Psychological Effects of Circumcision

In his writings on sexual development, Freud postulated that around the fourth or fifth year of life, the genital concentration of all sexual excitement is achieved and the boy's interest in the genitals attains a dominant significance. At this phase of infantile genital organization, the phallic stage, the sexual organs gain a great narcissistic value. The fear that something might happen to this prized organ is called castration anxiety.

Castration anxiety gains significance in the child's life also when related to the nature of relations characterizing the phallic stage. According to Freud, at this stage of development, the boys experiences strong genital strivings for his mother and death wishes for his father, conceptualized as the Oedipus complex. The discovery of sexual differences between boys and girls raises the expectations of castration for himself, as a retaliation for the forbidden sexual desires toward his mother (Freud, S.,1920, 1953).

Clinical observations by psychoanalysts, evidence from anthropology, religious and folk myths, artistic creations and various other sources suggest that the narcissistic fear over the loss of the genital organ leads to the renunciation of the Oedipal attachments. This resolution ushers in a new developmental stage - the latency period.

It is now generally accepted that under the impact of Oedipal strivings and castration anxiety, children at the phallic stage are disposed to experience fantastic fears of bodily damage. Masturbation, medical treatment, traumas, accidents have been shown by many to create disturbances in the psychic life of the child (Coleman 1950; Deutsch 1942; Jessner et al. 1952; Miller, 1951). Anna Freud has indicated that:

...any surgical interference with the child's body may serve as a focal point for the activation, reactivation, grouping, and rationalization of the ideas of being attacked, overwhelmed and (or) castrated....The actual experience of the operation lends a feeling of reality to the repressed fantasies, thereby multiplying the anxieties connected with it. Apart from the threatening situation in the outer world, this increase of anxiety presents an internal danger which the child's ego has to face. Where the defence mechanisms available at the time are strong enough to master these anxieties, all is well; where they have overstrained to integrate the experience, the child reacts to the operation with neurotic outbreaks; where the ego is unable to cope with the anxiety released, the operation becomes a trauma for the child
~ (Freud, A., 1952)

It is noted in the psychoanalytic literature that operations actually performed on the penis, such as circumcision, arouse castration fears whatever the level of libidinal development and facilitate the development of homosexual trends in boys. (Fenichel, 1945). Nunberg, in a most interesting article on circumcision and the problems of bisexuality, points out that injury to the penis may intimidate the boy and impair his development to full virility. However he also proposes that circumcision may stimulate the masculine strivings of the child by encouraging identification with the father. (Nunberg,1947).

Circumcision as a religious custom, has been and is being performed in various parts of the world, in primitive and modern societies. It is a general custom among the Turkish people, finding its justification mainly in religion. Among the educated, it is practised for hygienic purposes. Children are circumcised in Turkey between the ages of 2 and 10 but very often before starting school, i.e. around 5-7. Very little or misleading information is given to the child about the nature of the operation.

The practice of circumcision among the Turks around the phallic stage raises some interesting questions as to its effects on the psychology of the child. Although it is common knowledge in psychoanalytic circles that an operational procedure on the child's sexual organs at the phallic stage will augment his anxieties about castration, no research exists in the literature investigating the specific effects of circumcision practised around these ages. From the formulations of the psychoanalytically oriented writers, we can hypothesize that circumcision will be perceived by the child as an attack, will have detrimental effects on the ego, loosening the fears of castration and rendering a reality to them, thus establishing the feelings of 'I am now castrated'. According to Freud's hypothesis, we can also postulate that circumcision around the phallic stage, by establishing the feelings of being already castrated, will initiate in the child a confusion about sexual identity and dispose him toward femininity. This study was carried out to investigate the validity of these hypotheses.

PROCEDURE

Twelve children between the ages of 4 and 7 were used in the study, six came from families of low and six from average economic and social level. Except two cases, none was given explicit information about circumcision. Apart from two, none had yet begun schooling. Their physical condition during testing was normal. Prior to the study, only one had witnessed a physical trauma, specifically a head injury which had occurred 2-3 years ago. The other children had the usual sicknesses without any major complications or hospitalizations.

The children were seen about a month before the operation. A questionaire was given to the mother, which sought information concerning the child's living conditions, development, social, emotional, intellectual adaptation, his and the families reaction to circumcision. Following this, Goodenough Draw-a-man test, Rorshasch, CAT and a set of stories were admininistered to the child.

Three to seven days after the operation, the child was seen again and the same tests were readministered, except parallel form of stories. A second questionaire was given to the mother, this time investigating the child's physical and psychological reactions to the operation. By the time of the second testing most of the children had overcome the physical discomforts of the operation.

RESULTS

Although the results obtained from the two questionaires are not directly related to the subject of this study, they furnish material about the child's living conditions which might be of interest to psychologists abroad.

Only three of the subjects had separate bedrooms, two shared it with a close relative, but five with their parents. One child slept in the same bed with this brother and one with his sister.

The children from low income families lived under very strong psychological and physical deprivation. Most were threatened by a realistic fear of hunger and quite justified fears of destruction, resulting from continuous mal- treatment. The children from average income level faced the typical problems of an American child of the same social class.

The mothers showed considerable resistance against observing signs of mental disturbance in their children and, apart from two, described their children as 'emotionally, socially and intellectually healthy'. The observations made during testing sessions and the innocent remarks of the mothers revealed that all of the children had certain psychological problems, such as bed-wetting, phobias, temper tantrums. Two subjects were severely disturbed. However, the mothers considered these symptoms as normal manifestations of childhood and seemed totally unaware of their psychopathological character.

Only two mothers had given some information to their children about circumcision. The rest had refrained, due to various rationalizations. Often 'a small lie' was told to the child, such as 'you'll receive lots of gifts and have great fun'. However, the mothers reported that the child actually knew what would happen. Most children had collected some kind of information from friends or relatives. The mothers rationalized their reluctance to give information by stating that the child would be fearful if told the truth and refuse to cooperate. They preferred the child be fooled and should he manifest signs of alarm or disturbance after circumcision, this, they believed would be overcome by time or 'fate'.

The mothers were also resistant toward observing the psychological reactions of the children following the operation. In the second questionaire, they described the children's behaviour to the operation as 'healthy and mature'. They explained the temper tantrums the child manifested, a typical reaction, as the result of being 'spoiled by the attention and the gifts given to him'.

From the interviews with the mother, it seemed in general, that they had little understanding into the child's psychological state, regardless of circumcision. Particularly in the families with low income and little education, the child's needs and anxieties were rarely recognized and little or nothing was done to protect him from dispair. The child was left alone to struggle with and solve his fears, curiosities or strivings. The fathers, having left the care of the child to the mother, seemed to be even more distant emotionally.

A revised form of Goodenough Draw-a-man Test, as applied in most U.S.A. clinics, was used. The child was first asked to draw 'a person' instead of 'a man'. He was then asked a set of questions about the picture he was drawn.

The records showed some interesting changes following circumcision, both in respect of the quality of the drawing and of the responses to the questions.

Following circumcision, there was a remarkable decrease in the I. Q. obtained by this test and in the size of the drawing itself (Table 1). From the decrease in I. Q. we can assume that circumcision hampers smooth, spontaneous and efficient functioning by the child; however, it would be quite misleading to assert that it decreases the I. Q. per se, since it is now generally accepted amongst psychologists that the DAM test is not a very reliable measure of intelligence.

* Significant at 0.01 level by Wilcoxin Signed Rank Test. I.Q. was calculated according to the scoring system suggested by Goodenough (1926)
+ Significant at 0.05 level by Wilcoxin Signed Rank Test. The two sets of drawings were measured at their point of greatest length.

The decrease in the size of the drawings is of greater value in explaining the implicatios of circumcision for the child. In comparison to their previous perception, following the operation, the children feel 'smaller'. The body image shows a tendency to shrink, most probably this results from the feeling of 'being cut'. By depicting a smaller image of himself, the child may also be expressing his feeling of insecurity, inadequacy, inferiority under the impact of the outside world's attack on him (Levy, 1950; Machover, 1951).

Certain interesting changes are also observed in the quality of the responses to the questions asked after the drawing was completed. We can summarize these changes under two headings.

Disturbance in sexual indentification. Following circumcision, all of the children showend some disturbance in sexual identification on the DAM test; however each in a manner peculiar to himself. An interesting disturbance was noted in the sex attributed to the picture drawn before and after the operation. Out of twelve children, five showed definite change in identifying the sex of the figure, five seemed undisturbed in this respect, and two subjects were confused prior to this operation and continued to be so following it.

When the responses of the seemingly undisturbed five subjects are studied, it is seen that these children also manifested confusion over sexual identity. One subject responded to the question in the trunk item by 'he wore a pretty skirt and blouse, ribbon in her hair and high heeled shoes. Two children described the drawing as male, but drew a skirt instead of trousers. Another expressed his confusion in a different way. Although in his preoperative drawing he had not faced a difficulty in joinng his legs to the trunk, in his second drawing he took considerable time to accomplish it and was unable to correct a marked distortion he had made in joining the legs. Another interesting change was the omission of a significant part of the body, such as an arm or a leg. Some children omitted to draw the phallic objects, e. g. a gun, which they had previously included.

Regressive trends. Tendency to regress toward more infantile and primitive modes of expression was observed following circumcision. Half the children attributed a younger age to their drawing after the operation, which may be indicative of a wish to be a 'baby' or to live in an earlier stage when life was less threatening.

Another interesting regressive trait was noted in the responses to the 'three wishes' of the figure drawn. Following circumcision, two stated no wishes, one due to extreme withdrawal and the other from primitively expressed anger. Five subjects who had previously expressed more mature wishes, acceptable for their age level, openly manifested oral passive needs. A good example is the child whose preoperative respones was 'a ball, a whistle and toys'. Following circumcision, this child wished to eat 'plenty of food, cookies, custard and rice custard', the last being a mixture of milk and rice fed to infants. One very disturbed child expressed blatant oral aggressive drives. His preoperative response was 'find clothes, and a human being each day and talk to him. (Q: Why?) So that he can learn the best ideas and apply them in life.' In the post operative testing, this child wished 'Treasure, a very large pot, and to catch people so he can cook them in the pot and devour them.' The same child also linked the costumes in the 'trunk' item with extreme oral aggressive wishes, followinnng the circumcision. He dressed his hero in 'terrible clothes' and sent him off 'to eat little children up'. Two other little children used the costumes for aggressive purposes. Whereas some children showed definite narcissistic trends, they wished to possess articles which would make them look nicer, cleaner, and prettier, objects which were not previously wished.

This test was two sets of incomplete projective stories focusing on a projecting body organ, such as a tail, nose or finger, or animals or human beings. The child had to give an answer at the end of each story to a question such as: 'What happened to the little puppy?' A similar technique to the one used in this study was first suggested by Duss (1940), and later Friedman (1952) devised his own fables for an empirical study of castration anxiety and Oedipus complex. In this research, Friedman's stories were slightly changed to suit the Turkish culture and three parallel stories were devised to be applied following circumcision.

The responses to the two sets of stories were compared in order to evaluate the intensity of aggressive drives. The scoring system was adopted from Pine's (1960) method for evaluating TAT protocols.

Blatant and highly aggressive damage to the object of the stary was scored level I, e. g. mutilation, breakage, death. An aggressive damage such as sickness, was scored level II, Responses which only implied aggressin and a slight change in object were scored level II, e. g. change of colour.

Table 2 shows the results obtained from the evaluation of the intensity of aggressive drives and the content of the responses. We note that following circumcision level I shows a significant increase, indicating to the fact that the operation is experienced by the child as an aggressive attack, with deadening implications. Although before the operation, too, the subjects were somehow anxious of an impending danger, they could more easily control their fear and were capable of expressing it in more subtle, symobolic ways. If prior to circumcision, they experienced anxiety over castration, this anxiety was more of a probability than reality an their ego was strong enough to keep it under control.

Attempting to apply the concepts of psychoanalytic ego psychology to the dynamics underlying TAT stories, Pine (1960) prepared a scoring manual which enables the evaluation of ego strength. He suggests that (1) the integration of drive expression, and (2) the level of drive expression in the TAT stories can be used as a measure of ego control.

(1) The effectiveness with which the drive expression in the TAT stories are integrated into the theme of the story is considered an index of ego control and is scored thematic.

(2) The appearance of drive material in disruptive and inappropriate expressions implies a weakness of ego control and is scored non-appropriate.

(3) Sometimes drives are used incidentally in the TAT stories, so that the subject can hardly relate these experiences to the theme of the story or used it deliberately to give a dramatic effect. Such uses of drive are scored incidental.

The second measure of ego control, the level of drive expression, implies 'the moderation of drive intensity and socialization of its aim' (Pine, 1960). For this rating, Pine proposes three levels: level I--Direct unsocialized drive expression. Level II--Direct socialized drive expression. Level III--Disguised, indirect or weak drive expression. 'Although a heavy preponderance of direct socialized drive expression may have no pathognomic implications, a preponderance of direct-unsocialized and or of direct and disguised drive content suggests an imbalance between ego control and impulse expression, (Pine, 1960).

In order to evaluate the strength of the ego following circumcision, Pine's method of analysis was used to score the CAT protocols. The stories were scored according to the integration of drive expression. Since there was a striking preponderance of aggressive expressions, and practically no implications to libidinal impulses, the direction of the aggressive drives, i. e. their object, was also evaluated. The results of these three types of analyses are summarized in Table 3.

We note that following circumcision, a definite increase occurs in the incidental and non-appropriate use of instinctual energy, indicating a lack of integration of drives and impulses. We note also a striking increase in Level I, i.e. in direct-unsocialized drive expression. These two findings indicate that following circumcision there is a marked weakening in the control of the ego over the primitive discharges, in inability to make appropriate use of instinctual energy, impulses breaking through in ego-alien and maladaptive forms. Due to the traumatic effects of circumcision, and resulting weakening of ego strength, instincts find direct expression, overwhelm the ego and lose their socialized character.

Following circumcision changes are also noted in the direction of the drive, i.e. its object. Aggression directed to the self was taken as an index of castration. In both testings, subjects spontaneously expressed hostile and destructive wishes towards the hero of the story with whom they identified themselves. However, such remarks strikingly increased following the operation (Table 3), pointing to the fact that circumcision was perceived by the child as an aggressive attack, i.e. castration.

Concomitant with the increase in the amount of expression directed to the self, there was an increase in affressive remarks directed toward the mother figures. Only a slight change, which is not significant, occurred in the hostile impulses directed to father figures. According to these results, the females were held responsible for the damage; they were perceived as the castrators, and aggressive wishes were aimed at them.

Other objects, besides father and mother figures, were used by children as targets or sources of aggression, e.g. siblings, animals, society or lifeless objects. Some children manifested diffuse hostile impulses with no specific defined objects or sources (objectless aggression). None of these showed a significant change following circumcision.

Although the Rorschach protocols also show some changes after the operation, these do not seem to be as dramatic as the changes oberved in the other psychological tests. Quantitative analysis by Klopfer et al. (1954) of the two sets of protocols reveal that d%, F% and the number of reject responses significantly increase, whereas total R, C and M decrease following circumcision. The rest of the determinants were given by the subjects inconsistently, such that it was not possible to evaluate the change in each category separately. This all other determinants were grouped uder the heading 'Qualitative wealth of the record'. A significant decrease occurred in this category as well. There was only a slight tendency to derease in H%, and in the average and chromatic reaction times. None were statistically significant. (see Table 4)

The changes noted in the occurrence of various determinants indicate to a generalized constriction inability to respond affectively to the emotional demands of the external world, and withdrawal from human relationships. When prior to circumcision the child seemed more spontaneous in the expression of feelings or needs, following the operation, they are reluctant to reveal their inner world and are apt to isolate and/or insulate themselves from the people around them.

This general constriction and isolation may be a defensive protection of the self from the retaliations of the adults. Having been attacked and mutilated, the children may now be seeking safety in total withdrawal from interpersonal relationships and are thus protecting themselves from aggressive interferences.

In fact, the qualitative analysis of the Rorschach responses indicate that the children perceive the operation as castration (Table 4). References to broken, damaged, disfigured objects and figures occur with greater frequency. There is also a striking decrease in those responses containing phallic element or symbolism (Schafer, 1954). What was previously perceived as 'two bears', following circumcision is interpreted by the child as 'rabbits with heads cut off'. The 'sun' becames 'burning flames', 'head of a rabbit' is seen as 'scissors or clippers'.

No consistent evidence is obtained from the Rorschach with regard to a change in sexual identification. Almost half of the subjects manifested confusion in this area prior to the operation; two had established feminine identification. Although the content of the responses last their phallic element following the circumcision, this, we believe, cannot be taken as in index of feminine identification.

Besides the generalized constriction observed in all subjects, each child in the Rorschach showed a reaction peculiar to himself. When one child reacted to the operation with an aggressive rebellion from within, the other regressed to a state of passive submission. When one became interest in sexual organs, the other seemed concerned over oral deprivation. Such idiosyncratic reactions were not amenable to statistical evaluation.

Discussion

The results obtained for the different psychological tests indicate that circumcision is perceived by the child as an aggressive attack on 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.

Following circumcision, the ego weakens under the impact of the experience, is unable to cope efficiently and adaptively to the trauma and the instinctual drives, as well as the anxieties initiated. The psychoanalytic hypothesis that circumcision will be perceived as castration, and specifically Anna Freud's hypothesis that operations in childhood render a feeling of reality to those anxieties are confirmed through this study.

The main reaction to the operation is an increase in aggressive drives. Not only does the child feel attacked, but also, as a reaction strives to attack those who have mutilated him. The quality of the aggressive feelings is as archaic as the perception of the operation.

In order to protect himself from the threats of the outside world and of the instinctual drives loosened by the operation the child's ego seems to find safety in withdrawal. As a defensive measure, the ego insulates itself from all stimuli and this is protected from external and internal dangers.

Although the psychoanalytic formulations are in general confirmed, some questions arise from the data. One interesting finding is the perception of the females as the castrators. Freud postulates that because of his Oedipal attachments to the mother, the boys expect retaliation from the father, and asserts that it is fear of castration which makes the boy give up his love object. Contrary to this formulation, we note in our results, that children perceive the females as the mutilators and aggressive impulses are directed at them with greater intensity and frequency. This contradictory finding may arise for a cultural and experimental factor.

These cultural factors may have influenced the results of the study as follows: The Turkish child is closely bound to the mother and is so much under her control that immediate punishment and rewards of all kinds are expected from her; whereas the father is distant and detached member of the family and is systematically over-idealized by cultural codes and customs. It is most probable that the overidealization of the father and the close supervision of the mother initiate a deep repression of the hostile feelings nursed against him, allows freedom for the safe expression of the hostile feelings nursed against mother figures. The deeply repressed drives are apt to find expression in highly symbolic forms. In order not to create unreliability, such highly symbolic material was not evaluated in this study.

The second factor which might dispose the child to perceive the female as castrators, might be the facet that the investigator was a female.

The interviews with the mother, the visits to the home of the child before and after the operation, could have created in the child's mind, an association between circumcision and the female investigator.

Although no explanation was given to the child concerning the aim of psychological testing, it is most probable that the mothers explained to their children this unusual procedure in terms of circumcision. We suggest that the child help the investigator and the cooperating mother responsible for the mutilation and this displaced all his fury to the female figures. This issue, however, requires clarification by further research.

The second psychoanalytic hypothesis for which no definite evidence can be offered by this study is the one concerning the tendency towards femininity initated in the boy following circumcision. Only the results of the Goodenough DAM test reveal that most subjects experience some sort of confusion around their sexual identity following circumcision. But these results cannot as yet be accepted as proof of the tendency toward femininity. The Goodenough EAM test is not yet accepted as a reliable measure of such psychological trends.

CAT, Stories, and the Rorschach offer little evidence on this subject. The first two tests are so heavily loaded with aggressive material that reference to libidinal impulses are non-existent. Although in both pre- and post-operative Rorschach protocols confusion over sexual identity is noted in some subjects, the degree and quantity of the confusion does not show any significant change after the operation. One fruitful evidence may be the decrease in phallic symbolism. However, neither this evidence nor the feeling of 'I am now castrated' can allow us to assert that circumcision disposes the child to femininity. Tendency to identify with the female is only one way of coping with castration anxiety; other measures such as reaction formation, denial, etc., can be used by the ego to cope with this feeling. Therefore we suggest that after the initial experience of defensive withdrawal disappears, during which time the ego will gain its strength over the instinctual drives and outside threats, it will integrate and synthesize the trauma and the resulting feelings from it into the structure of the personality. This synthesis is apt to be brought up in a different way in each child according to his history and experience (Nunberg, 1931). Until this synthesis is achieved no definite assertions can be made concerning the course of the sexual tendencies in the circumcised child. To clarify the role of circumcision in the male homosexual, a longitudinal study needs to be arranged, which may also clarify the course of the sexual instincts and the synthetic function of the ego after a traumatic experience such as this.

This problem gains further significance when Nunberg's formulations of circumcision are taken into consideration. Nunberg postulates that circumcision may not only intimidate the boy's sexual impulses but may also stimulate this masculine strivings (Nunberg, 1947). How these two contradictory aims are achieved under the impact of circumcision deserves a great deal of attention. The Turkish male, with his strivings toward, on the one hand, bravery, courage and endurance to pain, and on the other hand total submission to authority, might offer a good example of the resolution of the conflict between masculinity and homosexuality. The relationship between cultural patterns and the synthesis achieved by the ego, following circumcision, in determining the course of the sexual instincts, is definitely a fruitful area for psychoanalytic investigation (Erikson,1950).

Besides the broad theoretical issue, other areas of investigation are offered by this exploratory study.

Although no specific analysis was made on the relationship between the child's psychological state prior to circumcision and the intensity of reaction to it, in general, it seems that children with more severe emotional problems tend to display greater disturbance after the operation. In line with Anna Freud's formulations, the child with neurotic conflicts and poor defence mechanisms seemed to find it much harder to cope with the experience, and 'where the ego' was unable 'to cope with the anxiety released, the operation, became 'a trauma for the child' (Freud, A.,1952). It is most probable that, in a longitudinal study, children with weaker ego strength will face greater difficulty in integrating the experience than those with reasonably good control.

A relationship was observed in the amount of information given to the child and his reaction to the operation. Those children who had received misleading information seemed to show greater disturbance than the two subjects whose mothers had enlightened and assured them. A study investigating the relation between the amount of information given to the child and the degree of reaction shown would be of value in clarifying this issue.

The study also raises a question concerning the socioeconomic level of the child and his ability to cope with traumatic experiences. Six children came from very deprived families and two were threatened by a realistic fear of starvation. One of these children were so fearful of total destruction that a mutilation, such as castration, was a relief to him. The other children with poor back- grounds also tended to take the experience more bravely than those with higher socio-economic standing and no physical deprivation. Clarification of this impression might be of value to those psychologists interested in the relationship between socio-economic level and endurance to psychological stress.

Summary

In order to evaluate the psychological effects of circumcision, a small study was arranged in which twelve children, from average and low socio-economic level, were given Goodenough and DAM test, CAT, Rorschach and two sets of stories, prior to the operation and following it. The results of the tests showed that circumcision, performed around the phallic stage is perceived by the child as an act of aggression and castration. It has detrimental effects on the child's functioning and adaptation, particularly on his ego strength. By weakening the controlling and defensive mechanisms of the ego, and initiating regression, it loosens the previously hidden fears, anxieties, and instinctual impulses, and renders a feeling of reality to them. What is expressed following the operation is primitive, archaic and unsocialized in character. As a defensive control and protection against the surge of the instinctual forces coming from within and the threats coming from outside, the ego of the child seeks safety in total withdrawal, this isolates and insulates itself from disturbing stimuli.

The results of the study raised some questions concerning certain psychoanalytic formulations, for which further research was suggested. Possibilities for future research were also discussed.

References

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Citation:

Cansever G. Psychological Effects of Circumcision. Brit J Med Psychol. 1965-12;38:321-31.

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