issue.⁶² When the Western narrative does address the question, it typically asserts that male and female genital procedures differ without offering reasons.⁶³ Arguments that the procedures might be comparable are met with disdain, mockery, or contempt: the comparison is bizarre⁶⁴ or crass.⁶⁵

The paucity of analysis that one encounters in the Western narrative is not itself an accident: it illustrates the pervasive power of the West's cultural beliefs. The legal and ideological background, displaying only minimal regulation of the process which genitally mutilates boys and a powerful norm against genitally mutilating girls, does not exist independent of the culture. On the contrary, the laws and judicial decisions that relate to genital mutilation serve as the visible embodiment of a deep-seated system of social attitudes, norms, and beliefs. This phenomenon has roots extending back thousands of years in Western culture. These legal materials may appear straightforward and unexceptional, but viewed in their cultural context, they are remarkable.

II. WESTERN ATTITUDES PRIOR TO THE LATE NINETEENTH CENTURY

This section examines attitudes toward circumcision from the earliest recorded sources until the middle of the nineteenth century.⁶⁶ The purpose of the present discussion is to identify general cultural attitudes about male circumcision in order to place these attitudes in their proper historical context. The analysis in this section provides a reference point for subsequent discussion of attitudes about male circumcision in the United States.

A. Background

Males as well as females are genitally altered in many cultures. Indeed, male genital surgery is more prevalent; approximately 13.3 million boys are operated on every year as compared with 2 million girls.⁶⁷ The most familiar form of male genital surgery is circumcision, the removal of the prepuce or foreskin, which is a sheath of skin surrounding the glans (or head) of the penis in humans and other mammals.⁶⁸ Yet circumcision is only one type of male genital surgery. Other forms include symbolic circumcision,⁶⁹ incision,⁷⁰ penile cutting,⁷¹ skin flaying,⁷² epispasm (foreskin elongation or restoration),⁷³ infibulation (fastening the foreskin over the glans),⁷⁴ urethral routing or cauterization,⁷⁵ duct resection,⁷⁶ and castration both actual⁷⁷ and imagined.⁷⁸ The focus of the present study, however, is on circumcision per se—the removal of the male foreskin.

Male circumcision is an ancient practice,⁷⁹ perhaps dating back to the Stone Age.⁸⁰ Herodotus, the Greek historian of the fifth century BCE,⁸¹ noted the antiquity of the custom in his time and speculated that it had originated in Egypt and spread from there outward across the Levant.⁸² Egyptian tomb scenes from the Old Kingdom show priests performing the ritual on young noblemen;⁸³ in one, the priest assures the boy that the procedure will not hurt.⁸⁴ Syrian warriors with circumcised genitalia are depicted on artifacts from the third millennium BCE, or five thousand years ago.⁸⁵ The Israelites practiced the custom beginning, according to the book of Genesis, with the circumcision of Abraham at age ninety-nine.⁸⁶ Arabian tribes followed similar practices, a tradition recorded in the circumcision of Ishmael.⁸⁷

Other ancient peoples did not engage in male genital surgery. The ice man whose 5,000-year-old frozen body emerged out of a Swiss glacier a few years ago turns out not to have been circumcised.⁸⁸ In the Middle East, residents of Shechem, a town in the Canaanite highlands, were apparently uncircumcised at one time. The Bible records how the Shechemite men agreed to be circumcised en masse in order to appease the sons of Jacob, who were outraged at the rape of their sister by a Shechemite prince.⁸⁹ The Philistines, traditional enemies of the Israelites, were also uncircumcised. When Saul wanted to get rid of David as a suitor for his daughter Michal, he demanded a hundred Philistine foreskins as a dowry; the foreskins were certain to be those of Philistines because all the Israelites would have been circumcised.⁹⁰ The Babylonians, who conquered the Northern Kingdom of Israel in 722 BCE, were not circumcised.⁹¹ Neither were the ancient Greeks and Romans.⁹²

Ritual circumcision of males is practiced in many cultures today. Among Jews, the tradition is to circumcise boys eight days after birth.⁹³ The bris is a joyous occasion to which guests are invited from near and far.⁹⁴ If possible, ten men constitute a minyan, or quorum required under religious law, to conduct worship services. The parents select a godmother and a godfather (sandak) for the ceremony. The mother hands the child to the godmother, who in turn passes him to the godfather, whose job is to hold the child during the miloh (cutting). The ritual expert, or mohel, performs the operation and recites the prescribed prayers.⁹⁵ At the mezizah, the traditional (but now largely abandoned) culmination of the ritual, the mohel sips wine and sucks the infant's penis, spitting the mixture of blood and wine into a glass.⁹⁶ Afterwards, the assembled crowd joins in a festive meal, the suedo shel mitzvo. Jews of all degrees of observance and assimilation practice circumcision, although Reform Jews may request that a doctor perform the operation in a hospital.⁹⁷

Muslims also circumcise boys as a matter of religious obligation.⁹⁸ There is no set time for circumcision in Islamic cultures, so long as the procedure occurs by the time the boy reaches adulthood.⁹⁹ Because there is no fixed time for the ritual, Muslim circumcisions can be performed on boys en masse. P.C. Remondino, a nineteenth century circumcision advocate, describes the festivities accompanying a traditional Arab circumcision.¹⁰⁰ The operation itself was preceded by eight days of feasting by the entire community. Everyone dressed up and engaged in merry-making and rejoicing. Young men conducted mock battles. Dancing, singing and drumming accompanied the feasts and other ceremonies. On the eve of the circumcisions, the entire community attended a grand banquet. The following day, the candidates for initiation were dressed in yellow silk gowns and seated on pans of sand previously collected by the women during a moonlight expedition. An assistant fixed each child's arms and held his thighs apart from behind. The circumciser removed the foreskin with a knife and dressed the wound. Meanwhile, the women in the gallery sang, chanted, and banged on drums, cymbals and saucepans. This drowned out the cries of the children and distracted them from their pain. At the close of the ceremonies, the prepuces were buried amidst great rejoicing.

The circumcision of boys is also common in Africa.¹⁰¹ The nature of the ritual on this continent varies across ethnic groups. Among the Xhosa of South Africa, circumcisions take place in the bush away from the routine of village life.¹⁰² These rituals are entirely set apart for men; women are not allowed to participate. Boys live in the initiates' camps for up to a month after their circumcision. Their separation from ordinary society is reinforced by dress and diet; they daub their faces with white paint, wear blankets, and restrict their diet.¹⁰³ Those that do not survive the ritual are seen as preordained not to achieve manhood.¹⁰⁴ The ritual among the Gikuyu of Kenya is also part of an extended coming-of-age ceremony. Traditionally, the candidate's parents select a knowledgeable man to act as the boy's mutiri, or adviser; his job is to prepare the boy for initiation, take care of him through the operation by physically supporting him, take care of the wound, and guide him afterwards.¹⁰⁵ The mutiri functions as a mentor, instructing the initiate on how to relate to women and maintain sexual discipline.¹⁰⁶ Many variations in the circumcision ritual are attested among other African peoples.¹⁰⁷

Traditional cultures offer a number of rationales for circumcision. It is said to be a deeply rooted part of the people's history.¹⁰⁸ The procedure may be necessary in order to marry.¹⁰⁹ It cements mutual respect among men.¹¹⁰ It wards off evil or appeases supernatural forces.¹¹¹ It contributes to social stability and coherence, marks identity, and confers honor.¹¹² It protects against sexually transmitted diseases,¹¹³ enhances fertility,¹¹⁴ promotes hygiene,¹¹⁵ confers purity, ¹¹⁶ and controls sexuality.¹¹⁷ Whatever the rationale, the traditions of male genital surgeries are deeply embedded in the cultures where they flourish.¹¹⁸

Ritual circumcision of boys is a durable tradition. Jews of ancient times refused to abandon the practice despite enormous pressure to do so. In 167 BCE the Seleucid emperor Antiochus IV, as part of a campaign to Hellenise the Jews, condemned to death every Hebrew who allowed a son to be circumcised.¹¹⁹ The Jews responded with the Maccabean revolt, a campaign of guerrilla warfare that resulted in major victories for the rebels and, eventually, a peace treaty that restored Jewish ritual prerogatives.¹²⁰ When the Roman Emperor Hadrian tried the same thing a few centuries later, the Jews revolted under Bar Kokhba in 132 CE.¹²¹ Although the rebellion was suppressed, Jews did not abandon circumcision. Perhaps because of the vigor with which traditional cultures protect their rituals of circumcision against outside interference, few imperial powers have emulated the Seleucids or Romans and suppressed circumcisions, either among the Jews or among other traditional peoples. Unlike many religions, Christianity does not practice circumcision. The reasons are historical. The unity of the early Christian church was threatened and probably fractured over the issue.¹²² Paul, the apostle to the Gentiles, viewed circumcision as meaningless and irrelevant.¹²³ Other early Christians who viewed themselves as Jews opposed Paul's efforts.¹²⁴ Eventually, Paul prevailed—a victory with profound consequences for the future of Western culture. The Church abandoned circumcision under the doctrine that Christ had abolished circumcision and other ritual separations between Jew and Gentile.¹²⁵ Christian circumcision was spiritualized into a circumcision of the heart.¹²⁶ This change permitted free admission of Gentiles into the Christian church and resulted in the nearly complete rejection of circumcision among Christians.

Circumcision became a mark, for Christians, of how they were different from Jews. Indeed, some early Jewish converts to Christianity apparently attempted to reverse their circumcisions. Paul disapproved the practice, instructing the Corinthians that if they were called to the Church after being circumcised, they should not seek to remove the marks of circumcision.¹²⁷ Paul treated the physical ritual of circumcision as meaningless, and therefore unimportant: circumcision is nothing, and uncircumcision is nothing, but obeying the commandments of God is everything. ¹²⁸

Although Christians eschewed circumcision, they displayed a curious fascination with the ritual. The Western calendar is based on the day of Christ's circumcision.¹²⁹ The Catholic Church celebrates the Feast of the Circumcision at the New Year. J.S. Bach's Christmas Oratorio contains a cantata dedicated to the circumcision, while some fine examples of Renaissance art—notably Federico Barocci's The Circumcision of Christ — celebrate the theme.¹³⁰ The prepuce of the infant Jesus was one of the most important holy relics of the Middle Ages,¹³¹ with at least twelve abbeys claiming the object.¹³² Thus, while Christians did not themselves become circumcised, they did not deny, and even celebrated, the circumcision of their Messiah. Because Christians lacked enthusiasm for circumcision, the practice was uncommon prior to the late nineteenth century.¹³³ Many births occurred at home, attended by midwives or by physicians untrained in this particular surgery.¹³⁴ The only practitioners who specialized in the operation were the Jewish mohelim, who would not ordinarily attend a Christian child. Outside the Jewish faith, circumcision was reserved for the treatment of physiological conditions.¹³⁵ For most Christians, circumcision was not even an option.

B. Culture

We turn to the cultural aspects of Western attitudes toward circumcision prior to the turn of the twentieth century. For approximately nineteen centuries, as we have seen, Christian men were not circumcised, although there was no attempt to suppress circumcision when it occurred among Jews. This cultural norm can be analyzed using the system of polarities discussed in the introduction to this article. Western culture gave circumcision a neutral status with respect to some of these polarities and a negative status with respect to others. Overall, the polarities operated to deter circumcision among the dominant culture.

Attitudes toward circumcision in Western culture differed markedly between the Jewish and Christian populations. For Jews, circumcision was a purifying ritual. Rabbinic interpretation linked the blood of the paschal lamb, shed to commemorate God's deliverance of Israel from Egyptian bondage, with the blood of circumcision, symbolizing God's covenant with Abraham.¹³⁶ Circumcision blood, in Rabbinic thought, was explicitly contrasted with menstrual blood, which was viewed as uncontrolled, impure, and dangerous.¹³⁷ Circumcision, moreover, was a valuable protection against falling into pollution. Maimonides, a physician as well as a philosopher, observed that the operation reduced the power of the affected organ.¹³⁸ Thus, men could better resist the temptation to sin.

For Christians, in contrast, circumcision was seen as neither pure nor polluting. This does not mean that the culture took no position on thepurity or impurity of circumcision. Christian society denied that circumcision was polluting and equally denied that it was purifying. The practice occupied a neutral ground between purity and pollution. This followed from the original compromise that made Christianity more than a Jewish sect; as Paul declared, circumcision was nothing and uncircumcision was nothing. Because physical circumcision had no spiritual meaning, it could be neither polluting nor purifying within Christian culture.

As a practical matter, the classification of circumcision as neither pure nor polluting did inhibit circumcision. Because Christians were not circumcised, those who wanted to promote the procedure bore the burden of changing cultural norms. The culture's neutrality ruled out arguments that non-circumcision was polluting, or circumcision purifying. Because these are some of the most powerful arguments available to induce cultural change, their unavailability tended to reinforce the status quo.¹³⁹

The polarity of health and harm was not a major factor in the cultural treatment of circumcision prior to the end of the nineteenth century. For Jews, the benefits of circumcision were principally spiritual rather than material. Even Maimonides, a distinguished physician, did not promote circumcision as healthful. His focus on the medical aspects of circumcision related to methods for reducing pain or the application of religious law to cases in which the procedure was likely to cause injury or death.¹⁴⁰ Christian culture, too, paid little attention to the health consequences of circumcision. Although beginning in the sixteenth century, physicians and anatomists began to posit benefits from the prepuce, such as protecting the glans from harm,¹⁴¹ until late in the nineteenth century, concerns about health and harm appear to have been secondary at best in shaping cultural attitudes.

Christian and Jewish attitudes toward circumcision also differed markedly along the polarity of self and other. For Jews, circumcision was by far the most salient mark of identity—it was the feature that distinguished a Jew from other peoples, a covenant demanded by God for all Jews. Circumcision, said Maimonides, was a reliable indicator of a person's Jewish identity because it was painful.¹⁴² People would not readily attempt to counterfeit a Jewish identity if the cost was undergoing such a procedure.¹⁴³ Circumcision for Jews was an essential mark of self and, accordingly, was highly esteemed within Jewish culture.

For Christians, on the other hand, the polarity of self and other worked to deter circumcision in Western culture. For Christians, circumcision appeared as foreign, alien, and grotesque.¹⁴⁴ Being uncircumcised was an indication of Christian, as opposed to Jewish, identity. A person who prided himself on being a Christian would not want to lose the mark of identity that lack of circumcision provided. If a man was circumcised, on the other hand, people who observed him might infer that he was Jewish, an attribution many Christians undoubtedly wished to avoid. Another aspect of identity was the connection between boys and their fathers. It would be odd, and disquieting, for the son to observe that his own anatomy differed from that of his father. Thus, if the father was not circumcised, the son would probably not be circumcised either. This factor tended to lend inertia to the social practice. In traditional Western culture, therefore, the circumcised phallus was other, and the uncircumcised phallus was self.

Traditional Christian culture tended to view alterations in the human body as intrusions on the natural order and, therefore, as contrary to divine will. Renaissance anatomist Jacopo Berengario da Carpi, for example, believed that Jewish circumcision, because it cut away a valuable layer of protection for the glans, was against the intent of nature.¹⁴⁵ To remove the foreskin both altered the natural anatomy and, implicitly, questioned the utility of God's design. As anatomical science developed, Christian researchers reinforced the idea of the prepuce's naturalness by conceptualizing it as an integral part of the penis.¹⁴⁶ Like any other part of the natural anatomy, the prepuce could fall prey to disease, but this was not a sufficient justification for its routine removal. Rather, the preferred approach was to retain as much of the organ as possible consistent with treating the disease.¹⁴⁷ Thus the polarity of natural and unnatural favored continuing the tradition of not circumcising Christian males.

Jewish thinkers gave much thought to the question of the naturalness of circumcision. Maimonides asked how a natural thing—the uncircumcised phallus—could be defective.¹⁴⁸ His philosophically sophisticated answer was that circumcision was not actually a correction of a natural condition.¹⁴⁹ The problem was that men were in an artificial condition because the moral qualities of the soul were adversely affected by bodily urges.¹⁵⁰ To bring people into a condition of conformity with divine law, it was therefore appropriate and useful to subdue the flesh.¹⁵¹ This could be accomplished by the process of driving the law into the body by the operation of the intellect, but it could also be achieved by correcting conditions of the body that were especially conducive to sin. Circumcision, in other words, was not actually an alteration of natural conditions but rather a measure taken so men could refrain from sin and thus realize their natural relationship with God. Through this reasoning, Maimonides argued that circumcision was not, in fact, an unnatural state even though it involved the alteration of the physical body.

Western aesthetics emphasized the uncircumcised phallus as the paragon of masculine beauty. In large measure, this concept of beautiful male genitals was inherited from the Greeks and Romans, whose sculptures of nude men and boys always displayed the genitals in their uncut state.¹⁵² These images of beauty received new attention, and emulation, in Western art during the Renaissance. Greek or Roman deities and symbolic figures, such as Nicola Pisano's Fortitude (1260), are invariably shown as uncircumcised. The same was true for Jewish figures from the Bible, even though the painters and their audience knew that these individuals were circumcised.¹⁵³ Michaelangelo's David (1492), perhaps the most famous nude male sculpture of all time, is uncircumcised, as is Donatello's David (1430s-1450s).¹⁵⁴ Even Jesus appears uncircumcised as an older child in Parmigianino's Madonna of the Rose (1529-30)¹⁵⁵ or as an adult, in Michaelangelo's Crucifix.¹⁵⁶ In short, the Western aesthetic of the phallus overwhelmingly evoked the image of the intact organ.

In traditional Christian culture, the polarity of male and female appears to have little bearing on the status of circumcision. A man was a man whether or not he was circumcised. Circumcision neither added to a man's gender, nor detracted from it. Nor was there anything in the lack of circumcision that either enhanced a person's manhood or detracted from it. Thus, circumcision was coded neutrally in Christian culture along the gender dimension.

For Jews, circumcision was coded in traditional culture as manifesting order rather than chaos. In part, the order reflected the fixed elements of the bris, which repeated in carefully orchestrated fashion a set of actions by the congregation and the mohel, which had been undertaken by Jews since time immemorial and was affirmed within Jewish culture as ordained by divine command. The ritual reflected the order of the universe and the submission to divine law that is emblematic of Jewish culture. As one Midrashic text states it, circumcision is great since, but for that, the Holy one would not have created his world.¹⁵⁷

Circumcision, for Jews, also reflected order rather than chaos insofar as it was considered a remedy against excessive sexuality. Maimonides argued that circumcision weakened the sexual organ in men and decreased their desire for sexual intercourse. By suppressing a source of temptation, circumcision thereby enhanced capacities for spirituality and reduced the incentive to sin.¹⁵⁸ Maimonides cleverly used this argument, not only as an affirmative justification for the procedure, but as an explanation for why something that might appear to be disorderly was in fact orderly. Maimonides did not deny that circumcision was traumatic, painful, bloody and violent. But the very trauma imposed by the procedure, which might appear from the outside as a chaotic event, was in fact necessary to induce order in human society and in the relationship between man and God. The trauma was also necessary to effect a permanent weakening of the sexual urge in men as they reached adulthood.¹⁵⁹

From the Christian perspective, circumcision was not strongly coded as either chaotic or orderly, although the images of the circumcision of Christ displayed the ritual as a blessed and peaceful event. During the nineteenth century, however, as the procedure began to be employed by physicians to treat various diseases and conditions of the penis, it came to be seen as somewhat chaotic. This was a function of surgical knowledge and technology. Circumcision was painful, cutting, as it did, through some of the most sensitive tissues in the body. The pain could be reduced by anesthetics, but the available painkillers at the end of the nineteenth century were not very safe.¹⁶⁰ And even if the patient did well with the anesthetic, he would experience pain during recovery. Moreover, prior to the late nineteenth century, surgeons knew little of antisepsis and regularly operated in non-sterile conditions.¹⁶¹ Infection was a frequent side effect of any operation, and circumcision was no exception. Candidates for circumcision could not have looked forward with much pleasure to the possibility of a gangrenous penis. Finally, most physicians and surgeons did not know how to perform circumcisions. As physician W.W. Sinclair remarked in 1889, the subject is passed over very casually by the majority of writers of surgical works, or, on the other hand, made rather complicated.¹⁶² The available techniques were formidable, tedious, slippery, bloody, inexact, and inelegant.¹⁶³ Even as late as 1905, no generally accepted method of circumcision had been devised, leaving the operation to the physician's discretion.¹⁶⁴

Traditional Western culture coded circumcision as neither good nor bad. The moral neutrality of circumcision followed from Paul's injunction that physical circumcision is nothing—neither good nor bad—and that what matters is the circumcision of the heart that is not marked in any physical way.¹⁶⁵ On the other hand, during the first part of the nineteenth century, many physicians entertained a negative moral view of circumcision from the standpoint of their professional discipline. The operation, in the view of these professionals, was barbarous and unwarrantable, except when performed for reasons of medical necessity.¹⁶⁶ Thus, although traditional Christian morality did not condemn circumcision, the medical profession's ethic sometimes did as part of its increasing autonomous claim to social authority.

Traditional Western epistemology was neutral on the practice of circumcision; the practice had no truth-value in Christian doctrine. Engaging in, or avoiding, the practice did not in itself reflect either knowledge or ignorance.¹⁶⁷ This epistemological neutrality did not mean that the culture had carte blanche to promote or discourage circumcision, however. Because Christian doctrine held that physical circumcision was meaningless, reflecting neither knowledge nor ignorance, any attempt to imbue circumcision with meaning would run counter to the doctrinal premises.

Thus, as in the case of purity and pollution, the Christian view that physical circumcision lacked truth-value in effect operated as a deterrent to the practice. Since Christians were not circumcised, proponents of circumcision had the burden of convincing Christians to change their ways, and religious doctrine removed arguments based on knowledge from the arsenal of weapons that a proponent of circumcision might have used to encourage social change.

III. THE TRIUMPH OF MEDICAL CIRCUMCISION

Toward the end of the nineteenth century, a remarkable change occurred in the attitudes and practices of the English-speaking world. Christians began to circumcise children, first as men and boys, and then as newborns. From a posture in which no males were circumcised except for treatment of disease or for religious reasons not shared by the majority culture, the society moved rapidly to a posture in which nearly every male was circumcised at birth.

A. Background

The movement towards routine neonatal circumcision occurred in two stages. First, physicians, acting as norm entrepreneurs, successfully promoted circumcision as a remedy for various diseases and conditions. In 1870, Lewis Sayre, a prominent orthopedic surgeon and president of the American Medical Association, was called to consult on the case of a five-year-old boy who was unable to straighten his legs.¹⁶⁸ Sayre concluded that the condition was the result of paralysis but could not, at first, discern the cause. The mystery cleared up when the nurse informed Dr. Sayre that the child's pee-pee was sore. On examination, Sayre discovered that the foreskin had contracted around the glans, causing inflammation. As excessive venery is a fruitful source of physical prostration and nervous exhaustion, sometimes producing paralysis, Sayre explained, I was disposed to look upon this case in the same light, and recommended circumcision as a means of relieving the irritated and imprisoned penis.¹⁶⁹ The results were miraculous; within a few weeks, the patient was completely cured. Generalizing from this case, Sayre hypothesized that genital irritation was a cause of many cases of paralysis and joint disease.¹⁷⁰ At the 1870 meeting of the American Medical Association, he delivered a sensational paper theorizing that adhesions between the prepuce and glans caused all sorts of conditions.¹⁷¹ Sayre's paper provided the intellectual basis for the pro-circumcision movement that developed over the next 30 years.¹⁷²

Within fairly short order, circumcision was promoted as a remedy for alcoholism, epilepsy, asthma, gout, rheumatism, curvature of the spine, and headache;¹⁷³ hysteria and other nervous disorders, paralysis, malnutrition, night terrors, and clubfoot;¹⁷⁴ eczema, convulsions, and mental retardation;¹⁷⁵ promiscuity, syphilis, and cancer.¹⁷⁶ Physicians also advised circumcision for the treatment of neurasthenia, a generalized condition characterized by morbid fears, fear of society, of solitude, or traveling, of places, of disease, or morbid impulses, to kill one's self or others, mental depression, wakefulness, headache, impaired memory, [or] deficient mental control.¹⁷⁷

By far the most important health benefit of circumcision lay in its efficacy at treating masturbation and spermatorrhoea (wet dreams).¹⁷⁸ Jonathan Hutchinson, a prominent British physician and President of the Royal College of Surgeons, advocated this position in an influential paper entitled Circumcision as Preventative of Masturbation.¹⁷⁹ Hutchinson argued that circumcision could reduce masturbation because it freed adhesions that caused irritation and induced the patient to handle the penis, an act that naturally led to self-abuse.¹⁸⁰ He expressed the hope that circumcision may often accomplish much, both in breaking the habit as an immediate result, and in diminishing the temptation to it subsequently.¹⁸¹

Hutchinson's theories found a receptive audience in the United States. Writing in the journal Medical Age in 1898, W.M. Donald, a lecturer at the Detroit College of Medicine, observed that a comfortable minority of masturbation cases were caused by preputial irritation, due to adhesions or undue length of the foreskin, or both, quite sufficient to account for the vice.¹⁸² For these cases, circumcision provided a cure, if performed early enough in life. Donald reported on three cases of masturbating boys ages six, nine, and ten in the Detroit orphan asylum. All suffered from elongated prepuces and phimosis. Circumcision was performed, with the following results:

The youngest was in the grasp of the vice to such an extent that he attempted to masturbate the day following the operation, but succeeded in inducing only a vast amount of swelling and soreness, with tearing of the stitches. Since that time to the present writing, three months later, his nurse reports that he has been absolutely free of the trouble. The second boy was cured by the operation, and has since remained cured. The third boy, aged ten, was such an incorrigible case, having probably masturbated for several years, that after the operation, despite the fact that during the day he showed no sign of indulgence in his vice, yet when soundly asleep at night his nurse would discover him practicing it unconsciously. I thereupon ordered rough mits [sic] placed on his hands at night, so that the rough friction would awaken him from his sound sleep. After a few nights of this treatment he gave us no further trouble.¹⁸³

Donald urged that where the physical indications were present, it was best to circumcise the boy during the first year of life, so that to a degree at least danger of future moral contamination may be avoided.¹⁸⁴

The pronounced benefits of circumcision led to an enormous increase in the frequency of the operation. By 1889, circumcision had become fashionable, even in vogue.¹⁸⁵ The operation appears to have become a virtual cottage industry, at least for some doctors.¹⁸⁶ Cincinnati physician Merrill Ricketts was one enthusiastic convert to the circumcision cause. Writing in 1894, Ricketts boasted that he had circumcised 200 males and compared his experience at foreskin removal to that of King David.¹⁸⁷

The triumph of circumcision was only half won, however, with the operation's acceptance as a means for curing disease. The problem was that circumcision as a remedial procedure was performed on older children or adults.¹⁸⁸ The field of medicine did not consider the circumcision of this population optimal. It was painful, and the recovery period not particularly pleasant.¹⁸⁹ Complications occurred frequently and were hard to disguise.¹⁹⁰ Moreover, if the operation was performed in order to cure a particular medical condition, the possibility always existed that it would fail.¹⁹¹

Accordingly, towards the end of the nineteenth century, as the medical efficacy of circumcision became firmly established, some normentrepreneurs began to promote neonatal circumcision, not as a remedy, but as a prophylactic.¹⁹² Because the benefits of circumcision were so manifest, and because the diseases against which it provided protection were so ubiquitous, the course of prudence was to remove the prepuce as soon as possible.¹⁹³ It was not advisable to wait for the symptoms of disease to appear, especially given the danger that, once a condition was diagnosed, it might be impossible to cure.¹⁹⁴ In practice, early circumcision meant performing the procedure soon after birth.¹⁹⁵

Physicians saw several benefits to neonatal circumcision. The operation could be accomplished with less invasive cutting, and was therefore safer.¹⁹⁶ Since they believed newborns could not feel pain, they could be circumcised without anesthetic.¹⁹⁷ Physicians could avoid the risks of ether, chloroform, or cocaine, the available surgical anesthetics of the time.¹⁹⁸ Although infants were likely to move around more than adults, this problem could be easily managed. The newborn could be held by two assistants¹⁹⁹ or bandaged to a board after the Indian fashion of strapping the papoose.²⁰⁰

Performing the procedure on infants had other advantages from the standpoint of the physician. Infants were incapable of resisting, and could not voice their objections through any means other than crying, which they were expected to do in any event. Bad results could be explained away more easily: because newborns were prone to medical problems, circumcision complications would not necessarily raise questions about the physician. If the baby died, it was unfortunate, but many babies died.²⁰¹ Moreover, since the neonatal operation was performed as a prophylactic rather than a cure, the physician did not have to explain any failure of the operation to achieve its intended result. If a child eventually developed some disease against which circumcision was protective, the physician who conducted the operation would often be out of the picture. Even if the physician was around, he could avoid blame. Circumcision was not thought of as a vaccine against masturbation and other diseases but only as a procedure that removed predisposing factors.²⁰² Finally, routine neonatal circumcision provided reliable and steady work for physicians. The chance to earn some extra income provided these specialists with an incentive to promote the operation among their patients, adding further impetus to a cultural tide that was already running in favor of neonatal circumcision.

Thus, after the turn of the century, physicians increasingly began to recommend newborn circumcision as a preventive measure. Articles appeared in medical journals advising the best means for performing the operation on young children.²⁰³ Nurses who tended the mother and newborn after delivery encouraged the operation. They were in the habit of checking whether the newborn had a retractable foreskin, and, if the baby did not (as most do not), they would suggest a little operation.²⁰⁴ Advanced thinkers of the time also took up the cause. Bertrand Russell, in his book of advice for parents, Education and the Good Life, expressed doubts that infantile masturbation was harmful to health,²⁰⁵ but noted that sometimes it is rendered more pronounced by some definite physical irritation which can be removed.²⁰⁶

Parents had every reason to accept neonatal circumcision. Medical opinion regarding the health benefits of the procedure was nearly universal.²⁰⁷ Circumcision alleviated parental concerns about masturbation: rather than constantly spying on their children to detect the telltale signs of solitary vice, parents could content themselves with the knowledge that they had done the right thing to stop masturbation before it began.²⁰⁸ Parents also gained social status from having circumcised children. Circumcisions were performed in the hospital, where physicians could operate under sanitary conditions and monitor the healing process for the first few days.²⁰⁹ Circumcision was thus a mark of hospital birth. It became an indicator of prestige.²¹⁰ Upwardly mobile middle class families had their boys circumcised in order to reinforce their sense of social superiority over the lower social classes, especially immigrants who were surging into the country from Europe at the time.²¹¹

By 1910, circumcision was one of the most common operations in the United States,²¹² being performed on 56 percent of boys.²¹³ Wealthier families in particular took to the procedure, a feature that continues to the present day.²¹⁴ During World War II, physicians frequently performed the procedure on soldiers as a preventative measure against venereal diseases.²¹⁵ Circumcision rates increased further during the baby boom years after these men returned home from the war.²¹⁶ Masters and Johnson, writing in 1966, reported that only two out of a sample of 120 men between twenty-one and thirty years old were not circumcised.²¹⁷ The authors reported that the uncircumcised male, particularly one born in an urban area, indeed, is becoming a rarity in our society.²¹⁸ Circumcision also became common in other English-speaking developed nations, ²¹⁹ although it never achieved the same popularity outside the Anglophone world.²²⁰

What accounts for the success of the norm entrepreneurs who promoted circumcision? Three explanations stand out. We have seen that a principal impediment to the adoption of circumcision by non-Jews was the overwhelming force of Christianity in the culture. As the nineteenth century drew to a close, traditional Christianity found itself under assault from humanism, evolutionism, cultural liberalization, and other aspects of a modernist worldview.²²¹ It was no longer so important, as time went on, for a man or boy to declare himself a Christian by remaining uncircumcised. In addition, as Christian beliefs lost their monopoly on the cultural background, those shaping public opinion could look to Jews as authority and even compare Christian beliefs unfavorably to those of the Jewish faith.²²²

By the end of the nineteenth century, moreover, physicians had begun to assume greater status and prestige in popular culture.²²³ Doctors became secular confessors. Patients would come to them to disclose the most intimate details of their personal lives in hopes of gaining absolution through medical treatment. Freud was the most visible, and influential, embodiment of this trend toward physician as secular priest,²²⁴ but many other physicians played a similar role. As a result of the charisma associated with their claim to professional knowledge, physicians were able to recommend changes in social habits on ostensibly medical grounds and to have these recommendations respected, at least by the educated middle class where the movement toward circumcision gained its first and most permanent foothold.²²⁵

Finally, and most importantly, circumcision provided a convenient means for managing cultural and professional anxieties.²²⁶ The Victorian era saw masturbation as immoral, disgusting, and deleterious to health.²²⁷ Physicians and moralists spearheaded a campaign against masturbation and spermatorrhoea that was massive in scope and pervasive in operation. Eventually, however, the campaign against masturbation and spermatorrhoea proved to be inconvenient for medical doctors and became a trap of their own making. On the one hand, while they had held seminal loss out as the cause of disease, the mechanisms of this disease, and the proper treatment for its ravages, were so vague that anyone with imagination could offer a cure and make money off it.²²⁸ Quacks and patent medicine vendors arose in profusion, siphoning income from trained doctors while threatening the public standing of the profession.²²⁹ Thus, the diseases of masturbation and spermatorrhoea, which physicians had promoted as a means for managing their occupational anxieties, ended up causing anxieties of their own. The medical profession also had to face the fact that, having identified these syndromes, it was unable to effect a cure, even with heroic measures such as night gloves, spiked penile rings, and wire cages.²³⁰ As masturbation panic grew, parents, advised by reputable medical authorities, came to believe that their children could begin to masturbate before puberty, even as early as age one.²³¹ Doctors attempted increasingly desperate remedies: burning the urethra with caustic agents, passing metal rods up the urethral canal, inserting peccaries through the anus in order to compress the spermatic ducts, passing electric sparks through the testicles, and even castrating incorrigible offenders.²³² Despite these measures, boys masturbated. The medical campaign was in danger of backfiring. Meanwhile, the principal anxiety for physicians that the disease of seminal loss warded off—the inability of medicine to understand the basis of disease, much less to cure it—began to fade as the century progressed.²³³ By the end of the nineteenth century, medicine had begun to make real advances, most especially with the development of germ theory. Because medicine was obtaining a more scientific handle on disease, it could dispense with the reliance on seminal loss as the cause of diffuse symptoms that could not be explained by other means.²³⁴

Circumcision grew in popularity at the end of the nineteenth century as a convenient solution to these problems. Because circumcision was viewed as a preventative to masturbation,²³⁵ it offered the promise of resolving the problem with a simple operation. Parents their circumcised could comfort themselves with the knowledge that they had done the responsible thing to reduce the risk that their sons would fall prey to the secret vice. The failure to circumcise a child, on the other hand, would be close to criminal negligence.²³⁶ In addition, physicians could rid themselves of some of the discomfort that the diseases of masturbation and spermatorrhoea were causing by recommending the relatively minor procedure of circumcision as a remedy and could, in the process, supplement their incomes with fees for performing the procedure. For these reasons, among others, circumcision became increasingly popular after the turn of the twentieth century as an exit strategy for concerns about masturbation.

B. Culture

As discussed above, Western culture, and especially the culture of the United States, moved rapidly from a state in which circumcision of boys was rare and threatening, to one in which it was nearly universal. This movement was framed and argued in terms of familiar cultural polarities, which norm entrepreneurs manipulated to promote circumcision as a medical and cultural practice. Norm entrepreneurs effected this change in social values through the construction of a standard narrative that emphasized the positive features of circumcision and discounted its negatives. The narrative portrayed the foreskin as evil and dangerous—the tight-constricted, glans-deforming, onanism-producing, cancer-generating prepuce.²³⁷ It pictured circumcision, on the other hand, as a quick, painless and sterile operation on a barely-sentient new-born, the sharp scalpel in the expert hands of a trained doctor ... justifiable on grounds of health.²³⁸ This narrative reconceived the phallus in such a way as to alter the values assigned to circumcision across the polarities that shaped Western culture's concept of the social world.

We have seen that prior to the late nineteenth century, circumcision in Western culture (except among Jews) was neither pure nor polluting. Part of the strategy of norm entrepreneurs who promoted circumcision was to change the cultural background by portraying the uncircumcised penis as polluting and circumcision as purifying. Circumcision signified precisely that aversion to dirt—and not just dirt, but vulgarity, nasty habits, and diseases—that symbolically set one on a higher plane.²³⁹ The strategy here was two-fold.

First, circumcision advocates stressed the operation's efficacy as a remedy for various polluting conditions. These included, most prominently, masturbation and spermatorrhoea. The loss of semen from these conditions was defiling.²⁴⁰ The culture was explicit on this point: masturbation and spermatorrhoea were pollution. Because circumcision provided protection against these conditions, it was also, by implication, a protection against pollution. By the same token, the lack of circumcision was polluting, or potentially so, because it left in place the adhesions and other irritations that conduced to seminal losses.²⁴¹ Thus, if a man was suffering from seminal losses (as most men were because of the near universality of masturbation and wet dreams), it was a good idea to submit to the purification ritual of circumcision.²⁴² Circumcision also came, over time, to be considered a remedy for a different but equally polluting set of conditions—venereal diseases such as syphilis and gonorrhea. Many physicians believed that the foreskin was a risk factor for these diseases. Doctors in the armed forces, concerned about these risks, strongly encouraged recruits to undergo the operation, and many submitted to the procedure.²⁴³

A second strategy of circumcision advocates, in the area of purity and pollution, was to characterize the prepuce and the smegma that accumulated underneath it as polluting. Smegma had previously been considered a healthy secretion of the sebaceous glands, and therefore part of the body's natural means for keeping the penile skin supple and soft.²⁴⁴ Circumcision advocates pointed to research findings that smegma contained only trace amounts of sebaceous matter; its principal constituent was, instead, desquamated, sloughed off) skin.²⁴⁵ Smegma was thus a form of waste, which in the normal course of things would be eliminated through washing or shedding, but which, unlike other wastes, was artificially trapped within the preputial space. Waste trapped under the foreskin could produce an added chemical irritation due to retained secretions constantly eroding the delicate mucous surfaces.²⁴⁶ Smegma was a dirty substance...likely to produce bad odors [in the uncircumcised male].²⁴⁷ It was infectious material and, as such, an agent in the spread of disease.²⁴⁸ As Jonathan Hutchinson put it, the prepuce constitutes a harbour [sic] for filth.²⁴⁹ Smegma, in short, was impure, polluting, and comparable to other polluting bodily wastes such as feces or urine.²⁵⁰

As time went on, physicians attributed ever-greater polluting powers to smegma, in particular the view that it was carcinogenic.²⁵¹ Circumcision advocates observed that Jewish men rarely contract penile cancer and concluded that the factor distinguishing Jews from others must be circumcision. And if smegma was carcinogenic for men, it had to be equally polluting for women. Jewish women were not prone to cervical cancer because their cervixes did not come into contact with smegma.²⁵² The preputial space, in short, was a cesspool for infectious agents.²⁵³

Advocates of circumcision did not claim that removal of the prepuce was the only way to control the buildup of pollutants. Regular genital hygiene could do the trick.²⁵⁴ However, the hygienic measures called for in the medical literature were heroic. Authoritative statements warned parents that the uncircumcised penis required lifelong hygienic care.²⁵⁵ The suggestion was that this part of the body was highly toxic (all external bodily parts require lifelong hygienic care, but medical societies don't issue grim warnings to this effect for the elbows or wrists). If hygienic measures were neglected, it was difficult to rectify the problem. As George M. Beard of Philadelphia observed, the accumulations of smegma are in some cases enormous, and are sometimes as hard as boards.²⁵⁶

Parents often found the hygienic demands to be overwhelming. Mothers, for example, were warned to forcibly retract the foreskins of their sons nearly from birth.²⁵⁷ This caused natural concern because infant foreskins are rarely retractable, so that the mother's well-intentioned cleaning efforts could produce pain and bleeding. Even when easy retraction of the foreskin was achieved, parents probably tired of the incessant cleaning thought necessary to deter the buildup of smegma. Mothers also experienced discomfort at the handling of their sons' genitals entailed by the recommended hygienic regime.²⁵⁸ Given one experience with an uncircumcised boy, parents were likely to circumcise later-born boys and, assumedly, to advise friends to do likewise.²⁵⁹

Circumcision advocates also addressed the polarity between health and disease. They argued that circumcision was a means toward enhancing health and that lack of circumcision was, if not itself a disease, at least a precursor and fertile condition for the development of disease. Not only was the lack of circumcision conducive to masturbation and spermatorrhoea, but it also caused all sorts of other serious conditions: cancer, gangrene, nervous conditions, joint problems, and much else.²⁶⁰ The nearly universal consensus of informed opinion, at least in the English-speaking world, held that circumcision was conducive to health and the lack of circumcision carried significant risks of harm.

Circumcision advocates drew on the polarity of self and other. An impediment to the acceptance of male genital surgery was the association of the ritual with Jewish religion and culture and, therefore, with a set of practices and beliefs which, although tolerated, were separate from the majority culture. If circumcision were seen as a Jewish ritual, it might be conceptualized by the majority culture as other and rejected for that reason. Recognizing this danger, circumcision advocates forthrightly addressed the Jewishness of circumcision. They stressed the Jewish roots of Christianity and praised rather than denigrated the Jewish way of life. Jonathan Hutchinson, for example, observed that no one who has seen the superior cleanliness of a Hebrew penis can have avoided a very strong impression in favour [sic] of the removal of the foreskin.²⁶¹ Echoing the theme, P.C. Remondino extolled Jews: their family structure is strong; they care for the aged and infirm; they contribute to the welfare of society; they rarely engage in criminality; and they are, in general, a remarkably long-lived and healthy people.²⁶² To these virtues of Jews Remondino boldly contrasted the deficits of Christians. Family veneration and attachment are weaker among Christians than among Jews, he claimed, and even weaker among Christians than in the Oriental races.²⁶³ As for the English, despite claims of superiority, they were actually in an acquired state of moral and physical degeneration.²⁶⁴ Remondino even questioned the authority of St. Paul to abolish circumcision, observing that the Apostle did not speak with the authority of a Disciple and that Paul's motives were more practical than spiritual.²⁶⁵ Jewish traditional views on circumcision were thereby rehabilitated.

Circumcision advocates enlisted concepts of self and other to associate the circumcised phallus with civilization and the uncircumcised phallus with savagery. They pushed this line with an argument from evolution. The foreskin's leathery pouch²⁶⁶ once had utility as an aid to primitive man.²⁶⁷ It protected naked men from briars, bark, bug bites, and attacks by small aquatic lizards.²⁶⁸ The prepuce had long outlived its usefulness, however. Man had cleared away the brambles and thorns that had threatened the genitals of savages, and clothes protected the glans from whatever dangers remained. Thus, the prepuce was superseded: environment and civilization have placed man in that position that he has no further use for this curious relic of a long-past barbaric age.²⁶⁹ By associating lack of circumcision with savagery, and circumcision with culture, advocates coded the circumcised condition as self — that is, partaking of civilized society—while relegating the uncircumcised state to the status of other.

Circumcision advocates reinforced the view of the foreskin as other by portraying the organ as the enemy of the glans. The connections between prepuce and glans were referred to as adhesions.²⁷⁰ The suggestion was that the interface between foreskin and glans was something unnatural, a bond that should not be present in ordinary development and that must be broken by the doctor if it does not resolve spontaneously.²⁷¹ According to the metaphor, the prepuce clings to the glans and interferes with its natural functions. The prepuce and glans are not part of an organic whole, but rather adversaries working at cross-purposes. As between them, the prepuce represents the primitive forces that hold man back, the glans, the forces of development—forces that were consonant with the late Victorian era's self-concept as a progressive age looking forward to a bright and exciting future.²⁷²

Circumcision advocates characterized the prepuce as unnatural. These norm entrepreneurs could not very well claim that the organ was itself unnatural, since it was self-evidently part of the human anatomy. The strategy was therefore to denigrate the prepuce as rudimentary²⁷³ and redundant,²⁷⁴ a mere appendage or appurtenance.²⁷⁵ Students at leading medical schools were instructed that the prepuce was tantamount to a minor birth defect.²⁷⁶ Because the prepuce was superfluous, it was not natural. Its removal would not affect bodily functions and thus would not detract from the human anatomy. Unlike other vestigial organs, which at least did no harm, the prepuce was dangerous and therefore doubly unnatural. As Remondino explained,

the opponents of circumcision base much of their opposition [on] the fact that circumcision interferes with the natural condition of the parts. The question may well be asked, which of these two shaped glans [the glans of the circumcised and uncircumcised penis] is the natural product as nature intended it should be? It is a well-known fact that the ... glans penis will, within a week or two after its liberation from its fetters of preputial bands, assume its true shape. We may naturally inquire if nature made the glans of a certain shape, which seems to be the proper shape for copulative purposes, only to have the condition most effectually abolished by a constricting, unnatural band? ²⁷⁷

Orificial surgeon G.A. Brown followed up the advantage of this argument with a compelling syllogism. If the prepuce were a natural organ, it would not cause disease. Yet the prepuce did cause disease. Ergo, the prepuce was unnatural. To argue otherwise was absurd in the extreme.²⁷⁸

Some circumcision advocates went further than contending that the foreskin was a vestigial organ that had become dangerous to natural functioning. They denied the prepuce a role as an independent organ with its own identity and structure. Chicago physician C.B. Walls, for example, denigrated it as a piece of tissue,²⁷⁹ suggesting that it is simply a mass of undifferentiated flesh. If the prepuce is an accumulation of flesh, its removal could not affect the naturalness of the male body. Indeed, as tissue, the prepuce was, at least implicitly, associated with other tissue masses, such as tumors or cysts, which while attached or embedded in the body, are unnatural rather than natural.

Related to the idea of the unnatural prepuce was the connection between lack of circumcision and masturbation. Masturbation, in the view of the late nineteenth century, was prototypically unnatural. It was, indeed, a sin against nature, as Victorian moralists never tired of pointing out.²⁸⁰ This unnatural aspect distinguished masturbation from coitus: although both caused loss of vital fluid, only masturbation debilitated the nervous system because intercourse was natural.²⁸¹ Males who were not circumcised tended to masturbate.²⁸² Thus lack of circumcision was unnatural. Circumcision, on the other hand, was conducive to natural functioning because it acted as a deterrent to the solitary vice.

Once it took hold, the idea of circumcision being natural reinforced itself in a reflexive fashion. Circumcision became so familiar, so normal, that it ceased even to be an issue. The category of natural is related to the concept of routine. When a procedure becomes routine, it stops being questioned. Evidence that might indicate the need for questioning—for example, hemorrhage, infection, surgical errors and other difficulties—would not be considered a problem. At the same time, the concept of the procedure as routine (i.e., natural) preconditioned the medical profession to accept the health benefits advanced for the procedure, such as prophylaxis against urinary tract infections, balanitis (localized infection of the glans) or penile or cervical cancer.²⁸³ Even baby doctor Benjamin Spock accepted the naturalness of circumcision, recommending the procedure in the 1957 and 1968 editions of His treatise, Baby and Child Care, on the ground that an uncircumcised boy might not feel regular.²⁸⁴ And these ideas are with us still. Despite some changes in attitudes, the popular view continues to be that the circumcised penis is normal and natural. As one new father said, It's the natural thing to circumcise a son.²⁸⁵

Advocates of circumcision also drew on the polarity of beauty and deformity. The strategy here was to portray the circumcised phallus as beautiful and the uncircumcised organ as ugly. P.C. Remondino, although speaking from the authority of a physician unconcerned with matters aesthetic, graphically depicted the deformities that the prepuce inflicted on the phallus. He explained that preputial tightness started a chain of unhappy events, involving the buildup of smegma, the irritation of the affected surfaces, inflammation, thickening, hardening, and loss of elasticity in the prepuce, and the formation of adhesions.²⁸⁶ The prepuce turned into an unyielding tube imprisoning the glans.²⁸⁷ The constricted glans, in turn, became elongated, cyanosed, and hyperaesthetic; the meatus of the urethra [the opening at the tip of the penis] is congested and hypertrophied; the corona is undeveloped and often absent, the glans having, on the whole, the long-nosed, conical appearance of the head of a field mouse.²⁸⁸ In contrast to this unappealing image of the uncircumcised phallus, Remondino offered a positive view of its circumcised cousin. The head is shorter, the face flat and abrupt, and the meatus, instead of being at the end of a conical point, is situated on the smooth, rounded front of the glans, and does not differ in color from the covering of the glans itself... .Its topographical outline may be said to describe two opposite segments of a circle, as seen in the cuts representing the glans in its natural shape. The corona is prominent and well developed.²⁸⁹

Remondino was careful to disguise these aesthetic judgments in scientific jargon. Some authorities were not so inhibited. They directly pronounced the beauty of the circumcised phallus.²⁹⁰ Physician Willard Goodwin is a case in point. He argued that circumcision is a beautification comparable to rhinoplasty [a nose job].²⁹¹ Goodwin praised the cosmetically-altered phallus because it appears in its flaccid state as an erect uncircumcised organ—a beautiful instrument of precise intent.²⁹² In contrast, by implication, the uncircumcised phallus was unattractive and in need of correction through plastic surgery.

The negative image of the uncircumcised penis matched well with views on masturbation as conducive to deformity and ugliness. These were ubiquitous during the Victorian era. The masturbator was portrayed in the most pitiful and unflattering terms. His was a low, mean look, a hang-dog expression; a pallid face; hollow, watery eyes; cold, moist hands; lustreless hair; constrained, embarrassed manner; drooping shoulders; a tendency toward twitching the muscles; frequent repetition of swallowing motions ...²⁹³ Men or boys who refrained from masturbation, on the other hand, were depicted as paragons of grace and beauty. They radiated the virile power of superb manhood to which all right-thinking men aspired, and which sparked the interest of all young women.²⁹⁴

Particular attention focused on the deforming effects of masturbation on the genitals, which in masturbators displayed defects beyond those caused by the prepuce alone. In these pathetic souls, the veins of the integumentary covering of the penis become very much enlarged and tortuous, and the skin itself becomes of a dull yellow color, with a tendency to wrinkle.²⁹⁵ The penis was likely to be thinner and smaller than usual, and could be elongated and cold to the touch.²⁹⁶ The organ might be bent laterally, usually to the left.²⁹⁷ The testicles, too, suffered from the ill effects of masturbation. In a person of evil habits, the testicles were soft and flabby²⁹⁸ and the left hung much lower than the right.²⁹⁹

As circumcision became established in American culture, images of the male body began to conceive of the phallus in its circumcised state. These images cannot generally be seen in fine art, where the male genitalia are ordinarily either not shown or displayed in such a way as to make it impossible to discern whether or not the subject is circumcised. Photography, however, took over the task of the representational portrayal of the male nude. Here we do see images of circumcised men.³⁰⁰ Many of these pictures were not widely distributed, circulating instead in an artistic and/or gay subculture; but the change in aesthetic attitudes seems to have filtered into the broader culture. By the 1970s, when graphic depictions of male nudity began to emerge from the shadows of pornography and censorship, the circumcised male phallus became normative. Presumably these magazines play to, as well as to some extent shape, popular aesthetic judgments. Some who worry about the appearance of their genitals have even had themselves circumcised for cosmetic reasons.³⁰¹ It is hard to judge popular attitudes on the relative attractiveness of the circumcised and the uncircumcised phallus, although some evidence suggests that sexual partners may now prefer the intact organ.³⁰²

Meanwhile, artists such as Robert Mapplethorpe began to play off against the normativeness of the circumcised phallus. Several of Mapplethorpe's more controversial photographs graphically display men with extravagantly uncircumcised organs; part of the shock value of these works is the frank display of the phallus in its uncut state.³⁰³

Concepts of male and female were also implicated in the movement towards circumcision during the late nineteenth and early twentieth centuries. Victorian culture was obsessed with virility.³⁰⁴ Manhood could be lost most easily through seminal leakage. Thus, the narrative of the times equated masturbation and spermatorrhoea with lack of manliness. As the Victorian psychologist Henry Maudsley put it, in the masturbator there is a want of manliness of appearance as of manliness of feeling.³⁰⁵ Such degenerate beings, he added, are very much as eunuchs are represented to be.³⁰⁶ To preserve manhood, it was essential to avoid seminal loss. Circumcision, as a treatment for masturbation and spermatorrhoea, thus became a source of virility.

Circumcision also preserved manhood by protecting against male infertility.³⁰⁷ P.C. Remondino explained that the prepuce could block the meatus, ballooning outward or forcing seminal fluid backward into the bladder. In such cases, the man would be partly eunuchised by a constricted prepuce.³⁰⁸ Even if the prepuce did not interfere with seminal discharge, it could still inhibit conception. The prepuce could cause the glans to be long, pointy, conical, and deficient in a corona. All these conditions worked to deter conception: not only was the semen directed away from the cervix, but the lack of a corona eliminated the valve action that served to retain the semen in a proper location.³⁰⁹

The prepuce also threatened potency. A man who suffered from phimosis was likely to experience difficulties in obtaining an erection because of the adhesions between glans and prepuce.³¹⁰ The results could be disastrous. A.W. Taylor, a New Jersey physician, phrased the matter with appropriate Victorian modesty, managed to interweave themes of pollution, masculinity, and anxiety about the welfare of the family. Domestic infelicity, he said, is often caused by an existing, and not understood, phimosis interfering with the proper performance of the marital functions... . I believe an examination and circumcision of the husband would often do more towards producing domestic harmony than the disgusting and prolonged divorce suits which drag their slimy length through our courts.³¹¹

The prepuce's threat to masculinity went beyond its deleterious effects on fertility and potency. It also threatened the virile organ in its entirety. A constricting foreskin created a risk that the penis would become infected and gangrenous, or that it would be stricken by cancer.³¹² Both of these conditions often required amputation.³¹³ The pitiful victim would be emasculated.³¹⁴ Circumcision, protective as it was against gangrene and cancer, also helped ensure against this most serious loss of manly powers.

Notions of order and chaos played a role in the promotion of circumcision as a remedy. In part, the equation of the prepuce with disorder was carried out in the realm of anatomy. Physicians were trained to distinguish disorders from normal anatomical structures. Viewed from this perspective, the prepuce came to be conceived of as displaying massive tendencies towards disorder. It was too long, too narrow, redundant, or adherent to the glans. By defining conditions for normalcy that few actual organs could satisfy, medical science identified a wide range of structures as disordered. The prepuce therefore came to appear, if not intrinsically disordered, at least as extraordinarily susceptible to abnormal development.³¹⁵

Further, as we have already observed,³¹⁶ before the late nineteenth century, the operation of circumcision was uncertain, messy, and painful—in short, chaotic. Circumcision advocates attempted to rectify this problem by means of education. As the century drew to a close, medical journals focused on illustrating or discussing techniques for circumcision.³¹⁷ Chaos began to subside as the profession developed protocols for the operation. By 1907, a physician could write, circumcision [is] unhesitatingly undertaken by most general practitioners.³¹⁸ Although this assessment may have been premature, it did presage a time, not many years hence, when circumcision would be a perfectly routine procedure.

Promoters of circumcision frequently couched their arguments in moralistic terms. Here, the first order of business was to disparage the prepuce. Remondino cast the prepuce in the role of an outlaw,³¹⁹ a dark and mysterious desperado.³²⁰ Similarly, Beard indicted the prepuce for plotting to murder the glans by strangulation.³²¹ Placing this diabolically-inclined criminal³²² on trial, Remondino empanelled himself and his readers as an impartial jury and pronounced a sentence of execution.³²³ Elsewhere, Remondino likened the prepuce to a voluptuary of the Roman Empire,³²⁴ a torturer of the Spanish Inquisition³²⁵ or a bully of the American frontier with a penchant for crushing testicles.³²⁶ These images conveyed the impression that the prepuce was itself an object of evil that richly deserved to be removed from the individual body, just as evil people must be eliminated from the body politic.

In addition to blaming the prepuce, norm entrepreneurs pointed to the immorality of masturbation. Authorities of the Victorian period never tired of denouncing this habit and those who practiced it. The British physician Henry Maudsley decried its utter moral perversion.³²⁷ In the United States, J.H. Kellogg condemned the sin of self-pollution as one of the vilest, the basest, and the most degrading that a human being can commit.³²⁸ American moralist and censor Anthony Comstock warned that masturbation sears the conscience, hardens the heart, and damns the soul. It leads to lust and lust breeds unhallowed living, and sinks man, made in the image of God, below the level of the beasts.³²⁹ Popular terminology reinforced these views. Masturbation was the solitary vice, and those who practiced it engaged in self-abuse.³³⁰

Victorian authorities were not the first to stigmatize masturbation. The Catholic Church had condemned the practice for centuries, and masturbation had been under full-scale cultural attack since the 1700s.³³¹ However, prior to Hutchinson's work connecting masturbation with preputial irritation,³³² the attack on masturbation did not relate to circumcision. Once circumcision became accepted as an efficacious treatment for masturbation, the situation changed. Now the full force of the social abhorrence of masturbation could bolster the argument that circumcision was good because it deterred self-abuse, and that lack of circumcision was bad because the uncircumcised boy was likely to fall prey to the evil.

Circumcision advocates promoted the procedure by emphasizing the degree to which it partook of knowledge rather than ignorance. The strategy here was two-fold, looking both to the wisdom of the ages and to cutting-edge scientific research.

Advocates of the procedure rehabilitated the knowledge of Jewish sages, who had been eclipsed during most of the Christian period. The Jewish religion which these sages espoused was clear, simple, and unambiguous. For the Jew, said Remondino, there is none of the gloomy, weird, mystical, mind-racking, ungodly theology that some of our creeds torture the poor brains of their professors with.³³³ The Jewish religion is very philosophical and rational.³³⁴ Thus, traditional Jewish thinking on circumcision deserved to be treated with the highest degree of respect.

Circumcision advocates also contended that the advantages of the procedure were demonstrated by recent medical and scientific discoveries. There was even a scholarly publication, the Journal of Orificial Surgery, devoted to extolling the virtues of circumcision and other surgeries in the genital area.³³⁵ Remondino couched his enormously erudite treatise in scientific language and included numerous footnotes and quotes from learned authorities.³³⁶ He drew on demographic data showing Jews to be healthier and longer-lived than Christians.³³⁷ Jews, he argued, had lower infant mortality and a greater resistance to diseases such as plague, consumption and syphilis. The most likely cause of these advantages was circumcision.³³⁸

Moving beyond demographics, Remondino advanced other scientific reasons for considering the circumcised phallus superior to its uncircumcised cousin. He highlighted Sayre's work on circumcision and paralysis.³³⁹ He associated cancer of the penis with preputial adhesions.³⁴⁰ He touted medical research suggesting that circumcision cured enuresis and other urinary conditions.³⁴¹ He discussed theories about the efficacy of circumcision at deterring masturbation and spermatorrhoea.³⁴² He argued, in short, that the overwhelming consensus of advanced medical opinion viewed the prepuce as a potentially dangerous cause of a variety of frightening diseases and conditions.

Remondino and his colleagues achieved an astonishing success in promoting circumcision within American culture. For much of the twentieth century, it appeared that their victory would be permanent. But as the following section demonstrates, predictions of lasting success may be premature.

IV. THE ANTI-CIRCUMCISION MOVEMENT

A. Background

Recently, in what appears to be a new stage in the evolution of cultural attitudes, circumcision rates in English-speaking countries have begun to fall. The rate in Great Britain is now only 5 to 6 percent.³⁴³ Even in the United States, which has long been the country most prone to circumcize its boys, the rate is dropping. Circumcision rates have been in a slow decline since their peak in the 1960s,³⁴⁴ with most recent estimates at around 60 percent.³⁴⁵

Reflecting these changes in American practices is a marked lack of consensus within the American medical establishment about the utility of routine newborn circumcision. The American Academy of Pediatrics' wavering course of authoritative recommendations is illustrative. In 1971, the Academy concluded that routine circumcision of newborn infants lacked medical justification.³⁴⁶ The Academy reiterated this finding in 1975, stating not only that there is no absolute medical indication for routine circumcision of the newborn, but also that good hygiene offers all the advantages of routine circumcision without the attendant surgical risk.³⁴⁷ In 1989, the Academy retreated, based on studies finding a correlation between lack of circumcision and urinary tract infections.³⁴⁸ More recently, in 1999, the Academy again reversed course, concluding that the health benefits of circumcision are not pronounced enough to warrant its routine use as a medical procedure, and that anesthesia should ordinarily be employed.³⁴⁹

Campaigning for the elimination of routine neonatal circumcision is a new breed of norm entrepreneurs.³⁵⁰ Anti-circumcision organizations operate both in the United States and in other countries.³⁵¹ Although small in numbers, these groups are passionately committed to their view of circumcision as a mutilating and unnecessary operation. Like their predecessors who advocated circumcision, contemporary circumcision opponents attempt to manipulate basic categories and social polarities in order to impress their views on the broader culture.

On the surface, it appears that these anti-circumcision activists are united by nothing more than their opposition to the procedure. In this respect they differ from the norm entrepreneurs who promoted circumcision during the late nineteenth century. As we have seen,³⁵² the earlier breed of activists was associated with a social group—physicians—that existed independently of circumcision. In the case of today's anti-circumcision movement, it is difficult to find similar constituent groups organized for other purposes. Accordingly, it is somewhat hard to identify the underlying social anxieties, if any, which motivate the members of this movement.

Nevertheless, some observations are possible. The anti-circumcision movement appears to reflect two broader social themes of contemporary American society. One is the concept of a childhood wound. A variety of social concerns and movements draw from this basic idea. Parental narcissism, emotional abuse, or distancing is enlisted to explain problems in a child's later life.³⁵³ The child suffers a primal wound which is so painful that he or she, in later life, will engage in dysfunctional or addictive behaviors as a way of avoiding the pain of the original trauma.³⁵⁴ Codependency (living through others) is a common sequel.³⁵⁵ Another version of the childhood wound in contemporary American culture is the concern about the effects of parental substance abuse.³⁵⁶ The adult children of alcoholics syndrome is now widely accepted, and support groups for individuals who suffer the after-effects of parental substance abuse (e.g., Alanon) function in cities across the country. Parental incest is also a major issue for contemporary culture.³⁵⁷ The notion of the inner child who can be recovered through therapy and liberated from the wounds of a dysfunctional or abusive upbringing is nearly ubiquitous in the self-help literature.³⁵⁸ The anti-circumcision movement finds a natural home within this broader social trend. Neonatal circumcision is, in a sense, the paradigmatic childhood wound. It is not only a wound to the psyche, but also a direct assault on the child's body. Whatever motivates the broader phenomenon of concern about childhood wounding also appears to play a role in stimulating concern about male circumcision.

The second theme one can detect in the contemporary anti-circumcision movement relates to issues of gender, masculinity, and feminism. It is men, after all, who are circumcised. For some men today, it seems that the condition of being circumcised symbolizes a sense of damage to their traditional role and status. In this respect, the campaign against circumcision shares common features with the contemporary men's movement.³⁵⁹ There is currently a sense among men that masculinity is under siege. Men's traditional roles as heads of the family and breadwinners have been challenged by feminist gains, which have placed women in competition with men.³⁶⁰ For some men, the journey into adulthood has been disappointing. They do not feel needed or valued.³⁶¹ This painful experience may be defined in terms of bodily imagery. For such men, circumcision can symbolize the existential experience: the mutilated phallus is a synecdoche for the male condition in general. Anxieties about gender relations can thus influence attitudes about circumcision.

While these twin anxieties—the breakdown of the family and the loss of the traditional male role—may be experienced by people who self-identify as circumcision opponents, the concerns are broader. Many people who are not circumcision activists feel such anxieties. Circumcision opponents draw on these anxieties and thereby seek to mold social perceptions into a different set of values and beliefs regarding circumcision. Whether they will be successful or not remains to be seen.

B. Culture

Today's circumcision opponents reverse the polarity of purity and pollution, arguing that the uncircumcised phallus is pure and that circumcision is polluting. With regard to masturbation and spermatorrhoea, the task becomes trivial because of current scientific knowledge and social attitudes. Masturbation and spermatorrhoea are accepted, albeit with some reservations, as natural and harmless outlets for sexual energies.³⁶² Victorian views on this topic are dismissed as hysteria or delusion.³⁶³ Arguments in favor of circumcision to deter masturbation or wet dreams seem today like hokum. Even if circumcision were protective against seminal loss, it would not be purifying since the condition is no longer polluting.

Anti-circumcision advocates contest the view that circumcision promotes purity by facilitating penile hygiene.³⁶⁴ They observe that care of the intact penis is simply a matter of keeping it clean. A little education, and some soap and water, can supply all the purification necessary from the standpoint of hygiene. Circumcision is therefore an inappropriate response to the problem.

Anti-circumcision advocates also rehabilitate smegma.³⁶⁵ Undeterred by awkwardness, opponents of circumcision boldly promote the substance as pure rather than polluting. Far from being a form of bodily waste captured within the preputial space, smegma is presented as a kind of lotion that anoints the penis in a purifying bath. It is a lubricant that keeps the skin supple and facilitates sex.³⁶⁶ In addition, it contains valuable anti-bacterial and anti-viral agents.³⁶⁷ Viewed as a lubricant and anti-microbial agent, Smegma is not a polluting waste substance but a part of the body's own mechanism for self-regulation. In the words of Paul Fleiss, a prominent anti-circumcision spokesman, smegma is probably the most misunderstood, most unjustifiably maligned substance in nature. Smegma is clean, not dirty, and is beneficial and necessary.³⁶⁸

Opponents of circumcision characterize the circumcised phallus as polluted. Circumcision complications are described in terms of defilement. Penises are displayed with gaping holes through which urine and semen spurt out in the wrong direction. They erupt in grotesque skin growths.³⁶⁹ They ooze with ulcerations, burn with infections, and rot with necrotizing fasciitis.³⁷⁰ Sometimes they disappear into the abdomen.³⁷¹ They are sliced in half or burned off.³⁷² Images of pollution are everywhere in this account.

Even if the circumcision does not result in polluting complications, the operation still defiles. Anti-circumcision activist Paul Fleiss observes that the artificially externalized glans and meatus of the circumcised penis are constantly exposed to abrasion and dirt, making the circumcised penis, in fact, more unclean.³⁷³ Along the same lines, the premise that the circumcised penis requires little or no care has recently been questioned. An article in the British Journal of Urology concluded that the circumcised penis actually requires more care during the first three years: circumcised boys were significantly more likely to have skin adhesions, irritated urinary openings, and inflammation of the glans than their uncircumcised peers.³⁷⁴

Today's circumcision opponents have radically reconceived the meaning of the prepuce along the dimension of health and harm. Instead of seeing it as an unnecessary and dangerous appendage, they view it as a vital, dynamic, essential component of the male body.³⁷⁵ Their argument in favor of the prepuce as friendly to physical health has three prongs: first, circumcision does not, in fact, promote health; second, circumcision itself is the cause of disease or harm; and third, the prepuce is a useful and health-enhancing organ.

Opponents of circumcision observe that the principal diseases and conditions for which circumcision was recommended at the end of the nineteenth century turn out either not to be harmful, or, if harmful, to have nothing to do with circumcision. Masturbation went out of fashion as a disease after the Second World War, and in any event is not cured by circumcision.³⁷⁶ Nor, along the same lines, does circumcision deter promiscuity or risky sexual behavior.³⁷⁷ Circumcision appears to play no role in the occurrence of prostate cancer,³⁷⁸ cervical cancer,³⁷⁹ alcoholism, epilepsy, asthma, gout, rheumatism, curvature of the spine, headache, insanity, paralysis, crossed eyes, rectal prolapse, hydrocephalus, clubfoot, eczema, convulsions, neurasthenia or mental retardation.³⁸⁰ As to phimosis, or tight foreskin,³⁸¹ the modern view is that the condition is rare in adults,³⁸² and its diagnosis in children is usually nothing more than a misperception of the normal separation process between the prepuce and glans.³⁸³

There remains some evidence that circumcision may play a role in preventing a number of conditions. Circumcised boys and men may be at lower risk of contacting balanitis (a minor infection of the glans),³⁸⁴ urinary tract infections ³⁸⁵ and penile cancer.³⁸⁶ A few studies have suggested that circumcised men experience lower rates of sexually transmitted diseases,³⁸⁷ including HIV.³⁸⁸

Circumcision opponents discount these studies as weak or unproven and, therefore, insufficient to place circumcision in the social category of health. They observe that balanitis is a minor infection with no serious health risks.³⁸⁹ As to urinary tract infections, they observe that the evidence for a correlation with circumcision is not unambiguous ³⁹⁰ and may reflect socioeconomic variables.³⁹¹ They note that urinary tract infections in boys are uncommon, whether or not the boy is circumcised, and observe that this condition can usually be treated with antibiotics.³⁹² As to penile cancer, anti-circumcision advocates observe that the evidence is again ambiguous: penile cancer occurs in circumcised as well as uncircumcised men,³⁹³ is virtually absent in some countries with no tradition of circumcision,³⁹⁴ and reflects other risk factors such as smoking and promiscuity.³⁹⁵ Cancer of the penis is exceedingly rare and does not pose a serious health risk to the male population in general.³⁹⁶ Because penile cancer is a form of skin cancer, it would not be surprising if it occurred more frequently in uncircumcised men, who have about a third more skin in the region than circumcised men.³⁹⁷ But the fact that circumcision removes tissue that may become cancerous is hardly an argument for the operation's performance on a prophylactic basis; otherwise, we might routinely remove breasts or noses that are subject to cancers. Moreover, penile cancer almost never affects children. It occurs in men who, if not circumcised as children, have the choice, as adults, whether to be circumcised or not. Leaving the circumcision decision up to the affected individual would appear to pose few increased risks.³⁹⁸ Anti-circumcision advocates maintain that the alleged correlation between sexually transmitted diseases and lack of circumcision is weak at best and possibly spurious.³⁹⁹ With respect to HIV, they challenge the strength of the correlation and observe that circumcision might actually increase HIV infection if circumcised men come to believe that other precautions are unnecessary.⁴⁰⁰

In addition to arguing that circumcision does little, if anything, to promote health, circumcision opponents highlight complications of the procedure, which range from the minor and common to the rare and catastrophic.⁴⁰¹ These arguments are enlisted to move circumcision from neutral ground—that is, neither promoting nor harming health—to the position of being affirmatively dangerous. Circumcision trauma may impair psychological⁴⁰² and intellectual⁴⁰³ development. Physical complications include hemorrhage,⁴⁰⁴ adhesions,⁴⁰⁵ skin bridges,⁴⁰⁶ skin tears,⁴⁰⁷ denudation,⁴⁰⁸ bivalved or grooved glans,⁴⁰⁹ fistulae,⁴¹⁰ concealed penis,⁴¹¹ urinary blockage,⁴¹² ulceration,⁴¹³ meatal stenosis,⁴¹⁴ and infections,⁴¹⁵ which may be severe.⁴¹⁶ The physician may botch the procedure, injuring the glans⁴¹⁷ or scrotum,⁴¹⁸ amputating the glans⁴¹⁹ or penis,⁴²⁰ or burning the penis off with electrosurgery.⁴²¹ One boy was even reassigned as a girl after a circumcision that destroyed the penis.⁴²² In extreme cases, circumcision kills.⁴²³ These complications occur even in Western societies, where circumcisions are performed with sterile instruments and usually under medical supervision. The situation is more serious in traditional cultures, where circumcisions are often performed in non-sterile conditions and without medical supervision.⁴²⁴

Finally, anti-circumcision advocates argue that the prepuce itself enhances health. Some attribute disease-fighting functions to the prepuce, observing that it blocks entry of contaminants and secretes immunological agents.⁴²⁵ Recent discoveries that preputial skin can be used for grafting may further enhance the perceived health benefits of the intact prepuce. The foreskin may provide a reservoir of skin that can be used for repairs if a person suffers damage to the skin elsewhere in his body.⁴²⁶

The polarity between self and other is reversed in the contemporary anti-circumcision rhetoric. While the earlier generation of norm entrepreneurs had accommodated circumcision to the category of self, the new anti-circumcision advocates dissociate circumcision from the culture's concept of its own identity. The strategy here is two-fold: first, to reconceive the prepuce as part of the self; and second, to undermine the religious prestige that has historically accompanied the procedure.

Circumcision advocates had denigrated the prepuce as an appendage, a redundancy, even a piece of tissue lacking in definite organic identity.⁴²⁷ In this way, the prepuce could be classified as extraneous to the organism, and therefore could be removed without detracting from the self. Circumcision opponents reverse these categorizations. The prepuce, in their view, is part of the self and cannot be discarded as an alien intruder into the human anatomy. It serves many useful functions and is an interesting and complex anatomical structure in its own right. It is to be compared with the eyelid, a dynamic shielding layer that preserves the sensitivity of the eyeball,⁴²⁸ which no one would consider excising in a routine operation.

With respect to the health-enhancing functions of the prepuce, anti-circumcision advocates revive and renovate the early theory that it protects the glans. In this respect, they cleverly reverse the argument of the previous generation of norm entrepreneurs. Remondino and colleagues had claimed that the prepuce once served a valuable protective function, but that in modern times, clothing did a better job.⁴²⁹ The organ, accordingly, was superfluous. For today's opponents, on the other hand, the development of clothing makes It necessary for the prepuce to protect the glans. For the infant in diapers, the foreskin protects the glans from exposure to urine and feces. Gairdner observed as early as 1949 that it seems to be no accident that during the years when the child is incontinent the glans is completely clothed by the prepuce, for, deprived of this protection, the glans becomes susceptible to injury from contact with sodden clothes or napkin.⁴³⁰ As the child becomes toilet trained, this protection is no longer necessary, and the prepuce separates naturally from the glans.⁴³¹ This argument is difficult to couch in evolutionary terms, since the prepuce existed before diapers came on the scene, and indeed is present in other mammals that do not wear any clothes at all. Anti-circumcision advocates do not claim that the prepuce evolved to protect against diaper rash, but rather present this advantage as a sort of happy accident of anatomy.

The prepuce is also said to enhance sexual pleasure. Without the protection of the foreskin, the glans hardens due to the circumcision trauma⁴³² or subsequent chafing.⁴³³ With the prepuce in place, on the other hand, the glans retains its sensitivity, heightening sexual pleasure. Quite apart from its function in protecting the glans, the foreskin is itself endowed with an abundant nerve supply,⁴³⁴ making it an erogenous organ in its own right.⁴³⁵ Working together, the prepuce and glans offer additional sensations: the prepuce slides back and forth over the glans during foreplay and intercourse.⁴³⁶ The prepuce also assists the sexual performance of women and older people: because the shaft of the penis slides back and forth inside the prepuce during intercourse, the organ reduces problems of vaginal dryness or weak erections.⁴³⁷ Although the prepuce's contribution to sex is difficult to measure, some men who have been circumcised as adults testify to its virtues.⁴³⁸

Others hypothesize that the foreskin has survival value because it inhibits sexual behavior. According to one theory, the presence of phimosis and preputial adhesions in younger males deters intercourse by making erections difficult.⁴³⁹ Where these conditions exist, boys delay sexual activity, and hence parenting, until they are older and better able to provide for children. Thus, males with adherent foreskins were more likely to pass on their genes to succeeding generations because their offspring were more likely to survive.⁴⁴⁰ Another theory conjectures that circumcision effects neurological reorganization by raising the threshold of sexual excitability, making men more tractable and cooperative.⁴⁴¹

In addition to stressing the prepuce's functionality, anti-circumcision advocates praise its anatomical form. Contrary to popular belief, the prepuce is not a small and insignificant bit of skin. It is richly endowed with nerves, blood vessels, glands, and interesting skin formations.⁴⁴² It does not strangle or imprison the glans, as norm entrepreneurs of an earlier generation argued. Rather, it gives form to, and is in turn formed by, the other organ.

The concept of the prepuce adhering to the glans, like a foreign body that holds the glans back from achieving its intended function, also receives criticism from circumcision opponents. The terminology of adhesions ignores the fact that the prepuce and the glans are not originally separate structures. In the fetus, the deep surface of the prepuce is continuous with the epidermis surrounding the glans.⁴⁴³ Only as the fetus develops does the prepuce begin to separate from the glans, creating the preputial space. However, the separation process is rarely complete at birth.⁴⁴⁴ Gairdner found that in four out of five newborns the prepuce is not retractable, and that even by age three, about 10 percent of boys have a non-retractable prepuce.⁴⁴⁵ The prepuce and glans are not separate structures working at cross purposes, as in the older account, but rather parts of a single organic structure that separate through a normal process as the child matures. Recently, the scientific rehabilitation of the prepuce has taken another step with the discovery that preputial tissue has unusually valuable qualities for the treatment of burns and wounds.⁴⁴⁶ Neonatal prepuce cells can be harvested and grown in a laboratory into sheets that can later be used to repair the injury without danger of rejection. This procedure is now under commercial development, although it has not yet been approved for clinical use.⁴⁴⁷

In addition to rehabilitating the prepuce, anti-circumcision advocates deal with the sensitive issue of religious circumcision. One finds no criticism of the Jewish rite of the bris, even among opponents of male genital surgery. However, anti-circumcision advocates undercut the religious justification for circumcision. They sharply distinguish religious from non-religious rationales for circumcision, point to the horrors of ritual circumcisions in Africa, and suggest that circumcision should be a matter of individual conscience. The core of their argument, in this respect, is that people who do not identify themselves as members of religions practicing circumcision should not undergo the procedure.⁴⁴⁸ Some anti-circumcision activists argue that medical circumcision in the United States is actually a secularized religious practice.⁴⁴⁹ This impeaches the credibility of arguments favoring medical circumcision by suggesting that they are based on religious rather than scientific considerations. Someone who has no religious justification for circumcision should therefore classify the procedure as other rather than self.

Critics of ritual circumcision focus on Africa. Here, the rhetoric stresses the ritualistic and primitive elements of African circumcisions.⁴⁵⁰ In an article in the London Sunday Times, journalist Robert Block describes the ordeal of South African youths of the Xhosa tribe.⁴⁵¹ Block relates that the young men had fallen into the hands of bush surgeons who subjected them to crude circumcisions to mark their coming of age.⁴⁵² Playing to the theme of the victims' youthfulness, Block describes one boy on the verge of tears who just wanted to be a man.⁴⁵³ The author describes the traditional ceremony as inflicting dozens of horrific disfigurements on boys every year as a result of botched procedures or infection.⁴⁵⁴ Others tell of a mass Xhosa circumcision in 1996, in which 34 initiates died and 26 required plastic and reconstructive surgery.⁴⁵⁵ In the same region the previous year, there were 34 deaths, 13 penis mutilations and 743 hospitalizations for infection.⁴⁵⁶ These reports implicitly undercut the value of ritual circumcision in general. However, they are not so threatening to supporters of the religious ritual in the United States because these accounts deal with tribal societies of Africa, the classic cultural other, rather than the cosmopolitan West.

Even Jewish circumcisions occasionally face criticism from Jews who feel discomfort with the traditional bris. A few Jews are beginning to question the practice,⁴⁵⁷ and Jewish alternatives to circumcision are publicized and endorsed in anti-circumcision circles.⁴⁵⁸ The suggestion is that circumcision, even for Jews, should be a matter of individual conscience. The debate over circumcision within the Jewish community is now sufficiently pronounced that mohelim express concern about Jews abandoning the ceremony for non-invasive procedures.⁴⁵⁹ Even for some Jews, circumcision can be separated, at least to an extent, from the core of personal and cultural identity, and thereby classified as alien.

Opponents of circumcision claim that the intact penis is natural and the circumcised penis is unnatural. The argument here is not difficult, given that the prepuce is self-evidently a natural part of the male anatomy. In fact, in the claims of today's anti-circumcision advocates, one hears echoes of arguments put forward during the nineteenth century by physicians skeptical of circumcision's remedial value. References to the unnaturalness of circumcision are ubiquitous in the contemporary literature. Non-circumcision is the natural state.⁴⁶⁰ The foreskin is normal.⁴⁶¹ Circumcision is not natural.⁴⁶² Circumcision tampers with the male genitals.⁴⁶³ It is a violent transgression of the rights of humans to whole, intact bodies.⁴⁶⁴ In this rhetoric of the anti-circumcision movement, the attempt to move circumcision from the category of natural to that of unnatural is clear and unequivocal.

Anti-circumcision advocates reject the idea that the circumcised phallus is an ideal of beauty, or that the prepuce is unattractive.

It is somewhat difficult to portray the male foreskin as intrinsically beautiful, at least by standards of Western culture. Circumcision opponents do not attempt this feat, but rather argue for a different sort of beauty. They point to the efficiency and utility of the prepuce's design, which involves it operating as an integrated whole with the glans and penile shaft. The prepuce is compared to the eyelid, another mucous-lined, protective skin covering that enjoys favorable aesthetic associations in Western culture.⁴⁶⁵ As an example of anatomical engineering, it is beautiful, even wondrous.⁴⁶⁶ Together with the penile shaft, the prepuce is like a rose bud, ready to blossom when the time is right.⁴⁶⁷

On the other hand, the circumcised phallus is deformed and unattractive. If the uncircumcised organ is a rosebud, its uncircumcised cousin is a rose that has been torn open before its time and spoiled.⁴⁶⁸ The glans are denuded, keratinized, dry and tough,⁴⁶⁹ with a dull, grayish, sclerotic appearance.⁴⁷⁰ Pieces of the glans may be torn off, leaving it pitted and scarred.⁴⁷¹ Shreds of foreskin adhere to it, forming tags and bridges of dangling, displaced skin.⁴⁷² The image is not pretty.

The penile shaft is also disfigured. The operation leaves a large circumferential surgical scar.⁴⁷³ Depending on the amount of skin cut off and how the scar forms, the penis may be permanently twisted, and may curve or bow during erection.⁴⁷⁴ The contraction of the scar tissue, moreover, may pull the shaft into the abdomen, in effect shortening the penis or burying it completely.⁴⁷⁵ These images portray the circumcised organ as maimed, disfigured, and completely lacking in natural beauty.

Anti-circumcision advocates reverse the cultural polarity of male and female by arguing that circumcision, far from enhancing masculinity, actually impairs it. Here, horror stories about damage to the penis are utilized to suggest that the operation is, in fact, a form of emasculation. In the worst cases, the penis may be amputated or burned away, resulting in actual castration.⁴⁷⁶ The victims of such procedures are not only emasculated, but also, in some cases, feminized as well; they may be reassigned gender, with the remaining tissues from their ruined genitals surgically reformed into an artificial vagina.⁴⁷⁷ Even successful circumcisions, in the view of circumcision opponents, are emasculating. Circumcision is penile reduction surgery.⁴⁷⁸ It robs a male of a large percentage of his penile skin.⁴⁷⁹ It also shortens the penis, by as much as 25 percent.⁴⁸⁰ It removes more than 3 feet of veins, arteries, and capillaries, 240 feet of nerves, and ... 20,000 nerve endings.⁴⁸¹ And it destroys muscles, glands, mucous membrane, and epithelial tissue.⁴⁸²

Notions of order and chaos are enlisted in the contemporary campaign against circumcision. Advocates of neonatal circumcision rationalized it as a routine procedure, carried out on subjects who because of their extreme youth are unaware of their surroundings, unable to experience pain, and incapable of remembering experiences.⁴⁸³ However, recent studies indicate that newborns are sensitive to the pain of circumcision,⁴⁸⁴ not only during the procedure itself but also for a considerable time thereafter.⁴⁸⁵ Notwithstanding the intense pain of the procedure, physicians continue to conduct the operation without anesthesia.⁴⁸⁶

The anti-circumcision movement has begun to develop its own narrative of the operation that suggests the chaos underlying the apparent orderliness of the procedure. A version of this narrative appeared in an article from Men's Health in 1998:

The baby, J. Hernandez, is less than a day old ... tiny head still slightly misshapen, eyelids puffy, mouth half-open in sleep. The nurse has taken him from his mother and is carrying him to a side room in the pediatric ward. The nurse pops on a white heat lamp with her elbow, removes the child from a blue blanket, and lays him in a molded plastic form bolted to the counter. This bathtub-like shell is called a Circumstraint. There are indentations for the baby's arms and legs. The nurse binds Velcro straps around his limbs, bends the light over him and steps back. The baby is naked and spread-eagled, and he begins to cry... .

The doctor enters the room, scrubs his hands in the sink, and snaps on plastic gloves. The nurse passes him a package, and he opens it on the counter beside the child. Inside are several large, light blue cloth napkins; some squares of gauze; a squeeze-tube of Betadin (an antiseptic ointment); and an assortment of stainless-steel utensils: a pair of scissors, two hemostats (small, needle-nose pliers), a heavy metal clamp attached to a hollow cone, a scalpel handle, and a scalpel in a sterile packet... . The doctor swabs the baby's testicles and penis with antiseptic-soaked gauze, then lays one cloth over his torso, another over his legs, and a third, with a small hole in the middle, over his genitals. He pops the tiny penis through the hole. The baby is still crying. The nurse mentions that babies feel safest in the fetal position. She says they hate having their arms held away from their bodies. The parents are not in the room. The nurse shuts the door... .

The doctor snaps the scalpel blade onto the handle, then places it besides the baby. Lifting the hemostat, which resembles a sharp-tipped pair of pliers, he begins. Holding the penis in one hand, he moves the point of the hemostat through the hole at the end of the foreskin. The foreskin is tightly attached to the glans, like a fingernail to a finger. The doctor begins pushing the point between the foreskin and the glans. The operation is similar to running a razor blade underneath the fingernail. The baby bucks on the plastic form, in obvious pain... . The child struggles against the straps. The foreskin is attached firmly to the glans, and it's difficult to pry loose. The doctor scrapes the point of the hemostat in a circular motion around the glans, tearing the skin off the head of the penis. The child continues to buck on the plastic form. This is why the Circumstraint is bolted to the counter... . The foreskin is still attached to the glans and the doctor must rake the hemostat around the head of the penis several times. The baby is shrieking now, his face red, his eyes squeezed shut.

The foreskin is finally separated from the glans. Using a second hemostat, the doctor runs the point up inside the foreskin, clamps it to constrict blood flow, moves the hemostat a quarter inch, takes up the scissors and slices the skin along the clamp line... . Suddenly the baby is quiet ... mouth open, but no sound; body rigid. The foreskin is splayed open and bleeding. The doctor tears a hole in the skin and forces a hollow cone up inside the foreskin. The baby begins screaming again, straining at the straps. The stainless-steel cone keeps the glans from being cut off. Using both hands, the doctor places a heavy clamp over the child's penis, which protrudes through a hole in the clamp. The doctor tightens the clamp, picks up the scalpel, and in one smooth, practiced motion circles it around the foreskin... . The foreskin is peeled away like the rind of an orange. The baby is still crying. After several minutes, the doctor removes the clamp, pops off his gloves, and leaves. The nurse quickly applies an antiseptic ointment and returns the trembling child to his parents.⁴⁸⁷

In this narrative, we are situated outside the perspective of the doctor conducting the procedure. For the physician conducting the procedure, the matter is simply one of technique and routine. He is oblivious to the baby's cries, focusing instead on getting the job done in a professional manner. His embeddedness in the professional role is evidenced by the economy of effort he displays in manipulating the surgical implements, and the apparent sense of professional validation and power he feels when he snaps on the surgical gloves.

Yet observed from without, the operation has all the elements of a ritual. It takes place in a ritually separated space, the side room of a pediatric ward. The physician wears specialized clothing set apart from the garments worn during everyday life. The tools of the ritual are laid out in a carefully specified order. His concentration is intense and focused. The practitioner's actions, and those of his ritual assistant, the nurse, are precise and scripted. The entire event is steeped in tradition, replicating thousands of other circumcisions extending back into medical time. The ritualistic quality of the event appears to be brought near the surface of the narrative because the observer who is recording the event has chosen a neutral stance that separates himself from involvement in the performative aspect of the ceremony.

For the child who forms the subject of the ritual, the occasion appears in still a different light. Of all the participants, the child experiences life with the most intensity. He is only a few days old. For him, the event is one of unspeakable terror. He is ripped from the arms of his mother, removed to an unfamiliar place, strapped by wrists and ankles to a hard board, and assaulted by a stranger who cuts away one of the most sensitive parts of his body. he is portrayed as experiencing confusion, pain and terror. His cries, which have previously brought comfort from a loving mother or a sympathetic nurse, are simply ignored. His parents are nowhere to be found. Anxiety and betrayal replace the reassuring sense that the world is a safe and comfortable place. As one man put it, imagine you have just gone through the most traumatic experience of your life, being held by your warm and cuddly mommy when someone whisks you away to be strapped naked to a board, and wants to cut you.⁴⁸⁸ The procedure, from the standpoint of the child, is portrayed as a terrifying descent into a chaotic hell of pain and confusion. Anti-circumcision advocates are adept at bringing out these chaotic elements in their narratives of neonatal circumcision.

Opponents of circumcision reverse the polarity of good and bad, arguing that circumcision is bad and lack of circumcision is good. The old view that the lack of circumcision was bad depended on outdated notions of sexuality and disease. Masturbation is not an evil, and those who practice it are not indulging in sin. Thus even if circumcision were protective against masturbation, which it is not, it would not for that reason be good.

Conversely, today's opponents of circumcision emphasize that the procedure itself is bad. They point to the cruelty of the pain the infant experiences when a circumcision is performed without anesthetic.⁴⁸⁹ They observe that the procedure is performed on children who are incapable of giving informed consent.⁴⁹⁰ They equate it to a form of torture and claim that it violates the right to bodily integrity to which all children are entitled.⁴⁹¹ And they compare the procedure to female genital mutilation, which is roundly and unequivocally condemned by Western authorities.⁴⁹² The thrust of all these arguments is to demonstrate that the operation of circumcision is morally bad, and that the intact genitalia are good.

Opponents of circumcision claim the high ground with respect to knowledge and ignorance. They point to a growing body of research to show that circumcision, in fact, has potentially harmful psychological and physical effects.⁴⁹³ To bolster their claim to superior scientific knowledge, anti-circumcision advocates include in their web pages bibliographies containing hundreds of studies of circumcision, all casting doubt on the efficacy of the procedure, raising questions about side effects, or highlighting the pain that infants experience when the operation is conducted without anesthetic.⁴⁹⁴

These contemporary norm entrepreneurs explain the former scientific consensus in favor of circumcision as premised on ignorance and false information.⁴⁹⁵ Physicians who promoted circumcision as a remedy for masturbation were well meaning, but subsequent research has proven them to be mistaken.⁴⁹⁶ As medical knowledge improves, the harm done by circumcision is being recognized and accepted.⁴⁹⁷ Those who continue to support routine neonatal circumcision are mired in an outdated scientific model.

Circumcision opponents argue that ignorance and outright misinformation accompany the procedure. Parents, for example, display confusion about the operation.⁴⁹⁸ Some do not even understand what circumcision is. The reasons they give for consenting to the procedure reflect a mix of accurate information, outdated views, and outright superstition. They circumcise boys to reduce crying,⁴⁹⁹ prevent masturbation,⁵⁰⁰ promote hygiene,⁵⁰¹ ward off infection,⁵⁰² or deter cancer.⁵⁰³ The most important consideration is often the wish that the child should resemble his father and not suffer ridicule.⁵⁰⁴ Some of the more thoughtful studies of circumcision conclude that the principal element in the circumcision decision is cultural rather than medical.⁵⁰⁵ As one observer put it, entrenched tradition of custom is probably the greatest obstacle faced by those who would decrease the number of circumcisions done in this country.⁵⁰⁶ Custom, however, is not knowledge, or at least not knowledge of the medical variety. Circumcision opponents highlight the cultural element in parental choice in order to disparage the claim that the operation is based on scientific knowledge rather than on ignorance, tradition, or superstition.

V. THE FUTURE

This final section looks to the future. Will today's anti-circumcision advocates be effective at changing social and legal norms? The question requires prediction, always a dangerous enterprise, especially when the matter is as complex and controversial as genital surgery. However, some tentative observations are possible.

First, it is probable that medical circumcision of boys, even in the United States, will soon no longer be normative. A growing body of medical research casts doubt on the medical benefits of the procedure while highlighting the pain a child experiences when it is performed without anesthesia. Circumcision opponents, although small in number, are vocal and active, and have been able to bring their message to the public in a variety of ways, such as holding conferences, publishing books, staging protests, and publishing data on the Internet.⁵⁰⁷ The circumcision rate is already dropping in the United States; in the Western states, it is already well below 50 percent.⁵⁰⁸ In countries such as England where circumcision was once common, the procedure is vanishing altogether except when performed for religious reasons. As fewer boys are circumcised, parents have less reason to fear that an uncircumcised boy will experience ridicule from his classmates. Indeed, at some point, which the United States is already approaching, the concern will reverse: parents will refrain from circumcising their boys out of fear that they will be mocked or ridiculed if they undergo the procedure. As one mother observed, by the time my son [reaches puberty], half of the boys won't be circumcised either.⁵⁰⁹ Some parents have already made the switch between children, so that the older boy is circumcised and the younger one is not.⁵¹⁰ Circumcision as a medical procedure, in short, appears to be headed the way of tonsillectomies and other once popular but now unfashionable surgical interventions. Like foot binding in China, a widespread social convention is likely to collapse as the culture reaches a tipping point and turns against the practice. In this respect, today's anti-circumcision advocates are likely to carry the day. Much more problematic is whether these advocates will be able to embody their beliefs in legal prohibitions that parallel the existing legal norms against female genital mutilation. In spite of the arguments by anti-circumcision advocates, Western culture does not view the male and female procedures as equivalent. Moreover, our culture's views on this matter are reinforced and magnified by powerful groups who oppose any equation between the two procedures—Jews and Muslims who cherish male circumcision as a precious cultural heritage, and opponents of female genital mutilation who do not want to dilute popular opposition to the female operation. These groups will exercise their influence over social meanings to prevent the sort of equation between the male and female procedures that might result in legislation outlawing male circumcision.

This does not mean that the law will remain entirely static either. As popular attitudes towards circumcision change, courts will likely view the procedure with less favoritism than they have shown heretofore. Unauthorized circumcisions are unlikely to escape legal sanction in the future, as they have in the past, on the ground that the operation was performed without malpractice. Courts are likely to insist on informed consent practices that equal those commonly used for other surgical procedures. And when damages are awarded, they are likely to be more substantial than awards in the past. In one area, in particular, the legal treatment of circumcision is likely to change: physicians' and hospitals' liability in connection with anesthesia. As we have seen, many studies find that infants feel pain and that circumcision is, in fact, quite painful.⁵¹¹ Investigators terminated a recent study of pain in circumcision on the ground that it would be unethical to continue, given the obvious fact that babies who were not anesthetized were suffering.⁵¹² So strong is this evidence that the American Academy of Pediatrics, in March 1999, recommended that all circumcisions be performed with anesthesia.⁵¹³ Sooner or later(probably sooner) the standard of care for circumcisions will include the routine administration of anesthesia. A physician who fails to use anesthesia during a circumcision would then face exposure to malpractice liability. Moreover, the informed consent requirement will almost certainly evolve to include disclosure about the availability of anesthesia. Given recent studies and authoritative recommendations, it would appear foolhardy for a hospital not to disclose to parents that they have the option of instructing the physician to use anesthesia. Although it might appear that the liability risk here is small, a plaintiff's attorney could craft a class action against a major hospital on behalf of all boys who have been circumcised without anesthetic after some triggering event, such as the 1999 recommendation by the American Academy of Pediatrics. With a class action procedure, damages can rapidly magnify into substantial sums.

Finally, what will be the culture's response to these changes along the polarities that have formed the conceptual basis of the analysis above? The most probable scenario is that the culture will revert to the attitudes it held toward male circumcision prior to the late nineteenth century. Circumcision, in other words, will not be viewed as pure or polluting, good or bad, true or false, male or female. The procedure probably will not be viewed as chaotic, both because the procedure is simple and relatively safe, and because the use of anesthetics is likely to become nearly universal. As it becomes increasingly uncommon, however, circumcision is likely to move in the direction of being thought of as alien, unnatural, and disfiguring. The practice of neonatal circumcision, meanwhile, may well take its place alongside other once popular medical procedures that have fallen into discredit or disuse.

CONCLUSION

This article has examined the operation of law and culture in American society as it relates to the issue of male circumcision. What is remarkable here is not so much what the law has done to regulate the procedure, but rather what it has not done. One might expect that the infliction of painful, disfiguring, and possibly unnecessary surgeries on the bodies of innocent children would be a subject for legal concern. Yet, as we have seen, the law not only permits such an operations to take place but also affirmatively favors the procedure in a variety of ways. This legal approach might seem particularly surprising given the fact that the law powerfully condemns surgeries on girls that appear to be analogous in some respects to male circumcision.

The explanation for this puzzle lies in our culture. Cultural values, norms and beliefs heavily influence American laws on genital surgery. In particular, the culture's attitudes toward genital surgeries reflects underlying polarities that structure social reality. This article traced the evolution of those attitudes across several distinct phases. Traditionally, the culture viewed male circumcision as neutral along the dimensions of purity/pollution, male/female, good/bad, and true/false. However, the culture generally viewed circumcision as alien, unnatural, unhealthy, deforming, and chaotic. Because the values placed on circumcision were either negative or neutral, and because the culture did not practice circumcision, the effect of these cultural polarities was to deter Christians from using the procedure.

In the latter half of the nineteenth century, a group of norm entrepreneurs arose to promote circumcision as a desirable medical procedure. They claimed that the uncircumcised phallus was polluted, unhealthy, alien, unnatural, ugly, emasculated, chaotic, bad and false. The circumcised organ, in contrast, was given a positive value along each of these dimensions. These circumcision advocates succeeded brilliantly, first at establishing the legitimacy of the operation as a remedy for all sorts of diseases and conditions, and later at securing a place for the operation as a routine prophylactic procedure for newborn boys. Their success is probably due to the fact that circumcision offered the culture, and discrete sub-groups within it, an effective anxiety-management technique that avoided many of the difficulties encountered by the struggle against masturbation and spermatorrhoea.

More recently, a new breed of activists has emerged, this time campaigning against routine neonatal circumcision. These norm entrepreneurs reverse the value structure of the earlier, pro-circumcision authorities. They describe the circumcised phallus as polluted, unhealthy, alien, unnatural, ugly, emasculated, chaotic, bad, and false, and they claim that opposite values attach to the intact phallus. Although few in number, these circumcision opponents are vocal and militant and have contributed to the discrediting of the operation in several countries where it was once popular. In the United States, circumcision is still normative, but the signs are that within a relatively short span of years, perhaps a generation, medical circumcision will be uncommon in the United States.

Despite the likely reversal in practice, American culture has not accepted, and will probably never accept, the views of anti-circumcision advocates in full. While circumcision will no longer be normative, neither will it be condemned. The operation is too firmly embedded in American culture for that. Jews and others who view circumcision as a religious heritage will work to prevent a wholesale moral repudiation of the procedure, while feminists and human rights advocates will reject any attempt to equate male circumcision in the United States with female genital mutilation in Africa and the Middle East. Rather than repudiating the procedure out of hand, as today's anti-circumcision advocates would prefer, the culture is likely to revert to a posture similar to the one it occupied prior to the late nineteenth century, viewing circumcision with some suspicion but tolerating it where it occurs.

The implications for the law are these. It is inconceivable, at least at present, that the United States will prohibit male circumcision as it has done with female genital mutilation, even if religious ceremonies are exempted from such a ban. However, the law is likely to change at the margin. Standards for informed consent are likely to toughen significantly, and the threat of damages for circumcisions performed without consent is likely to pose an increased risk for physicians and hospitals. Perhaps most immediately, it is likely that tort law will soon require that all circumcisions be performed with anesthesia, at least unless there are contra-indications in the patient's medical history. Not only will failing to provide anesthesia eventually constitute a form of malpractice in its own right, but, more immediately, hospitals will face exposure to liability if they do not include information about the availability of anesthesia in the consent-to-surgery forms they distribute to the patients' guardians.

Overall, this paper has attempted to demonstrate that law and culture are not distinct spheres of social action. Law IS culture. In the area of circumcision, we observe the impact of cultural forces quite clearly, but the point is general. All forms of law are cultural artifacts. A challenge for future research is to tease out the cultural elements in other legal rules, practices and institutions.

* Professor of Law,

New York University. For comment, criticism, and inspiration on various aspects of this topic, I thank Amy Adler, Yochai Benkler, Mary Anne Case, Oscar Chase, Mark Geistfeld, Helen Hershkoff, Larry Kramer, Thomas Franck, Clay Gilette, Joy Medley, Eric Posner, Mindy Recht, David Richards, Ruti Teitel, Howard Venable, and participants at the New York University Brown Bag workshop. The staff of the New York University Law Library, and especially Jeanne Rehberg, provided outstanding assistance in locating obscure sources. My debt to Mary Douglas should be evident throughout.

References

Genesis 17:11.
See sources cited infra notes 343-345 (circumcision rates); see infra note 487 and accompanying text (description of circumcision procedure).
See infra notes 483-486 (studies of newborns' ability to feel pain).
See infra notes 402-403 (describing lasting effects of pain in circumcision).
See discussion infra notes 401-424 and accompanying text (complications resulting from circumcision).
The law's attitude towards circumcision of infant boys contrasts with its treatment of genital surgeries on girls, where both the federal government and several states have enacted criminal sanctions against the procedure. See infra notes 43-54 and accompanying text.
The connection between culture and law is explored to some extent in the Law and Literature movement, which relates literary texts to law. Law and Society studies also relate culture to law by emphasizing law's relationship with broader cultural phenomena. The recent interest in norms among legal scholars has a strong cultural element. See generally, e.g., Robert Ellickson, Order Without Law: How Neighbors Settle Disputes (1991) (outlines theory using informal and formal norm study to define human activity that falls within —and beyond—the scope of the law.); Geoffrey P. Miller, The Song of Deborah: A Legal-Economic Analysis, 144 U. Pa. L. Rev. 2293 (1996) (exploring the role of the Song of Deborah in norm-creating and norm-enforcing in ancient Israel); Cass R. Sunstein, Social Norms and Social Rules, 96 Colum. L. Rev. 903 (1996) (suggesting norm management as an important strategy for accomplishing the objectives of law); Richard H. McAdams, The Origin, Development and Regulation of Norms, 96 Mich. L. Rev. 338 (1997) (advocating the use of norms in economic analysis of the law); Lisa Bernstein, Social Norms and Default Rule Analysis, 3 S. Cal. Interdisc. L.J. 59 (1993) (arguing social norms directly relevant to default rules analysis); Eric A. Posner, Law, Economics, and Inefficient Norms, 144 U. Pa. L. Rev. 1697 (1996) (analyzing norm efficiency and suggesting state rules more efficient than group norms); Lawrence Lessig, Social Meaning and Social Norms, 144 U. Pa. L. Rev. 2181 (1996) (urging consideration of cultural context, in addition to action, in social norm analysis). A few constitutional law scholars also examine the importance of culture in their disciplines. See, e.g., Paul W. Kahn, The Cultural Study of Law: Reconstructing Legal Scholarship 1 (1999) (The culture of the law's rule needs to be studied in the same way as other cultures.); David A.J. Richards, Women, Gays, and the Constitution: The Grounds for Feminism and Gay Rights in Culture and Law 149-155 (1998) (describing the women's suffrage movement leaders as working within conventional gender roles, shaped...by highly contingent cultural factors to accomplish legal reform.).
For anthropological studies emphasizing the importance of polarities in the organization of various cultures, see, e.g., Victor Turner, The Ritual Process 40-41 (1966); Mary Douglas, Purity and Danger: An Analysis of the Concepts of Pollution and Taboo (1966); Robert Hertz, The Pre-eminence of the Right Hand: A Study of Religious Polarity, in Right & Left: Essays on Dual Symbolic Classification 13-14 (Rodney Needham, ed., 1973). These writers vary to some extent in the degree to which they believe that the polarities have cross-cultural universality, but all accept the basic idea that societies tend to organize their models of the world in terms of polar oppositions.
See infra notes 135-138 and accompanying text.
The ground is part of an image that the viewer perceives as background, while the figure is that part of the image that the viewer perceives as meaningful. See Douglas R. Hofstadter, Godel, Escher, Bach: An Eternal Golden Braid 61-74, passim (1979) (discussing the distinction between figure and ground).
See infra notes 122-135 and accompanying text.
See infra notes 128,165text accompanying.
See infra notes 152-156 and accompanying text.
Circumcision never achieved the same popularity in non-English speaking countries. See infra note 220.
A norm entrepreneur is an individual who takes on for himself or herself the task of defining or changing norms or values in the culture. Sunstein, supra note 7, at 909.
See discussion infra notes 168-236.
On tipping points, see Thomas C. Schelling, Micromotives and Macrobehavior 99, 101-10 (1978) (describing tipping as a special case…of critical-mass phenomena).
See George W. Kaplan, Circumcision—An Overview, 7 Current Probs. in Pediatrics 1, 3 (1977).
See David L. Gollaher, Circumcision: A History of the World's Most Controversial Surgery 127 (2000).
See id. at 91, 102-04 (discussing health claims of early circumcision advocates).
See infra notes 384-388 and accompanying text.
See infra notes 350-361.
See id.
See, e.g., John Ananopoulous, Letter to the Editor, 105 Pediatrics 681, 684 (2000) (citing data on dropping circumcision rates in Canada, where circumcisions were performed on less than 17% of newborn male infants in 1996-97, as compared to a 1970 study, when approximately 48% of the Canadian male population was estimated to be circumcised).
See Gollaher, supra note 19, at 127 (nationwide circumcision rate dropped almost four percentage points from 1995 to 1996).
A recent policy statement from the American Academy of Pediatrics, which concluded that existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision, may provide the impetus for a rapid change in cultural practices. American Academy of Pediatrics, Task Force on Circumcision, Circumcision Policy Statement, 103 Pediatrics 686, 691 (1999). The Task Force report has generated heated debate. Compare Edgar J. Schoen et al., New Policy on Circumcision—Cause for Concern, 105 Pediatrics 620, 620-23 (2000) (criticizing the inappropriate conclusions of the Task Force Report), with American Academy of Pediatrics, Task Force on Circumcision, Circumcision Debate, 105 Pediatrics 641, 641-42 (2000) (defending the report) and Circumcision—The Debate Goes On, 105 Pediatrics 681, 681-85 (2000) (compilation of letters pro and con). For a suggestion that the American Academy of Pediatrics should face tort liability for negligently failing to present a truthful assessment of the risks and benefits of the procedures, see Matthew R. Giannetti, Note, Circumcision and the American Academy of Pediatrics: Should Scientific Misconduct Result in Trade Association Liability?, 85 Iowa L. Rev. 1507 (2000).
For recent works condemning female genital mutilation, see generally, e.g., Alice Walker, Possessing the Secret of Joy (1992) (describing the procedures and rationales behind African female genital mutilation); Olayanka Koso-Thomas, The Circumcision of Women: A Strategy for Eradication (1987) (outlining strategy for eliminating African female genital mutilation); Fauziya Kassindja & Layli Miller Bashir, Do They Hear You When You Cry (1998) (autobiographical account of a Togo woman who sought asylum in the U.S. to escape circumcision); Waris Dirie & Cathleen Miller, Desert Flower: The Extraordinary Journey of a Desert Nomad (1998) (autobiography of a Somali woman who endured circumcision and fled an arranged marriage).
See, e.g., Cal Penal Code 667.83 (repealed 1999); Idaho Code 18-1506A(2)(b) (2000); 720 Ill. Comp. Stat. 5/12-32(c), 5/12-33(b)(2) (2001).
See, e.g., 24 Del. Code Ann. tit. 24 1703(e)(4) (2000); Minn. Stat. 147.09(10) (2000); Mont. Code Ann. 37-3-103(1)(h) (2000).
See, e.g., Doe v. Raezer, 664 A.2d 102 (Pa. Super. Ct. 1995) (awarding plaintiff damages for circumcision that resulted in shortening and disfigurement of his penis); Felice v. Valleylab, Inc., 520 So. 2d 920 (La. Ct. App. 1987) (penis burned off by electrosurgical device during circumcision).
See complications from circumcision discussion infra notes 401-424 and accompanying text.
See, e.g., Johnson v. Colp., 300 N.W. 791, 792 (Minn. 1941) (court precluded from applying res ipsa loquitur to failed circumcision resulting in scarring because no inference of skill or care can be drawn from a failure on a part of a physician or surgeon by treatment or operation to effect a cure.); Johnson v. Hammond, 589 N.E.2d 65, 67 (Ohio Ct. App. 1990) (no application of res ipsa loquitur because plaintiffs failed to produce evidence of lack of ordinary care by the physician when Gomco clamp slipped after circumcision, resulting in infection and cyst).
See Ericson v. Roberts, 910 S.W.2d 608, 613 (Tex. Ct. App. 1995) (married couple's claim barred because they knew or should have known cause of action existed after botched adult circumcision; two-year statute of limitations held to run from date of circumcision).
See generally J. Steven Svoboda et al., Informed Consent for Neonatal Circumcision: An Ethical and Legal Conundrum, 17 J. Contemp. Health L. & Pol'y 61 (2000) (examining whether and when parental consent to circumcision should be legally effective).
See id. at 83.
721 So. 2d 1063 (La. Ct. App. 1998).
Id at 1065.
See id. at 1064-65.
629 F.Supp. 682 (E.D. Mo. 1986).
Id. at 686.
220 N.Y.S.2d 733, 735 (N.Y. Sup. Ct. 1961), aff'd, 235 N.Y.S.2d 808 (N.Y. App. Div. 1962), aff'd, 195 N.E.2d 309 (N.Y. 1963) (holding defendants physician and assistants only had duty to infant patient, and did not assume any risk of liability that their acts might violate the personal sensibilities of others... .).
See Svoboda et al., supra note 34, at 132-133 (attributing persistence of routine circumcision to cultural blindness).
11 Del. Code Ann. tit. 11 780 (1999).
720 Ill. Comp. Stat. 5/12-34 (2000).
Md. Code Ann., Health-General, 20-601 (1999).
Minn. Stat. 609.2245 (1999). Minnesota also provides outreach programs for immigrant populations that traditionally practice female genital mutilation. Minn. Stat. 144.3872 (2000).
N.D. Cent. Code 12.1-36-01 (1995).
N.Y. Penal 130.85 (Consol. 1999).
R.I. Gen. Laws 11-5-2(a)(3) (2001).
Tenn. Code Ann. 39-13-110 (2001).
Wis. Stat. 146.35 (2000).
Pub. L. 104-140, codified at 18 U.S.C. 116 (2001). This statute provides that whoever knowingly circumcises, excises, or infibulates the whole or any part of the labia majora or labia minora or clitoris of another person who has not attained the age of 18 years shall be fined under this title or imprisoned not more than 5 years, or both. 18 U.S.C. 116(a). These state and federal laws specifically reject a cultural defense. Delaware, for example, provides that it is not a defense to a violation that the [illegal] conduct ... is required as a matter of custom, ritual or standard practice. 11 Del. Code Ann. tit. 11 780(c) (1999). New York law, echoing the federal statute, provides that no account shall be taken of the effect on the person on whom such procedure is to be performed of any belief on the part of that or any other person that such procedure is required as a matter of custom or ritual. N.Y. Penal Law 130.85(1)(b); see also 18 U.S.C. 116(c) . Congress also has required the Immigration and Naturalization Service to provide aliens from countries in which female genital mutilation is commonly practiced with information concerning the harm caused by such conduct and the legal consequences for either performing or consenting to it. See 8 U.S.C. 1374(a)-(b) (2001).
See generally Arthur C. Helton and Alison Nicoll, Female Genital Mutilation as Ground for Asylum in the United States: The Recent Case of in re Fauziya Kasinga and Prospects for More Gender-Sensitive Approaches, 28 Colum. Hum. Rts. L. Rev. 375 (1997) (discussing the Kasinga case and gender-based asylum law).
Cindy Shiner, African Woman Who Fled Circumcision is Granted Asylum: U.S. Board of Immigration Appeals' Decision Binds Courts, Challenges Tradition, Washington Post, July 7, 1996, available at 1996 WL 10963176.
William E. Brigman, Circumcision as Child Abuse: The Legal and Constitutional Issues, 23 J. Fam. L. 337, 337-38 (1984).
Abbie J. Chessler, Justifying the Unjustifiable: Rite vs. Wrong, 45 Buff. L. Rev. 555, 559, 574-75 (1997).
Id. at 559.
Germaine Greer, The Whole Woman (1999).
See Shea Lita Bond, State Laws Criminalizing Female Circumcision: A Violation of the Equal Protection Clause of the Fourteenth Amendment?, 32 J. Marshall L. Rev. 353, 365-66 (1999) (contending that male circumcision is medically unnecessary and painful, and protection awarded only to female children discriminates on the basis of gender).
115 F.3d 580 (8th Cir. 1997).
Id. at 581.
The United Nations Children's Fund ( UNICEF ), which promotes itself as dedicated to the survival, development and protection of children, guided in its programs by the Convention on the Rights of the Child, has made no efforts to apply the same principles to the circumcision of boys, either in the developing world or in the industrialized nations. Nor have other organizations in the international health community. The World Health Organization, the United Nations Fund for Population Activities, Amnesty International, and other human rights oriented organizations, which have all spoken out strongly against female genital mutilation, have been deafeningly silent about male circumcision. This has been so even though there is compelling evidence that traditional circumcisions in Africa have many of the same adverse health effects as female genital mutilations. See generally UNICEF Executive Board Paper EICEF/1992/LIS (condemning female genital mutilation); World Health Organization, Female Genital Mutilation Information Pack, available at http://www.who.int/frh-whd/FGM/; Amnesty International, Human Rights Information Pack, available at http://www.amnesty.org/ailib/intcam/femgen/fgm1.htm; United Nations Fund for Population, Eradication of Female Genital Mutilation (FGM) in Kenya, available at http://www.un.org/pubs/chronicle/1999/issue3/0399p72-z.htm.
As a spokesperson for the British Columbia College of Physicians and Surgeons remarked, It's apples and oranges. It happens to involve the same area but the problems with it and the reasons for doing it are widely different. Female circumcision is an extremely disfiguring and potentially hazardous procedure. Quoted in Eleanor LeBourdais, Circumcision No Longer a Routine Surgical Procedure 152 Canadian Med. Ass'n. J. 1873, 1876 (1995). The spokesperson did not explain why male circumcision was not also disfiguring or potentially hazardous.
Ellen Goodman, Barbaric Custom Infiltrates U.S., Dayton Daily News, Oct. 23, 1995, available at 1995 WL 11441229.
Michael Freeman, Children's Rights in a Land of Rites, in The Handbook of Children's Rights 70, 82 (Bob Franklin, ed., 1995).
Obviously, this is a huge topic, and a full treatment would require a book-length analysis. For a recent general history, see Gollaher, supra note 19.
George C. Denniston & Marilyn Fayre Milos, Preface to Sexual Mutilations: A Human Tragedy (George C. Denniston & Marilyn Fayre Milos, eds., 1997).
See Daniel Whiddon, The Widdicombe File, 2 The Lancet 337, 337-38 (1953).
In some cultures, genital alteration of males is performed symbolically, without any actual damage to the virile member. For example, among the Nive of the South Pacific, the practitioner performs a mimic operation on his own finger. See Rosemary Romberg, Circumcision: The Painful Dilemma 3 (1985). When converts join an Islamic sect in Mysore, a betel leaf is substituted for the foreskin and excised. See id.
Incision, or cutting of the foreskin without removal of tissue, is attested among peoples of East Africa, Asia, and the Pacific Islands. See James DeMeo, The Geography of Male and Female Genital Mutilations, in Sexual Mutilations: A Human Tragedy 1, 3 (George C. Denniston and Marilyn Fayre Milos eds., 1997). The depth and length of the cut varies from culture to culture, ranging from a small wound to a deep gash that exposes the glans but does not remove the foreskin. See id. For a detailed anthropological study of incision among one culture, see Ian Hogbin, The Island of Menstruating Men: Religion in Wogeo, New Guinea 88-92, 102-03, 120-21 (1970). Closer to full circumcision is the practice attested in Ancient Egypt, where priests and other men of elite status would slit the foreskin to let it hang free, but not remove it. See Robert G. Hall, Circumcision, in I Anchor Bible Dictionary 1025 (David Noel Freedman, ed., 1992). More extreme forms of incision involve cuts along the top or bottom of the penile shaft. Australian tribes practiced sub-incision, in which the urethra is laid open from the meatus (the opening at the tip of the penis) back to the junction with the scrotum. See Bruno Bettelheim, Symbolic Wounds: Puberty Rites and the Envious Male 14 (author's note citing studies by Spencer and Gillen) (1954). In Polynesia, some cultures practice super-incision in which the prepuce is cut longitudinally from the upper surface back to the pubic region. See 3 Encyclopedia of Religion and Ethics 659-60 (J. Hasting ed. 1951).
See Gilbert Lewis, Day of Shining Red: An Essay on Understanding Ritual 78-79 (1980) (describing penile cutting in New Guinea tribal puberty rite).
Among Arab tribesmen in Yemen and adjoining territories on the Red Sea, a candidate for marriage was flayed in the genital region until skin was stripped off the penis and adjoining areas. See DeMeo, supra note 70, at 3.
The ancient Greeks valued the prepuce because it covered the glans, which modesty required to be shielded from public view. See Gollaher, supra note 19, at 14; Hall, supra note 70, at 1027. If the foreskin was too short, so that some of the glans was visible, Greek men would resort to epispasm, the practice of artificially lengthening the foreskin by hanging a weight from the organ. Jews suffering persecution under Antiochus IV (168 BCE) attempted to reverse their circumcisions by means of a weight known as the pondus judaeus. See Dirk Schultheiss et al., Uncircumcision: A Historical Review of Preputial Restoration, 101 Plastic & Reconstructive Surgery 1990, 1991 (1998). Jews suffering persecution by Romans around the time of the Bar Kokhba revolt, in 132 C.E., followed suit. Gollaher, supra note 19, at 16. Similar efforts occurred during the Nazi persecution. Schultheiss et al., supra, at 1994-95. A modern version of epispasm, sometimes known as uncircumcision, is practiced today by men who want to revert to the intact state. See Willard E. Goodwin, Uncircumcision: A Technique for Plastic Reconstruction of a Prepuce After Circumcision, 144 J. Urology 1203, 1203 (1990); M.J. Lynch & J.P. Pryor, Uncircumcision: a One-Stage Procedure, 72 Brit. J. Urology 257, 257-58 (1993).
Greek men secured the foreskin in place with a pin (fibula). Hall, supra note 70, at 1027. The term infibulation, used to describe the Greek practices, is now defined as a process of fastening such as the sewing together of the foreskin over the glans of the penis. See Taber's Cyclopedic Medical Dictionary 989 (18th ed. 1997). Infibulation could be accomplished by transfixing the prepuce with a ring of gold, silver or iron or by sewing the foreskin together with sutures. See Peter Charles Remondino, History of Circumcision from the Earliest Times to the Present 48 (1891). Similar practices are attested among some South American tribes:
men wear just a waist string to which is attached the tied outstretched foreskin of the penis. If this minimal attire accidentally unties, the owner immediately must refasten it. Even during combat, a man will stop fighting to retie his foreskin lest the head of his penis becomes an object of public display. While bathing, foreskins have to be untied and retied under water, discretely avoiding any chance that others may see one's glans. Anthony Layng, Confronting the Public Nudity Taboo: Liberalization of American Mores 126 USA Today: The Magazine of the American Scene 24 (1998). In other cultures, infibulation guarded against sexual arousal. The procedure was a popular lust-inhibiting device among early Christian monks and other ascetics, who would sometimes compete over who had the most extreme arrangement. During the nineteenth century, infibulation found a new popularity among men who wanted to protect themselves against masturbatory impulses or nocturnal emissions. See, e.g., Louis Bauer, Infibulation as a Remedy for Epilepsy and Seminal Losses, 6 St. Louis Clinical Rec. 163, 163-65 (1879).
Victorian medicine devised a variety of techniques for mutilating or otherwise affecting penile structure. One of the principal targets was the urethra. Nineteenth century physicians often recommended passing a bougie—a long, narrow steel rod—up the urethral canal, cauterizing the urethra, prostate and seminal vesicles with silver nitrate in order to prevent the production and loss of sperm. See Frederick Hodges, A Short History of the Institutionalization of Involuntary Sexual Mutilation in the United States, in Sexual Mutilations: A Human Tragedy 17, 19 (George C. Denniston & Marilyn Fayre Milos, eds., 1997); The term is from the French bougie, or candle, see Taber's Cyclopedic Medical Dictionary, supra note 74, at 253; Arthur N. Gilbert, Doctor, Patient, and Onanist Diseases in the Nineteenth Century, J. of the Hist. of Med. 217, 229-30 (1975) (description of patient's bougie treatment); J.L. Milton, On Spermatorrhoea; Its Pathology, Results, and Complications 154-55 (1881) (describing successful, although agonizing, bougie treatment for spermatorrhoea). In cases of persistent masturbation the spine and genitals would be cauterized. See Rene A. Spitz, Authority and Masturbation: Some Remarks on a Bibliographical Investigation, 9 Y.B. Psychoanalysis 113, 123 (1953).
See Timothy Haynes, Surgical Treatment of Hopeless Cases of Masturbation and Nocturnal Emissions, Boston Med. & Surgical J. 130, 130 (1883).
Castration has served numerous cultural purposes. Among the Hottentots, one testicle was removed as part of an infancy ritual. See Felix Bryk, Sex & Circumcision: A Study of Phallic Worship and Mutilation in Men and Women 123-24 (1967). In many cultures, victorious soldiers cut off the male members of defeated foes as a way of demonstrating ferocity and humiliating enemies. See P.C. Remondino, supra note 74, at 28-29 (1891). Boys would also be castrated in order to convert them into eunuchs. In the Middle East, eunuchs served in harems as guardians of a chief's wives. In China, they served as civil servants. See Cathy Joseph, Compassionate Accountability: An Embodied Consideration of Female Genital Mutilation, 24 J. Psychohistory 2, 10 (1996). In Europe, they were valued for the purity of their voices, especially for ecclesiastical music; even up to the end of the eighteenth century, thousands of boys were castrated each year in order to supply the choirs of European churches. See Didier Diers & Xavier Valla, The Skoptzy: The Russian Sect of the Castrated, in Sexual Mutilations: A Human Tragedy 63, 63-66 (George C. Denniston and Marilyn Fayre Milos, eds., 1997). Castration was also used as a mark of religious fervor and devotion. Origen, a father of the Christian Church castrated himself, and 72 eunuchs have been beatified. See id. at 63. In Russia, a sect of castrated men, the Skoptzy, flourished in the eighteenth and nineteenth centuries, claiming as many as 10,000 members in the mid-nineteenth century. See id. at 64. Resort to castration as a mark of religious fervor has not disappeared from Western culture: in 1997, members of an American flying saucer cult castrated themselves before committing mass suicide. See John Lang, Cult Deaths Remain a Mystery, Detroit News, Mar. 26, 1998, at A12. Castration could also be enlisted as a means of treating medical conditions. Not a few nineteenth century physicians recommended it as a remedy for otherwise intractable cases. See, e.g., H.C. Sharp, The Severing of the Vasa Deferentia and its Relation to the Neuropsychopathic Constitution, 75 N.Y. Med. J., 411, 413 (1902) (Superintendent of the Kansas Asylum for Idiotic and Imbecile Youth castrated 47 of his inmates, claiming a marked physical and mental improvement in consequence, including one case in which the patient could be discharged.) In India, more than 50,000 castrated males and hermaphrodites, the hijras, still operate at the fringes of society, living largely through extortion and prostitution. See Zia Jaffrey, The Invisibles: A Tale of the Eunuchs of India 39-41 (1996). In the United States, chemical castration, in the form of drug treatments that destroy sexual capacities, is touted in some quarters as a treatment for repeat sex offenders. See, e.g., Philip J. Henderson, Section 645 of the California Penal Code: California's Chemical Castration Law—A Panacea or Cruel and Unusual Punishment?, 32 U.S.F.L. Rev. 653 (1998) (discussing chemical castration as a violation of the Eighth Amendment). Castration is also employed these days as part of gender reassignment surgery for men, with some of the penile tissue being reconstructed into a surgically-created vagina. See, e.g., J.Rehman & A. Melman, Formation of Neoclitoris from Glans Penis by Reduction of Gensplasty with Preservation of Neurovascular Bundle in Male-to-Female Gender Surgery: Functional and Cosmetic Outcome, 161 J. of Urology 200, 200-06 (1999).
Even when castration is not actually performed, it may be feared. Freud's theory of neurosis is premised on genital mutilation —the fear of castration at the hands of fathers that boys supposedly experience during the fourth or fifth year of life. See Sigmund Freud, The Passing of the Oedipus-Complex [1924], in Sexuality and the Psychology of Love 166 (Philip Rieff ed., 1963).
See Ira M. Rutkow, Surgery: An Illustrated History 17 (1993) (beginnings of circumcision operation are clothed in mystery.). Gollaher reports that mummies from as early as 4000 BCE show signs of circumcision. See Gollaher, supra note 19, at 3.
The Bible's reference to knives of flint used for the circumcision may imply that the procedure originated prior to the time when metal substituted for stone in cutting implements. See Joshua 5:2-3.
The term BCE, short for before the common era, has the same meaning as the more traditional BC.
See Hall, supra note 70, at 1025.
See Gollaher, supra note 19, at 1.
Geraldine Pinch, Private Life in Ancient Egypt, in I Civilizations of the Ancient Near East 363, 378 (Jack M. Sasson, ed., 1995).
Jack M. Sasson, Circumcision in the Ancient Near East, 85 J. Biblical Literature 473, 475-76 (1966).
Genesis 17:24.
Hermann Gunkel, Genesis 267 (citing Genesis 34:23-27 ) (Mark E. Biddle trans., 1997).
Timothy Taylor, The Prehistory of Sex 3 (1996).
Genesis 34:2-24. The Shechemites regretted their gesture, however, for the sons of Jacob swept into the city while the men were recovering from their wounds, killed all the men, and pillaged the town. Genesis 34:25-29. This story may reflect a practice on the part of Israelites of forcing foreign people under their rule to undergo the ritual. For other possible examples, see e.g., Steven Weitzman, Forced Circumcision and the Shifting Role of Gentiles in Hasmonean Ideology, 92 Harv. Theological Rev. 37 (1999) (discussing forced circumcision of vanquished Gentiles).
1 Samuel 18:20-25. David, one-upping Saul, delivered 200 Philistine foreskins instead. 1 Samuel 18:27.
Hall, supra note 70, at 1026.
Id. at 1027.
For a study analyzing rabbinical approaches to circumcision from the perspective of structural anthropology, see generally Lawrence A. Hoffman, Covenant of Blood: Circumcision and Gender in Rabbinic Judaism (1996).
The following description is based on Romberg, supra note 69, at 41-47.
There are about 200 mohelim practicing in the United States today. See Nadine Brozan, Religious Circumcision in a Changing World, N.Y. Times, Oct. 19, 1998, available at 1998 WL 5431516.
See Romberg, supra note 69, at 53. Although in the traditional ritual this step was considered a great honor, and appears to have been widely practiced in the nineteenth century, see The Danger of Circumcision, 47 N. Y. Med. Rec. 124, 124-25 (letters to the editor concerned with infection from the mohelim's saliva and non-antiseptic procedures) (George F. Shaeady ed., 1895). This part of the ritual is now in desuetude. See Eugene A. Hand, History of Circumcision, 49 J. Mich. St. Med. Soc'y 573, 574 (1950).
Recently, however, a small group of Reform Jews have begun to question the necessity for circumcision, and have sought alternatives such as naming ceremonies. See All Things Considered, (National Public Radio), Aug. 24, 1998, transcript available at 1998 WL 3646173.
Gollaher, supra note 19, at 45.
Id at 46.
Remondino, supra note 74, at 37-38.
See Gollaher, supra note 19, at 53,70.
See Alec Russell, International: Ancient Practice of Tribal Circumcision Divides South Africa, London Daily Telegraph, Jan. 23, 1997, available at 1997 WL 2279024.
See id.; I.P. Crowley & K.M. Kesner, Ritual Circumcision (Umkhwetha) Among the Xhosa of the Ciskei, 66 Brit.J. Urology 318, 318-21 (1990).
See Crowley & Kesner, supra note 103, at 319.
Ingela Krantz & Beth Maina Ahlberg, Circumcision and HIV, 345 The Lancet 730, 730 (1995).
See id.
The literature on circumcision in Africa is vast. For a sampling, see Victor Turner, The Forest of Symbols (1967) (collection of articles on Ndembu ritual, including theoretical discussion of manipulation of Ndembu circumcision ritual in local political contexts); Andre Droogers, The Dangerous Journey: Symbolic Aspects of Boys' Initiation among the Wagenia of Kisangani, Zaire (1980) (anthropologic study of initiation rites, including circumcision, of Wagenia boys); Maurice Bloch, From Blessing to Violence (1986) (combined historical and anthropological study of circumcision rites among the Merina of Madagascar); Walter de Mahieu, Qui a Obstrue la Cascade? Analyse Semantique du Rituel de la Circumcision Chez les Komo du Zaire (1985) (sociological study of Komo circumcision practices).
See Absalom Shigwedha, Namibia: Traditional Methods of Circumcision Raise Controversy, Inter Press Service, Feb. 12, 1997, available at 1997 WL 7073853.
See id.; Crowley & Kesner, supra note 103, at 318 (no self-respecting Xhosa girl would marry an uncircumcised Xhosa male).
See Shigwedha, supra note 108.
See Gunkel, supra note 87, at 265. (citing Exodus 4:24-25). The Phoenician God El escapes from peril by sacrificing his son and them circumcising himself. See Hall, supra note 70, at 1025.
See Hall, supra note 70, at 1026.
See Shigwedha, supra note 108.
See Genesis 17 (In 17:2, God tells Abraham: And I will make My covenant between Me and thee, and will multiply thee exceedingly. Abraham's wife Sarah later gives birth to Isaac.).
This was the view of the twelfth-century Jewish scholar and physician Maimonides. See Moses Maimonides, Guide for the Perplexed 594 (1963) (referring to the issue of semen as disgusting and unclean). According to Maimonides, circumcision would reduce the sexual urge (and assumedly the production of semen) Id. at 609.
See, e.g., Peter Just, Men, Women and Mukanda: A Transformational Analysis of Circumcision Among Two West Central African Tribes, 13 African Social Res. 187, 192 (1972) (uncircumcised boy referred to as wunabulakatooka, one who lacks whiteness or purity.).
Philo, the Jewish Platonist of the first century of the Common Era, held this view, observing that circumcision contributed to the excision of the pleasures which delude the mind; for since of all the delights which pleasure can afford, the association of man with woman is the most exquisite, it seemed good to the lawgivers to mutiliate the organ which he ministers to such connections; by which rite they signified figuratively the excision of all superfluous and excessive pleasure, not indeed, of one only, but of all others whatever, through that one which is the most imperious of all. Philo, De Specialibus Legibus 1.9, in The Works of Philo 534 (C.D. Yonge, trans.,1993). See also John M. G. Barclay, Paul and Philo on Circumcision: Romans 2.25-9 in Social and Cultural Context, 44 New Testament Studies, 536, 536-56 (1998) (outlining Philo's treatment of circumcision). Maimonides observes that one of its objects is to bring about a decrease in sexual intercourse and a weakening of the organ in question, so that this activity be diminished and the organ be in as quiet a state as possible... . Violent concupiscence and lust that goes beyond what is needed are diminished. Maimonides, supra note 115, at 609.
Among the Komo of the Congo, for example, the term for the circumcision ceremony (ganjá) is used synonymously with the name for the religion (esonba). See de Mahieu, supra note 107, at 2.
See John Whitehorne, Antiochus, in I Anchor Bible Dictionary 270 (1992).
The revolt is described in the biblical books of Maccabees See id. at 271.
See Benjamin Isaac and Aaron Oppenheimer, Bar Khokba, in I Anchor Bible Dictionary 598 (1992). The term CE is short for common era.
See Hall, supra note 70, at 1029.
See id. at 1030 (Neither circumcision nor uncircumcision is anything.).
See id.
Ephesians 2:13-22 (For He Himself is our peace, who has made both one, and broken down the middle wall of division between us. Id. at 2:14).
Romans 2:29.
1 Corinthians 7:17-20.
1 Corinthians 7:19.
The Gregorian calendar begins the year on January 1, the date of Christ's circumcision when Christ's birth is dated to December 25. See Calendopaedia—The Christian Calendar, available at http://geocities.com/CapeCanaveral/Lab7671/christian.htm (visited June 20, 2002).
See, e.g., Leo Steinberg, The Sexuality of Christ in Renaissance Art and in Modern Oblivion (1983).
See Gollaher, supra note 19, at 36-37.
See Romberg, supra note 69, at 91. The prepuce of the infant Jesus could, it was said, render barren women fertile and ensure a healthy delivery to boot. Henry V, victor at the famous battle of Agincourt, commandeered the object from one abbey to promote the birth of an heir to the throne of England and France, apparently causing considerable consternation among the monks because of fears that the precious piece of flesh would not be returned. All worked out for the best, however. The relic proved efficacious at producing an heir, and a grateful Henry not only returned the object but also built a shrine. See Remondino, supra note 74, at 71. Other claimants to the title of the holy prepuce had an equally exciting history. The prepuce given by Charlemagne to the Abbey of Charroux in 783 disappeared during the period of Huguenot control in the sixteenth century, but turned up in a abbey wall approximately 300 years later. It was entrusted to the Ursuline Sisters, who were apparently deemed more responsible caretakers than the Huguenots. See id. at 72.
Based on a study in Los Angeles, Dunn and Buell estimated that only 8% of males born before 1870 were circumcised. John E. Dunn and Philip Buell, Association of Cervical Cancer With Circumcision of Sexual Partner, 22 J.Nat'l Cancer Inst. 749, 752 (1959).
In Europe, for example, births in hospital became common only during the twentieth century. See Signild Vallgårda, Hospitalization of Deliveries: The Change of Place of Birth in Denmark and Sweden from the Late Nineteenth Century to 1970, 40 Med. Hist. 173, 173 (1996).
See Gollaher, supra note 19, at 73-82 (describing medical use of circumcision for various maladies).
See id. at 17-18.
Id. at 18.
Id. at 20-21.
Non-western cultures that practice circumcision also use concepts of purity and pollution to emphasize the value of genital cutting. Among the Ndembu of northwestern Zambia, for example, the glans of an uncircumcised boy is regarded as wet and filthy. See Turner, supra note 8, at 17. On the other hand, the circumcised penis is seen as dry and hence highly auspicious and desirable. Id.
See Gollaher, supra note 19, at 20.
Id. at 111.
See id. at 20.
See id. at 20.
See id. at 41.
Id. at 111 (quoting Berengario da Carpi).
Id. at 112.
See id.
See Maimonides, supra note 115, at 609.
Id.
Id.
Id.
Recall that the Greeks and Romans viewed the prepuce as an article of attire that covered the glans. See supra notes 73-74 and accompanying text.
These artists knew that their subjects were circumcised because the Bible recorded the fact. See Genesis 17:12 (commanding that Abraham's children through Isaac must be circumcised on the eighth day after birth).
See Roberta J.M. Olson, Italian Renaissance Sculpture, Frontspiece and 84 (1992).
See Marcia Hall: After Raphael: Painting in Central Italy in the Sixteenth Century 119 (1999).
See Roberta J.M. Olson, supra note 154, at 160.
Gollaher, supra note 19, at 19(quoting Midrashic text).
Maimonides, supra note 115, at 609.
See id.
See generally Cambridge Illustrated History of Medicine 228-29 (Roy Porter ed., 1996) (describing introduction of anesthesia in surgery).
See id. at 230.
W.W. Sinclair, On Circumcision, 67 The Lancet 783, 783 (1889).
J.W. Ross, A New Departure in Circumcision, 28 Med. Rec. 363, 363-64 (1885).
See George Tully Vaughan, Circumcision, 44 JAMA 1986, 1986 (1905).
See Galatians. 6:12-13 ; 5:6 ; Colossians. 3:9-11 ; Romans 2:29.
See P.C. Remondino, supra note 74, at 21.
This proposition derived from St. Paul, who argued that circumcision was irrelevant to the life of Christians. See Hall, supra note 70, at 100.
See Gollaher, supra note 19, at 73-79 (describing Sayre's discovery and endorsement of circumcision as a cure for various ailments).
David L. Gollaher, From Ritual to Science: The Medical Transformation of Circumcision in America, 28 J. Soc. Hist. 5, 6 (1994)(quoting Sayre).
See id. at 6-7.
Lewis A. Sayre, Partial Paralysis from Reflex Irritation, Caused by Congenital Phimosis and Adherent Prepuce, 21 Transactions of the Am. Med.Ass'n 205, 210-11 (1870).
See Gollaher, supra note 19, at 82.
See Remondino , supra note 74, at 18.
See Hodges, supra note 75, at 23-32.
See B.M. Rickets, Circumcision from a Dermatological Standpoint, 20 Cincinnati Lancet-Clinic 40, 42 (1888).
Jonathan Hutchinson, A Plea for Circumcision, Brit. Med. J. Sept. 27, 1890, at 769.
George M. Beard, Circumcision as a Cure for Nervous Symptoms, 4 Philadelphia Med. Bull. 248, 248-49 (1882).
Jonathan Hutchinson, On Circumcision as Preventive of Masturbation, 2 Archives of Surgery 267, 268 (1890-91).
Id.
See id.
Id. at 268.
W. M. Donald, Circumcision as a Therapeutic Measure, 16 Med. Age 292, 293 (1898).
Id. at 293.
Id.
W.W. Sinclair, supra note 162, at 783.
See Gollaher, supra note 19, at 82-85 (examples of physicians using circumcision to cure various ailments).
B. Merrill Ricketts, Circumcision: The Last Fifty of a Series of Two Hundred Circumcisions, 59 N.Y. Med. J. 431, 431-32 (1894).
The patients in Ricketts' population, for example, were from eighteen months to forty years old. Id.
On pain in circumcision, see infra note 483, at 484-486 and accompanying text.
S.L. Kistler, a Los Angeles physician, observed in 1910 that notwithstanding the simplicity of the procedure, circumcision were bunglingly done in many instances. Many a surgeon, he said, has lost his best clients, and likewise many a good prospect has gone glimmering because of the unfortunate outcome of this little operation. S.L. Kistler, Rapid Bloodless Circumcision, 54 JAMA 1782, 1782-83 (1910).
Even Lewis Sayre had his failures. He circumcised dozens of boys at a New York idiot's asylum, hoping that the operation would cure their dementia, but no patient recovered enough to be discharged. See Gollaher, supra note 19, at 79.
For a summary and catalog of the prophylactic benefits of neonatal circumcision, see Abraham L. Wolbarst, Universal Circumcision as a Sanitary Measure, 62 JAMA 92, 92-97 (1914).
See Gollaher, supra note 19, at 84-85 (describing the use of circumcision as a prophylactic measure even in the absence of disease).
Orificial surgeon C.B. Walls highlighted this concern in an article published in 1896-97. See generally C.B. Walls, Circumcision: Is it a Fad?, 5 J. Orificial Surgery 504 (1896-97). Walls warned that if circumcision is deferred until a boy was in school, he was likely to encounter evil influences, which he may not overcome during the remainder of his life, for, in the majority of cases, it is during the school period that the masturbation habit is acquired. Id. at 510. Circumcision performed after the habit was acquired could mitigate the effects of the disease, but might not cure the habit. Id. at 511. Thus, Walls concluded, it was preferable for the operation to be performed on a young child, because of the benefits derived—the various conditions and diseases which it avoids to those who have the matter attended to early. Id. at 509-10.
See Gollaher, supra note 19, at 10 (describing growth of neonatal circumcision).
Ricketts, supra note 187, at 432.
See Marilyn Fayre Milos & Donna R. Macris, Circumcision: Male-Effects Upon Human Sexuality, in Human Sexuality: An Encyclopedia 119, 120 (Vern L. Bullough & Bonnie Bullough eds., 1994); C. Anthony Ryan & Neil N. Finer, Changing Attitudes and Practices Regarding Local Analgesia for Newborn Circumcision, 94 Pediatrics 230, 230-33 (1994) (discussing modern belief that newborns could indeed feel pain, yet noting that the majority of circumcisions are performed without analgesia).
See Ricketts, supra note 187, at 432.
Samuel E. Newman, A Circumcision Operation for the Young, 53 JAMA 1737, 1738 (1909).
Id.
See Gollaher, supra note 19, at 10 (shocking rates of infant mortality in late nineteenth century America).
See id. at 104 (describing medical opinion that even circumcised boys sometimes masturbated, although they did so much less frequently than uncircumcised boys).
See Newman, supra note 199, at 1738 (describing a procedure which gives most pleasing results when done in patients before the age of ten or twelve years).
See E.J. Abbott, Circumcision, 12 St. Paul Med. J. 71, 72 (1910).
Bertrand Russell, Education and the Good Life 211 (1926).
Id. at 210-11 (displaying uncharacteristic prudery, Russell went on to note that it is not my province to go into medical details). Id.
See Gollaher, supra note 19, at 10 (describing the cumulative weight of expert opinion as favoring circumcision during the early years of the twentieth century).
See id. at 108 (describing how circumcision relieved parental anxiety about childhood masturbation).
See Richard W. Wertz and Dorothy C. Wertz, Lying-In: A History of Childbirth in America 133 (1977).
See Gollaher, Ritual to Science, supra note 169, at 23.
See Gollaher, supra note 19, at 10 (circumcision as a mark of social status).
Kistler, supra note 190, at 1782-1783.
See Dunn & Buell, supra note 133, at 752.
Circumcision tends to follow class, ethnic, and national lines. In Britain, Gairdner observed in 1949 that circumcision was much more common among boys of the upper classes than among lower class boys. Douglas Gairdner, The Fate of the Foreskin: A Study of Circumcision, 2 Brit. Med. J. 1433, 1433-37 (1949) (citing one study of boys entering university which found that 84 percent of students coming from the best-known public schools were circumcised, whereas only 50 percent of students coming from grammar or secondary schools were circumcised). In the United States, circumcision appears to be more prevalent in higher socio-economic groups. For example, Laumann et al.'s study found a strong positive correlation between circumcision and mother's educational level. Edward O. Laumann, et al., Circumcision in the United States: Prevalence, Prophylactic Effects, and Sexual Practice, 277 JAMA 1052, 1054 (1997). The demographics of circumcision have not been fully studied. Indeed, in a 1997 survey article, Laumann et al. concluded that beyond limited records on historical circumcision rates, very little is known regarding how the practice is distributed across various groups and strata of Americans. Id. at 1052. Some information is available, however. In the United States, it is European Americans who are most likely to be circumcised. The circumcision rate for African Americans is only half the rate for whites, and the rate for Hispanics is only one-third the European American rate. Id. at 1053. For similar findings on lower circumcision rates for non-European Americans, see Thomas Metcalf, et al., Circumcision: A Study of Current Practices, 22 Clinical Pediatrics 575, 576 (1983); Michael S. Wilkes & Steve Blum, Current Trends in Routine Newborn Male Circumcision in New York State, 90 N.Y. St. J. Med. 243, 244 (1990) (lower rates among Hispanic and Asian population). There is also a significant disparity across the country, with Western states showing low circumcision rates (around 36 percent) compared with the rest of the country. See Ian Ith, A Sensitive Decision: Parents Face a Wide Array of Factors in Choosing Whether or Not to Have their Infant Sons Circumcised, Seattle Times, Aug. 12, 1998, at E1 (citing National Center for Health Statistics data).
See Ith, supra note 214, at E1.
See Sharon Bass, Circumcision Persists Despite Doctors' Disapproval, Maine Times, Jan. 2, 1997, at V29.
William H. Masters & Virginia E. Johnson, Human Sexual Response 17 (1966). Of the total sample, Masters and Johnson found only 35 out of 312 men were circumcised. Id.
Id. at 190.
Leitch estimated in 1970 that 69-97% of all boys and men in the United States had been circumcised, compared with 70% in Victoria, Australia, 48% in Kingston General Hospital, Canada, and 24% in the UK. See I. O. W. Leitch, Circumcision—A Continuing Enigma, 6 Austl. Paediatric J. 59, 63 (1970).
In Denmark, for example, there is no tradition of routine neonatal circumcision. See Jakob Øster, Further Fate of the Foreskin: Incidence of Preputial Adhesions, Phimosis, and Smegma Among Danish Schoolboys, 43 Archives of Disease in Childhood 200, 201 (1968). The rate in Asia, and Central and South America is also much lower than in the United States. See Fetus & Newborn Committee, Canadian Paediatric Society, Neonatal Circumcision Revisited, 154 Can. Med. Ass'n J. 769, 770 (1996); Karen Ericksen Paige, The Ritual of Circumcision, Hum. Nature 40, 43 (May 1978) (asking why circumcision survives in some areas and not others). On the other hand, circumcision of boys is very common in the Middle East for religious reasons. In Turkey, for example, the rate approaches 99 percent. See E. Özdemir, Significantly Increased Complication Risks with Mass Circumcisions, 80 Brit. J. Urology 136, 136-139 (1997).
For an interesting recent account of the corrosive effects of the modernist perspective on Christian faith, see generally A.N. Wilson, God's Funeral (1999).
As was the case with Peter Remondino, who extolled the Jewish race as compared with Christian culture. See Remondino, supra note 74, at 1-2 (1891).
See Gollaher, supra note 19, at 78.
See John S. Haller, Jr. & Robin M. Haller, The Physician and Sexuality in Victorian America 13 (1974) (rising status of physicians gradually assuming the roles and duties heretofore reserved to the minister during the Victorian period).
See Gollaher, supra note 19, at 106-108 (documenting class distinctions in circumcision).
See Geoffrey P. Miller, Law, Self-Pollution, and the Management of Social Anxiety, 7 Mich. J. Gender & L. 221, 276-87 (2001).
See Robert T. Michael, et al., Sex in America: A Definitive Survey 159-61 (1994). For general discussion of the nineteenth century's theory of seminal loss, see Geoffrey P. Miller, supra note 226, at 276-287.
See Miller, supra note 226, at 222.
See id.
See id. at 248-61.
See id.
See id.
See id. at 270-75
See generally Gilbert, supra note 75, at 21-34 (explaining that masturbation became less necessary as an explanation for disease as level of medical knowledge increased).
See Gollaher, supra note 19, at 101-106.
Id. at 108 (discussing attitudes of early twentieth century).
Remondino, supra note 19, at 18.
Kate Green & Hilary Lim. What is this Thing About Female Circumcision? Legal Education and Human Rights, 7 Soc. & Legal Stud. 365, 381 (1998).
Gollaher, supra note 19, at 10.
The Western discourse on the purity and pollution has remarkable parallels to traditional principles of Indian Aruvedic medicine, which are themselves based on a well-developed system of purity and pollution in which sperm plays a crucial role. See Alain Bottero, Consumption by Semen Loss in India and Elsewhere, 15 Culture, Med. & Psychiatry 303, 306 (1991).
See Gollaher, supra note 19, at 88-92 (discussing perceived connection between circumcision and improved genital hygiene).
Id. at 84. As one physician stated the idea in 1882, if circumcision was more generally practised at the present day, I believe that we would hear far less of the pollutions and indiscretions of youth; and that our daily papers would not be so profusely flooded with all kinds of sure cures for loss of manhood. Norman H. Chapman, Some of the Nervous Affections Which Are Liable to Follow Neglected Congenital Phimosis in Children, 41 Med. News 317, 317 (1882).
See id. at 118.
See Rickets, supra note 175, at 40.
Id.
Abraham L. Wolbarst, Circumcision and Penile Cancer, 222 The Lancet 150, 151 (1932).
Paige, supra note 220, at 44(describing views of pro-circumcision advocates).
Gollaher, supra note 19, at 89.
Hutchinson, supra note 196, at 769.
See id. at 89 (late nineteenth century mind associated smegma with excrement, urine, blood, pus, and other secretions).
See Wolbarst, supra note 246, at 153 (referring to accumulation of pathogenic products in the preputial cavity, and infering that there is a direct relationship between the lack of hygenic care of the male genitals and the occurrence of penile cancer.); Hawa Patel, The Problem of Routine Circumcision, 95 Can. Med. Ass'n. J. 576, 579 (1966) (in eviewing practice of circumcision, many authors believe, from their direct clinical observations, that smegma is an irritant agent, responsible for carcinoma of the penis.). In an attempt to substantiate the danger of the substance, A. Plaut and A.C. Kohn-Speyer introduced horse smegma into a tube on the backs of several mice, and claimed to find a weak carcinogenic effect (the authors used horse smegma since human smegma could not be obtained in sufficient amounts). See Alfred Plaut & Alice C. Kohn-Speyer, The Carcinogenic Action of Smegma, 105 Science 391, 391-92 (1947).
See Gollaher, supra note 19, at 140-141 (describing W.S. Hadley's guess that cervical cancer was attributed to carcinogenic material transmitted to a woman from an uncircumcised man during sexual intercourse.).
Id. at 141.
See Committee on Fetus & Newborn, Am. Acad. of Pediatrics, Report of the Ad Hoc Task Force on Circumcision, 56 Pediatrics 610, 611 (1975) (A program of education leading to continuing good personal hygiene would offer all the advantages of routine circumcision without the attendant surgical risk.).
Id. at 610.
Beard, supra note 177, at 249.
See Edward Wallerstein, Circumcision: The Uniquely American Medical Enigma, 12 Urologic Clinics of N. Am. 123, 127 (1985).
See id.; For anecdotal evidence of the effect on the uncircumcised son, see also Abbott, supra note 204, at 73.
See Wallerstein, supra note 257, at 128 (citing a study which found retraction of the foreskin caused such anxiety that 40 percent of these mothers [of uncircumcised sons] stated that they would have their next child circumcised.).
See Ricketts, supra note 187, at 432 (listing 29 indications for circumcision).
Hutchinson, supra note 176, at 769.
Remondino, supra note 74, at 1-3.
Id. at 1-2.
Id. at 3.
Id. at 18-19.
Id. at 8.
S.G.A. Brown, The Mosaic Rite of Circumcision: A Plea for its Performance During Childhood, 5 J. of Orificial Surgery 299, 299-300 (1896-97).
Remondino, supra note 74, at 8.
Brown, supra note 267, at 300.
Øster, supra note 220, at 200.
See David A. Grimes, Routine Circumcision of the Newborn Infant: A Reappraisal, 130 Am. J. Obstetrics & Gynecology 125, 126 (1978) (erroneous use of term adhesions).
See Peter J. Bowler: The Invention of Progress: Victorians and the Past 2 (1989) (The nineteenth century saw itself as an age of transition from mediaeval to modern values.).
Walls, supra note 194, at 506.
Brown, supra note 267, at 300.
Id. at 299.
Gollaher, supra note 19, at 112.
Remondino, supra note 74, at 211.
Brown, supra note 267, at 300.
Walls, supra note 194, at 506. See also Brown, supra note 267, at 304 (redundant tissue).
See J.H. Kellogg, Plain Facts for Old and Young: Embracing the Natural History and Hygiene of Organic Life 231 (1888).
See R.P. Neuman, Masturbation, Madness, and the Modern Concepts of Childhood and Adolescence, 7 J. of Soc. Hist. 1, 15 (1975) (discussing Victorian views).
See supra notes 178-184 and accompanying text.
See LeBourdais, supra note 63, at 1873.
Quoted in Paige, supra note 220, at 44(Dr. Spock later changed his mind, saying that routine circumcision was not medically necessary.).
Chris Meehan, Second Thoughts, Grand Rapids Press, Mar. 18, 1999, available at 1999 WL 6410686.
See Remondino, supra note 74, passim.
Id. at 210.
Id.
Id.
See Wallerstein, supra note 257, at 130 (describing one of the circumcision myths: the uncovered glans is more esthetically pleasing (that is, the foreskin is ugly).).
Paige, supra note 220, at 44.
Id.
Edward Martin, Impotence and Sexual Weakness in the Male and Female 40 (1893).
See Bernarr A. MacFadden, The Virile Powers of Superb Manhood: How Developed, How Lost: How Regained 11-32 (1900) (Name any man famous in the world...and in nearly every instance he will be found to possess evidence of a strong virility... .If a fine, vigorous man acquires a complaint that weakens his sexual organs, his powers in every way will begin to decline... .).
Joseph W. Howe, Excessive Venery Masturbation and Continence: The Etiology, Pathology and Treatment of the Diseases Resulting from Venereal Excesses, Masturbation and Continence 33 (1884).
Id. at 68.
Id.
Id. at 37-38.
Id. at 69.
A definitive treatment is David Leddick, Naked Men: Pioneering Male Nudes 1935-1955 (1997). See also David Leddick, The Male Nude (1998).
See Red Symons, A Cut Above the Rest, Sun Herald, Feb. 14, 1999, at 35, available at 1999 WL 8487420 (male nude dancer obtained a circumcision for career reasons).
See Scott Raab, The Foreskin, Esquire, Jan. 1, 2000, at 91, available at 2000 WL 14763912 (reporting on a survey in which 118 of 138 women preferred uncircumcised men.)
See Robert Mapplethorpe, Ten by Ten (1996), especially the works Bob Love (1979) and Man in Polyester Suit (1980).
For a classic example, see generally MacFadden, supra note 294, at 6. (stating that virile manhood is the foundation upon which must rest all the results that accrue from education and the refining influences of civilized life.).
Ed Cohen, (R)evolutionary Scenes: The Body Politic and the Political Body in Henry Maudsley's Nosology of Masturbatory Insanity, 11 Nineteenth-Century Contexts 179, 184 (1987) (emphasis added) (quoting Henry Maudsley, Illustrations of a Variety of Insanity, 14 J. Mental Sci. 149 (July 1868)).
Id. at 186.
See Remondino, supra note 74, at 212.
Id. at 216.
Id. at 212-13.
Id. at 215-16.
A.W. Taylor, Circumcision: Its Moral and Physical Necessities and Advantages, Transactions of the Medical Society of New Jersey 187-92, 190 (1899).
See Remondino, supra note 74, at 246.
Id. at 246-47.
Id. at 246.
See Gollaher, supra note 19, at 113.
See supra notes 189-191 and accompanying text.
See, e.g., W. Reynolds Wilson, Simple Method of Circumcision in the Newborn, 58 Am. J. Obstetrics & Diseases of Women & Children 559, 559-60 (1908); Kistler, supra note 190, at 1782-1783.
Richard A. Barr, Circumcision, 11 Am. J. Dermatology & Genito-Urinary Diseases 125, 125-26 (1907).
Remondino, supra note 74, at 206 (prepuce as an outlaw).
Id. at 18.
See Beard, supra note 177, at 249 (strangulation of the glans penis).
Remondino, supra note 74, at 218.
Id.
Id. at 207.
Id. at 210.
Id. at 246.
Cohen, supra note 305, at 186.
Kellogg, supra note 280, at 339.
Anthony Comstock, Traps for the Young 132 (1967).
Miller, supra note 226, at 242.
Id. at 225-26, 237.
See supra notes 179-181 and accompanying text.
Remondino, supra note 74, at 167.
Id. at 167-68.
Orificial surgeons specialized on surgery on the prepuce, clitoris and rectum, and which published its own professional journal from 1890 to 1925. Members of this school enthusiastically recommended circumcision both for girls and for boys. See Alex Comfort, The Anxiety Makers: Some Curious Preoccupations of the Medical Profession 104, (1967) (Though not precisely dedicated to the proposition that men and women were created equal, they...[used] a variety of ethnographic instances of genital mutilation, to make them as similar as possible.).
See P.C. Remondino, supra note 74, passim.
See Remondino, supra note 74, at 161-182.
Id.
Sayre, supra note 171.
Id. at 226-35.
Id. at 275-83.
Id.
N. Williams & L. Kapila, Complications of Circumcision, 80 Brit. J. Surgery 1231, 1231 (1993). The fall-off in the circumcision rate in Great Britain appears to have begun shortly after the Second World War. See M. Calnan et al., Tonsillectomy and Circumcision: Comparisons of Two Cohorts, 7 Int'l J. of Epidemiology 79, 82 (1978) (noting the rate in Britain fell from 22.7 percent in children born in 1946 to 10.9 percent for those born in 1958).
See Laumann et al., supra note 214, at 1053 (rates declined through 1974, the final year of the authors' sample); Metcalf et al., supra note 214, at 576 (discussing circumcision rates in Utah from 1974 to 1979 declined slightly, although not at all in Salt Lake City, where rates varied between 92 and 83 percent). Cf. R.S. Van Howe, Variability in Penile Appearance and Penile Findings: A Prospective Study, 80 Brit. J. Urology 776, 777 (1997) (discussing a study of 468 males in Minocqua, Wisconsin between 1995 and 1997 found that 92 percent were circumcised); Thomas R. O'Brien et al., Incidence of Neonatal Circumcision in Atlanta, 1985-86, 88 S. Med. J. 411, 412-13 (1995) (finding circumcision rates dropped from 89.3 percent to 84.3 percent from July 1985 to September 1986); Christopher J. Mansfield et al., Neonatal Circumcision: Associated Factors and Length of Hospital Stay, 41 J. Fam. Prac. 370, 372 (1995) (discussing a survey of records of over 3,000 male infants born in four U.S. sites in 1990 and 1991 found an overall circumcision rate of 85 percent).
Bass, supra note 216; Ith, supra note 214.
Committee on Fetus & Newborn, supra note 254, at 610.
Id. at 611.
Task Force on Circumcision, American Academy of Pediatrics, Report of the Task Force on Circumcision, 84 Pediatrics 388, 388 (1989).
Task Force on Circumcision (1999), supra note 26, at 691. Medical societies in other countries have not been so conflicted. The Canadian Pediatric Society, for example, issued a policy statement in 1996 concluding that circumcision of newborns should not be routinely performed. Fetus and Newborn Committee, Canadian Pediatric Soc'y, supra note 220, at 769.
On the anti-circumcision movement, see, e.g., Sandra Pertot, Sensitivity is the Rising Issue on Circumcision, Australian Doctor, Nov. 25, 1994, available at https://www.cirp.org/library/restoration/pertot/.
Examples include the Circumcision Resource Center, Doctors Opposing Circumcision, the National Organization to Halt the Abuse and Routine Mutilation of Males (NOHARMM), the National Organization of Circumcision Information Resource Centers (NOCIRC), and the National Organization for Restoring Men (NORM). See Marilyn Linton, Anti-Circumcision Movement Grows in Strength, Fin. Post, Sept. 12, 1998, at R17; Group Fights Circumcision, Toronto Star, Feb. 16, 1996, at B2, available at 1996 WL 3351157; Donna Koehn, Foe of Circumcision Recalls the Pain, Tampa Trib., Dec. 5, 1995, at 5, available at 1995 WL 13837931.
See supra notes 168-236 and accompanying text.
See, e.g., Alice Miller, Prisoners of Childhood: The Drama of the Gifted Child and the Search for the True Self (1981); James F. Masterson, The Narcissistic and Borderline Disorders 13-14 (1981) (citing the role of parental narcissism and emotional unavailability in narcissistic personality disorder).
See, e.g., John Firman & Ann Gila, The Primal Wound: A Transpersonal View of Trauma, Addiction, and Growth (1997).
See, e.g., Pia Mellody, Facing Love Addiction: Giving Yourself the Power to Change the Way You Love 2 (1992) (defining codependence as a disease of immaturity caused by childhood trauma.).
See, e.g., Charles L. Whitfield, Healing the Child Within: Discovery and Recovery for Adult Children of Dysfunctional Families 5-6, 25-27, 142 (1987).
For a sampling of a vast literature, see, e.g., Christine A. Courtois, Healing the Incest Wound: Adult Survivors in Therapy (1988) (discussing various types of incest, symptoms and after effects of incest, and therapy); David Finkelhor, Sexually Victimized Children (1979) (studying sexually abused children, including victims of incest); Blair Justice & Rita Justice, The Broken Taboo: Sex in the Family (1979) (outlining types of incest, family dynamics, and therapy/preventive measures for the family).
See, e.g., Whitfield, supra note 356, at 82, 59-66 (defining the child within and methods for healing him or her).
For different strands within the men's movement, see, e.g., R. William Betcher & William S. Pollack, In a Time of Fallen Heroes: The Re-Creation of Masculinity (1993) (psychological); Robert Bly, Iron John: A Book about Men (1990) (mythopoetic); Michael Kimmel, Manhood in America: A Cultural History (1996) (historical); Steve Lee & Chap Clark, Boys to Men: How Fathers Can Help Build Character in their Sons (1995) (evangelical).
The literature on the changing role of men in today's society is vast. For a sampling, see, e.g., Bly, supra note 359, at 2tracing the development of the soft male in American society); Ellis Cose, A Man's World: How Real is Male Privilege—and How High is its Price? (1995) (exploring male discontent and bewilderment); Geoff Dench, ransforming Men: Changing Patterns of Dependency and Dominance in Gender Relations xi (1998) (characterizing sex war as alternative strategies for transforming men into more caring partners); Warren Farrell, The Liberated Man (1974) (exploring a human liberation view of women's and men's liberation); Sam Keen, Fire in the Belly: On Being a Man 7 (1991) (arguing modern rites of passage—war, work, and sex—impoverish and alienate men.); Ronald F. Levant, Masculinity Reconstructed: Changing the Rules of Manhood—At Work, in Relationships, and in Family Life 1-4 (1996) (describing the collapse of the traditional masculine code and the need for a middle path between traditional masculinity and the sensitive man ideal).
See Reuben Fine, Troubled Men: The Psychology, Emotional Conflicts, and Therapy of Men 1-24 (1988) (analyzing social and cultural restraints imposed on men and recommended therapy).
See Miller, supra note 226, at 273-275.
Robert H. MacDonald, The Frightful Consequences of Onanism: Notes on the History of a Delusion, 28 J. Hist. of Ideas 423 (1967); Spitz, supra note 75, at 120-124 (describing the sadistic trend in anti-masturbationist therapy in Victorian times).
See Gollaher, supra note 19, at 168-169 (discussing American Academy of Pediatrics Task Force conclusion that a program of education to continuing good personal hygiene would offer all the advantages of routine circumcision without the attendant surgical risk.).
See, e.g., Joyce Wright, How Smegma Serves the Penis, 37 Sexology 50, 50 (1970) (Is smegma useful? Yes, certainly.).
Mark Jenkins, Separated at Birth (Circumcision), Men's Health, July 17, 1998, at 132.
Id.
Paul M. Fleiss, The Case Against Circumcision, Mothering Mag., Winter 1997, at 36, available at https://www.cirp.org/news/1997/1997-12-01_Mothering.php.
See infra note 406 and accompanying text.
See infra notes 415-416 and accompanying text.
See infra note 411 and accompanying text.
See infra notes 417-421 and accompanying text.
Fleiss, supra note 368.
Van Howe, supra note 344, at 781.
Gollaher, infra note 19, at 119.
Not only is masturbation now considered a natural activity rather than a disease, but the effect of circumcision on masturbation appears to be opposite to what the nineteenth century writers believed: men who are circumcised are more, not less, likely to masturbate than men who are not circumcised. See Laumann et al., supra note 214, at 1055. (stating that 47 percent of the circumcised respondents reported masturbating at least once a month, as compared with 34 percent of their uncircumcised peers).
Circumcised men actually engage in more elaborate sexual practices than uncircumcised men. See id. They are more likely than uncircumcised men to engage in high-risk sexual behaviors such as anal intercourse and active or passive homosexual oral sex. See P.M. Fleiss, et al., Immunological Functions of the Human Prepuce, 74 Sexually Transmitted Infections 364, 365 (1998) hereinafter Immunological Functions]. Laumann et al. also found a small, but significant, negative correlation between circumcision and sexual dysfunction, especially in older men. Laumann et al., supra note 214, at 1054.
See E. Noel Preston, Whither the Foreskin? A Consideration of Routine Neonatal Circumcision, 213 JAMA 1853,1856-57 (1970).
See John P. Warren, Norm UK and the Medical Case Against Circumcision, in Sexual Mutilations: A Human Tragedy 85, 97 (George C. Denniston and Marilyn Fayre Milos, eds., 1997). The theory that smegma is carcinogenic also led to the belief that circumcision prevented cancer of the cervix in the partner of a circumcised man. Id. Again, the evidence for this was largely drawn from the low incidence of cervical cancer in Jewish women. See Øster, supra note 220, at 200. This theory has been discredited. See Milton Terris et al., Relation of Circumcision to Cancer of the Cervix, 117 Am. J. Obstetrics & Gynecology 1056, 1056-66 (1973).
Cf. Task Force on Circumcision (1999), supra note 26, at 690-691 (discussing possible health benefits of circumcision, and failing to identify any of these conditions as associated with lack of circumcision).
This was one of the most frequent diagnoses indicating the need for circumcision. For example, a study of 140 infants circumcised in a British hospital in 1983 found that congenital phimosis was the reason for circumcision in 74 cases and secondary phimosis was the reason in 38 cases. D. Mervyn Griffiths et al., A Prospective Survey of the Indications and Morbidity of Circumcision in Children, 11 Eur. Urology 184, 185 (1985).
See Whiddon, supra note 68, at 337 (citing cases of true phimosis as occurring in one in a thousand.).
Adhesions between prepuce and glans are normal in the infant, with more than nine out of ten boys being born with non-retractable foreskins. See Grimes, supra note 271, at 126. The common epithelium (skin layer) between prepuce and glans separates gradually and spontaneously during the course of childhood, resulting in complete separation in nearly all boys by age 17 if left undisturbed. See Øster, supra note 220, at 202.
Balanitis is defined as an inflammation of the skin covering the glans penis. Taber's Cyclopedic Medical Dictionary 193 (18th ed. 1997). Although often thought to occur only in uncircumcised boys, Van Howe's study found that in children under three years old balanitis was more prevalent in circumcised boys. Van Howe, supra note 344, at 776. Balanitis is a minor infection, easily treated with improved hygiene or topical medication, and is fairly uncommon (it occurs in up to 4% of uncircumcised boys). Rowena Hitchcock, Commentary, 77 Archives of Disease in Childhood 260, 260 (1997).
Wiswell, Smith and Bass examined a cohort of 5,261 infants and found a higher incidence of urinary tract infections among uncircumcised males (4.12%) than among circumcised males (0.21%). See Thomas E. Wiswell et al., Decreased Incidence of Urinary Tract Infections in Circumcised Male Infants, 75Pediatrics 901, 902 (1985). A later study by Wiswell and colleagues examined records of over 200,000 boys born at U.S. armed forces hospitals between 1975 and 1979, and found that uncircumcised boys experienced urinary tract infections at a ten-fold higher rate than circumcised boys (1.03% compared with 0.10%). Thomas E. Wiswell et al., Declining Frequency of Circumcision: Implications for Changes in the Absolute Incidence and Male to Female Sex Ratio of Urinary Tract Infections in Early Infancy, 79 Pediatrics 338, 340-41 (1987). See also Thomas E. Wiswell & John D. Roscelli, Corroborative Evidence for the Decreased Incidence of Urinary Tract Infections in Circumcised Male Infants, 78 Pediatrics 96, 96-99 (1986); Thomas E. Wiswell & Dietrich W. Geschke, Risks from Circumcision During the First Month of Life Compared with Those for Uncircumcised Boys, 83 Pediatrics 1011, 1011 (1989). Along the same lines, Lynn Herzog evaluated febrile infants seen in an outpatient clinic, and found a higher incidence of urinary tract infections in uncircumcised infants, Lynn Herzog, Urinary Tract Infections and Circumcision: A Case-Control Study, 143 Am. J. Diseases Child. 348, 349 (1989), while Spach, Stapleton, and Stamm found that lack of circumcision increases the risk of urinary tract infections in a population of young adult men. David H. Spach et al., Lack of Circumcision Increases the Risk of Urinary Tract Infection in Young Men, 267 JAMA 679, 679-81 (1992).
See Christopher Maden et al., History of Circumcision, Medical Conditions, and Sexual Activity and Risk of Penile Cancer, 85 J. Nat'l Cancer Inst. 19, 22 (1993) (relative to men circumcised at birth, risk of penile cancer was 3.2 times greater for uncircumcised men).
For example, Grosskurth and colleagues, in a recent study, found circumcision to be protective against syphilis in a rural African population. H. Grosskurth et al., Risk Factors for Seroconversion to Syphilis: Results from a Case-Control Study in Mwanza, Tanzania, World Disease Weekly Plus, Oct. 5, 1998, available at 1998 WL 21168969.
See D. William Cameron et al., Female to Male Transmission of Human Immunodeficiency Virus Type 1: Risk Factors for Seroconversion in Men, The Lancet 403, 406 (1989); J. Neil Simonsen et al., Human Immunodeficiency Virus Infection Among Men with Sexually Transmitted Diseases: Experience from a Center in Africa, 319 New Eng. J. Med. 274, 275-76 (1988); M. Quigley et al., Sexual Behaviour Patterns and Other Risk Factors for HIV Infection in Rural Tanzania: A Case-Control Study, AIDS Weekly Plus, Mar. 17, 1997, available at 1997 WL 6217481; Jeff Seed et al., Male Circumcision, Sexually Transmitted Disease, and Risk of HIV, 8 J. Acquired Immune Deficiency Syndrome & Hum. Retrovirology 83, 88-89 (1995); B. Donovan et al., Male Circumcision and Common Sexually Transmissible Diseases in a Developed Nation Setting, 70 Genitoruinary Med. 317, 319-320 (1994).
See supra note 384.
A recent review of the literature on urinary tract infections in infants fails to conclude that circumcision has a role in urinary tract infections, instead characterizing the topic as controversial. See Syed M. Ahmed & Steven K. Swedlund, Evaluation and Treatment of Urinary Tract Infections in Children, 57 Am. Fam. Physician 1573, 1573 (1998).
Circumcision is more common in wealthier families, which presumably have better access to health care, proper nutrition, and other benefits that increase health in general. Moreover, the incidence of urinary tract infections in uncircumcised boys may reflect the colonization of hospital wards by bacteria of non-maternal origin, to which the newborn has no immunity—a function of hospital conditions that could be controlled by other means, such as rooming-in of mother and baby. See Jan Winberg et al., The Prepuce: A Mistake of Nature?, The Lancet 598, 598-99 (1989). In another study indicating the importance of sociological considerations, Goldman and colleagues found a high incidence of urinary tract infections in Israeli children undergoing ritual circumcision; they demonstrate that urinary tract infections are common at least in one cohort of circumcised boys. See Michael Goldman et al., Urinary Tract Infection Following Ritual Jewish Circumcision, 32 Isr. J. Med. Sci. 1098, 1098-1101 (1996).
See George H. McCraken, Options in Antimicrobial Management of UTI's in Infants and Children, 8 Pediatric Infectious Disease J. 552, 552-55 (1989).
See Williams & Kapila, supra note 343, at 1234.
The influence of other variables is suggested by the fact that the incidence of carcinoma of the penis in the U.S., where most men are circumcised, is actually higher than in countries such as Denmark and Japan, where circumcisions are rare. See Morten Frisch et al., Falling Incidence of Penis Cancer in an Uncircumcised Population (Denmark 1943-90), 311 Brit. Med. J. 1471, 1471-73 (1995).
Risk factors for penile cancer include tobacco usage and number of sexual partners. See Maden et al., supra note 386, at 19-24.
Penile cancer occurs in only one out of every 100,000 men—A rarer form of cancer than male breast cancer. Bass, supra note 216. One authority estimated that a physician would have to conduct 140 circumcisions a week for 25 years to prevent one case of carcinoma of the penis. See John W. Duckett, A Temperate Approach to Neonatal Circumcision, 46 Urology 771, 771-72 (1995).
See Gollaher, supra note 19, at 145.
See Williams & Kapila, supra note 343, at 1234. However, there is some evidence that to be protective against penile cancer, circumcision must be performed during childhood. See Gollaher, supra note 19, at 144.
Donovan and colleagues found no significant effect on sexually transmitted diseases in a study of 300 men attending a clinic in Sydney, Australia. Donovan et al., supra note 388, at 317. Laumann et al.'s study found a small, although not statistically significant, positive correlation between circumcision and sexually transmitted diseases. Laumann et al., supra note 214, at 1054. For chlamydia, the results were especially pronounced: 26 of 1,033 circumcised men reported contacting this disease, whereas none of the 353 uncircumcised men reported having it. Id.
See Gollaher, supra note 19, at 150-152.
See generally Dimitri A. Christakis et al., A Trade-off Analysis of Routine Newborn Circumcision, 105 Pediatrics 246, 246-49 (2000) (finding complication rate from circumcision of approximately .2 percent); Metcalf et al., supra note 214, at 577-578 (finding greater incidence of complications in circumcised boys); Kaplan, supra note 18, at 16-31 (describing complications with illustrations); William F. Gee & Julian S. Ansell, Neonatal Circumcision: A Ten Year Overview: With Comparison of the Gomco Clamp and the Plastibell Device, 58 Pediatrics 824, 825-27 (1976) (discussing types and frequencies of complications in two devices); Williams & Kapila, supra note 343, at 1231-1236 (discussing complications); Grimes, supra note 271, at 125-129 (arguing that neonatal circumcision lacks sufficient medical justification); Louis T. Byars and William C. Trier, Some Complications of Circumcision and Their Surgical Repair, 76 A.M.A. Archives of Surgery 477, 477-82 (1958) (showing that about one percent of circumcisions resulted in surgical complications). See also Metcalf et al., supra note 214, at 577 tbl.3. Cases of surgical complication may require subsequent surgical procedures; in the Metcalf study, about one percent of all circumcisions required revision. Id.
As David Grimes, a circumcision opponent, puts it, The application of crushing clamps and excision of penile tissue ... probably do little to engender a trusting, congenial relationship with the infant's new surroundings. Grimes, supra note 271, at 127-128. Circumcision seems well calculated to evoke castration anxiety in the infant. As G. Cansever puts it, Circumcision is perceived by the child as an aggressive attack upon his body, which damaged, mutilated, and, in some cases, totally destroyed him. The feeling of I am now castrated seems to prevail in the psychic world of the child. As a result he feels inadequate, helpless, and functions less efficiently. Gocke Cansever, Psychological Effects of Circumcision, 38 Brit. J. Med. Psychol. 321, 328 (1965). David M. Levy, in a study of a somewhat older child, observed that immediately after the anesthesia wore off, he said over and over, They cut my penis. I wish I were dead. The rest of the day the patient never left his mother's side. Thereafter his previous temper tantrums developed into destructive rages. During the treatment he played numerous killing games, in which his father was the principal victim. The operation represented a castration by his father. David M. Levy, Psychic Trauma of Operations in Children, 69 Am. J. of Diseases of Children 7, 10 (1945).
Cansever's study of twelve Turkish boys who were circumcised between ages 4 and 7 found a significant reduction in IQ scores, as measured by the Goodenough Draw-a-man Test, after the procedure. Cansever, supra note 402, at 321-322. Cansever also found that the Draw-a-man Test signaled that after circumcision, a child's body image appeared to shrink in consequence of a feeling of having been cut. Id. Overall, Cansever found that following circumcision, the ego weakens under the impact of the experience, is unable to cope efficiently and adaptively with the trauma and the instinctual drives, as well as the anxieties initiated. Id. at 328.
Circumcision is a fairly bloody procedure, because the prepuce must be separated from the glans and then excised. Patel's study found slight to moderate bleeding in 35% of the cases studied. See Patel, supra note 251, at 577 tbl. 11. The rate of hemorrhage is difficult to determine precisely because it depends on the diagnostic criteria employed. See Williams & Kapila, supra note 343, at 1231. Studies report that circumcision results in hemorrhage complication in up to 2 percent of the time. John Denton et al., Circumcision Complication: Reaction to Treatment of Local Hemorrhage with Topical Epinephrine in High Concentration, 17 Clinical Pediatrics 285, 285 (1978). In addition, hemorrhaging occasionally requires hospitalization, see Metcalf et al., supra note 214, at 577, and the use of electrosurgical diathermy for coagulating vessels can cause accidents, including, in a few cases, complete ablation of the penis. Williams & Kapila, supra note 343, at 1232. See also Felice v. Valleylab, Inc. 520 So. 2d 920, 922 (1987) (physician burned off child's penis with electrical device during circumcision).
In a fair number of cases, eight percent in Metcalf's sample, the foreskin left from circumcision adheres to the glans, resulting in the accumulation of smegma under the adhesion. Metcalf et al., supra note 214, at 578.
Skin bridges occur when the left over foreskin fuses with the glans. See George T. Klauber & James Boyle, Preputial Skin-Bridging: omplication of Circumcision, 3 Urology 722, 722-23 (1974). These typically need to be lysed by a pediatrician in a corrective procedure. Van Howe's study found that 25.6 percent of the circumcised boys under three years old experienced adhesions and 4.1 percent had a skin bridge. See Van Howe, supra note 344, at 776-777.
If too much skin is removed during circumcision, there may not be enough left after puberty to cover the penis during an erection without tearing the skin. See John Money & Jackie Davison, Adult Penile Circumcision: Erotosexual and Cosmetic Sequelae, 19 J. Sex Research 289, 290-91 (1983). When skin tears occur, restorative surgery may be required. See, e.g., Bill Thompson, Man Sues 2 Over Surgery, Tampa Tribune, Apr. 9, 1998, at 1 (patient experienced pain and bleeding, requiring corrective surgery, after doctor allegedly removed too much skin during circumcision).
See Marie-Claude D. Bettencourt & Raymond A. Costabile, Penile Denudation after Adult Circumcision, 156 J. Urology 177, 177-78 (1996); Selwyn B. Levitt et al., Iatrogenic Microphallus Secondary to Circumcision, 8Urology 472, 472-73 (1976).
See Grimes, supra note 271, at 126.
See, e.g., Laurence S. Baskin et al., Surgical Repair of Urethral Circumcision Injuries, 158 J. Urology 2269, 2269-71 (1997); John T. Lackey et al., Urethral Fistula Following Circumcision, 206 JAMA 2318, 2318 (1968); J.T.K. Lau & G.B. Ong, Subglandular Urethral Fistula Following Circumcision: Repair by the Advancement Method, 126 J. Urology 702, 702-03 (1981). Fistula, a rare complication, is thought to result from damage to the urethral wall, either as a result of an improperly placed suture or because of improper operation of the Plastibell device or the Gomco clamp. See Williams & Kapila, supra note 343, at 1233.
In this condition, the penis retracts beneath the skin, either as a result of the contraction of the wound to the prepuce or as a result of inadvertent injury to the penis. See Rudolph D. Talarico & Joseph E. Jasaitis, Concealed Penis: A Complication of Neonatal Circumcision, 110 J. Urology 732, 732-33 (1973); W.C. Trier and G.W. Drach, Concealed Penis: Another Complication of Circumcision, 125 Am. J. Dis. Child 276, 276-77 (1973); M. Kon, A Rare Complication Following Circumcision: The Concealed Penis, 130 J. Urology 573, 573-74 (1983); Jayant Radhakrishnan & Hernan M. Reyes, Penoplasty for Buried Penis Secondary to Radical Circumcision, 19 J. Pediatric Surgery 629, 629-31 (1984).
In some cases, the circumcision may result in blockage of the urethral tract preventing passage of urine, with potential renal impairment . See Julian D. Eason et al., Male Ritual Circumcision Resulting in Acute Renal Failure, 309 Brit. Med. J. 660, 660-661 (1994); Aaron Hanukoglu et al., Serious Complications of Routine Ritual Circumcision in a Neonate: Hydro-Ureteronephrosis, Amputation of Glans Penis, and Hyponatraemia, 154 European J. Pediatrics 314, 314-15 (1995). This can result from an over-tight dressing being applied to the glans after circumcision, and appears to happen most frequently in Jewish ritual circumcisions, in which the mohel applies a tight dressing to the wound. See, e.g., J.C. Craig et al., Acute Obstructive Uropathy: A Rare Complication of Circumcision, 153 European J. Pediatrics 369, 369-71 (1994). In one case, a botched circumcision blocked the urinary tract at the meatus and diverted the urinary stream into the child's pelvis. See Randall G. Fisher, Plastibell Circumcision: A Novel Complication, 133 J. Pediatrics 468, 468 (1998).
After circumcision, the exposed glans of the penis may be irritated by the ammonia of wet diapers, leading to ulceration. In one survey of 100 male infants who underwent circumcision at Kingston General Hospital in Ontario, 31 percent of neonates suffered meatal ulceration after circumcision. Patel, supra note 251, at 577. Most cases were mild, but one case caused severe discomfort. Id.
Meatal stenosis is a blockage of the meatus, or tip of the urethra with the resulting impairment of urinary flow. See R. Persad et al., Clinical Presentation and Pathophysiology of Meatal Stenosis Following Circumcision, 75 Brit. J. Urology 91, 91-93 (1995). Meatal stenosis occurs nearly entirely in circumcised boys, and may require surgical revision. Id. Patel's survey found meatal stenosis in 8% of the subjects, often in association with meatal ulceration. Patel, supra note 251, at 577.
Like other operations, circumcisions result in infections. Different infection rates have been reported; a recent survey concluded that some type of infection occurs in about ten percent of the cases. See Williams & Kapila, supra note 343, at 1233. Most infections following circumcision are mild and only one case in Patel's study of 100 infants required antibiotic treatment. See Patel, supra note 251, at 577. At least one study suggests that cirucumcision may increase risk of staph infection in newborn boys. See Robert W. Enzenauer et al., Increased Incidence of Neonatal Staphylococcal Pyoderma in Males, 149 Military Med. 408, 408-410 (1984).
See Williams & Kapila, supra note 343, at 1233; Thomas G. Cleary & Steve Kohl, Overwhelming Infection with Group B Beta-Hemolytic Streptococcus Associated with Circumcision, 64 Pediatrics 301, 301-03 (1979); David P. Bliss, Jr. et al., Necrotizing Fasciitis After Plastibell Circumcision, 31 J. Pediatrics 459, 459-62 (1997); Fischer, supra note 412, at 468.
See, e.g., Williams & Kapila, supra note 443, at 1231-1232 (1993) (physicians have accidentally injured the glans as a result of inadequate separation of preputial adhesions); Andrew J. McGowan, Jr., A Complication of Circumcision, 207 JAMA 2104, 2104-05 (1969) (discussing possible bifurcation of the glans).
See Louis T. Byars & William C. Trier, supra note 401, at 477-482.
See Bruce S. Strimling, Partial Amputation of Glans Penis During Mogen Clamp Circumcision, 97 Pediatrics 906, 906-07 (1996); Baskin et al., supra note 410, at 2269-2271 (urethral repair procedure following partial glans amputation); E. Neulander et al., Amputation of Distal Penile Glans During Neonatal Ritual Circumcision—A Rare Complication, 77 Brit. J. Urology 924, 924-25 (1996); Gordon R. Gluckman et al., Newborn Penile Glans Amputation During Circumcision and Successful Reattachment, 153 J. Urology 778, 778-79 (1995); Joel Sherman et al., Circumcision: Successful Glanular Reconstruction and Survival Following Traumatic Amputation, 156 J. Urology 842, 842-44 (1996); Medina; Doc Settles in Circumcision Suit, Dayton Daily News, Mar. 26, 1999, at 8B.
See Williams & Kapila, supra note 343, at 1231-1232; Kamal A. Hanash, Plastic Reconstruction of Partially Amputated Penis at Circumcision, 18 Urology 291, 291-93 (1981); Clinic to Pay for Circumcision that Went Awry, Rocky Mountain News, Dec. 10, 1995, at 40A (permanent shortening and disfigurement of the penis); Semih Özkan & Tayfun Gürpinar, A Serious Circumcision Complication: Penile Shaft Amputation and New Reattachment Technique with a Successful Outcome, 158 J. Urology 1946, 1946-47 (1997); G. Audry et al., J. Buis, Amputation of Penis After Circumcision: Penoplasty Using Expandable Prosthesis, 4 European J. Pediatric Surgery 44, 44-45 (1994); E.A. Ameh et al., Amputation of the Penis During Traditional Circumcision, 27 Tropical Doctor 117, 117 (1997).
See H. Stefan, Reconstruction of the Penis After Necrosis Due to Circumcision Burn, 4 European J. Pediatric Surgery 40, 40-43 (1994); A. Azmy et al., Successful Reconstruction Following Circumcision with Diathermy, 57 Brit. J. Urology 587, 587-88 (1985).
One such case received widespread publicity in 1997. See, e.g., A Tragedy Yields Insight into Gender, Newsweek, Mar. 24, 1997, at 66. During a circumcision at eight months of age performed in the late 1960s, a surgeon accidentally cut off most of a boy's penis. Id. The boy's parents were persuaded by an eminent sex researcher, John Money, to have him surgically converted into a girl by means of the creation of a vagina from his remaining penile tissue and hormone therapy. By the time he reached age 12, he had reportedly accepted his life as a woman—a result that was widely viewed as confirming the view of gender as socially rather than biologically constructed. In 1997, however, a report in the Archives of Pediatric and Adolescent Medicine described how Joan never did adjust to life as a girl, and at age 14 decided to switch back to being a boy, which was successfully accomplished by means of male hormone injections, mastectomy, and phalloplasty. Milton Diamond & H. Keith Sigmundson, Sex Reassignment at Birth: Long-Term Review and Clinical Implications, 151 Archives of Pediatrics & Adolescent Med. 298, 300 (1997). For an account of the experience of this subject—whose actual name is David Reimer—see John Colapinto, As Nature Made Him: The Boy Who Was Raised as a Girl (2000).
The actual incidence of life-threatening complications is difficult to assess because, when a child dies or becomes gravely ill as a complication of circumcision, the matter is likely to be settled quickly out of court by the doctor's or hospital's insurance carrier. Reports of life-threatening complications do appear from time to time, however. See, e.g., Circumcision Fix Leads To Tot's Death, Oct. 21, 1998, at B03; Houston Anesthesiologist Resigns After Boy's Death, 11 Lawsuits, Austin American-Statesman, Aug. 20, 1995, at B5; Sweet v. Sisters of Providence in Washington, 895 P.2d 484 (Wash.1995)(child developed infection after routine hospital circumcision and was eventually left with profound mental retardation as well as cerebral palsy and blindness); Baby Bled to Death After Circumcision, Orlando Sentinel, June 26, 1993, at B4. In 1998, a 3-week old boy experienced a blockage in his urethra from a circumcision; when he went back into surgery to repair the problem, he had an allergic reaction to the anesthetic and died in hospital. See James F. McCarty, Coroner Calls Anesthesia Death Unpreventable, Cleveland Plain Dealer, Nov. 19, 1998, at 1B. The risk of death from circumcision is very small, however. See Harold Speert, Circumcision of the Newborn: An Appraisal of its Present Status, 2 Obstetr Gynecol 164, 170-71 (1953).
See E. Özdemir, supra note 220, at 138.
See, e.g., Immunological Functions, supra note 377, at 364. The thesis that the prepuce offers immunological protection is supported by studies showing that during infancy circumcised children are more prone to penile infections than uncircumcised children. See D.M. Fergusson et al., Circumcision and Penile Problems: An 8-Year Longitudinal Study, 81 Pediatrics 537, 537-541 (1988); R.W. Enzenauer et al., Increased Incidence of Neonatal Staphylococcal Pyoderma in Males, 149 Military Med. 408, 408-410 (1984); R.W. Enzenauer et al., Male Predominance in Persistent Staphylococcal Colonization and Infection of the Newborn, 4 Haw. Med. J. 389. 389-92, 394-96 (1985). An immunological role for the prepuce is also suggested by evidence that uncircumcised men appear to have a lower rate of some sexually transmitted diseased than their circumcised peers. See Immunological Functions, supra note 377, at 365-366.
See Nancy McVicar, Healing Skin: Newborns' Foreskins Used in Graft Technique, Ft. Lauderdale Sun-Sentinel, Sept. 20, 1998, at 3E.
See text accompanying supra note 279.
Gollaher, supra note 19, at 119 (describing views of anti-circumcision advocates).
See Remondino, supra note 74, at 8.
Gairdner, supra note 214, at 1433-1437.
Id.
Milos & Macris, supra note 197, at 120.
See Preston, supra note 378, at 1854. On the other hand, Masters and Johnson found no significant differences in the sensitivity of the glans in a study of 35 uncircumcised and 35 circumcised men. Masters & Johnson, supra note 217, at 190.
See R.K. Winkelmann, The Cutaneous Innervation of Human Newborn Prepuce, 26 J. Investigative Dermatology 53, 53-67 (1956); J.P. Taylor et al., The Prepuce: Specialized Mucosa of the Penis and its Loss to Circumcision, 77 Brit. J. Urology 291, 291-95 (1996).
See Milos & Macris, supra note 197, at 120. The prepuce's sensitivity to light touch and pain are similar to that of the skin of the penis as a whole. See J.P. Taylor et al., supra note 434 . In this respect, the prepuce contrasts with the glans, which in fact is insensitive to light, touch, heat, cold, and pinprick, and which is one of the few areas of the body which enjoys nothing beyond primitive sensory modalities such as deep pressure or pain. Id.; Immunological Functions, supra note 377, at 365.
See John P. Warren & Jim Bigelow, The Case Against Circumcision, Brit. J. Sexual Med. 6, 6-9 (Sept./Oct. 1994).
See id; Milos & Macris, supra note 197, at 121.
See John Money & Jackie Davison, Adult Penile Circumcision: Erotosexual and Cosmetic Sequelae, 19 J. Sex Res. 289, 289-92 (1983). One man circumcised at age 26 said, I had ample sexual experience, and I was quite happy as an intact male. After my circumcision, that pleasure was utterly gone. On a scale of 10, the uncircumcised penis experiences pleasure of at least 11 or 12; the circumcised penis is lucky to get to 3. Jenkins, supra note 366, at 132.
See Guy Cox, De Virginibus Puerisque: The Function of the Human Foreskin Considered from an Evolutionary Perspective, 45 Med. Hypotheses 617, 617-21 (1995).
Id.
See Ronald S. Immerman & Wade C. Mackey, A Proposed Relationship Between Circumcision and Neural Reorganization, 159 J. Genetic Psychol. 367, 367-78 (1998).
See Fetus and Newborn Committee, supra note 220, at 771 (The prepuce is...[ richly supplied with] numerous oval, rounded or elongated nerve corpuscles in the inner mucosal surface); P.M. Fleiss, supra note 377, at 365; Douglas Gairdner, supra note 214, at 1433-1437.
Gairdner, supra note 214, at 1433-1437.
Id.
See id.
See Gollaher, supra note 19, at 123.
See id.
This implication follows from the characterization of circumcision as religious: if it is a religious ritual, it need not be observed by people who do not share the religious faith underlying the procedure.
Robert Dozor, Routine Neonatal Circumcision, 41 Amer. Fam. Physician 820, 820-22 (1990).
See, e.g., Clint Summer, Don't Circumcise, Santa Rosa Press Democrat, Mar. 17, 1999, at P2.
Robert Block, Tribal Rite Robs Youths of Manhood, London Sunday Times, Dec. 29, 1996, at 16.
Id.
Id.
Id.
Id; see also Botched Circumcisions Lead to Arrest for Murder, 313 Brit. Med. J. 647, 647 (1996); Four Boys Die, 36 in Hospital as Circumcision Rituals Go Wrong, Agence France-Press, July 18, 1996.
Id.
See, e.g., Clemente Angelo Lisi, Circumcision No Longer Automatic in Jewish Households, Grand Rapids Press, May 2, 1998, at B3.
See Some Jews Question, Reject Age-Old Rite of Circumcision, Las Vegas Review-Journal, Sept. 21, 1998, at 4A (naming ceremony used instead of circumcision).
See Francesca Lunzer Kritz, Circumcision Unnecessary: Pediatricians; Rabbis Concerned by Report Citing Limited Benefits of Procedure, Westchester Jewish Week, Mar. 5, 1999, at 1, 32.
See Carol Ann Campbell, Pediatrics Academy Decides Circumcision Isn't Essential, Newark Star-Ledger, Mar. 2, 1999, available at 1999 WL 2959148; Andrew Shulman, Foes of Circumcision Make Clear-Cut Case for Opposition: Feeling Deprived, Some Men Opt to Restore Foreskin, Wash. Times, July 8, 1998, at A2.
See Andrew Gordon & Jack Collin, Save the Normal Foreskin, 306 Brit. Med. J. 1, 1-2 (1993).
See Stephanie Mayrose, Circumcision is Mutilation, Grand Rapids Press, Mar. 26, 1999, at A14.
John Delano, Deconstructing Circumcision, Pittsburgh Post-Gazette, Mar. 16, 1999, at G4.
See, e.g., Summer, supra note 450, at 16.
See Fleiss, supra note 368, at 36.
Id.
Id.
See id.
Id.
Id.
Id
Id.
Id.
Id.
Id.
See Felice v. Valleylab, Inc., 520 So. 2d 920, 922 (La. Ct. App.1987) (penis burned off by electrosurgical device during circumcision).
See Fleiss, supra note 368, at 36.
Id.
Id.
Id.
Id.
Id.
Until recently, most doctors believed that the newborn was not capable of feeling pain because of the immaturity of its nervous system. See K.J.S. Anand & P.R. Hickey, Pain and its Effects in the Human Neonate and Fetus, 317 New Eng. J. Med. 1321, 1321-29 (1987). Moreover, because infants may not be able to remember painful experiences, they were not thought capable of interpreting pain in a manner similar to adults. See id. Infants were also thought to have a high pain threshold because this would protect them from the pain of childbirth. See id.
Numerous studies have documented that newborns do feel pain, and have shown, in particular, that circumcision causes intense pain to the neonate. See, e.g., Janice Lander et al., Comparison of Ring Block, Dorsal Penile Nerve Block, and Topical Anesthesia for Neonatal Circumcision: A Randomized Controlled Trial, 278 JAMA, 2157 (1997) (without exception, newborns in this study who did not receive an anesthetic suffered great distress during and following the circumcision, and ... were exposed to unnecessary risk); Fran Lang Porter et al., Pain and Pain Management in Newborn Infants: a Survey of Physicians and Nurses, 100 Pediatrics 626 (1997); John W. Scanlon, Appreciating Neonatal Pain, 38 Advances in Pediatrics 317-33 (1991). The presence of pain during circumcision is inferred from physiological changes, such as increases in heart rate and blood pressure, or changes in crying behavior. See Paul S. Williamson & Marvel L. Williamson, Physiologic Stress Reduction by a Local Anesthetic During Newborn Circumcision, 71 Pediatrics 36, 36-40 (1983); Richard. L. Holve et al., Regional Anesthesia During Newborn Circumcision: Effect on Infant Pain Response, 22 Clinical Pediatrics 813, 813-18 (1983); Fran Lang Porter et al., 57 Child Dev. 790, 790-802 (1986). Both serum cortisal and cortisone levels rise after circumcision, see Luther M. Talbert, Adrenal Cortical Response to Circumcision in the Neonate, 48 Obstetrics & Gynecology 208, 208-10 (1976), while transcutaneous oxygen tension falls dramatically, see David J. Rawlings et al., The Effect of Circumcision Upon Transcutaneous P02 in Term Infants, 134 Am. J.Dis. of Childhood 676, 676-78 (1980). Local anesthesia prevents or reduces the physiological changes associated with pain in circumcision. See Newborn Circumcision, 71 Pediatrics 36-40 (1983); In one recent study, the investigators terminated the research because they believed it was unethical to continue to subject test subjects to the pain of circumcision without anesthesia. Janice Lander et al., supra at 157-62 (1997).
Pain from circumcision is not just a temporary or fleeting phenomenon. Rather, it seems to affect a newborn's pain response over a substantial period. See Suzanne Dixon et al., Behavioral Effects of Circumcision With and Without Anesthesia, 5 J. Dev. Behavioral Pediatrics 246, 246-50 (1984). A double blind study using the Brazelton Neonatal Behavioral Assessment Scale found that 90 percent of circumcised neonates had changed behavioral states for more than 22 hours after the procedure, as compared with only 16 percent of uncircumcised infants. See Richard E. Marshall et al., Circumcision I: Effects upon Newborn Behavior, 3 Infant Behavior & Dev. 1, 1-14 (1980). Anna Taddio and her colleagues studied the effect of circumcision on pain response of infants during subsequent routine vaccination, finding that circumcised boys had significantly longer crying bouts and higher pain scores during routine vaccinations at four to six months. Anna Taddio et al., Effect of Neonatal Circumcision on Pain Response During Subsequent Routine Vaccination, 349 The Lancet 599, 599-603 (1997). Their research suggests that neonatal circumcision has long-range psychological effects similar in some respects to post-traumatic stress disorder. See Robert S. Van Howe, Neonatal Circumcision, 349 The Lancet 1257, 1257 (1997). Circumcision may also affect other behavioral patterns in the newborn. For example, after circumcision infants feed less frequently and are less available for interactions with their mothers. See Richard E. Marshall et al., at 1-14; Suzanne Dixon et al., supra at 246-50; Robert N. Emde et al., Stress and Neonatal Sleep, 33 Psychosomatic Med. 491, 491-97 (1971). The deterioration in the ability to breast-feed may contribute to frustration in mother-child interactions or to breast-feeding failure. See Cynthia R. Howard, Acetaminophen Analgesia in Neonatal Circumcision: The Effect on Pain, 93 Pediatrics 641, 641-46 (1994).
On the lack of anesthesia in circumcision, see, e.g., Anna Taddio et al., supra note 485, at 599-603; Howard J. Stang and Leonard W. Snellman, Circumcision Practice Patterns in the United States, 101 Pediatrics E5 (1998) (abstract); Nancy Wellington & Michael J. Rieder, Attitudes and Practices Regarding Analgesia for Newborn Circumcision, 92 Pediatrics 541, 541-43 (1993); William L. Toffler et al., Dorsal Penile Nerve Block During Newborn Circumcision: Underutilization of a Proven Technique?, 3 J. Am. Bd. Family Practice 171,171-74 (1990); K.J.S. Anand & P.R. Hickey, supra note 483, at 1321-1329 (1987). While the principal reason for dispensing with anesthesia in newborn circumcisions appears to be the belief that the patients cannot feel pain, considerations of economics and convenience may also play a role: dispensing with anesthetics saves money, and the physician does not have to wait to perform the operation until the anesthetic has taken hold. See E.O. Horger, Local Anesthesia for Infants Undergoing Circumcision (Letter), 279 JAMA 1169, 1169 (1998)(physicians resist giving anesthesia for circumcision because of a belief that it slows down the procedure). The leading anesthetics for circumcision are a topical anesthetic cream and types of penile nerve block. See, e.g., Meggan Butler-O'Hara et al., Analgesia for Neonatal Circumcision: A Randomized Controlled Trial of EMLA Cream Versus Dorsal Penile Nerve Block, 101 Pediatrics E5 (1998) (abstract); Janice Lander et al., Comparison of Ring Block, Dorsal Penile Nerve Block, and Topical Anesthesia for Neonatal Circumcision: A Randomized Controlled Trial, 278 JAMA 2157, 2157-62 (1997). Even the use of analgesia, however, would not prevent newborns from experiencing pain from circumcision. Anesthetics reduce, but probably do not eliminate, pain from the procedure. See Paul M. Fleiss, Circumcision, 345 The Lancet 927, 927 (1995). Moreover, the effects of the recommended anesthetics are short-term; while they may blunt the pain of the separation of the prepuce from the glans and the severing of the prepuce from the penis, they have no efficacy against the pain the infant experiences during the healing of the wound, especially if the area is abraded by contact with diapers after the surgery. See John Warren, Circumcision, 345 The Lancet 927, 927 (1995). In 1999, recognizing the impact of these studies, the American Association of Pediatrics recommended that all circumcisions be performed with anesthesia. See American Academy of Pediatrics, Task Force on Circumcision, Circumcision Policy Statement, 103 Pediatrics 686, 686-93 (1999).
Mark Jenkins, supra note 366, at 131.
Mayrose, supra note 462.
See, e.g., Robert Dozor, Routine Neonatal Circumcision, 41 Am. Fam. Physician 820, 820-22 (1990).
See generally J. Steven Svoboda et al., supra 34, at 61.
See Gollaher, supra note 19, at 161 (describing claims by anti-circumcision activists that the procedure constitutes torture and cruel, inhuman, and degrading treatment).
See supra notes 55-59 and accompanying text.
https://www.cirp.org/pages/
See, e.g., Circumcision Information Resource Homepage, https://www.cirp.org/.
Fleiss, supra note 368.
See Circumcision Information and Resources, https://www.cirp.org/pages/ (visited Apr. 3, 2001).
https://www.cirp.org/pages/
A surprising percentage of women—between ten and fifty percent—don't even know if their husbands are circumcised! Grimes, supra note 271, at 126.
Id.
Id.
Metcalf et al., supra note 214, at 576-577.
Id.
Id.
See, e.g., Mark S. Brown & Cheryl A. Brown, Circumcision Decision: Prominence of Social Concerns, 80 Pediatrics 215, 215-19 (1987); Ith, supra note 214; John E. Lovell & James Cox, Maternal Attitudes Toward Circumcision, 9 J. Fam. Practice 811, 811-13 (1979). Other reasons provided for the procedure by mothers of infants were that it prevents rupture, that it was advised by women's magazines, and that friends, relatives and neighbors advised the operation. See Patel, supra note 251, at 578.
See, e.g., Laumann et al, supra note 214, at 1054-1055 (cultural, rather than physiological forces may be responsible for observed differences in sexual practices between circumcised and uncircumcised men); William Keith C. Morgan, The Rape of the Phallus, 193 JAMA 123, 123-24 (1965) (Why is the operation of circumcision performed? One might as well attempt to explain the rites of voodoo!); Whiddon, supra note 68, at 337 (Why is the operation of circumcision practiced? As well ask: Why do races all over the world make symbols of the egg and the hare in the spring, the bonfire in the autumn, and the evergreen tree in midwinter?); Patel, supra note 251, at 581 (The majority of parents ...were influenced more by social and cultural factors, often without foundation, than by medical advice.); Robert Dozor, Routine Neonatal Circumcision, 41 Am. Fam. Physician 820, 820-22 (1990) (this is not a matter of science but of deeply held cultural values); Wallerstein, supra note 257, at 130 (Circumcision today has become cultural surgery, not very different from ear-and nose-piercing and tattooing.).
Metcalf et al., supra note 214, at 578.
See generally Gollaher, supra note 19, at 162-185 (discussing activities of anti-circumcision activists).
See id. at 127.
Sylvia Wood, Circumcision is No Longer the Obvious Choice for Newborn Boys, Albany Times-Union, Mar. 16, 1999, at D4.
See Bob Condor, Circumcision Needs Careful Study by Parents, Chicago Tribune, Mar. 28, 1999, at 3.
See supra notes 484-486 and accompanying text.
Janice Lander et al., supra note 484, at 2161.
Circumcision Policy Statement, supra note 486, at 686-693.

Citation:

Geoffrey P. Miller*. Circumcision: Cultural-Legal Analysis. Virginia J Soc Policy & The Law. Spring 2002;9:497-585.

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